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Pfeuffer S, Rolfes L, Wirth T, Steffen F, Pawlitzki M, Schulte-Mecklenbeck A, Gross CC, Brand M, Bittner S, Ruck T, Klotz L, Wiendl H, Meuth SG. Immunoadsorption versus double-dose methylprednisolone in refractory multiple sclerosis relapses. J Neuroinflammation 2022; 19:220. [PMID: 36071461 PMCID: PMC9450381 DOI: 10.1186/s12974-022-02583-y] [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: 06/09/2022] [Accepted: 08/23/2022] [Indexed: 12/03/2022] Open
Abstract
Objective Intravenous methylprednisolone is the standard treatment for a multiple sclerosis relapse; however, this fails to improve symptoms in up to one quarter of patients. Immunoadsorption is an accepted treatment for refractory relapses, but prospective comparator-controlled studies are missing. Methods In this observational study, patients with steroid-refractory acute multiple sclerosis relapses receiving either six courses of tryptophan-immunoadsorption or double-dose methylprednisolone therapy were analysed. Outcomes were evaluated at discharge and three months later. Immune profiling of blood lymphocytes and proteomic analysis were performed by multi-parameter flow cytometry and Olink analysis, respectively (NCT04450030). Results 42 patients were enrolled (methylprednisolone: 26 patients; immunoadsorption: 16 patients). For determination of the primary outcome, treatment response was stratified according to relative function system score changes (“full/best” vs. “average” vs. “worse/none”). Upon discharge, the adjusted odds ratio for any treatment response (“full/best” + ”average” vs. “worse/none”) was 10.697 favouring immunoadsorption (p = 0.005 compared to methylprednisolone). At follow-up, the adjusted odds ratio for the best treatment response (“full/best” vs. “average” + ”worse/none”) was 103.236 favouring IA patients (p = 0.001 compared to methylprednisolone). Similar results were observed regarding evoked potentials and quality of life outcomes, as well as serum neurofilament light-chain levels. Flow cytometry revealed a profound reduction of B cell subsets following immunoadsorption, which was closely correlated to clinical outcomes, whereas methylprednisolone had a minimal effect on B cell populations. Immunoadsorption treatment skewed the blood cytokine network, reduced levels of B cell-related cytokines and reduced immunoglobulin levels as well as levels of certain coagulation factors. Interpretation Immunoadsorption demonstrated favourable outcomes compared to double-dose methylprednisolone. Outcome differences were significant at discharge and follow-up. Further analyses identified modulation of B cell function as a potential mechanism of action for immunoadsorption, as reduction of B cell subsets correlated with clinical improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-022-02583-y.
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Affiliation(s)
- Steffen Pfeuffer
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Leoni Rolfes
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.,Department of Neurology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Timo Wirth
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Falk Steffen
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Marc Pawlitzki
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.,Department of Neurology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Catharina C Gross
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Marcus Brand
- Medical Department D - Nephrology, University Hospital Muenster, Muenster, Germany
| | - Stefan Bittner
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Tobias Ruck
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.,Department of Neurology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Luisa Klotz
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| | - Sven G Meuth
- Department of Neurology and Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany. .,Department of Neurology, University Hospital Duesseldorf, Duesseldorf, Germany.
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2
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Arrambide G, Iacobaeus E, Amato MP, Derfuss T, Vukusic S, Hemmer B, Brundin L, Tintore M. Aggressive multiple sclerosis (2): Treatment. Mult Scler 2020; 26:1352458520924595. [PMID: 32530366 PMCID: PMC7412878 DOI: 10.1177/1352458520924595] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/18/2020] [Accepted: 04/16/2020] [Indexed: 01/04/2023]
Abstract
The natural history of multiple sclerosis (MS) is highly heterogeneous. A subgroup of patients has what might be termed aggressive MS. These patients may have frequent, severe relapses with incomplete recovery and are at risk of developing greater and permanent disability at the earlier stages of the disease. Their therapeutic window of opportunity may be narrow, and while it is generally considered that they will benefit from starting early with a highly efficacious treatment, a unified definition of aggressive MS does not exist and data on its treatment are largely lacking. Based on discussions at an international focused workshop sponsored by the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS), we review our current knowledge about treatment of individuals with aggressive MS. We analyse the available evidence, identify gaps in knowledge and suggest future research needed to fill those gaps. A companion paper details the difficulties in developing a consensus about what defines aggressive MS.
