1
|
Lasek-Bal A, Bartoszek K, Steposz A, Puz P, Bal W, Kazibutowska Z. Efficacy and safety of mitoxantrone use in primary and secondary progressive multiple sclerosis – study site experience based on the therapy of 104 patients. Int J Neurosci 2016; 127:859-863. [DOI: 10.1080/00207454.2016.1269327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Anetta Lasek-Bal
- Department of Neurolog, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
- Department of Neurology, Professor Leszek Giec Upper Silesian Medical Centre, Medical University of Silesia Hospital No. 7, Katowice, Poland
| | - Karina Bartoszek
- Department of Neurology, Professor Leszek Giec Upper Silesian Medical Centre, Medical University of Silesia Hospital No. 7, Katowice, Poland
| | - Arkadiusz Steposz
- Department of Neurolog, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
- Department of Neurology, Professor Leszek Giec Upper Silesian Medical Centre, Medical University of Silesia Hospital No. 7, Katowice, Poland
| | - Przemyslaw Puz
- Department of Neurolog, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
- Department of Neurology, Professor Leszek Giec Upper Silesian Medical Centre, Medical University of Silesia Hospital No. 7, Katowice, Poland
| | - Wieslaw Bal
- Department of Radiation Oncology and Chemotherapy, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Zofia Kazibutowska
- Department of Neurology, Professor Leszek Giec Upper Silesian Medical Centre, Medical University of Silesia Hospital No. 7, Katowice, Poland
| |
Collapse
|
2
|
Reduce the risk of adverse events associated with disease-modifying therapies for multiple sclerosis by following appropriate mitigation strategies. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0293-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
3
|
Influence of fingolimod on basic lymphocyte subsets frequencies in the peripheral blood of multiple sclerosis patients - preliminary study. Cent Eur J Immunol 2015; 40:354-9. [PMID: 26648781 PMCID: PMC4655387 DOI: 10.5114/ceji.2015.54599] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 08/19/2015] [Indexed: 01/18/2023] Open
Abstract
Background Fingolimod is a drug administered orally to adult patients treated for relapsing remitting course of multiple sclerosis (MS). Mode of action of fingolimod is based on intense S1P1 receptor stimulation and “arresting” lymphocytes in lymphatic organs. Objective of the research was to assess changes in the frequencies of basic lymphocyte subsets in patients treated for multiple sclerosis with the use of fingolimod. Material and methods Study group comprised of 25 previously untreated adult patients with MS. Venous blood samples were collected from each patient before and one month, three months and six months after treatment initiation. Peripheral blood lymphocyte immunophenotype was assessed with a set of monoclonal antibodies bounded to appropriate fluorochromes and flow cytometer FACSC alibur. Statistical analysis of the results was conducted using Statistica 9.0 software. Results Before fingolimod administration median of lymphocyte subsets percentage in each patient was in reference range. After 1 month of treatment we noticed significant changes in frequencies of following lymphocyte subsets: NK cells – 51.22% (p = 0.016), T CD4+ cells – 11.58% (p = 0.01), T CD4+:T CD8+ cells ratio – 0.61 (p = 0.005). After 3 and 6 months of treatment there was further increase of deviation from normal state. Conclusions The use of fingolimod is associated with profound changes in lymphocyte subsets distribution, which might bear a risk of the development of cellular immune deficiency symptoms.
Collapse
|
4
|
Subei AM, Ontaneda D. Risk Mitigation Strategies for Adverse Reactions Associated with the Disease-Modifying Drugs in Multiple Sclerosis. CNS Drugs 2015; 29:759-71. [PMID: 26407624 PMCID: PMC4621807 DOI: 10.1007/s40263-015-0277-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Over the past several years, the number of disease-modifying therapies (DMTs) for the treatment of multiple sclerosis (MS) has doubled in number. The 13 approved agents have shown a wide range of efficacy and safety in their clinical trials and post-marketing experience. While the availability of the newer agents allows for a wider selection of therapy for clinicians and patients, there is a need for careful understanding of the benefits and risks of each agent. Several factors such as the medication efficacy, side-effect profile, patient's preference, and co-morbidities need to be considered. An individualized treatment approach is thus imperative. In this review, risk stratification and mitigation strategies of the various disease-modifying agents are discussed.
Collapse
Affiliation(s)
- Adnan M Subei
- Mellen Center for MS Treatment and Research, Cleveland Clinic Foundation, 9500 Euclid Avenue/U10, Cleveland, OH, 44195, USA.
| | - Daniel Ontaneda
- Mellen Center for MS Treatment and Research, Cleveland Clinic Foundation, 9500 Euclid Avenue/U10, Cleveland, OH, 44195, USA.
| |
Collapse
|
5
|
Fleischer V, Salmen A, Kollar S, Weyer V, Siffrin V, Chan A, Zipp F, Luessi F. Cardiotoxicity of mitoxantrone treatment in a german cohort of 639 multiple sclerosis patients. J Clin Neurol 2014; 10:289-95. [PMID: 25324877 PMCID: PMC4198709 DOI: 10.3988/jcn.2014.10.4.289] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 04/18/2014] [Accepted: 04/21/2014] [Indexed: 02/01/2023] Open
Abstract
Background and Purpose The aim of this study was to elucidate the role of therapy-related cardiotoxicity in multiple sclerosis (MS) patients treated with mitoxantrone and to identify potential predictors for individual risk assessment. Methods Within a multicenter retrospective cohort design, cardiac side effects attributed to mitoxantrone were analyzed in 639 MS patients at 2 MS centers in Germany. Demographic, disease, treatment, and follow-up data were collected from hospital records. Patients regularly received cardiac monitoring during the treatment phase. Results None of the patients developed symptomatic congestive heart failure. However, the frequency of patients experiencing cardiac dysfunction of milder forms after mitoxantrone therapy was 4.1% (26 patients) among all patients. Analyses of the risk for cardiotoxicity revealed that cumulative dose exposure was the only statistically relevant risk factor associated with cardiac dysfunction. Conclusions The number of patients developing subclinical cardiac dysfunction below the maximum recommended cumulative dose is higher than was initially assumed. Interestingly, a subgroup of patients was identified who experienced cardiac dysfunction shortly after initiation of mitoxantrone and who received a low cumulative dose. Therefore, each administration of mitoxantrone should include monitoring of cardiac function to enhance the treatment safety for patients and to allow for early detection of any side effects, especially in potential high-risk subgroups (as determined genetically).
