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Gudesblatt M, Bumstead B, Buhse M, Zarif M, Morrow SA, Nicholas JA, Hancock LM, Wilken J, Weller J, Scott N, Gocke A, Lewin JB, Kaczmarek O, Mendoza JP, Golan D. De-escalation of Disease-Modifying Therapy for People with Multiple Sclerosis Due to Safety Considerations: Characterizing 1-Year Outcomes in 25 People Who Switched from Ocrelizumab to Diroximel Fumarate. Adv Ther 2024; 41:3059-3075. [PMID: 38861218 PMCID: PMC11263251 DOI: 10.1007/s12325-024-02902-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 05/14/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Switching disease-modifying therapy (DMT) may be considered for relapsing-remitting multiple sclerosis (RRMS) if a patient's current therapy is no longer optimal. This was particularly important during the recent COVID-19 pandemic because of considerations around immune deficiency and impaired vaccine response associated with B cell-depleting DMTs. This real-world, single-center study aimed to evaluate change or decline in functional ability and overall disease stability in people with RRMS who were switched from B cell-depleting ocrelizumab (OCRE) to diroximel fumarate (DRF) because of safety concern related to the COVID-19 pandemic. METHODS Adults with RRMS were included if they had been clinically stable for ≥ 1 year on OCRE. Data collected at baseline and 1 year post switch included relapse rate, magnetic resonance imaging (MRI), blood work for assessment of peripheral immune parameters, the Cognitive Assessment Battery (CAB), optical coherence tomography (OCT), and patient-reported outcomes (PROs). RESULTS Participants (N = 25) had a mean (SD) age of 52 (9) years, and a mean (SD) duration of 26 (8) months' treatment with OCRE before the switch to DRF. Median washout duration since the last OCRE infusion was 7 months (range 4-18 months). No participants relapsed on DRF during follow-up, and all remained persistent on DRF after 1 year. There were no significant changes in peripheral immune parameters, other than an increase in the percentage of CD19+ cells 1 year after switching (p < 0.05). Similarly, there were no significant changes in CAB, OCT, and PROs. CONCLUSION These preliminary findings suggest that transition to DRF from OCRE may be an effective treatment option for people with RRMS who are clinically stable but may need to switch for reasons unrelated to effectiveness. Longer follow-up times on larger samples are needed to confirm these observations.
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Affiliation(s)
- Mark Gudesblatt
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA.
| | - Barbara Bumstead
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | - Marijean Buhse
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | - Myassar Zarif
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | - Sarah A Morrow
- Department of Clinical Neurosciences, University of Calgary, Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Jacqueline A Nicholas
- OhioHealth Multiple Sclerosis Center, Riverside Methodist Hospital, Columbus, OH, USA
| | - Laura M Hancock
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey Wilken
- Washington Neuropsychology Research Group, Fairfax, VA, USA
- Department of Neurology, Georgetown University School of Medicine, Washington, DC, USA
| | - Joanna Weller
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | | | | | | | - Olivia Kaczmarek
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | | | - Daniel Golan
- Multiple Sclerosis and Neuroimmunology Center, Lady Davis Carmel Medical Center, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Hallberg S, Evertsson B, Lillvall E, Boremalm M, de Flon P, Wang Y, Salzer J, Lycke J, Fink K, Frisell T, Al Nimer F, Svenningsson A. Hypogammaglobulinaemia during rituximab treatment in multiple sclerosis: A Swedish cohort study. Eur J Neurol 2024; 31:e16331. [PMID: 38794973 PMCID: PMC11236063 DOI: 10.1111/ene.16331] [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: 01/30/2024] [Revised: 04/08/2024] [Accepted: 04/24/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND AND PURPOSE Mechanisms behind hypogammaglobulinaemia during rituximab treatment are poorly understood. METHODS In this register-based multi-centre retrospective cohort study of multiple sclerosis (MS) patients in Sweden, 2745 patients from six participating Swedish MS centres were identified via the Swedish MS registry and included between 14 March 2008 and 25 January 2021. The exposure was treatment with at least one dose of rituximab for MS or clinically isolated syndrome, including data on treatment duration and doses. The degree of yearly decrease in immunoglobulin G (IgG) and immunoglobulin M (IgM) levels was evaluated. RESULTS The mean decrease in IgG was 0.27 (95% confidence interval 0.17-0.36) g/L per year on rituximab treatment, slightly less in older patients, and without significant difference between sexes. IgG or IgM below the lower limit of normal (<6.7 or <0.27 g/L) was observed in 8.8% and 8.3% of patients, respectively, as nadir measurements. Six out of 2745 patients (0.2%) developed severe hypogammaglobulinaemia (IgG below 4.0 g/L) during the study period. Time on rituximab and accumulated dose were the main predictors for IgG decrease. Previous treatment with fingolimod and natalizumab, but not teriflunomide, dimethyl fumarate, interferons or glatiramer acetate, were significantly associated with lower baseline IgG levels by 0.80-1.03 g/L, compared with treatment-naïve patients. Switching from dimethyl fumarate or interferons was associated with an additional IgG decline of 0.14-0.19 g/L per year, compared to untreated. CONCLUSIONS Accumulated dose and time on rituximab treatment are associated with a modest but significant decline in immunoglobulin levels. Previous MS therapies may influence additional IgG decline.
