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Lal AP, Foong YC, Sanfilippo PG, Spelman T, Rath L, Levitz D, Fabis-Pedrini M, Foschi M, Habek M, Kalincik T, Roos I, Lechner-Scott J, John N, Soysal A, D'Amico E, Gouider R, Mrabet S, Gross-Paju K, Cárdenas-Robledo S, Moghadasi AN, Sa MJ, Gray O, Oh J, Reddel S, Ramanathan S, Al-Harbi T, Altintas A, Hardy TA, Ozakbas S, Alroughani R, Kermode AG, Surcinelli A, Laureys G, Eichau S, Prat A, Girard M, Duquette P, Hodgkinson S, Ramo-Tello C, Maimone D, McCombe P, Spitaleri D, Sanchez-Menoyo JL, Yetkin MF, Baghbanian SM, Karabudak R, Al-Asmi A, Jakob GB, Khoury SJ, Etemadifar M, van Pesch V, Buzzard K, Taylor B, Butzkueven H, Van der Walt A. A multi-centre longitudinal study analysing multiple sclerosis disease-modifying therapy prescribing patterns during the COVID-19 pandemic. J Neurol 2024; 271:5813-5824. [PMID: 38935148 PMCID: PMC11377668 DOI: 10.1007/s00415-024-12518-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The COVID-19 pandemic raised concern amongst clinicians that disease-modifying therapies (DMT), particularly anti-CD20 monoclonal antibodies (mAb) and fingolimod, could worsen COVID-19 in people with multiple sclerosis (pwMS). This study aimed to examine DMT prescribing trends pre- and post-pandemic onset. METHODS A multi-centre longitudinal study with 8,771 participants from MSBase was conducted. Two time periods were defined: pre-pandemic (March 11 2018-March 10 2020) and post-pandemic onset (March 11 2020-11 March 2022). The association between time and prescribing trends was analysed using multivariable mixed-effects logistic regression. DMT initiation refers to first initiation of any DMT, whilst DMT switches indicate changing regimen within 6 months of last use. RESULTS Post-pandemic onset, there was a significant increase in DMT initiation/switching to natalizumab and cladribine [(Natalizumab-initiation: OR 1.72, 95% CI 1.39-2.13; switching: OR 1.66, 95% CI 1.40-1.98), (Cladribine-initiation: OR 1.43, 95% CI 1.09-1.87; switching: OR 1.67, 95% CI 1.41-1.98)]. Anti-CD20mAb initiation/switching decreased in the year of the pandemic, but recovered in the second year, such that overall odds increased slightly post-pandemic (initiation: OR 1.26, 95% CI 1.06-1.49; Switching: OR 1.15, 95% CI 1.02-1.29. Initiation/switching of fingolimod, interferon-beta, and alemtuzumab significantly decreased [(Fingolimod-initiation: OR 0.55, 95% CI 0.41-0.73; switching: OR 0.49, 95% CI 0.41-0.58), (Interferon-gamma-initiation: OR 0.48, 95% CI 0.41-0.57; switching: OR 0.78, 95% CI 0.62-0.99), (Alemtuzumab-initiation: OR 0.27, 95% CI 0.15-0.48; switching: OR 0.27, 95% CI 0.17-0.44)]. CONCLUSIONS Post-pandemic onset, clinicians preferentially prescribed natalizumab and cladribine over anti-CD20 mAbs and fingolimod, likely to preserve efficacy but reduce perceived immunosuppressive risks. This could have implications for disease progression in pwMS. Our findings highlight the significance of equitable DMT access globally, and the importance of evidence-based decision-making in global health challenges.