Collapse
Affiliation(s)
- Vinzenz Fleischer
- Department of Neurology, Focus Program Translational Neuroscience, Rhine Main Neuroscience Network, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Anke Salmen
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Susanne Kollar
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Veronika Weyer
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Volker Siffrin
- Department of Neurology, Focus Program Translational Neuroscience, Rhine Main Neuroscience Network, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Andrew Chan
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience, Rhine Main Neuroscience Network, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Felix Luessi
- Department of Neurology, Focus Program Translational Neuroscience, Rhine Main Neuroscience Network, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany
| |
Collapse
|
6
|
Broadley SA, Barnett MH, Boggild M, Brew BJ, Butzkueven H, Heard R, Hodgkinson S, Kermode AG, Lechner-Scott J, Macdonell RAL, Marriott M, Mason DF, Parratt J, Reddel SW, Shaw CP, Slee M, Spies J, Taylor BV, Carroll WM, Kilpatrick TJ, King J, McCombe PA, Pollard JD, Willoughby E. Therapeutic approaches to disease modifying therapy for multiple sclerosis in adults: an Australian and New Zealand perspective: part 1 historical and established therapies. MS Neurology Group of the Australian and New Zealand Association of Neurologists. J Clin Neurosci 2014; 21:1835-46. [PMID: 24993135 DOI: 10.1016/j.jocn.2014.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 01/28/2014] [Indexed: 01/05/2023]
Abstract
Multiple sclerosis (MS) is a potentially life-changing immune mediated disease of the central nervous system. Until recently, treatment has been largely confined to acute treatment of relapses, symptomatic therapies and rehabilitation. Through persistent efforts of dedicated physicians and scientists around the globe for 160 years, a number of therapies that have an impact on the long term outcome of the disease have emerged over the past 20 years. In this three part series we review the practicalities, benefits and potential hazards of each of the currently available and emerging treatment options for MS. We pay particular attention to ways of abrogating the risks of these therapies and provide advice on the most appropriate indications for using individual therapies. In Part 1 we review the history of the development of MS therapies and its connection with the underlying immunobiology of the disease. The established therapies for MS are reviewed in detail and their current availability and indications in Australia and New Zealand are summarised. We examine the evidence to support their use in the treatment of MS.
Collapse
Affiliation(s)
- Simon A Broadley
- School of Medicine, Griffith University, Gold Coast Campus, QLD 4222, Australia; Department of Neurology, Gold Coast University Hospital, Southport, QLD, Australia.
| | - Michael H Barnett
- Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia
| | - Mike Boggild
- Department of Neurology, The Townsville Hospital, Douglas, QLD, Australia
| | - Bruce J Brew
- Department of Neurology and St Vincent's Centre for Applied Medical Research, St Vincent's Hospital, University of New South Wales, Darlinghurst, NSW, Australia
| | - Helmut Butzkueven
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Robert Heard
- Westmead Clinical School, University of Sydney, NSW, Australia
| | - Suzanne Hodgkinson
- South Western Sydney Clinical School, University of New South Wales, NSW, Australia
| | - Allan G Kermode
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, WA, Australia; Institute of Immunology and Infectious Diseases, Murdoch University, WA, Australia
| | | | | | - Mark Marriott
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Deborah F Mason
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - John Parratt
- Central Clinical School, University of Sydney, NSW, Australia
| | - Stephen W Reddel
- Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia
| | | | - Mark Slee
- Centre for Neuroscience and Flinders Medical Centre, Flinders University, SA, Australia
| | - Judith Spies
- Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia
| | - Bruce V Taylor
- Menzies Research Institute, University of Tasmania, TAS, Australia
| | - William M Carroll
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, WA, Australia
| | | | - John King
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Pamela A McCombe
- University of Queensland Centre for Clinical Research, QLD, Australia
| | - John D Pollard
- Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia
| | - Ernest Willoughby
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
7
|
Cocco E, Marrosu MG. The current role of mitoxantrone in the treatment of multiple sclerosis. Expert Rev Neurother 2014; 14:607-16. [PMID: 24834466 DOI: 10.1586/14737175.2014.915742] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Mitoxantrone is an immunosuppressive drug approved for aggressive relapsing and progressive multiple sclerosis. In recent years, its use has decreased due to the risk of severe adverse events and the introduction of novel therapies, such as natalizumab or fingolimod. Mitoxantrone is effective in reducing inflammatory activity by decreasing the number of relapses and MRI lesions and simultaneously decreasing the worsening of disability. Apart from its role as a second/third-line therapy, some studies suggest its use as an induction therapy. However, mitoxantrone use is limited because of its potential risk of severe adverse events, such as cardiotoxicity and the induction of therapy-related acute leukemia. Genetic markers are on evaluation to predict side effects and therapeutic efficacy, which is consistent with the direction of personalized treatment. Considering its efficacy and the potential risks, mitoxantrone use is limited to active patients after a careful, individualized evaluation of the risk/benefit balance.