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Affiliation(s)
- Susanna Hallberg
- Department of Clinical SciencesKarolinska Institutet, Danderyds SjukhusStockholmSweden
| | - Björn Evertsson
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Ellen Lillvall
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Malin Boremalm
- Department of Clinical Science, NeurosciencesUmeå UniversityUmeåSweden
| | - Pierre de Flon
- Department of Clinical Sciences, Neurosciences, Unit of Neurology, ÖstersundUmeå UniversityUmeåSweden
| | - Yunzhang Wang
- Department of Clinical SciencesKarolinska Institutet, Danderyds SjukhusStockholmSweden
| | - Jonatan Salzer
- Department of Clinical Science, NeurosciencesUmeå UniversityUmeåSweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Katharina Fink
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Faiez Al Nimer
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Anders Svenningsson
- Department of Clinical SciencesKarolinska Institutet, Danderyds SjukhusStockholmSweden
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Gross RH, Corboy J. De-escalation and Discontinuation of Disease-Modifying Therapies in Multiple Sclerosis. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01355-w. [PMID: 38995483 DOI: 10.1007/s11910-024-01355-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE OF REVIEW Long-term use of multiple sclerosis (MS) disease-modifying therapies (DMTs) is standard practice to prevent accumulation of disability. Immunosenescence and other age-related changes lead to an altered risk-benefit ratio for older patients on DMTs. This article reviews recent research on the topic of de-escalation and discontinuation of MS DMTs. RECENT FINDINGS Observational and interventional studies have shed light on what happens to patients who de-escalate or discontinue DMTs and the factors, such as age, treatment type, and presence of recent disease activity, that influence outcomes. Though many questions remain, recent findings have been valuable for the development of an evidence-based approach to making de-escalation and discontinuation decisions in MS.
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Affiliation(s)
- Robert H Gross
- Department of Neurology, University of Colorado School of Medicine, 12631 East 17thAvenue, Mail Stop F727, Aurora, CO, 80045, USA.
- Department of Neurology, Rocky Mountain Regional Veterans Administration Medical Center, Aurora, CO, USA.
| | - John Corboy
- Department of Neurology, University of Colorado School of Medicine, 12631 East 17thAvenue, Mail Stop F727, Aurora, CO, 80045, USA
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Tran TDQ, Hall L, Heal C, Haleagrahara N, Edwards S, Boggild M. Planned dose reduction of ocrelizumab in relapsing-remitting multiple sclerosis: a single-centre observational study. BMJ Neurol Open 2024; 6:e000672. [PMID: 38912173 PMCID: PMC11191820 DOI: 10.1136/bmjno-2024-000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/04/2024] [Indexed: 06/25/2024] Open
Abstract
Background Ocrelizumab, a humanised anti-CD20 monoclonal, is a highly effective treatment for relapsing-remitting multiple sclerosis (RRMS). The long-term safety of B-cell depletion in RRMS, however, is uncertain and there are no data on dose reduction of ocrelizumab as a risk mitigation strategy. This study aimed to evaluate the effectiveness and safety of reducing ocrelizumab dose from 600 to 300 mg in patients with RRMS. Method Data were collected through the Townsville neurology service. Following the standard randomised controlled trial regimen of 600 mg every 6 months for 2 years, sequential patients consented to dose reduction to 300 mg every 6 months. Patients were included if they were diagnosed with RRMS and received at least one reduced dose of ocrelizumab. Relapse, disability progression, new MRI lesions, CD19+ cell counts and immunoglobulin concentrations were analysed. Results A total of 35 patients, treated with 177 full and 107 reduced doses, were included. The mean follow-up on reduced dose was 17 (1-31) months. We observed no relapses or new MRI activity in the cohort receiving the reduced dose, accompanied by persistent CD19+B cell depletion (≤0.05×109/L). Mean IgG, IgA and IgM levels remained stable throughout the study. No new safety concerns arose. Conclusions In this single-centre observational study, dose reduction of ocrelizumab from 600 to 300 mg every 6 months after 2 years appeared to maintain efficacy in terms of new inflammatory disease activity. A randomised trial may be warranted to confirm this and explore the impact of dose reduction on long-term safety.
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Affiliation(s)
- Trung Dang Quoc Tran
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Leanne Hall
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Clare Heal
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nagaraja Haleagrahara
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Sharon Edwards
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Mike Boggild
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
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Virtanen S, Piehl F, Frisell T. Impact of previous treatment history and B-cell depletion treatment duration on infection risk in relapsing-remitting multiple sclerosis: a nationwide cohort study. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-333206. [PMID: 38744458 DOI: 10.1136/jnnp-2023-333206] [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: 12/13/2023] [Accepted: 04/22/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND B-cell depletion displays striking effectiveness in relapsing-remitting multiple sclerosis (RRMS), but is also associated with increased infection risk. To what degree previous treatment history, disease-modifying therapy (DMT) switching pattern and time on treatment modulate this risk is unknown. The objective here was to evaluate previous DMT use and treatment duration as predictors of infection risk with B-cell depletion. METHODS We conducted a nationwide RRMS cohort study leveraging data from the Swedish MS registry and national demographic and health registries recording all outpatient-treated and inpatient-treated infections and antibiotics prescriptions from 1 January 2012 to 30 June 2021. The risk of infection during treatment was compared by DMT, treatment duration, number and type of prior treatment and adjusted for a number of covariates. RESULTS Among 4694 patients with RRMS on B-cell depletion (rituximab), 6049 on other DMTs and 20 308 age-sex matched population controls, we found higher incidence rates of inpatient-treated infections with DMTs other than rituximab used in first line (10.4; 95% CI 8.1 to 12.9, per 1000 person-years), being further increased with rituximab (22.7; 95% CI 18.5 to 27.5), compared with population controls (6.6; 95% CI 6.0 to 7.2). Similar patterns were seen for outpatient infections and antibiotics prescriptions. Infection rates on rituximab did not vary between first versus later line treatment, type of DMT before switch or exposure time. CONCLUSION These findings underscore an important safety concern with B-cell depletion in RRMS, being evident also in individuals with shorter disease duration and no previous DMT exposure, in turn motivating the application of risk mitigation strategies.