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Affiliation(s)
- Georgina Arrambide
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Vall d’Hebron Institut de Recerca, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ellen Iacobaeus
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Tobias Derfuss
- Departments of Neurology and Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sandra Vukusic
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France/Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR5292, Lyon, France/Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany/Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Lou Brundin
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Mar Tintore
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Vall d’Hebron Institut de Recerca, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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3
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Plasma Exchange or Immunoadsorption in Demyelinating Diseases: A Meta-Analysis. J Clin Med 2020; 9:jcm9051597. [PMID: 32466101 PMCID: PMC7290597 DOI: 10.3390/jcm9051597] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/14/2022] Open
Abstract
Multiple sclerosis (MS) is an inflammatory disease mainly affecting the central nervous system. In MS, abnormal immune mechanisms induce acute inflammation, demyelination, axonal loss, and the formation of central nervous system plaques. The long-term treatment involves options to modify the disease progression, whereas the treatment for the acute relapse has its focus in the administration of high-dose intravenous methylprednisolone (up to 1000 mg daily) over a period of three to five days as a first step. If symptoms of the acute relapse persist, it is defined as glucocorticosteroid-unresponsive, and immunomodulation by apheresis is recommended. However, several national and international guidelines have no uniform recommendations on using plasma exchange (PE) nor immunoadsorption (IA) in this case. A systematic review and meta-analysis was conducted, including observational studies or randomized controlled trials that investigated the effect of PE or IA on different courses of MS and neuromyelitis optica (NMO). One thousand, three hundred and eighty-three patients were included in the evaluation. Therapy response in relapsing-remitting MS and clinically isolated syndrome was 76.6% (95%CI 63.7–89.8%) in PE- and 80.6% (95%CI 69.3–91.8%) in IA-treated patients. Based on the recent literature, PE and IA may be considered as equal treatment possibilities in patients suffering from acute, glucocorticosteroid-unresponsive MS relapses.
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4
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Moser T, Harutyunyan G, Karamyan A, Otto F, Bacher C, Chroust V, Leitinger M, Novak HF, Trinka E, Sellner J. Therapeutic Plasma Exchange in Multiple Sclerosis and Autoimmune Encephalitis: a Comparative Study of Indication, Efficacy and Safety. Brain Sci 2019; 9:brainsci9100267. [PMID: 31601005 PMCID: PMC6827054 DOI: 10.3390/brainsci9100267] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 09/23/2019] [Accepted: 10/08/2019] [Indexed: 12/19/2022] Open
Abstract
Therapeutic plasma exchange (TPE) is a well-established method of treatment for steroid-refractory relapses in multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). Little is known about indications and clinical responses to TPE in autoimmune encephalitis and other immune-mediated disorders of the central nervous system (CNS). We performed a retrospective chart review of patients with immune-mediated disorders of the CNS undergoing TPE at our tertiary care center between 2003 and 2015. The response to TPE within a 3- to 6-month follow-up was scored with an established rating system. We identified 40 patients including 21 patients with multiple sclerosis (MS, 52.5%), 12 with autoimmune encephalitis (AE, 30%), and 7 with other immune-mediated CNS disorders (17.5%). Among patients with AE, eight patients had definite AE (Immunolobulin G for N-methyl-D-aspartate receptor n = 4, Leucine-rich, glioma inactivated 1 n = 2, Ma 2 n = 1, and Alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic Acid n = 1). Intravenous immunoglobulins had been given prior to TPE in all but one patient with AE, and indications were dominated by acute psychosis and epileptic seizures. While TPE has a distinct place in the treatment sequence of different immune-mediated CNS disorders, we found consistent efficacy and safety. Further research should be directed toward alternative management strategies in non-responders.
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Affiliation(s)
- Tobias Moser
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Gayane Harutyunyan
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Anush Karamyan
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Ferdinand Otto
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Carola Bacher
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Vaclav Chroust
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Helmut F Novak
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, 81675 Mücnhen, Germany.
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, 2130 Mistelbach, Austria.