Collapse
Affiliation(s)
- Eleonora Cocco
- Multiple Sclerosis Center, Department of Public Health, Clinical and molecular medicine, University of Cagliari, Cagliari, Italy
| | | |
Collapse
|
8
|
Salmen A, Gold R, Chan A. Management of disease-modifying treatments in neurological autoimmune diseases of the central nervous system. Clin Exp Immunol 2014; 176:135-48. [PMID: 24358961 PMCID: PMC3992026 DOI: 10.1111/cei.12258] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2013] [Indexed: 12/19/2022] Open
Abstract
The therapeutic armamentarium for autoimmune diseases of the central nervous system, specifically multiple sclerosis and neuromyelitis optica, is steadily increasing, with a large spectrum of immunomodulatory and immunosuppressive agents targeting different mechanisms of the immune system. However, increasingly efficacious treatment options also entail higher potential for severe adverse drug reactions. Especially in cases failing first-line treatment, thorough evaluation of the risk-benefit profile of treatment alternatives is necessary. This argues for the need of algorithms to identify patients more likely to benefit from a specific treatment. Moreover, paradigms to stratify the risk for severe adverse drug reactions need to be established. In addition to clinical/paraclinical measures, biomarkers may aid in individualized risk-benefit assessment. A recent example is the routine testing for anti-John Cunningham virus antibodies in natalizumab-treated multiple sclerosis patients to assess the risk for the development of progressive multi-focal leucoencephalopathy. Refined algorithms for individualized risk assessment may also facilitate early initiation of induction treatment schemes in patient groups with high disease activity rather than classical escalation concepts. In this review, we will discuss approaches for individiualized risk-benefit assessment both for newly introduced agents as well as medications with established side-effect profiles. In addition to clinical parameters, we will also focus on biomarkers that may assist in patient selection.
Collapse
Affiliation(s)
- A Salmen
- Department of Neurology, St Josef-Hospital, Ruhr-University, Bochum, Germany
| | | | | |
Collapse
|
9
|
Rommer PS, Zettl UK, Kieseier B, Hartung HP, Menge T, Frohman E, Greenberg BM, Hemmer B, Stüve O. Requirement for safety monitoring for approved multiple sclerosis therapies: an overview. Clin Exp Immunol 2014; 175:397-407. [PMID: 24102425 DOI: 10.1111/cei.12206] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2013] [Indexed: 12/12/2022] Open
Abstract
During the last two decades, treatment options for patients with multiple sclerosis (MS) have broadened tremendously. All agents that are currently approved for clinical use have potential side effects, and a careful risk-benefit evaluation is part of a decision algorithm to identify the optimal treatment choice for an individual patient. Whereas glatiramer acetate and interferon beta preparations have been used in MS for decades and have a proven safety record, more recently approved drugs appear to be more effective, but potential risks might be more severe. The potential complications of some novel therapies might not even have been identified to their full extent. This review is aimed at the clinical neurologist in that it offers insights into potential adverse events of each of the approved MS therapeutics: interferon beta, glatiramer acetate, mitoxantrone, natalizumab, fingolimod and teriflunomide, as well as recently approved therapeutics such as dimethyl fumarate and alemtuzumab. It also provides recommendations for monitoring the different drugs during therapy in order to avoid common side effects.
Collapse
Affiliation(s)
- P S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Podlecka-Piętowska A, Kochanowski J, Zakrzewska-Pniewska B, Opolski G, Kwieciński H, Kamińska AM. The N-terminal pro-brain natriuretic peptide as a marker of mitoxantrone-induced cardiotoxicity in multiple sclerosis patients. Neurol Neurochir Pol 2014; 48:111-5. [DOI: 10.1016/j.pjnns.2013.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 12/06/2013] [Indexed: 12/01/2022]
|
11
|
Ferrero S, Esposito F, Pretta S, Ragni N. Fetal risks related to the treatment of multiple sclerosis during pregnancy and breastfeeding. Expert Rev Neurother 2014; 6:1823-31. [PMID: 17181429 DOI: 10.1586/14737175.6.12.1823] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In women with multiple sclerosis, pregnancy does not have a long-term adverse effect on lifetime disability; however, there is an increased risk of relapses during the postpartum. Therapies taken during pregnancy may have adverse effects on pregnancy outcome. The small number of pregnancies included in most studies, particularly those evaluating the risks related to the administration of immunomodulating drugs, do not allow firm conclusions to be drawn with regards to their safety. Therefore, until more information regarding safety is available, glatiramer acetate, mitoxantrone and interferon-beta should be discontinued before an anticipated pregnancy. By contrast, glucocorticoids can be used to treat acute relapses during pregnancy.
Collapse
Affiliation(s)
- Simone Ferrero
- Department of Obstetrics and Gynaecology, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy.
| | | | | | | |
Collapse
|
12
|
Assessing risks of multiple sclerosis therapies. J Neurol Sci 2013; 332:59-65. [DOI: 10.1016/j.jns.2013.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 05/21/2013] [Accepted: 06/12/2013] [Indexed: 11/24/2022]
|
13
|
Rivera VM, Jeffery DR, Weinstock-Guttman B, Bock D, Dangond F. Results from the 5-year, phase IV RENEW (Registry to Evaluate Novantrone Effects in Worsening Multiple Sclerosis) study. BMC Neurol 2013; 13:80. [PMID: 23841877 PMCID: PMC3710498 DOI: 10.1186/1471-2377-13-80] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 07/01/2013] [Indexed: 12/22/2022] Open
Abstract
Background Registry to Evaluate Novantrone Effects in Worsening Multiple Sclerosis (RENEW) was a 5-year, phase IV study in which the safety of Mitoxantrone was monitored in a patient cohort from the United States (US). The objective of the study was to evaluate the long-term safety profile of Mitoxantrone in patients with secondary progressive multiple sclerosis (SPMS), progressive relapsing multiple sclerosis (PRMS), and worsening relapsing-remitting multiple sclerosis (RRMS). Methods Overall, 509 patients (395 SPMS, 81 worsening RRMS, 33 PRMS) were enrolled and treated at 46 multiple sclerosis (MS) treatment centers located in the US. Patients received Mitoxantrone in accordance with the package insert every 3 months. During the treatment phase, patients received laboratory workups and cardiac monitoring every 3 months and then annually for a total of 5 years. Results Five hundred and nine subjects were enrolled in this trial and received at least one infusion of Mitoxantrone. Overall, 172 (33.8%) completed the 5-year trial (i.e., participated for 5 years ± 3 months [treatment + follow-up]); 337 (66.2%) did not complete the 5-year trial. Annual follow-up data were available for 250 of 509 enrolled patients. Left ventricular ejection fraction reduction under 50% was reported in 27 (5.3%) patients during the treatment phase (n = 509) and 14 (5.6%) patients during the annual follow-up phase (n = 250). Signs and symptoms of congestive heart failure were observed in 10 (2.0%) patients (six during treatment phase and four during the annual follow-up phase). Post-hoc analyses of the risk for cardiotoxicity outcomes revealed that cumulative dose exposure is the primary risk factor associated with the risk of cardiac toxicity with Mitoxantrone. Therapy-related leukemia was reported in three (0.6%) patients who received total cumulative Mitoxantrone doses of 73.5 mg/m2, 107.3 mg/m2, and 97.1 mg/m2 respectively. During the treatment phase, persistent amenorrhea developed in 22% (28/128) of women with regular menses and 51% (25/49) of women with irregular menses at baseline. During the annual follow-up phase, persistent amenorrhea developed in 5% (4/73) of women with regular menses at baseline. Conclusion RENEW results are consistent with the known safety profile of Mitoxantrone, and provide additional long-term safety data for Mitoxantrone in MS patients.