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Affiliation(s)
- Anoushka P Lal
- Department of Neuroscience, Central Clinical School, The Alfred, Melbourne, VIC, Australia
- Department of Neurology, The Alfred Hospital, 55 Commercial Road, Melbourne, 3004, Australia
| | - Yi Chao Foong
- Department of Neuroscience, Central Clinical School, The Alfred, Melbourne, VIC, Australia
- Department of Neurology, The Alfred Hospital, 55 Commercial Road, Melbourne, 3004, Australia
- Royal Hobart Hospital, Hobart, Australia
| | - Paul G Sanfilippo
- Department of Neuroscience, Central Clinical School, The Alfred, Melbourne, VIC, Australia
| | - Tim Spelman
- Department of Neuroscience, Central Clinical School, The Alfred, Melbourne, VIC, Australia
| | - Louise Rath
- Department of Neuroscience, Central Clinical School, The Alfred, Melbourne, VIC, Australia
| | - David Levitz
- Department of Neuroscience, Central Clinical School, The Alfred, Melbourne, VIC, Australia
| | - Marzena Fabis-Pedrini
- Perron Institute for Neurological and Translational Science, The University of Western Australia, Perth, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Perth, Australia
| | - Matteo Foschi
- Department of Neuroscience, MS Center, Neurology Unit, S. Maria Delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L'Aquila, L'Aquila, Italy
| | - Mario Habek
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Tomas Kalincik
- Department of Neurology, Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Izanne Roos
- Department of Neurology, Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Australia
| | | | - Nevin John
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
- Department of Neurology, Monash Health, Clayton, Australia
| | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | - Emanuele D'Amico
- Medical and Surgical Sciences, Universita Di Foggia, Foggia, Italy
| | - Riadh Gouider
- Department of Neurology, LR 18SP03, Clinical Investigation Centre Neurosciences and Mental Health, Razi University Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Saloua Mrabet
- Department of Neurology, LR 18SP03, Clinical Investigation Centre Neurosciences and Mental Health, Razi University Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Katrin Gross-Paju
- Multiple Sclerosis Centre, West-Tallinn Central Hospital, Tallinn, Estonia
| | - Simón Cárdenas-Robledo
- Department of Neurology, Centro de Esclerosis Múltiple (CEMHUN), Hospital Universitario Nacional de Colombia Bogota, Bogota, Colombia
- Departamento de Medicina InternaFacultad de Medicina, Universidad Nacional de Colombia, Bogota, Colombia
| | - Abdorreza Naser Moghadasi
- Multiple Research Centre, Neuroscience Institute, Tehran University of Medical Science, Tehran, Iran
| | - Maria Jose Sa
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | - Orla Gray
- South Eastern HSC Trust, Belfast, UK
| | - Jiwon Oh
- St. Michael's Hospital, Toronto, Canada
| | - Stephen Reddel
- Department of Neurology, Concord Repatriation General Hospital, Sydney, Australia
| | - Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre and Brain and Mind Centre, Concord Hospital, Sydney, Australia
| | - Talal Al-Harbi
- Neurology Department, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Ayse Altintas
- Department of Neurology, School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), İstanbul, Turkey
| | - Todd A Hardy
- Department of Neurology, Concord Repatriation General Hospital, Sydney, Australia
| | - Serkan Ozakbas
- Izmir University of Economics, Medical Point Hospital, Izmir, Turkey
- Multiple Sclerosis Research Association, Izmir, Turkey
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Allan G Kermode
- Perron Institute for Neurological and Translational Science, The University of Western Australia, Perth, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Perth, Australia
| | - Andrea Surcinelli
- Department of Neuroscience, MS Center, Neurology Unit, S. Maria Delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Guy Laureys
- Department of Neurology, University Hospital Ghent, Ghent, Belgium
| | - Sara Eichau
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | | | - Marc Girard
- CHUM and Universite de Montreal, Montreal, Canada
| | | | - Suzanne Hodgkinson
- Immune Tolerance Laboratory Ingham Institute and Department of Medicine, UNSW, Sydney, Australia
| | | | - Davide Maimone