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5
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Rolfes L, Pfeuffer S, Ruck T, Melzer N, Pawlitzki M, Heming M, Brand M, Wiendl H, Meuth SG. Therapeutic Apheresis in Acute Relapsing Multiple Sclerosis: Current Evidence and Unmet Needs-A Systematic Review. J Clin Med 2019; 8:jcm8101623. [PMID: 31590282 PMCID: PMC6832170 DOI: 10.3390/jcm8101623] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 12/13/2022] Open
Abstract
Multiple sclerosis (MS) is the most abundant inflammatory demyelinating disorder of the central nervous system. Despite recent advances in its long-term immunomodulatory treatment, MS patients still suffer from relapses, significantly contributing to disability accrual. In recent years, apheresis procedures such as therapeutic plasma exchange (TPE) and immunoadsorption (IA) have been recognized as two options for treating MS relapses, that do not respond to standard treatment with corticosteroids. TPE is already incorporated in most international guidelines, although evidence for its use resulted mostly from either case series or small unblinded and/or non-randomized trials. Data on IA are still sparse, but several studies indicate comparable efficacy between both apheresis procedures. This article gives an overview of the published evidence on TPE and IA in the treatment of acute relapses in MS. Further, we outline current evidence regarding individual outcome predictors, describe technical details of apheresis procedures, and discuss apheresis treatment in children and during pregnancy.
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Affiliation(s)
- Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Michael Heming
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Marcus Brand
- Department of Internal Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
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6
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Lipphardt M, Mühlhausen J, Kitze B, Heigl F, Mauch E, Helms HJ, Müller GA, Koziolek MJ. Immunoadsorption or plasma exchange in steroid-refractory multiple sclerosis and neuromyelitis optica. J Clin Apher 2019; 34:381-391. [PMID: 30698295 DOI: 10.1002/jca.21686] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Plasma exchange (PE) and immunoadsorption (IA) are alternative treatments of steroid-refractory relapses of multiple sclerosis (MS) or neuromyelitis optica (NMO). METHODS Adverse events and neurological follow-ups in 127 MS- (62 PE, 65 IA) and 13 NMO- (11 PE, 2 IA) patients were retrospectively analyzed. Response was defined by improvements in either expanded disability status scale (EDSS) by at least 1.0 or visual acuity (VA) to 0.5, confirmed after 3 and/or 6 months. RESULTS Hundred and forty patients were included in safety analysis, 102 patients provided sufficient neurological follow-up-data. There were no significant differences between IA and PE in side effects (3.9% vs 3.6%, P = .96) or response-rate (P = .65). Responders showed significant lower age (P = .02) and earlier apheresis-initiation (P = .01). Subgroup-analysis confirmed significant lower age in patients with relapsing-remitting MS (RRMS) /clinical isolated syndrome (CIS). CONCLUSION IA and PE seem equally safe and effective in steroid-resistant MS- or NMO-relapses. Early apheresis and low patient age are additional prognostic factors.
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Affiliation(s)
- Mark Lipphardt
- Department of Nephrology and Rheumatology, Georg-August-University Göttingen, Germany
| | - Johannes Mühlhausen
- Department of Nephrology and Rheumatology, Georg-August-University Göttingen, Germany
| | - Bernd Kitze
- Department of Neurology, Georg-August-University Göttingen, Germany
| | - Franz Heigl
- Department of Neurology, Medical Healthcare Centre Kempten, Kempten-Allgäu, Germany
| | - Erich Mauch
- Neurological Hospital Dietenbronn, Schwendi, Germany
| | - Hans-Joachim Helms
- Department of Medical Statistics, Georg-August-University Göttingen, Göttingen, Germany
| | - Gerhard A Müller
- Department of Nephrology and Rheumatology, Georg-August-University Göttingen, Germany
| | - Michael J Koziolek
- Department of Nephrology and Rheumatology, Georg-August-University Göttingen, Germany
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7
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Abstract
Neuromyelitis optica spectrum disorders (NMOSD) are important evolving entities, which have reached much attention in the recent years. NMOSD are characterized by inflammatory lesions in the optic nerves, spinal cord, and central parts of the brain, as well as an autoimmune process directed against aquaporin-4. As disability in NMOSD accumulates by inflammatory damage from attacks, both the treatment and prevention of attacks are decisive for the long-term outcome. NMOSD attacks are treated with high-dose intravenous corticosteroids and apheresis therapies, in particular therapeutic plasma exchange. In cases of incomplete remission, escalation of attack treatment is recommended. Preventive therapy is immunosuppressive and should by commenced as early as possible. Apart from classical immunosuppressants such as azathioprine and mycophenolate mofetil, repurposed biologicals are increasingly used. B-cell depletion with rituximab and other agents, inhibition of the interleukin-6 receptor with tocilizumab, and blockade of complement-mediated damage by eculizumab all are promising therapeutic strategies evaluated in randomized controlled trials. In this review, we will discuss present and future immunotherapies for NMOSD and also consider combination of treatments, plasma, cellular and other therapies. Current advances in immunopathological knowledge are translated into innovative concepts and begin a new era of NMOSD therapy.