Collapse
|
14
|
Abstract
BACKGROUND This is an updated Cochrane review of the previous published version.Mitoxantrone (MX) has been shown to be moderately effective in reducing the clinical outcome measures of disease activity in multiple sclerosis (MS) patients. OBJECTIVES The main objective was to assess the efficacy and safety of MX compared to a control group in relapsing-remitting (RRMS), progressive relapsing (PRMS) and secondary progressive (SPMS) MS participants. SEARCH METHODS We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register (June 2012) and reference lists of articles. We also undertook handsearching and contacted trialists and pharmaceutical companies. SELECTION CRITERIA Randomised, double-blinded, controlled trials (RCTs) comparing the administration of MX versus placebo or MX plus steroids treatment versus placebo plus steroids treatment were included. DATA COLLECTION AND ANALYSIS The review authors independently selected articles for inclusion. They independently extracted clinical, safety and magnetic resonance imaging (MRI) data, resolving disagreements by discussion. Risk of bias was evaluated to assess the quality of the studies. Treatment effect was measured using odds ratios (OR) with 95% confidence intervals (CI) for the binary outcomes and mean differences (MD) with 95% CI for the continuous outcomes. If heterogeneity was absent, a fixed-effect model was used. MAIN RESULTS Three trials were selected and 221 participants were included in the analyses. MX reduced the progression of disability at two years follow-up (proportion of participants with six months confirmed progression of disability (OR 0.30, 95% CI 0.09 to 0.99 and MD -0.36, 95% CI- 0.70 to -0.02; P = 0.04)). Significant results were found regarding the reduction in annualised relapse rate (MD -0.85, 95% CI -1.47 to -0.23; P = 0.007), the proportion of patients free from relapses at one year (OR 7.13, 95% CI 2.06 to 24.61; P = 0.002) and two years (OR 2.82, 95% CI 1.54 to 5.19; P = 0.0008), and the number of patients with active MRI lesions at six months or one year only (OR 0.24, 95% CI 0.10 to 0.57; P = 0.001). Side effects reported in the trials (amenorrhoea, nausea and vomiting, alopecia and urinary tract infections) were more frequent in treated patients than in controls, while no major adverse events have been reported. These results should be considered with caution because of the heterogeneous characteristics of included trials in term of drug dosage, inclusion criteria and quality of included trials. Moreover, it was not possible to estimate the long-term efficacy and safety of MX. AUTHORS' CONCLUSIONS MX shows a significant but partial efficacy in reducing the risk of MS progression and the frequency of relapses in patients affected by worsening RRMS, PRMS and SPMS in the short-term follow-up (two years). No major neoplastic events or symptomatic cardiotoxicity related to MX have been reported; however studies with longer follow-up (not included in this review) have raised concerns about the risk of systolic disfunction (˜12%) and therapy-related acute leukaemias (0.8%), which are increasingly reported in the literature.MX should be limited to treating patients with worsening RRMS and SPMS and with evidence of persistent inflammatory activity after a careful assessment of the individual patients' risk and benefit profiles. Assessment should also consider the present availability of alternative therapies with less severe adverse events.
Collapse
|
15
|
Mähler A, Mandel S, Lorenz M, Ruegg U, Wanker EE, Boschmann M, Paul F. Epigallocatechin-3-gallate: a useful, effective and safe clinical approach for targeted prevention and individualised treatment of neurological diseases? EPMA J 2013; 4:5. [PMID: 23418936 PMCID: PMC3585739 DOI: 10.1186/1878-5085-4-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 01/25/2013] [Indexed: 12/12/2022]
Abstract
Neurodegenerative disorders show an increasing prevalence in a number of highly developed countries. Often, these diseases require life-long treatment mostly with drugs which are costly and mostly accompanied by more or less serious side-effects. Their heterogeneous manifestation, severity and outcome pose the need for individualised treatment options. There is an intensive search for new strategies not only for treating but also for preventing these diseases. Green tea and green tea extracts seem to be such a promising and safe alternative. However, data regarding the beneficial effects and possible underlying mechanism, specifically in clinical trials, are rare and rather controversial or non-conclusive. This review outlines the existing evidence from preclinical studies (cell and tissue cultures and animal models) and clinical trials regarding preventive and therapeutic effects of epigallcatechin-3-gallate in neurodegenerative diseases and considers antioxidative vs. pro-oxidative properties of the tea catechin important for dosage recommendations.