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Affiliation(s)
- Suvi Virtanen
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Jouvenot G, Courbon G, Lefort M, Rollot F, Casey R, Le Page E, Michel L, Edan G, de Seze J, Kremer L, Bigaut K, Vukusic S, Mathey G, Ciron J, Ruet A, Maillart E, Labauge P, Zephir H, Papeix C, Defer G, Lebrun-Frenay C, Moreau T, Laplaud DA, Berger E, Stankoff B, Clavelou P, Thouvenot E, Heinzlef O, Pelletier J, Al-Khedr A, Casez O, Bourre B, Cabre P, Wahab A, Magy L, Camdessanché JP, Doghri I, Moulin S, Ben-Nasr H, Labeyrie C, Hankiewicz K, Neau JP, Pottier C, Nifle C, Collongues N, Kerbrat A. High-Efficacy Therapy Discontinuation vs Continuation in Patients 50 Years and Older With Nonactive MS. JAMA Neurol 2024; 81:490-498. [PMID: 38526462 PMCID: PMC10964164 DOI: 10.1001/jamaneurol.2024.0395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/05/2024] [Indexed: 03/26/2024]
Abstract
Importance A recent randomized clinical trial concluded that discontinuing medium-efficacy therapy might be a reasonable option for older patients with nonactive multiple sclerosis (MS), but there is a lack of data on discontinuing high-efficacy therapy (HET). In younger patients, the discontinuation of natalizumab and fingolimod is associated with a risk of rebound of disease activity. Objective To determine whether discontinuing HET in patients 50 years and older with nonactive MS is associated with an increased risk of relapse compared with continuing HET. Design, Setting, and Participants This observational cohort study used data from 38 referral centers from the French MS registry (Observatoire Français de la Sclérose en Plaques [OFSEP] database). Among 84704 patients in the database, data were extracted for 1857 patients 50 years and older with relapsing-remitting MS treated by HET and with no relapse or magnetic resonance imaging activity for at least 2 years. After verification of the medical records, 1620 patients were classified as having discontinued HET or having remained taking treatment and were matched 1:1 using a dynamic propensity score (including age, sex, disease phenotype, disability, treatment of interest, and time since last inflammatory activity). Patients were included from February 2008 to November 2021, with a mean (SD) follow-up of 5.1 (2.9) years. Data were extracted in June 2022. Exposures Natalizumab, fingolimod, rituximab, and ocrelizumab. Main Outcomes and Measures Time to first relapse. Results Of 1620 included patients, 1175 (72.5%) were female, and the mean (SD) age was 54.7 (4.8) years. Among the 1452 in the HET continuation group and 168 in the HET discontinuation group, 154 patients in each group were matched using propensity scores (mean [SD] age, 57.7 [5.5] years; mean [SD] delay since the last inflammatory activity, 5.6 [3.8] years; mean [SD] follow-up duration after propensity score matching, 2.5 [2.1] years). Time to first relapse was significantly reduced in the HET discontinuation group compared with the HET continuation group (hazard ratio, 4.1; 95% CI, 2.0-8.5; P < .001) but differed between HETs, with a hazard ratio of 7.2 (95% CI, 2.1-24.5; P = .001) for natalizumab, 4.5 (95% CI, 1.3-15.5; P = .02) for fingolimod, and 1.1 (95% CI, 0.3-4.8; P = .85) for anti-CD20 therapy. Conclusion and Relevance As in younger patients, in patients 50 years and older with nonactive MS, the risk of relapse increased significantly after stopping HETs that impact immune cell trafficking (natalizumab and fingolimod). There was no significant increase in risk after stopping HETs that deplete B-cells (anti-CD20 therapy). This result may inform decisions about stopping HETs in clinical practice.
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Affiliation(s)
- Guillaume Jouvenot
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Guilhem Courbon
- Department of Neurology, University Hospital of Rennes, Rennes, France
| | - Mathilde Lefort
- University of Rennes, EHESP, CNRS, INSERM, Arènes—UMR 6051, RSMS (Recherche sur les Services et Management en Santé)—U 1309, Rennes, France
| | - Fabien Rollot
- Université de Lyon, Université Claude Bernard, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 and CNRS UMR 5292, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Romain Casey
- Université de Lyon, Université Claude Bernard, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 and CNRS UMR 5292, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Emmanuelle Le Page
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
| | - Laure Michel
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
| | - Gilles Edan
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
| | - Jérome de Seze
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Laurent Kremer
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Kevin Bigaut
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Sandra Vukusic
- Université de Lyon, Université Claude Bernard, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 and CNRS UMR 5292, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Guillaume Mathey
- Department of Neurology, Nancy University Hospital, Nancy, France
- Université de Lorraine, APEMAC, Nancy, France
| | - Jonathan Ciron
- CRC-SEP, Department of Neurology, CHU de Toulouse, Toulouse, France
| | - Aurélie Ruet
- Department of Neurology, CHU de Bordeaux, CIC Bordeaux CIC1401, Bordeaux, France
| | - Elisabeth Maillart
- Département de Neurologie, Hôpital Pitié-Salpêtrière, APHP, Centre de Ressources et de Compétences SEP, Paris, France
| | | | | | - Caroline Papeix
- Department of Neurology, Fondation Rothschild, Paris, France
| | - Gilles Defer
- Department of Neurology, MS Expert Centre, CHU de Caen, Caen, France
| | - Christine Lebrun-Frenay
- Neurology, UR2CA-URRIS, Centre Hospitalier Universitaire Pasteur2, Université Nice Côte d’Azur, Nice, France
| | | | - David Axel Laplaud
- Department of Neurology, CHU de Nantes, Nantes, France
- Nantes Université, CHU Nantes, INSERM, CIC 14131413, Center for Research in Translational Immunology, UMR 1064, Nantes, France
| | - Eric Berger
- Service de Neurologie, CHU de Besançon, Besançon, France
| | - Bruno Stankoff
- Department of Neurology, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Pierre Clavelou