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Affiliation(s)
- Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University, Bochum, Germany.
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University, Bochum, Germany
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8
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Kleiter I, Gahlen A, Borisow N, Fischer K, Wernecke KD, Wegner B, Hellwig K, Pache F, Ruprecht K, Havla J, Krumbholz M, Kümpfel T, Aktas O, Hartung HP, Ringelstein M, Geis C, Kleinschnitz C, Berthele A, Hemmer B, Angstwurm K, Stellmann JP, Schuster S, Stangel M, Lauda F, Tumani H, Mayer C, Zeltner L, Ziemann U, Linker R, Schwab M, Marziniak M, Then Bergh F, Hofstadt-van Oy U, Neuhaus O, Winkelmann A, Marouf W, Faiss J, Wildemann B, Paul F, Jarius S, Trebst C. Neuromyelitis optica: Evaluation of 871 attacks and 1,153 treatment courses. Ann Neurol 2015; 79:206-16. [PMID: 26537743 DOI: 10.1002/ana.24554] [Citation(s) in RCA: 258] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 11/02/2015] [Accepted: 11/02/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Neuromyelitis optica (NMO) attacks often are severe, are difficult to treat, and leave residual deficits. Here, we analyzed the frequency, sequence, and efficacy of therapies used for NMO attacks. METHODS A retrospective review was made of patient records to assess demographic/diagnostic data, attack characteristics, therapies, and the short-term remission status (complete remission [CR], partial remission [PR], no remission [NR]). Inclusion criteria were NMO according to Wingerchuk's 2006 criteria or aquaporin-4 antibody-positive NMO spectrum disorder (NMOSD). Remission status was analyzed with generalized estimating equations (GEEs), a patient-based statistical approach. RESULTS A total of 871 attacks in 185 patients (142 NMO/43 NMOSD, 82% female) were analyzed. The 1,153 treatment courses comprised high-dose intravenous steroids (HD-S; n = 810), plasma exchange (PE; n = 192), immunoadsorption (IA; n = 38), other (n = 80), and unknown (n = 33) therapies. The first treatment course led to CR in 19.1%, PR in 64.5%, and NR in 16.4% of attacks. Second, third, fourth, and fifth treatment courses were given in 28.2%, 7.1%, 1.4%, and 0.5% of attacks, respectively. This escalation of attack therapy significantly improved outcome (p < 0.001, Bowker test). Remission rates were higher for isolated optic neuritis versus isolated myelitis (p < 0.001), and for unilateral versus bilateral optic neuritis (p = 0.020). Isolated myelitis responded better to PE/IA than to HD-S as first treatment course (p = 0.037). Predictors of CR in multivariate GEE analysis were age (odds ratio [OR] = 0.97, p = 0.011), presence of myelitis (OR = 0.38, p = 0.002), CR from previous attack (OR = 6.85, p < 0.001), and first-line PE/IA versus HD-S (OR = 4.38, p = 0.006). INTERPRETATION Particularly myelitis and bilateral optic neuritis have poor remission rates. Escalation of attack therapy improves outcome. PE/IA may increase recovery in isolated myelitis.