Collapse
Affiliation(s)
- Anja Mähler
- Experimental and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and Max Delbrueck Center for Molecular Medicine, Berlin, D-13125, Germany.
| | | | | | | | | | | | | |
Collapse
|
16
|
Repeated intrathecal triamcinolone acetonide administration in progressive multiple sclerosis: a review. Mult Scler Int 2011; 2011:219049. [PMID: 22096630 PMCID: PMC3196978 DOI: 10.1155/2011/219049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 03/09/2011] [Accepted: 04/27/2011] [Indexed: 11/18/2022] Open
Abstract
At the present time, anti-inflammatory, immunomodulatory, or immunosuppressive treatments of multiple sclerosis (MS) are mainly effective in the early phases of the disease but are of less advantage in progressive phases. Current therapeutic strategies of both primary and secondary progressive MS are rare. One alternative may be intrathecal application of triamcinolone acetonide (TCA). Number of papers deal with advantages and disadvantages of intrathecal administration in MS. Former trials lacked detailed selection of MS patients, with small sample sizes, low steroid dosages, and only a small number of intrathecal administration of short acting steroids. The present paper summarizes recent trials performed following a different treatment regime. They were conducted in patients with progressive MS suffering mainly from spinal symptoms and documented a significant improvement of EDSS and walking distance (WD). Intrathecal TCA administration is a proposal to take into account as one therapy option in patients with a progressive clinical course and predominantly spinal symptoms.
Collapse
|
17
|
Le Page E, Leray E, Edan G. Long-term safety profile of mitoxantrone in a French cohort of 802 multiple sclerosis patients: a 5-year prospective study. Mult Scler 2011; 17:867-75. [DOI: 10.1177/1352458511398371] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: From 2001, a French multicentre study was conducted prospectively in a large cohort of MS patients and annually updated up to at least 5 years after initiation of MITOX therapy. Objective: To determine long-term safety profile of mitoxantrone (MITOX) in multiple sclerosis (MS). Methods: Eight hundred and two patients from 12 MS centres (308 relapsing–remitting, 352 secondary progressive and 142 primary progressive) received MITOX monthly for 6 months (87%) or every 3 months (13%). Patients underwent clinical and haematologic evaluations before every MITOX infusion and every 6–12 months up to 5 years after MITOX start. Echocardiograms were performed at the start and end of MITOX and up to 5 years after. Results: The cohort was followed for 5354 patient-years (mean). One out of 802 patients (0.1%) presented with acute congestive heart failure and 39 out of 794 patients (4.9%) presented with asymptomatic left ventricular ejection fraction reduction under 50% (persistent in 11 patients (28%), transient in 27 patients (69%), on the last scan at year 5 in 1 patient). Two cases of therapy-related leukaemia (0.25%) were detected 20 months after MITOX start (one death and one with 8 years confirmed remission). Of the 317 women treated before the age of 45, 17.3% developed a persistent age-dependant amenorrhea. Conclusion: This large cohort with at least 5 years of follow-up provided good insights into the long-term safety profile of MITOX in MS.
Collapse
Affiliation(s)
- E Le Page
- CHU Pontchaillou, service de Neurologie, Rennes, France
- INSERM, CIC 0203, Hôpital Pontchaillou, Rennes, France
- UEB, Université de Rennes 1, Faculté de médecine, Rennes, France
| | - E Leray
- CHU Pontchaillou, service de Neurologie, Rennes, France
- INSERM, CIC 0203, Hôpital Pontchaillou, Rennes, France
- UEB, Université de Rennes 1, Faculté de médecine, Rennes, France
| | - G Edan
- CHU Pontchaillou, service de Neurologie, Rennes, France
- INSERM, CIC 0203, Hôpital Pontchaillou, Rennes, France
- UEB, Université de Rennes 1, Faculté de médecine, Rennes, France
| | | |
Collapse
|
18
|
Mitoxantrone for worsening multiple sclerosis: Tolerability, toxicity, adherence and efficacy in the clinical setting. Clin Neurol Neurosurg 2010; 112:876-82. [DOI: 10.1016/j.clineuro.2010.07.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2009] [Revised: 06/28/2010] [Accepted: 07/19/2010] [Indexed: 11/21/2022]
|
19
|
Marriott JJ, Miyasaki JM, Gronseth G, O'Connor PW. Evidence Report: The efficacy and safety of mitoxantrone (Novantrone) in the treatment of multiple sclerosis: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2010; 74:1463-70. [PMID: 20439849 DOI: 10.1212/wnl.0b013e3181dc1ae0] [Citation(s) in RCA: 185] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The chemotherapeutic agent mitoxantrone was approved for use in multiple sclerosis (MS) in 2000. After a review of all the available evidence, the original report of the Therapeutics and Technology Assessment Subcommittee in 2003 concluded that mitoxantrone probably reduced clinical attack rates, MRI activity, and disease progression. Subsequent reports of decreased systolic function, heart failure, and leukemia prompted the US Food and Drug Administration to institute a "black box" warning in 2005. This review was undertaken to examine the available literature on the efficacy and safety of mitoxantrone use in patients with MS since the initial report. METHODS Relevant articles were obtained through a review of the medical literature and the strength of the available evidence was graded according to the American Academy of Neurology evidence classification scheme. RESULTS The accumulated Class III and IV evidence suggests an increased incidence of systolic dysfunction and therapy-related acute leukemia (TRAL) with mitoxantrone therapy. Systolic dysfunction occurs in approximately 12% of patients with MS treated with mitoxantrone, congestive heart failure occurs in approximately 0.4%, and leukemia occurs in approximately 0.8%. The number needed to harm is 8 for systolic dysfunction and 123 for TRAL. There is no new efficacy evidence that would change the recommendation from the previous report. CONCLUSIONS The risk of systolic dysfunction and leukemia in patients treated with mitoxantrone is higher than suggested at the time of the previous report, although comprehensive postmarketing surveillance data are lacking.