- Department of Neurology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Eric Thouvenot
- Department of Neurology, Nimes University Hospital, Nimes, France
| | | | - Jean Pelletier
- Service de Neurologie, APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille, France
| | | | - Olivier Casez
- CHU Grenoble Alpes, Department of Neurology, Neurology MS Clinic Grenoble, Grenoble Alpes University Hospital, Grenoble, France
| | | | - Philippe Cabre
- Department of Neurology, CHU de la Martinique, Fort-de-France, France
| | - Abir Wahab
- Department of Neurology, APHP, Hôpital Henri Mondor, Créteil, France
| | - Laurent Magy
- Department of Neurology, CHU de Limoges, Hôpital Dupuytren, Limoges, France
| | | | - Ines Doghri
- Department of Neurology, CHU de Tours, Hôpital Bretonneau, Tours, France
| | - Solène Moulin
- Department of Neurology, CHU de Reims, CRC-SEP, Reims, France
| | - Haifa Ben-Nasr
- Hôpital Sud Francilien, Department of Neurology, Corbeil-Essonnes, France
| | - Céline Labeyrie
- Department of Neurology, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Karolina Hankiewicz
- Department of Neurology, Hôpital Pierre Delafontaine, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Jean-Philippe Neau
- Department of Neurology, CHU La Milétrie, Hôpital Jean Bernard, Poitiers, France
| | - Corinne Pottier
- Department of Neurology, CH de Pontoise, Hôpital René Dubos, Pontoise, France
| | - Chantal Nifle
- Departement of Neurology, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Nicolas Collongues
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
- Department of Pharmacology, Addictology, Toxicology and Therapeutics, Strasbourg University, Strasbourg, France
| | - Anne Kerbrat
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
- Empenn U1228, University of Rennes, Inria, CNRS, INSERM, IRISA UMR 6074, Rennes, France
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Freeman SA, Zéphir H. Anti-CD20 monoclonal antibodies in multiple sclerosis: Rethinking the current treatment strategy. Rev Neurol (Paris) 2024:S0035-3787(24)00474-0. [PMID: 38599976 DOI: 10.1016/j.neurol.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 04/12/2024]
Abstract
Anti-CD20 monoclonal antibodies are highly-effective B-cell-depleting therapies in multiple sclerosis (MS). These treatments have expanded the arsenal of highly effective disease-modifying therapies, and have changed the landscape in understanding the pathophysiology of MS and the natural course of the disease. Nevertheless, these treatments come at the cost of immunosuppression and risk of serious infections, diminished vaccination response and treatment-related secondary hypogammaglobulinemia. However, the COVID pandemic has given way to a possibility of readapting these therapies, with most notably extended dosing intervals. While these new strategies show efficacy in maintaining inflammatory MS disease control, and although it is tempting to speculate that tailoring CD20 therapies will reduce the negative outcomes of long-term immunosuppression, it is unknown whether they provide meaningful benefit in reducing the risk of treatment-related secondary hypogammaglobulinemia and serious infections. This review highlights the available anti-CD20 therapies that are available for treating MS patients, and sheds light on encouraging data, which propose that tailoring anti-CD20 monoclonal antibodies is the next step in rethinking the current treatment strategy.
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Affiliation(s)
- S A Freeman
- Department of Neurology, CRC-SEP, CHU of Toulouse, Toulouse, France; University Toulouse III, Inserm UMR1291, CHU Purpan, Toulouse Institute for Infectious and Inflammatory Diseases (INFINITY), 59000 Toulouse, France.
| | - H Zéphir
- Department of Neurology, CRC-SEP, CHU of Lille, Lille, France; University of Lille, Inserm, CHU of Lille, Laboratory of Neuroinflammation and Multiple Sclerosis (NEMESIS), U1172, Lille, France
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8
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Carlson AK, Amin M, Cohen JA. Drugs Targeting CD20 in Multiple Sclerosis: Pharmacology, Efficacy, Safety, and Tolerability. Drugs 2024; 84:285-304. [PMID: 38480630 PMCID: PMC10982103 DOI: 10.1007/s40265-024-02011-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 04/02/2024]
Abstract
Currently, there are four monoclonal antibodies (mAbs) that target the cluster of differentiation (CD) 20 receptor available to treat multiple sclerosis (MS): rituximab, ocrelizumab, ofatumumab, and ublituximab. B-cell depletion therapy has changed the therapeutic landscape of MS through robust efficacy on clinical manifestations and MRI lesion activity, and the currently available anti-CD20 mAb therapies for use in MS are a cornerstone of highly effective disease-modifying treatment. Ocrelizumab is currently the only therapy with regulatory approval for primary progressive MS. There are currently few data regarding the relative efficacy of these therapies, though several clinical trials are ongoing. Safety concerns applicable to this class of therapeutics relate primarily to immunogenicity and mechanism of action, and include infusion-related or injection-related reactions, development of hypogammaglobulinemia (leading to increased infection and malignancy risk), and decreased vaccine response. Exploration of alternative dose/dosing schedules might be an effective strategy for mitigating these risks. Future development of biosimilar medications might make these therapies more readily available. Although anti-CD20 mAb therapies have led to significant improvements in disease outcomes, CNS-penetrant therapies are still needed to more effectively address the compartmentalized inflammation thought to play an important role in disability progression.
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Affiliation(s)
- Alise K Carlson
- Mellen Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Ave U10, Cleveland, OH, 44195, USA
| | - Moein Amin
- Mellen Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Ave U10, Cleveland, OH, 44195, USA
| | - Jeffrey A Cohen
- Mellen Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Ave U10, Cleveland, OH, 44195, USA.