- Centro Sclerosi Multipla, UOC Neurologia, Azienda Ospedaliera Per L'Emergenza Cannizzaro, Catania, Italy
| | - Pamela McCombe
- University of Queensland, Brisbane, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Daniele Spitaleri
- Azienda Ospedaliera Di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy
| | - Jose Luis Sanchez-Menoyo
- Department of Neurology, Galdakao-Usansolo University Hospital, Osakidetza-Basque Health Service, Galdakao, Spain
| | | | - Seyed Mohammad Baghbanian
- Neurology Department, Booalisina Hospital, Mazandaran University of Medical Sciences, Sari, Iran
- Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Rana Karabudak
- Department of Neurological Sciences, Faculty of Medicine, Yeditepe University, Istanbul, Turkey
- Neuroimmunology Unit, Koşuyolu Hospitals, Istanbul, Turkey
| | - Abdullah Al-Asmi
- College of Medicine & Health Sciences and Sultan Qaboos University Hospital, Sultan Qaboos University, Al-Khodh, Oman
| | - Gregor Brecl Jakob
- Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Samia J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Masoud Etemadifar
- Neurology, Dr. Etemadifar MS Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vincent van Pesch
- Department of Neurology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | | | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, The Alfred, Melbourne, VIC, Australia
- Department of Neurology, The Alfred Hospital, 55 Commercial Road, Melbourne, 3004, Australia
| | - Anneke Van der Walt
- Department of Neuroscience, Central Clinical School, The Alfred, Melbourne, VIC, Australia.
- Department of Neurology, The Alfred Hospital, 55 Commercial Road, Melbourne, 3004, Australia.
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Carlini F, Lusi V, Rizzi C, Assogna F, Laroni A. Cladribine Tablets Mode of Action, Learning from the Pandemic: A Narrative Review. Neurol Ther 2023; 12:1477-1490. [PMID: 37421556 PMCID: PMC10444742 DOI: 10.1007/s40120-023-00520-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 06/16/2023] [Indexed: 07/10/2023] Open
Abstract
Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system, characterized by chronic, inflammatory, demyelinating, and neurodegenerative processes. MS management relies on disease-modifying drugs that suppress/modulate the immune system. Cladribine tablets (CladT) have been approved by different health authorities for patients with various forms of relapsing MS. The drug has been demonstrated to deplete CD4+ and CD8+ T-cells, with a higher effect described in the former, and to decrease total CD19+, CD20+, and naive B-cell counts. COVID-19 is expected to become endemic, suggesting its potential infection risk for immuno-compromised patients, including MS patients treated with disease-modifying drugs. We report here the available data on disease-modifying drug-treated-MS patients and COVID-19 infection and vaccination, with a focus on CladT. MS patients treated with CladT are not at higher risk of developing severe COVID-19. While anti-SARS-CoV-2 vaccination is recommended in all MS patients with guidelines addressing vaccination timing according to the different disease-modifying drugs, no vaccination timing restrictions seem to be necessary for cladribine, based on its mechanism of action and available evidence. Published data suggest that CladT treatment does not impact the production of anti-SARS-CoV-2 antibodies after COVID-19 vaccination, possibly due to its relative sparing effect on naïve B-cells and the rapid B-cell reconstitution following treatment. Slightly lower specific T-cell responses are likely not impacting the risk of breakthrough COVID-19. It could be stated that cladribine's transient effect on innate immune cells likely contributes to maintaining an adequate first line of defense against the SARS-CoV-2 virus.
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Affiliation(s)
- Federico Carlini
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genoa, Italy
| | - Valeria Lusi
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genoa, Italy
| | - Caterina Rizzi
- Merck Serono S.P.A., Italy an Affiliate of Merck KGaA, Piazza del Pigneto 9, Rome, Italy
| | - Francesco Assogna
- Merck Serono S.P.A., Italy an Affiliate of Merck KGaA, Piazza del Pigneto 9, Rome, Italy
| | - Alice Laroni
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genoa, Italy.
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, Genoa, Italy.