Collapse
Affiliation(s)
- James J Marriott
- The Multiple Sclerosis Clinic, St. Michael's Hospital, Division of Neurology, University of Toronto, Canada
| | | | | | | | | |
Collapse
|
20
|
Killestein J, van der Meer ML, Regelink JC, Huijgens PC, Polman CH. SEVERE CARDIAC FAILURE IN A PATIENT WITH MULTIPLE SCLEROSIS FOLLOWING LOW-DOSE MITOXANTRONE TREATMENT. Neurology 2010; 74:934; author reply 934. [DOI: 10.1212/wnl.0b013e3181d2b7de] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
21
|
Kuntz NL, Chabas D, Weinstock-Guttman B, Chitnis T, Yeh EA, Krupp L, Ness J, Rodriguez M, Waubant E. Treatment of multiple sclerosis in children and adolescents. Expert Opin Pharmacother 2010; 11:505-20. [DOI: 10.1517/14656560903527218] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
22
|
Müller T. Role of intraspinal steroid application in patients with multiple sclerosis. Expert Rev Neurother 2009; 9:1279-87. [PMID: 19769444 DOI: 10.1586/ern.09.60] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Clinical trials on patients with progressive multiple sclerosis (MS) have shown no clear evidence of an effective symptomatic treatment with improving disability. Immunomodulatory compounds efficaciously reduce the relapse rate. Numerous earlier papers exist on the pros and cons and/or on the efficacy of intrathecal administration of differing dosages of various conventional released steroids. Furthermore, this treatment approach was nearly abondoned owing to a debate on side effects and a missing proven superiority over intravenous systemic high dosage steroid administration. However, recent open-label studies in progressive MS patients with predominant spinal symptomatology investigated the repeated intraspinal application of the sustained-release compound triamcinolone acetonide (TCA). A distinct improvement of walking distance and MS scores in the short term and stabilization of this beneficial effect after repeat TCA application every 6-12 weeks was found. Moreover, patients with a relapse with acute onset of painful sensations showed a marked pain improvement after repeated TCA application following prior unsuccessful treatment with intravenous steroids. The available data from open studies ask for the performance of a randomized clinical trial, comparing intravenous with intrathecal steroid administration, to confirm the higher efficacy of the more invasive therapy with repeated lumbar puncture.
Collapse
Affiliation(s)
- Thomas Müller
- Department of Neurology, St Joseph Hospital, Berlin-Weissensee, Gartenstrasse 1, 13088 Berlin, Germany.
| |
Collapse
|
23
|
Luchowski P, Mitosek-Szewczyk K, Bartosik-Psujek H, Rubaj A, Jankiewicz M, Wojczal J, Szczepańska-Szerej A, Stelmasiak Z. B-type natriuretic peptide as a marker of subclinical heart injury during mitoxantrone therapy in MS patients--preliminary study. Clin Neurol Neurosurg 2009; 111:676-8. [PMID: 19632767 DOI: 10.1016/j.clineuro.2009.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 06/15/2009] [Accepted: 06/19/2009] [Indexed: 11/18/2022]
Abstract
The aim of this study was to evaluate the plasma level changes of B-type natriuretic peptide (BNP), biochemical marker of heart failure, and echocardiographic parameters during mitoxantrone treatment in 22 multiple sclerosis (MS) patients (8 males, 14 females, mean age 37.1+/-6.6). Mitoxantrone (after mean cumulative dose of 58.0+/-7.0 mg/m(2)) did not alter left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), posterior wall thickness (PWT) and left ventricular end-diastolic volume (LVEDV). However, mean plasma level of BNP raised from 14.53+/-3.29 pg/ml at the baseline to 16.79+/-3.05 pg/ml and 18.83+/-4.90 pg/ml (P<0.01) after mean mitoxantrone dose of 30.7+/-5.9 mg/m(2) and 58.0+/-7.0 mg/m(2), respectively. These results strongly suggest subclinical myocardial dysfunction in mitoxantrone-treated group. We assume, that low-cost, repeated BNP measurements may be a good alternative for detection of early subtle myocardial injury in MS patients during routine mitoxantrone therapy.
Collapse
Affiliation(s)
- Piotr Luchowski
- Department of Neurology, Medical University, Jaczewskiego 8, 20-950 Lublin, Poland.
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Chan A, Stüve O, von Ahsen N. Immunosuppression in clinical practice: approaches to individualized therapy. J Neurol 2009; 255 Suppl 6:22-7. [PMID: 19300956 DOI: 10.1007/s00415-008-6005-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite novel immunoactive agents, immunosuppressants still play a considerable role in the treatment of MS, especially in rapidly progressive cases. Given the limited tolerability and potentially severe side effects of most immunosuppressive drugs, identification of patients with a favorable benefit-risk profile is essential. A narrow therapeutic index, with sometimes high interindividual variability in terms of response and side effects may partially be explained by genetic factors affecting different metabolic pathways. Here, we will review practical aspects in the clinical use of immunosuppressants in MS and discuss approaches to individualized treatment schemes, including novel pharmacogenetic strategies.
Collapse
Affiliation(s)
- Andrew Chan
- Department of Neurology, Ruhr University Bochum, St. Josef Hospital, Gudrunstr. 56, 44791 Bochum, Germany.
| | | | | |
Collapse
|
25
|
Chan JS, Beer TM, Quinn DI, Pinski JK, Garzotto M, Sokoloff M, Dehaze DR, Ryan CW. A phase II study of high-dose calcitriol combined with mitoxantrone and prednisone for androgen-independent prostate cancer. BJU Int 2008; 102:1601-6. [PMID: 18782306 DOI: 10.1111/j.1464-410x.2008.08017.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the preliminary efficacy, safety, and impact on quality of life (QoL) of high-dose calcitriol (DN-101) combined with mitoxantrone and glucocorticoids in androgen-independent prostate cancer (AIPC). PATIENTS AND METHODS Nineteen patients with metastatic AIPC and no previous chemotherapy received DN-101 180 microg orally on day 1 and mitoxantrone 12 mg/m(2) intravenously on day 2 every 21 days with continuous daily prednisone 10 mg orally for a maximum of 12 cycles. A confirmed decline in prostate-specific antigen (PSA) levels by half was the primary endpoint. QoL was evaluated using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, and pain and analgesic use were evaluated. RESULTS Five of 19 patients (26%; 95% confidence interval, CI, 9-51) achieved a >/=50% decline in PSA level. The median (95% CI) time to PSA progression was 16 (6-26) weeks. The overall median (95% CI) survival was 16 (6-26) months; 47 (21-73)% of patients achieved an analgesic response. Toxicity was similar to that expected with mitoxantrone and prednisone alone. The QoL analysis suggested a decrease in physical functioning and increase in fatigue, insomnia, and diarrhoea. CONCLUSIONS DN-101 given every 3 weeks does not add significant activity to mitoxantrone and prednisone in AIPC, as measured by the PSA decline. The high rate of analgesic response is encouraging. The addition of DN-101 does not appear to increase the toxicity of mitoxantrone.