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Venet M, Lepine A, Maarouf A, Biotti D, Boutiere C, Casez O, Cohen M, Durozard P, Demortière S, Giorgi L, Maillart E, Mathey G, Mazzola L, Rico A, Camdessanche JP, Deiva K, Pelletier J, Audoin B. Control of disease activity with large extended-interval dosing of rituximab/ocrelizumab in highly active pediatric multiple sclerosis. Mult Scler 2024; 30:261-265. [PMID: 38166437 DOI: 10.1177/13524585231223069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
Recent studies in adults suggested that extended-interval dosing of rituximab/ocrelizumab (RTX/OCR) larger than 12 months was safe and could improve safety. This was an observational cohort study of very active pediatric-onset multiple sclerosis (PoMS) (median (range) age, 16 (12-17) years) treated with RTX/OCR with 6 month standard-interval dosing (n = 9) or early extended-interval dosing (n = 12, median (range) interval 18 months (12-25)). Within a median (range) follow-up of 31 (12-63) months after RTX/OCR onset, one patient (standard-interval) experienced relapse and no patient showed disability worsening or new T2-weighted lesions. This study suggests that the effectiveness of RTX/OCR is maintained with a median extended-interval dosing of 18 months in patients with very active PoMS.
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Affiliation(s)
- Melany Venet
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
- Neurology Department, University Hospital, Saint-Etienne, France
| | - Anne Lepine
- Paediatric Neurology Department, Assistance Publique des Hôpitaux de Marseille, Hôpital Universitaire, Marseille, France
| | - Adil Maarouf
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | - Damien Biotti
- Centre Ressources et Compétences Sclérose en Plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France
- INSERM UMR1291-CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Clémence Boutiere
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | - Olivier Casez
- Neuro-inflammatory Disease Center, Centre Hospitalier Universitaire de Grenoble Alpes, Grenoble, France
| | - Mikael Cohen
- CRC-SEP CHU Nice, UR2CA-URRIS, Université Nice Cote d'Azur, Hôpital Pasteur 2, Nice, France
| | | | - Sarah Demortière
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | - Laetitia Giorgi
- Department of Paediatric Neurology, National Reference Center for Rare Inflammatory and auto-immune Brain and Spinal Diseases, Hopitaux Universitaires Paris-Saclay, Hôpital Bicêtre, Le Kremlin-Bicetre, France
- UMR 1184, Immunology of Viral Infections and Autoimmune Diseases, Universite Paris Saclay, Le Kremlin-Bicetre, France
| | - Elisabeth Maillart
- Department of Neurology, National Reference Center for Rare Inflammatory and auto-immune Brain and Spinal Diseases, Pitie Salpetriere Hospital, APHP, Paris, France
| | - Guillaume Mathey
- Neurology Unit, University Hospital of Nancy, Hôpital Central, Nancy Cedex, France
| | - Laure Mazzola
- Neurology Department, University Hospital, Saint-Etienne, France
| | - Audrey Rico
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | | | - Kumaran Deiva
- Department of Paediatric Neurology, National Reference Center for Rare Inflammatory and auto-immune Brain and Spinal Diseases, Hopitaux Universitaires Paris-Saclay, Hôpital Bicêtre, Le Kremlin-Bicetre, France
- UMR 1184, Immunology of Viral Infections and Autoimmune Diseases, Universite Paris Saclay, Le Kremlin-Bicetre, France
| | - Jean Pelletier
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | - Bertrand Audoin
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
- Pôle de Neurosciences Cliniques, Service de Neurologie, Aix Marseille Univ, APHM, Hôpital de la Timone, Marseille, France
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Nabizadeh F, Ahmadabad MA, Mohamadi M, Mirmosayyeb O, Maleki T, Kazemzadeh K, Seyedmirzaei H. Efficacy and safety of rituximab in multiple sclerosis: a systematic review and meta-analysis. Acta Neurol Belg 2023; 123:2115-2127. [PMID: 37428437 DOI: 10.1007/s13760-023-02329-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/28/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE We aimed to synthesize all available observational studies and clinical trials of rituximab to estimate the safety and efficacy of this monoclonal antibody in people with multiple sclerosis (MS). METHODS The four databases including PubMed, Scopus, Embase, and Web of Science were comprehensively searched in April 2022. We defined PICO as follows. Problem or study population (P): patients with MS; intervention (I): Rituximab; comparison (C): none; outcome (O): efficacy and safety. RESULTS After two-step screening, a total of 27 studies entered into our qualitative and quantitative synthesis. Our analysis showed a significant decrease in EDSS score in all patients with MS after treatment (SMD: - 0.44, 95% CI - 0.85, - 0.03). In addition, the ARR was reduced after using rituximab compared to the pre-treatment period (SMD: - 0.65, 95% CI - 1.55, 0.24) but it was not significant. The most common side effect after rituximab with a pooled prevalence of 28.63% (95% CI 16.61%, 42.33%). Furthermore, the pooled prevalence of infection was 24% in patients with MS (95% CI 13%, 36%). In the end, the pooled prevalence of malignancies after rituximab treatment was 0.39% (95% CI 0.02%, 1.03%). CONCLUSION Our findings illustrated an acceptable safety for this treatment. However, further studies with randomized design, long follow-up, and large sample sizes are needed to confirm the safety and efficacy of rituximab in patients with MS.