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Clavelou P, Castelnovo G, Pourcher V, De Sèze J, Vermersch P, Ben-Amor AF, Savarin C, Defer G. Expert Narrative Review of the Safety of Cladribine Tablets for the Management of Relapsing Multiple Sclerosis. Neurol Ther 2023; 12:1457-1476. [PMID: 37382841 PMCID: PMC10444734 DOI: 10.1007/s40120-023-00496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/11/2023] [Indexed: 06/30/2023] Open
Abstract
Cladribine tablets (CladT) is a highly active oral disease-modifying therapy (DMT) for the management of relapsing multiple sclerosis (RMS). CladT acts as an immune reconstitution therapy, in that two short courses of treatment 1 year apart have been shown to suppress disease activity for a prolonged period in most patients, without need for continued DMT. Each course of CladT induces a profound reduction in B lymphocytes that recovers over months, and serious lymphopenia (Grade 3-4) is uncommon. Smaller reductions in levels of T lymphocytes occur slightly later: on average, these remain within the normal range and repopulate progressively. A larger effect occurs on CD8 vs. CD4 cells. Reactivation of latent or opportunistic infections (e.g. varicella zoster, tuberculosis) is mostly associated with very low lymphocyte counts (< 200/mm3). Screening and managing pre-existing infections, vaccinating non-exposed patients and delaying the 2nd year of treatment with CladT to allow lymphocytes to recover to > 800/mm3 (if necessary) are important for avoiding infections and higher-grade lymphopenia. There was no demonstrable or apparent effect of CladT on the efficacy of vaccinations, including against Covid-19. Adverse events consistent with drug-induced liver injury (DILI) represent a rare but potentially serious complication of CladT therapy in spontaneous adverse event reporting; patients should be screened for liver dysfunction before starting treatment. Ongoing hepatic monitoring is not required, but CladT must be withdrawn if signs and symptoms of DILI develop. There was a numerical imbalance for malignancies when comparing cladribine to placebo in the clinical programme, particularly in short-term data, but recent evidence shows that the risk of malignancy with CladT is similar to the background rate in the general population and to that with other DMTs. Overall, CladT is well tolerated with a favorable safety profile appropriate for the management of RMS.
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Affiliation(s)
- Pierre Clavelou
- Department of Neurology, Clermont-Ferrand University Hospital, 58 Rue Montalembert, 63003, Clermont-Ferrand Cedex 1, France.
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Valérie Pourcher
- Department of Infectious and Tropical Diseases, Pitié-Salpêtrière Hospital, APHP, Sorbonne Université, INSERM 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique Paris, Paris, France
| | - Jerome De Sèze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Ali-Frederic Ben-Amor
- Global Medical Affairs Neurology and Immunology, Ares Trading SA (An affiliate of Merck KGaA, Darmstadt, Germany), Eysins, Switzerland
| | - Carine Savarin
- Neurology Department, Medical Affairs (An affiliate of Merck KGaA, Darmstadt, Germany), Merck Santé, Lyon, France
| | - Gilles Defer
- Department of Neurology, Caen University Hospital, Caen, France
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4
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Moiola L, Riva A, Nicoletti F, Uccelli A, Salvetti M, Battistini L, Furlan R. Vaccination Opportunities in Multiple Sclerosis Patients Treated with Cladribine Tablets. Curr Neuropharmacol 2022; 20:1811-1815. [PMID: 34923946 PMCID: PMC9886810 DOI: 10.2174/1570159x20666211217160451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/12/2021] [Accepted: 12/12/2021] [Indexed: 11/22/2022] Open
Abstract
COVID 19 pandemic and mass vaccination campaigns have revealed the situation of the most vulnerable patients. In this work, we focused our attention to patients who have Multiple Sclerosis (MS), particularly in treatment with cladribine tablets, trying to understand if and when it is possible to administer the vaccine successfully. In light of the novel topic, we studied the existing literature and analysed experiences with previous vaccinations, such as influenza and VZV, as well as data from countries where vaccination campaigns had already begun. Overall, we have taken into account the mechanism of action, the pharmacokinetic/pharmacodynamic of cladribine, and the changes in the immune system after its administration, together with the preliminary data about the humoral response to influenza, VZV, and SARS-CoV-2 vaccinations in cladribine treated patients. In conclusion, data showed that the use of cladribine tablets seems to permit flexibility regarding vaccination timing and we suggest that vaccination in those patients should be safe and effective. The current COVID 19 pandemic has re-ignited the interest in vaccines and vaccination procedures. The importance of including fragile individuals has increased as a result of mass vaccination. Millions of patients with multiple sclerosis (MS) around the world are debating whether they can safely receive their vaccine shot with the same efficacy despite receiving immune-modulating or immune-suppressive treatments. In the absence of conclusive empirical data, we will review and discuss the available evidence and the reasonable conclusions for one specific treatment, namely cladribine tablets (Mavenclad).