Collapse
Affiliation(s)
- Joseph S Chan
- Oregon Health & Science University, Portland, OR 97239, USA
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Gonsette RE. Compared benefit of approved and experimental immunosuppressive therapeutic approaches in multiple sclerosis. Expert Opin Pharmacother 2007; 8:1103-16. [PMID: 17516874 DOI: 10.1517/14656566.8.8.1103] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An important amount has been learnt about the mechanisms of action, efficacy and long-term toxicities of mitoxantrone. Importantly, recent observations strongly suggest that early administration of potent immunosuppressants (mitoxantrone and alemtuzumab) is definitely more effective than approved immunomodulators to delay or even reverse disability progression. Given the cardiotoxicity of mitoxantrone, restricting exposure to the drug to 2 or 3 years, the benefits and risks of immunosuppressants previously used as off-label treatments (cyclophosphamide and cladribine) have been revisited, and the potential efficacy in multiple sclerosis of recent immunosuppressants used in other autoimmune diseases, organ transplantation and cancer therapy has received increasing attention. Those immunosuppressants comprise monoclonal antibodies targeting B cells, lymphocytes and monocytes, IL-2 receptor and alpha4 integrin, as well as new molecules (pixantrone and isoxazole derivatives) and a new generation of immunosuppressants (fingolimod), which modulate lymphocyte re-circulation. This review addresses the most recent data concerning the efficacy and safety of mitoxantrone and of new experimental therapies that are presently in progress.
Collapse
|
27
|
Wiendl H, Kieseier BC, Weissert R, Mylius HA, Pichlmeier U, Hartung HP, Melms A, Kuker W, Weller M. Treatment of active secondary progressive multiple sclerosis with treosulfan. J Neurol 2007; 254:884-9. [PMID: 17446994 DOI: 10.1007/s00415-006-0459-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2006] [Revised: 10/05/2006] [Accepted: 10/24/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To study the safety and efficacy of treosulfan, a cytotoxic alkylating agent, in patients with active secondary progressive multiple sclerosis. BACKGROUND Treosulfan (L-threitol-1,4-bis(methanesulfonate)) is a bifunctional alkylating agent with a favorable profile of side effects, approved for the treatment of ovarian cancer. Treosulfan has previously been shown to reduce the severity of experimental allergic encephalomyelitis under pre-therapeutic and therapeutic conditions. In human peripheral blood mononuclear cells, treosulfan reduces proliferative capacity and increases apoptosis. STUDY DESIGN This is a nonrandomized, open label study conducted in two centers. Eleven patients with active secondary progressive MS that failed to or did not qualify for approved disease modifying drugs were treated with treosulfan for 1 year. Patients received intravenous infusions of 7 g/m(2) every 4 weeks for 3 months (cycles 1-4, induction phase) with a predefined one-step dose escalation, thereafter every 3 months for the following 9 months (cyles 5-7, maintainance phase). Cranial MRI was performed every 3 months, EDSS and MSFC as well as physical examination were assessed at each clinical visit. RESULTS Treatment with treosulfan was safe and well tolerated. Nine of 11 patients remained on study drug over the complete treatment period and showed clinical stabilisation or improvement as determined by EDSS and MSFC. Two patients discontinued study drug because of leukocytopenia and withdrawal of consent, respectively. No clinical relapses were observed during the treatment period. Thus, the median number of relapses per year was reduced signifi- cantly by 1.5 (range -3 to 0), p < 0.016, compared to prestudy. Therapy with treosulfan lead to a clear reduction of MRI activity as revealed by a reduced number of Gd + enhancing lesions on T1 weighted images. The mean number and volume of T2 lesions remained unchanged over 1 year. Four out of 9 patients under treosulfan showed no detectable disease activity (no Gd enhancing lesions, no new or newly enlarging T2 lesions). CONCLUSIONS Application of treosulfan in MS was safe and well tolerated. Further studies are warranted to evaluate the efficacy of this treatment in secondary progressive MS.
Collapse
Affiliation(s)
- Heinz Wiendl
- Department of Neurology, University of Wuerzburg, Josef-Schneider-Str. 11, D-97080 Wuerzburg, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Hellwig K, Schimrigk S, Lukas C, Hoffmann V, Brune N, Przuntek H, Müller T. Efficacy of mitoxantrone and intrathecal triamcinolone acetonide treatment in chronic progressive multiple sclerosis patients. Clin Neuropharmacol 2006; 29:286-91. [PMID: 16960474 DOI: 10.1097/01.wnf.0000229545.81245.a4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Treatment approaches are rare for chronic progressive patients with multiple sclerosis (MS). Objective was to evaluate the clinical benefit of repeated intrathecal application of the sustained release steroid triamcinolone acetonide or the administration of mitoxantrone (MIX) in 2 similar cohorts of chronic progressive patients with MS in an open-label fashion. Expanded Disability Status Scale scores significantly decreased after the first 6 intraspinal triamcinolone acetonide injections, which were performed every third day, and then remained stable. Walking distance significantly increased and did not reduce until the end of the 1-year-long trial period. Mitoxantrone treatment did not improve the Expanded Disability Status Scale score; however, no further significant deterioration appeared. Walking distance did not significantly decrease. Both treatment regimens were safe; the patients experienced nearly no adverse effects. Triamcinolone acetonide application provided a clinical benefit, whereas MIX administration prevented further worsening of MS symptoms. We stress that only specialists with a broad experience in intraspinal triamcinolone acetonide application and MIX administration should perform both kinds of therapy only after a careful information and risk-benefit evaluation in cooperation with the patient. Future trials will show the efficacy of combination of both treatment approaches in chronic progressive patients with MS.