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Affiliation(s)
- Fardin Nabizadeh
- Neuroscience Research Group (NRG), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Mona Asghari Ahmadabad
- Neuroscience Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Mobin Mohamadi
- Neuroscience Research Group (NRG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Omid Mirmosayyeb
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Tahereh Maleki
- School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Kimia Kazemzadeh
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Homa Seyedmirzaei
- School of Medicine, Tehran University of Medical Science, Tehran, Iran
- Interdisciplinary Neuroscience Research Program (INRP), Tehran University of Medical Sciences, Tehran, Iran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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Freeman SA, Lemarchant B, Alberto T, Boucher J, Outteryck O, Labalette M, Rogeau S, Dubucquoi S, Zéphir H. Assessing Sustained B-Cell Depletion and Disease Activity in a French Multiple Sclerosis Cohort Treated by Long-Term IV Anti-CD20 Antibody Therapy. Neurotherapeutics 2023; 20:1707-1722. [PMID: 37882961 PMCID: PMC10684468 DOI: 10.1007/s13311-023-01446-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/27/2023] Open
Abstract
Few studies have investigated sustained B-cell depletion after long-term intravenous (IV) anti-CD20 B-cell depleting therapy (BCDT) in multiple sclerosis (MS) with respect to strict and/or minimal disease activity. The main objective of this study was to investigate how sustained B-cell depletion after BCDT influences clinical and radiological stability as defined by "no evidence of disease activity" (NEDA-3) and "minimal evidence of disease activity" (MEDA) status in MS patients at 12 and 18 months. Furthermore, we assessed the frequency of serious adverse events (SAE), and the influence of prior lymphocytopenia-inducing treatment (LIT) on lymphocyte subset counts and gammaglobulins in MS patients receiving long-term BCDT. We performed a retrospective, prospectively collected, study in a cohort of 192 MS patients of all clinical phenotypes treated by BCDT between January 2014 and September 2021. Overall, 84.2% and 96.9% of patients attained NEDA-3 and MEDA status at 18 months, respectively. Sustained CD19+ depletion was observed in 85.8% of patients at 18 months. No significant difference was observed when comparing patients achieving either NEDA-3 or MEDA at 18 months and sustained B-cell depletion. Compared to baseline levels, IgM and IgG levels on BCDT significantly decreased at 6 months and 30 months, respectively. Patients receiving LIT prior to BCDT showed significant CD4+ lymphocytopenia and lower IgG levels compared to non-LIT patients. Grade 3 or above SAEs were rare. As nearly all patients achieved MEDA at 18 months, we suggest tailoring IV BCDT after 18 months given the occurrence of lymphocytopenia, hypogammaglobulinemia, and SAE after this time point.
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Affiliation(s)
- Sean A Freeman
- Department of Neurology, CRC-SEP, CHU of Lille, Lille, France.
| | - Bruno Lemarchant
- Department of Neurology, CRC-SEP, CHU of Lille, Lille, France
- Laboratory of Neuroinflammation and Multiple Sclerosis (NEMESIS), Univ. Lille, INSERM, CHU Lille, U1172, Lille, France
| | - Tifanie Alberto
- Department of Neurology, CRC-SEP, CHU of Lille, Lille, France
| | - Julie Boucher
- Department of Neurology, CRC-SEP, CHU of Lille, Lille, France
| | - Olivier Outteryck
- Laboratory of Neuroinflammation and Multiple Sclerosis (NEMESIS), Univ. Lille, INSERM, CHU Lille, U1172, Lille, France
- Department of Neuroradiology, CHU Lille, Roger Salengro Hospital, Lille, France
| | - Myriam Labalette
- Univ. Lille, INSERM, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
| | - Stéphanie Rogeau
- Univ. Lille, INSERM, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
| | - Sylvain Dubucquoi
- Univ. Lille, INSERM, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
| | - Hélène Zéphir
- Department of Neurology, CRC-SEP, CHU of Lille, Lille, France
- Laboratory of Neuroinflammation and Multiple Sclerosis (NEMESIS), Univ. Lille, INSERM, CHU Lille, U1172, Lille, France
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12
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Claverie R, Perriguey M, Rico A, Boutiere C, Demortiere S, Durozard P, Hilezian F, Dubrou C, Vely F, Pelletier J, Audoin B, Maarouf A. Efficacy of Rituximab Outlasts B-Cell Repopulation in Multiple Sclerosis: Time to Rethink Dosing? NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200152. [PMID: 37604695 PMCID: PMC10442066 DOI: 10.1212/nxi.0000000000200152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/05/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients with multiple sclerosis (PwMS) receiving extended dosing of rituximab (RTX) have exhibited no return of disease activity, which suggests that maintenance of deep depletion of circulating B cells is not necessary to maintain the efficacy of RTX in MS. METHODS This was a prospective monocentric observational study including all consecutive PwMS who started or continued RTX after 2019, when the medical staff decided to extend the dosing interval up to 24 months for all patients. Circulating B-cell subsets were monitored regularly and systematically in case of relapse. The first extended interval was analyzed. RESULTS We included 236 PwMS (81% with relapsing-remitting MS; mean [SD] age 43 [12] years; median [range] EDSS score 4 [0-8]; mean relapse rate during the year before RTX start 1.09 [0.99]; 41.5% with MRI activity). The median number of RTX infusions before extension was 4 (1-13). At the time of the analysis, the median delay in dosing was 17 months (8-39); the median proportion of circulating CD19+ B cells was 7% (0-25) of total lymphocytes and that of CD27+ memory B cells was 4% (0-16) of total B cells. The mean annual relapse rate did not differ before and after the extension: 0.03 (0.5) and 0.04 (0.15) (p = 0.51). Similarly, annual relapse rates did not differ before and after extension in patients with EDSS score ≤3 (n = 79) or disease duration ≤5 years (n = 71) at RTX onset. During the "extended dosing" period, MRI demonstrated no lesion accrual in 228 of the 236 patients (97%). Five patients experienced clinical relapse, which was confirmed by MRI. In these patients, the level of B-cell subset reconstitution at the time of the relapse did not differ from that for patients with the same extension window. DISCUSSION The efficacy of RTX outlasted substantial reconstitution of circulating B cells in PwMS, which suggests that renewal of the immune system underlies the prolonged effect of RTX in MS. These findings suggest that extended interval dosing of RTX that leads to a significant reconstitution of circulating B cells is safe in PwMS, could reduce the risk of infection, and could improve vaccine efficacy.