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Affiliation(s)
- Lucia Moiola
- Multiple Sclerosis Center, IRCCS San Raffaele Hospital, Milan, Italy/Neurology Department, IRCCS San Raffaele Hospital, Milan, Italy;
| | - Agostino Riva
- Department of Biomedical and Clinical Sciences 'L.Sacco' University of Milan, Milan, Italy;
| | - Ferdinando Nicoletti
- Università Sapienza, Roma, Istituto Neurologico Mediterraneo (INM); Neuromed, Pozzilli, Italy;
| | - Antonio Uccelli
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa; Ospedale Policlinico San Martino, IRCCS, Genoa; and Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Italy;
| | - Marco Salvetti
- Department of Neurosciences, Mental Health and Sensory Organs, Sapienza University, Rome, Italy; Istituto Neurologico Mediterraneo (INM) Neuromed, Pozzilli, Italy;
| | - Luca Battistini
- Neuroimmunology Unit, IRCCS Fondazione Santa Lucia, Rome, Italy;
| | - Roberto Furlan
- Clinical Neuroimmunology Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy,Address correspondence to this author at the Clinical Neuroimmunology Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy; Tel: +390226434867; Fax: +390226434855; E-mail:
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Golshani M, Hrdý J. Multiple Sclerosis Patients and Disease Modifying Therapies: Impact on Immune Responses against COVID-19 and SARS-CoV-2 Vaccination. Vaccines (Basel) 2022; 10:vaccines10020279. [PMID: 35214735 PMCID: PMC8876554 DOI: 10.3390/vaccines10020279] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/01/2022] [Accepted: 02/09/2022] [Indexed: 02/04/2023] Open
Abstract
This article reviews the literature on SARS-CoV-2 pandemic and multiple sclerosis (MS). The first part of the paper focuses on the current data on immunopathology of SARS-CoV-2 and leading vaccines produced against COVID-19 infection. In the second part of the article, we discuss the effect of Disease Modifying Therapies (DMTs) on COVID-19 infection severity or SARS-CoV-2 vaccination in MS patients plus safety profile of different vaccine platforms in MS patients.