Collapse
Affiliation(s)
- Kerstin Hellwig
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
| | | | | | | | | | | | | |
Collapse
|
29
|
Perini P, Calabrese M, Tiberio M, Ranzato F, Battistin L, Gallo P. Mitoxantrone versus cyclophosphamide in secondary-progressive multiple sclerosis: a comparative study. J Neurol 2006; 253:1034-40. [PMID: 16609811 DOI: 10.1007/s00415-006-0154-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Accepted: 01/24/2006] [Indexed: 10/24/2022]
Abstract
Fifty secondary progressive multiple sclerosis (SPMS) patients who had lost one or more EDSS points in the prior two years were selected to receive either cyclophosphamide (25 patients, 13 females, 12 males, F/M = 1.08; mean age: 42.4 years; mean disease duration: 13.3 years; mean EDSS at study entry: 5.7) or mitoxantrone (25 patients, 14 females, 11 males, F/M = 1.27; mean age: 38.2 years; mean disease duration: 11.5 years; mean EDSS at study entry: 5.5). SPMS patients were treated for two years with clinical evaluation (relapse rate, disability progression) every three months and radiological imaging (conventional magnetic resonance imaging) before therapy initiation and at the end of the first and second years of therapy. Safety profile and costs of the two therapeutic protocols were also analysed. In terms of clinical and radiological measures the drugs exerted a quite identical effect on both, and produced a significant reduction in both relapse rate (mitoxantrone Mito): p = 0.001, cyclophosphamide (Cy): p = 0.003) and disability progression (Mito: p = 0.01; Cy: p = 0.01). Subgroups of mitoxantrone- and cyclophosphamide-responding patients were identified (14/25 and 17/25, respectively) and were characterized by a significantly shorter duration of the secondary progressive phase of the disease. In these subgroups, the improvement in the EDSS score at the end of therapy was highly significant (p<0.0001 for Mito, p = 0.0004 for Cy). The safety profiles of both drugs were acceptable; however, the Cy-based therapy protocol was significantly less expensive. We conclude that Cy should be considered as a therapeutic option in rapidly deteriorating SPMS patients.
Collapse
Affiliation(s)
- Paola Perini
- Multiple Sclerosis Centre of Veneto Region First Neurology Clinic, University Hospital of Padova, Via Giustiniani 5, 35128 Padova, Italy
| | | | | | | | | | | |
Collapse
|
30
|
Abstract
BACKGROUND Mitoxantrone (MX) has been shown to be moderately effective in reducing the clinical outcome measures of disease activity in multiple sclerosis (MS) patients. OBJECTIVES The objective was to assess the efficacy and safety of MX in relapsing-remitting MS (RRMS), progressive relapsing MS (PRMS) and secondary progressive MS (SPMS). SEARCH STRATEGY We searched the Cochrane MS Group Trials Register (searched April 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2004), MEDLINE (Pub Med) (January 1966 to April 2005), EMBASE (January 1974 to April 2005), and reference lists of articles. We also undertook hand searching and contacting trialists and pharmaceutical companies. SELECTION CRITERIA The trials were selected if double-blinded, placebo-controlled, randomised, irrespective of eventual additive therapy (such as steroids). DATA COLLECTION AND ANALYSIS Three reviewers independently selected articles for inclusion, assessed trials' quality and extracted data. MAIN RESULTS Four trials involving 270 participants were included. MX was found to reduce the progression of disability at 2 years follow-up (proportion of participants with 6-months confirmed progression of disability: Odds Ratios (OR) 0.3, p = 0.05). Similar figures were found regarding the reduction in annualised relapse rate and the proportion of patients free from relapses at 1 and 2 years, as well as the number of patients with active MRI lesions at 6 months/ 1 year only. Side effects reported in the trials were more frequent in treated patients than in controls. Caution must be exercised in drawing conclusions from such data because of the heterogeneous quality and characteristics of the included trials, which are different in terms of treatment schedule and type of enrolled patients. More than half of the included patients came from a single study. Moreover, from the included trials, it was not possible to estimate the long-term efficacy and safety of MX, which may raise concerns about the risk of cardiotoxicity and therapy-related leukemias, which is increasingly reported in the literature. AUTHORS' CONCLUSIONS MX is moderately effective in reducing the disease progression and the frequency of relapses in patients affected by RR, PR and SP MS in the short-term follow-up (2 years), even if the results are based on trials heterogeneous in terms of drug dosage and inclusion criteria. No major neoplastic or symptomatic cardiotoxicity related to MX have been reported from the trials. However, longer follow-up studies are highly warranted to better explore the efficacy and safety of the drug, mainly as regards the long-term risk of therapy-related leukemias and cardiotoxicity. As a conclusion, MX has a partial efficacy, but, due to its unclear long-term safety profile, it should be used to treat patients with worsening RR and SP MS with evidence of worsening disability.
Collapse
Affiliation(s)
- F Martinelli Boneschi
- Scientific Institute Ospedale San Raffaele, Nerological Department, Via Olgettina, 48, Milano, Italy 20132.
| | | | | | | |
Collapse
|
31
|
Neuhaus O, Kieseier BC, Hartung HP. Therapeutic role of mitoxantrone in multiple sclerosis. Pharmacol Ther 2005; 109:198-209. [PMID: 16095713 DOI: 10.1016/j.pharmthera.2005.07.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Accepted: 07/07/2005] [Indexed: 11/26/2022]
Abstract
Mitoxantrone is approved by several health authorities for treatment of active forms of relapsing-remitting or secondary progressive multiple sclerosis (SPMS). This review provides an outline on relevant preclinical as well as clinical studies, places mitoxantrone in the context of other therapeutic approaches against multiple sclerosis (MS), and discusses relevant side effects. The current knowledge of the putative mechanisms of action of the compound is discussed.
Collapse
Affiliation(s)
- Oliver Neuhaus
- Department of Neurology, Heinrich Heine University, Moorenstrasse 5, D-40225 Düsseldorf, Germany.
| | | | | |
Collapse
|