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Affiliation(s)
- Roxane Claverie
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Marine Perriguey
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Audrey Rico
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Clemence Boutiere
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Sarah Demortiere
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Pierre Durozard
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Frederic Hilezian
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Clea Dubrou
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Frederic Vely
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Jean Pelletier
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
| | - Bertrand Audoin
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France.
| | - Adil Maarouf
- From the Department of Neurology (B.A., M.P., A.R., C.B., S.D., F.H., J.P., A.M.), CRMBM, University Hospital of Marseille, Aix-Marseille University; Service d'immunologie (D.C., F.V.), Marseille Immunopôle, APHM, Aix Marseille University, CNRS, INSERM, CIML; Faculté de Pharmacie (R.C.), Aix-Marseille University; and Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, France
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Demortiere S, Maarouf A, Rico A, Boutiere C, Hilezian F, Durozard P, Pelletier J, Audoin B. Disease Evolution in Women With Highly Active MS Who Suspended Natalizumab During Pregnancy vs Rituximab/Ocrelizumab Before Conception. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200161. [PMID: 37550074 PMCID: PMC10406425 DOI: 10.1212/nxi.0000000000200161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND AND OBJECTIVES In women with highly active multiple sclerosis (MS), suspending rituximab (RTX) for planning pregnancy is associated with low disease reactivation. Whether this strategy reduces the risk of disease reactivity as compared with suspending natalizumab (NTZ) 3 months after conception is unclear. METHODS We retrospectively included women with MS followed in our department during pregnancy and 1 year after birth who suspended NTZ at the end of the first trimester (option mostly proposed before 2016) or suspended RTX/ocrelizumab (RTX/OCR) in the year before conception (option proposed since 2016). RESULTS In women who suspended NTZ, 45 pregnancies resulted in 3 miscarriages and 42 live births, including 1 newborn with major malformations. In women who suspended RTX/OCR, 37 pregnancies resulted in 3 miscarriages and 33 live births; 1 pregnancy was terminated for malformation. During pregnancy, relapse occurred in 3/42 (7.1%) patients of the NTZ group and 1/33 (3%) of the RTX/OCR group (p = 0.6). After delivery, relapse occurred in 9/42 (21.4%) patients of the NTZ group and 0/33 of the RTX/OCR group (p < 0.01). In the NTZ group, 8/9 relapses occurred in patients who restarted NTZ less than 4 weeks after delivery. The proportion of patients with gadolinium-enhanced and/or new T2 lesions on brain or spinal cord MRI performed after delivery was higher in the NTZ than RTX/OCR group (14/40 [35%] vs 1/31 [3%] patients, p = 0.001), the proportion with EDSS score progression during the period including pregnancy and the year after delivery was higher (7/42 [17%] vs 0/33 patients, p = 0.01), and the proportion fulfilling NEDA-3 during this period was lower (21/40 [53%] vs 30/31 [97%] patients, p < 0.001). DISCUSSION Suspending RTX/OCR in the year before conception in women with highly active MS was associated with no disease reactivation during and after pregnancy. As previously reported, stopping NTZ at the end of the first trimester was associated with disease reactivation. In women receiving NTZ who are planning pregnancy, a bridge to RTX/OCR for pregnancy or continuing NTZ until week 34 are both reasonable clinical decisions. The RTX/OCR option is more comfortable for women and reduces the exposure of infants to monoclonal antibodies.
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Affiliation(s)
- Sarah Demortiere
- From the Department of Neurology (S.D., A.M., A.R., C.B., F.H., J.P., B.A.), CRMBM, APHM, Aix Marseille University; and Centre Hospitalier d'Ajaccio (P.D.), France
| | - Adil Maarouf
- From the Department of Neurology (S.D., A.M., A.R., C.B., F.H., J.P., B.A.), CRMBM, APHM, Aix Marseille University; and Centre Hospitalier d'Ajaccio (P.D.), France
| | - Audrey Rico
- From the Department of Neurology (S.D., A.M., A.R., C.B., F.H., J.P., B.A.), CRMBM, APHM, Aix Marseille University; and Centre Hospitalier d'Ajaccio (P.D.), France
| | - Clemence Boutiere
- From the Department of Neurology (S.D., A.M., A.R., C.B., F.H., J.P., B.A.), CRMBM, APHM, Aix Marseille University; and Centre Hospitalier d'Ajaccio (P.D.), France
| | - Frederic Hilezian
- From the Department of Neurology (S.D., A.M., A.R., C.B., F.H., J.P., B.A.), CRMBM, APHM, Aix Marseille University; and Centre Hospitalier d'Ajaccio (P.D.), France
| | - Pierre Durozard
- From the Department of Neurology (S.D., A.M., A.R., C.B., F.H., J.P., B.A.), CRMBM, APHM, Aix Marseille University; and Centre Hospitalier d'Ajaccio (P.D.), France
| | - Jean Pelletier
- From the Department of Neurology (S.D., A.M., A.R., C.B., F.H., J.P., B.A.), CRMBM, APHM, Aix Marseille University; and Centre Hospitalier d'Ajaccio (P.D.), France
| | - Bertrand Audoin
- From the Department of Neurology (S.D., A.M., A.R., C.B., F.H., J.P., B.A.), CRMBM, APHM, Aix Marseille University; and Centre Hospitalier d'Ajaccio (P.D.), France.