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Affiliation(s)
- Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum
| | - Anna Gahlen
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum
| | - Nadja Borisow
- NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité University Medicine, and Max Delbrueck Center for Molecular Medicine, Berlin
| | - Katrin Fischer
- Department of Neurology, Asklepios Clinic Teupitz, Teupitz
| | | | - Brigitte Wegner
- Clinical Research Organisation Sostana and Charité University Medicine, Berlin
| | - Kerstin Hellwig
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum
| | - Florence Pache
- NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité University Medicine, and Max Delbrueck Center for Molecular Medicine, Berlin.,Department of Neurology and Clinical and Experimental Multiple Sclerosis Research Center, Charité University Medicine, Berlin
| | - Klemens Ruprecht
- Department of Neurology and Clinical and Experimental Multiple Sclerosis Research Center, Charité University Medicine, Berlin
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Medical Campus Grosshadern, Ludwig Maximilians University, Munich
| | - Markus Krumbholz
- Institute of Clinical Neuroimmunology, Medical Campus Grosshadern, Ludwig Maximilians University, Munich
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, Medical Campus Grosshadern, Ludwig Maximilians University, Munich
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf
| | - Christian Geis
- Department of Neurology, University Hospital Würzburg, Würzburg
| | | | - Achim Berthele
- Department of Neurology, Technical University of Munich, Munich
| | - Bernhard Hemmer
- Department of Neurology, Technical University of Munich and Munich Cluster for Systems Neurology, Munich
| | | | - Jan-Patrick Stellmann
- Institute for Neuroimmunology and MS and Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Simon Schuster
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Martin Stangel
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hannover
| | | | | | - Christoph Mayer
- Department of Neurology, Goethe University Frankfurt, Frankfurt
| | - Lena Zeltner
- Department of Neurology and Stroke and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen
| | - Ulf Ziemann
- Department of Neurology and Stroke and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen
| | - Ralf Linker
- Department of Neurology, Friedrich Alexander University Erlangen-Nuremberg, Erlangen
| | - Matthias Schwab
- Hans Berger Department of Neurology, Jena University Hospital, Jena
| | | | | | | | - Oliver Neuhaus
- Department of Neurology, SRH Hospital Sigmaringen, Sigmaringen
| | | | - Wael Marouf
- Department of Neurology, HELIOS Hanse Hospital Stralsund, Stralsund
| | - Jürgen Faiss
- Department of Neurology, Asklepios Clinic Teupitz, Teupitz
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg
| | - Friedemann Paul
- NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité University Medicine, and Max Delbrueck Center for Molecular Medicine, Berlin.,Department of Neurology and Clinical and Experimental Multiple Sclerosis Research Center, Charité University Medicine, Berlin
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Hannover, Germany
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9
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Hoffmann F, Kraft A, Heigl F, Mauch E, Koehler J, Harms L, Kümpfel T, Köhler W, Klingel R, Fassbender C, Schimrigk S. [Tryptophan immunoadsorption for multiple sclerosis and neuromyelitis optica: therapy option for acute relapses during pregnancy and breastfeeding]. DER NERVENARZT 2015; 86:179-86. [PMID: 25604838 DOI: 10.1007/s00115-014-4239-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Approximately 25 % of women with multiple sclerosis (MS) suffer clinically relevant relapses during pregnancy. Almost all disease-modifying drugs are contraindicated in pregnancy. High-dose glucocorticoids have some serious risks, especially within the first trimester. Tryptophan immunoadsorption (IA) provides a safe option to treat MS relapses during pregnancy. OBJECTIVES In this case series we describe for the first time the use of tryptophan IA for MS and neuromyelitis optica (NMO) relapses during pregnancy and breastfeeding. PATIENTS AND METHODS In this study a total of 9 patients were retrospectively analyzed of which 7 patients received IA treatment during pregnancy, 2 during breastfeeding and 4-6 tryptophan IA treatments were performed per patient with the single use tryptophan adsorber. Primary outcome was symptom improvement of the relapse. RESULTS In this study four patients with MS and one with NMO relapse during pregnancy were treated with IA without preceding glucocorticoid pulse therapy. The MS patients showed improvement in the expanded disability status scale (EDSS) by at least one point, the NMO patient showed significant improvement in visual acuity and two pregnant patients with steroid-refractory relapses showed clinically relevant improvement after IA. Of the patients two suffered from steroid-refractory relapses during breastfeeding and relapse symptoms improved in both cases after treatment with IA. All treatments were well tolerated and no serious adverse events occurred. CONCLUSION Tryptophan IA was found to be safe, well-tolerated and effective in the treatment of MS and NMO relapses during pregnancy and breastfeeding, sometimes without preceding glucocorticoid pulse therapy. A binding recommendation is limited without prospective clinical studies.