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Affiliation(s)
| | - Jiří Hrdý
- Correspondence: ; Tel.: +420-224968509
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Rieckmann P, Centonze D, Giovannoni G, Hua LH, Oreja-Guevara C, Selchen D, Sørensen PS, Vermersch P, Wiendl H, Salloukh H, Yamout B. Expert opinion on COVID-19 vaccination and the use of cladribine tablets in clinical practice. Ther Adv Neurol Disord 2021; 14:17562864211058298. [PMID: 34899987 PMCID: PMC8655448 DOI: 10.1177/17562864211058298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/19/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Gaps in current evidence and guidance leave clinicians with unanswered questions on the use of cladribine tablets for the treatment of multiple sclerosis (MS) in the era of the COVID-19 pandemic, in particular relating to COVID-19 vaccination. OBJECTIVE We describe a consensus-based program led by international MS experts with the aim of supplementing current guidelines and treatment labels by providing timely recommendations relating to COVID-19 vaccination and the use of cladribine tablets in clinical practice. METHODS A steering committee (SC) of 10 international MS experts identified 7 clinical questions to answer concerning the use of cladribine tablets and COVID-19 vaccination, which addressed issues relating to patient selection, timing and efficacy, and safety. Clinical recommendations to address each question were drafted using available evidence combined with expert opinion from the SC. An extended faculty of 28 MS experts, representing 19 countries, in addition to the 10 SC members, voted on the recommendations. Consensus on recommendations was achieved when ⩾75% of respondents expressed an agreement score of 7-9, on a 9-point scale. RESULTS Consensus was achieved on all 13 recommendations. Clinical recommendations are provided on whether all patients with MS receiving cladribine tablets should be vaccinated against COVID-19, and whether they should be prioritized; the timing of vaccination around dosing of cladribine tablets (i.e. before and after a treatment course); and the safety of COVID-19 vaccination for these patients. CONCLUSION These expert recommendations provide timely guidance on COVID-19 vaccination in patients receiving cladribine tablets, which is relevant to everyday clinical practice.
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Affiliation(s)
- Peter Rieckmann
- Center for Clinical Neuroplasticity, Medical Park Loipl, Bischofswiesen, Germany
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Diego Centonze
- Unit of Neurology and Neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Le H. Hua
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Celia Oreja-Guevara
- Neurology, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Daniel Selchen
- Division of Neurology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, University of Copenhagen and Rigshospitalet, Copenhagen, Denmark
| | - Patrick Vermersch
- Université de Lille, INSERM-U1172, Centre Hospitalier Universitaire de Lille, Fédératif Hospitalo-Universitaire Precise, Lille, France
| | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Hashem Salloukh
- Ares Trading SA, Eysins, Switzerland (an affiliate of Merck KGaA)
| | - Bassem Yamout
- Neurology Institute, Harley Street Medical Center, Abu Dhabi, UAE
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut, 1107 2020 Beirut, Lebanon
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HUMORAL RESPONSE TO SARS-CoV-2 AND COVID-19 VACCINES IN PATIENTS WITH MULTIPLE SCLEROSIS TREATED WITH IMMUNE RECONSTITUTION THERAPIES. Mult Scler Relat Disord 2021; 54:103150. [PMID: 34298478 PMCID: PMC8280377 DOI: 10.1016/j.msard.2021.103150] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/05/2021] [Accepted: 07/11/2021] [Indexed: 12/13/2022]
Abstract
Background It has been generally accepted that people with MS (PwMS) should be vaccinated against COVID-19. The aim of our investigation was to evaluate the humoral response to natural SARS-CoV-2 infection and to two COVID-19 vaccines (BNT162b2 Pfizer-BioNTech and Beijing/Sinopharm BBIBP-CorV) in our cohort of PwMS under high efficacy disease modifying therapies (DMTs), cladribine and alemtuzumab. Methods Twenty two PwMS treated at the Clinic of Neurology, in Belgrade, who developed COVID-19 and/or were vaccinated against SARS-CoV-2, during treatment with cladribine and alemtuzumab, were included. Out of 18 patients treated with cladribine, 11 developed COVID-19, and 11 were vaccinated against SARS-CoV-2 (four with mRNA vaccine, 7 with Sinopharm). Four MS patients under alemtuzumab were vaccinated against SARS-CoV-2; three with mRNA, and one with Sinopharm vaccine. SARS-Cov-2 IgG response was measured using ELISA anti-spike protein-based serology (INEP, Belgrade, Serbia). Results All 7 patients under cladribine treatment who suffered from COVID-19, developed IgG antibodies, 2.0-5.5 months after last symptoms. All four (100%) patients under cladribine who were vaccinated with Pfizer-BioNTech vaccine, and three out of seven (42.9%) vaccinated with Sinopharm, developed antibodies. All 4 patients under alemtuzumab developed antibodies after vaccination. In all cases, seroprotection occurred, irrespective of timing of vaccination and absolute lymphocyte count. Conclusion Our findings in a small number of highly active PwMS in whom, lymphodepleting, immune reconstitution therapies, were applied in order to successfully manage MS, indicate that in a number of these patients it was possible to develop at the same time seroprotection in these patients after COVID-19 vaccination in these complex circumstances.