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Affiliation(s)
- F Hoffmann
- Klinik für Neurologie, Krankenhaus Martha-Maria Halle-Dölau GmbH, Röntgenstr. 1, 06120, Halle (Saale), Deutschland,
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Dramatic recovery of steroid-refractory relapsed multiple sclerosis following Fingolimod discontinuation using selective immune adsorption. BMC Neurol 2015; 15:125. [PMID: 26227815 PMCID: PMC4521477 DOI: 10.1186/s12883-015-0377-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 07/10/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Selective immune adsorption (SIA) is an emerging method for treating immune-mediated neurological diseases, given its superior safety profile compared to plasma exchange (PEX). However, the available literature concerning Multiple Sclerosis includes no cases of SIA applied to steroid-refractory rebound after Fingolimod discontinuation. CASE PRESENTATION Here we report the case of a 32-year-old woman suffering from multiple sclerosis treated with Fingolimod and admitted to a Multiple Sclerosis Centre after drug discontinuation due to the occurrence of lymphopenia. During the few weeks preceding admission, the patient experienced progressive and severe neurological deterioration that did not respond to an initial cycle of pulsed high doses of intravenous 6-methyl prednisolone (IVMP). Given the ineffectiveness of a second cycle of IVMP, the patient was treated with plasma immunoadsorption, leading to dramatic functional recovery. The patient then started a neuro-rehabilitation program. About one month after the final SIA procedure the patient started Natalizumab-based therapy, while maintaining a stable neurological condition. We noted significant modification of C3/C4 complement components and total gamma globulin concentrations (IgG) during SIA. CONCLUSIONS Our observations show that however serious, steroid-refractory neurological deterioration occurring after Fingolimod discontinuation in multiple sclerosis can be treated with selective immune-adsorption therapy which thus represents a good alternative in these cases. It could be speculated that this clinical condition was associated with pattern II of demyelination, given the good response to a form of treatment that acts on autoantibodies. Thus, SIA represented an effective therapeutic strategy for this case of relapsed MS as steroid-resistent rebound post Fingolimod cessation.
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Heigl F, Hettich R, Arendt R, Durner J, Koehler J, Mauch E. Immunoadsorption in steroid-refractory multiple sclerosis: clinical experience in 60 patients. ATHEROSCLEROSIS SUPP 2013; 14:167-73. [PMID: 23357160 DOI: 10.1016/j.atherosclerosissup.2012.10.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is the most common autoimmune inflammatory demyelinating disease of the central nervous system with a frequently relapsing or progressive course. For steroid-resistant relapse, plasma exchange (PE) has been established as guidelines-recommended treatment option. While PE is a non-selective extracorporeal blood purification process with elimination of plasma and subsequent substitution, immunoadsorption (IA) is a selective technique for the removal of autoantibodies and immune complexes with less adverse effects. So far there are only few reports on the treatment of MS by IA. The aim of this retrospective study was to assess the efficacy and safety of IA as an escalation therapy in MS patients. PATIENTS AND METHODS A total of 60 patients with steroid-refractory MS relapse were treated by IA and analyzed retrospectively. Patients received six standardized IA sessions using a non-regenerable tryptophan immunoadsorber, at average 58 days after first indications of relapse. The treated plasma volume was two liters per IA session. Outcome was measured as improvement in relapse symptoms. From the pilot phase of the study comprising the first fourteen patients, detailed neurological examinations before and after IA such as Expanded Disability Status Scale (EDSS), Functional System Score (FS) and visual acuity are reported. Of the following 46 patients, only qualitative data regarding the therapeutic success, and in addition clinical data on tolerability, are presently available. RESULTS In 53 of 60 patients clinically relevant improvement of the main symptom of MS relapse was noted after IA, there was no change in six patients, deterioration in one. This corresponds to a response rate of 88%. Symptomatic improvement was first registered on average after the third IA. 87.5% of patients could be treated through a peripheral venous access. Only 12.5% needed a central venous catheter. In four of 396 single treatments (1%) significant complications occurred, mild side effects or discomfort were registered 16 times (4%). If peripheral venous access was chosen, missed puncture or puncture hematoma occurred in 22 cases (5.5%). CONCLUSION Immunoadsorption for the treatment of steroid-refractory MS relapse is safe and effective. The response rate was 88% and non-inferior to previous results with plasma exchange. Due to good tolerability, the treatment with immunoadsorption, which is usually possible through a peripheral venous access, can be performed on an outpatient basis.
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Affiliation(s)
- Franz Heigl
- Dres Heigl, Hettich & Partner Medizinisches Versorgungszentrum Kempten-Allgäu, Robert-Weixler-Straße 19, 87439 Kempten, Germany.
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Meca-Lallana JE, Hernández-Clares R, León-Hernández A, Genovés Aleixandre A, Cacho Pérez M, Martín-Fernández JJ. Plasma Exchange for Steroid-Refractory Relapses in Multiple Sclerosis: An Observational, MRI Pilot Study. Clin Ther 2013; 35:474-85. [DOI: 10.1016/j.clinthera.2013.02.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 02/27/2013] [Indexed: 01/30/2023]
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Koziolek M, Mühlhausen J, Friede T, Ellenberger D, Sigler M, Huppke B, Gärtner J, Müller GA, Huppke P. Therapeutic Apheresis in Pediatric Patients with Acute CNS Inflammatory Demyelinating Disease. Blood Purif 2013; 36:92-7. [DOI: 10.1159/000354077] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 06/19/2013] [Indexed: 11/19/2022]
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Neurologic diseases of the central nervous system with pathophysiologically relevant autoantibodies – Perspectives for immunoadsorption. ATHEROSCLEROSIS SUPP 2013; 14:161-5. [DOI: 10.1016/j.atherosclerosissup.2012.10.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Koziolek MJ, Kitze B, Mühlhausen J, Müller GA. Immunoadsorption in steroid-refractory multiple sclerosis. ATHEROSCLEROSIS SUPP 2013; 14:175-8. [DOI: 10.1016/j.atherosclerosissup.2012.10.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Koziolek MJ, Tampe D, Bähr M, Dihazi H, Jung K, Fitzner D, Klingel R, Müller GA, Kitze B. Immunoadsorption therapy in patients with multiple sclerosis with steroid-refractory optical neuritis. J Neuroinflammation 2012; 9:80. [PMID: 22537481 PMCID: PMC3418188 DOI: 10.1186/1742-2094-9-80] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 04/26/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In multiple sclerosis relapses refractory to intravenous corticosteroid therapy, plasma exchange is recommended. Immunoadsorption (IA) is regarded as an alternative therapy, but its efficacy and putative mechanism of action still needs to be established. METHODS We prospectively treated 11 patients with multiple sclerosis who had optical neuritis and fulfilled the indications for apheresis therapy (Trial registration DE/CA25/00007080-00). In total, five IA treatments were performed using tryptophan-IA. Clinical activity (visual acuity, Expanded Disability Status Scale, Incapacity Status Scale), laboratory values and visual evoked potentials were measured before, during and after IA, with a follow-up of six months. Moreover, proteomic analyses were performed to analyze column-bound proteins as well as corresponding changes in patients' sera. RESULTS After the third IA, we detected an improvement of vision in eight of eleven patients, whom we termed responders. Amongst these, the mean visual acuity improved from 0.15 ± 0.12 at baseline to 0.47 ± 0.32 after the third IA (P = 0.0252) up to 0.89 ± 0.15 (P < 0.0001) at day 180 ± 10 after IA. Soluble interleukin-2 receptor decreased in responders (P = 0.03), whereas in non-responders it did not. Proteomic analyses of proteins adsorbed to IA columns revealed that several significant immunological proteins as well as central nervous system protein fragments, including myelin basic protein, had been removed by IA. CONCLUSIONS IA was effective in the treatment of corticosteroid-refractory optic neuritis. IA influenced the humoral immune response. Strikingly, however, we found strong evidence that demyelination products and immunological mediators were also cleared from plasma by IA.
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Affiliation(s)
- Michael J Koziolek
- Department of Nephrology and Rheumatology, Georg-August-University Göttingen, Robert-Koch-Strasse 40, D-37075 Göttingen, Germany.
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