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Cabreira V, Abreu P, Soares-dos-Reis R, Guimarães J, Sá MJ. Multiple Sclerosis, Disease-Modifying Therapies and COVID-19: A Systematic Review on Immune Response and Vaccination Recommendations. Vaccines (Basel) 2021; 9:773. [PMID: 34358189 PMCID: PMC8310076 DOI: 10.3390/vaccines9070773] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022] Open
Abstract
Understanding the risks of COVID-19 in patients with Multiple Sclerosis (MS) receiving disease-modifying therapies (DMTs) and their immune reactions is vital to analyze vaccine response dynamics. A systematic review on COVID-19 course and outcomes in patients receiving different DMTs was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Emerging data on SARS-CoV-2 vaccines was used to elaborate recommendations. Data from 4417 patients suggest that MS per se do not portend a higher risk of severe COVID-19. As for the general population, advanced age, comorbidities, and higher disability significantly impact COVID-19 outcomes. Most DMTs have a negligible influence on COVID-19 incidence and outcome, while for those causing severe lymphopenia and hypogammaglobulinemia, such as anti-CD20 therapies, there might be a tendency of increased hospitalization, worse outcomes and a higher risk of re-infection. Blunted immune responses have been reported for many DMTs, with vaccination implications. Clinical evidence does not support an increased risk of MS relapse or vaccination failure, but vaccination timing needs to be individually tailored. For cladribine and alemtuzumab, it is recommended to wait 3-6 months after the last cycle until vaccination. For the general anti-CD20 therapies, vaccination must be deferred toward the end of the cycle and the next dose administered at least 4-6 weeks after completing vaccination. Serological status after vaccination is highly encouraged. Growing clinical evidence and continuous surveillance are extremely important to continue guiding future treatment strategies and vaccination protocols.
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Affiliation(s)
- Verónica Cabreira
- Serviço de Neurologia, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal; (P.A.); (R.S.-d.-R.); (J.G.); (M.J.S.)
- Departamento de Neurociências Clínicas e Saúde Mental, Faculdade de Medicina da Universidade do Porto, 4200-319 Porto, Portugal
| | - Pedro Abreu
- Serviço de Neurologia, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal; (P.A.); (R.S.-d.-R.); (J.G.); (M.J.S.)
- Departamento de Neurociências Clínicas e Saúde Mental, Faculdade de Medicina da Universidade do Porto, 4200-319 Porto, Portugal
| | - Ricardo Soares-dos-Reis
- Serviço de Neurologia, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal; (P.A.); (R.S.-d.-R.); (J.G.); (M.J.S.)
- Departamento de Neurociências Clínicas e Saúde Mental, Faculdade de Medicina da Universidade do Porto, 4200-319 Porto, Portugal
- i3S-Instituto de Investigação e Inovação da Universidade do Porto, 4200-135 Porto, Portugal
| | - Joana Guimarães
- Serviço de Neurologia, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal; (P.A.); (R.S.-d.-R.); (J.G.); (M.J.S.)
- Departamento de Neurociências Clínicas e Saúde Mental, Faculdade de Medicina da Universidade do Porto, 4200-319 Porto, Portugal
| | - Maria José Sá
- Serviço de Neurologia, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal; (P.A.); (R.S.-d.-R.); (J.G.); (M.J.S.)
- Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, 4249-004 Porto, Portugal
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Kulikowska J, Kulczyńska-Przybik A, Mroczko B, Kułakowska A. The Significance of COVID-19 Immunological Status in Severe Neurological Complications and Multiple Sclerosis-A Literature Review. Int J Mol Sci 2021; 22:5894. [PMID: 34072715 PMCID: PMC8199258 DOI: 10.3390/ijms22115894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 01/08/2023] Open
Abstract
SARS-CoV-2/Coronavirus 2019 (COVID-19) is responsible for the pandemic, which started in December 2019. In addition to the typical respiratory symptoms, this virus also causes other severe complications, including neurological ones. In diagnostics, serological and polymerase chain reaction tests are useful not only in detecting past infections but can also predict the response to vaccination. It is now believed that an immune mechanism rather than direct viral neuroinvasion is responsible for neurological symptoms. For this reason, it is important to assess the presence of antibodies not only in the serum but also in the cerebrospinal fluid (CSF), especially in the case of neuro-COVID. A particular group of patients are people with multiple sclerosis (MS) whose disease-modifying drugs weaken the immune system and lead to an unpredictable serological response to SARS-CoV-2 infection. Based on available data, the article summarizes the current serological information concerning COVID-19 in CSF in patients with severe neurological complications and in those with MS.
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Affiliation(s)
- Joanna Kulikowska
- Department of Neurology, Medical University of Bialystok, 15-276 Bialystok, Poland;
| | - Agnieszka Kulczyńska-Przybik
- Department of Neurodegeneration Diagnostics, Medical University of Bialystok, 15-269 Bialystok, Poland; (A.K.-P.); (B.M.)
| | - Barbara Mroczko
- Department of Neurodegeneration Diagnostics, Medical University of Bialystok, 15-269 Bialystok, Poland; (A.K.-P.); (B.M.)
| | - Alina Kułakowska
- Department of Neurology, Medical University of Bialystok, 15-276 Bialystok, Poland;
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Jack D, Damian D, Nolting A, Galazka A. COVID-19 in patients with multiple sclerosis treated with cladribine tablets: An update. Mult Scler Relat Disord 2021; 51:102929. [PMID: 33813097 PMCID: PMC7997846 DOI: 10.1016/j.msard.2021.102929] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/23/2021] [Indexed: 11/30/2022]
Abstract
Background We previously summarized outcomes for 46 cladribine tablets (CladT)-treated patients with multiple sclerosis (MS) and confirmed or suspected COVID-19, as reported to the Merck KGaA Global Patient Safety Database. This report updates on these findings, to 15 January 2021, for a total of 272 reported cases of COVID-19 among CladT recipients. Methods Case definitions: confirmed (COVID-19 diagnostic test was positive); suspected (no confirmatory test performed/reported). Cases fulfilling the criteria of hospitalized, medically significant, or fatal were designated as serious and outcomes were classified per usual pharmacovigilance practice. Results The evaluable cohort comprised 261 patients (confirmed COVID-19, n=160; suspected, n=101); an additional 11 patients had symptoms compatible with COVID-19 but were not evaluated further given their negative diagnostic tests. Median time to onset of COVID-19 from the most recent preceding CladT treatment course was 162 days (n=139). Outcomes were: recovered/recovering, n=133 (51%); not recovered/not resolved, n=19 (7%); died, n=1 (0.4%); and not reported/missing/pending, n=108 (41%). Of the total cohort, 40 (15%) experienced serious COVID-19. Conclusion Our results suggest that CladT-treated patients with MS are generally not at greater risk of serious disease and/or a severe outcome with COVID-19 compared with the general population and other patients with MS who acquired COVID-19.
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Affiliation(s)
| | - Doris Damian
- EMD Serono Research & Development Institute Inc., Billerica, MA, United States
| | | | - Andrew Galazka
- Merck, Aubonne, Switzerland, a division of Merck KGaA, Darmstadt, Germany
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