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14
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Demuth S, Collongues N, Audoin B, Ayrignac X, Bourre B, Ciron J, Cohen M, Deschamps R, Durand-Dubief F, Maillart E, Papeix C, Ruet A, Zephir H, Marignier R, De Seze J. Rituximab De-escalation in Patients With Neuromyelitis Optica Spectrum Disorder. Neurology 2023; 101:e438-e450. [PMID: 37290967 PMCID: PMC10435052 DOI: 10.1212/wnl.0000000000207443] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 04/07/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Exit strategies such as de-escalations have not been evaluated for rituximab in patients with neuromyelitis optica spectrum disorder (NMOSD). We hypothesized that they are associated with disease reactivations and aimed to estimate this risk. METHODS We describe a case series of real-world de-escalations from the French NMOSD registry (NOMADMUS). All patients met the 2015 International Panel for NMO Diagnosis (IPND) diagnostic criteria for NMOSD. A computerized screening of the registry extracted patients with rituximab de-escalations and at least 12 months of subsequent follow-up. We searched for 7 de-escalation regimens: scheduled discontinuations or switches to an oral treatment after single infusion cycles, scheduled discontinuations or switches to an oral treatment after periodic infusions, de-escalations before pregnancies, de-escalations after tolerance issues, and increased infusion intervals. Rituximab discontinuations motivated by inefficacy or for unknown purposes were excluded. The primary outcome was the absolute risk of NMOSD reactivation (one or more relapses) at 12 months. AQP4+ and AQP4- serotypes were analyzed separately. RESULTS We identified 137 rituximab de-escalations between 2006 and 2019 that corresponded to a predefined group: 13 discontinuations after a single infusion cycle, 6 switches to an oral treatment after a single infusion cycle, 9 discontinuations after periodic infusions, 5 switches to an oral treatment after periodic infusions, 4 de-escalations before pregnancies, 9 de-escalations after tolerance issues, and 91 increased infusion intervals. No group remained relapse-free over the whole de-escalation follow-up (mean: 3.2 years; range: 0.79-9.5), except pregnancies in AQP+ patients. In all groups combined and within 12 months, reactivations occurred after 11/119 de-escalations in patients with AQP4+ NMOSD (9.2%, 95% CI [4.7-15.9]), from 0.69 to 10.0 months, and in 5/18 de-escalations in patients with AQP4- NMOSD (27.8%, 95% CI [9.7-53.5]), from 1.1 to 9.9 months. DISCUSSION There is a risk of NMOSD reactivation whatever the rituximab de-escalation regimen. TRIAL REGISTRATION INFORMATION Registered on ClinicalTrials.gov: NCT02850705. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that de-escalation of rituximab increases the probability of disease reactivation.
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Affiliation(s)
- Stanislas Demuth
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Nicolas Collongues
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Bertrand Audoin
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Xavier Ayrignac
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Bertrand Bourre
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Jonathan Ciron
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Mikael Cohen
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Romain Deschamps
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Françoise Durand-Dubief
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Elisabeth Maillart
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Caroline Papeix
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Aurélie Ruet
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Helene Zephir
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Romain Marignier
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Jerome De Seze
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France.
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15
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Techa-Angkoon P, Siritho S, Tisavipat N, Suansanae T. Current evidence of rituximab in the treatment of multiple sclerosis. Mult Scler Relat Disord 2023; 75:104729. [PMID: 37148577 DOI: 10.1016/j.msard.2023.104729] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/15/2023] [Accepted: 04/22/2023] [Indexed: 05/08/2023]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system. The immunopathology of MS involves both T and B lymphocytes. Rituximab is one of the anti-CD20 monoclonal antibody therapies which deplete B-cells. Although some anti-CD20 therapies have been approved by the Food and Drug Administration for treatment of MS, rituximab is used off-label. Several studies have shown that rituximab has a good efficacy and safety in MS, including certain specific patient conditions such as treatment-naïve patients, treatment-switching patients, and the Asian population. However, there are still questions about the optimal dose and duration of rituximab in MS due to the different dosing regimens used in each study. Moreover, many biosimilars have become available at a lower cost with comparable physicochemical properties, pharmacokinetics, pharmacodynamics, efficacy, safety, and immunogenicity. Thus, rituximab may be considered as a potential therapeutic option for patients without access to standard treatment. This narrative review summarized the evidence of both original and biosimilars of rituximab in MS treatment including pharmacokinetics, pharmacodynamics, clinical efficacy, safety, and dosing regimen.
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Affiliation(s)
- Phanutgorn Techa-Angkoon
- Division of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Sasitorn Siritho
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Siriraj Neuroimmunology Center, Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Bumrungrad International Hospital, Bangkok, Thailand
| | | | - Thanarat Suansanae
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Ratchathewi, Bangkok 10400, Thailand.
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16
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Rual C, Biotti D, Lepine Z, Delourme A, Berre JL, Treiner E, Ciron J. 2 grams versus 1 gram rituximab as maintenance schedule in multiple sclerosis, neuromyelitis optica spectrum disorders and related diseases: What B-cell repopulation data tell us. Mult Scler Relat Disord 2023; 71:104563. [PMID: 36791624 DOI: 10.1016/j.msard.2023.104563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Rituximab (RTX) is largely used as a long-term maintenance therapy in various inflammatory neurological diseases. Reducing the dose of maintenance therapy of RTX from 2 grams every 6 months (traditional regimen) to 1 gram every 6 months (reduced regimen) is a widely applied practice, with the assumption that it decreases the risk of side effects while maintaining efficacy. METHODS In order to better describe the biological consequences of this strategy, we retrospectively compared, in a single center, the B-cell count after the traditional regimen and after the reduced regimen in patients who underwent both (n = 161). RESULTS The rate of patients with B-cell repopulation was not significantly different between traditional and reduced regimens (9.9% vs 15.6%, p = 0.18). Among the 145 patients who did not have B-cell repopulation following the traditional regimen, B-cell repopulation following the reduced regimen occurred in only 16 cases (11.0%) and was usually slight: 11/16 patients had only 1% of CD19+ cells. CONCLUSION These data emphasize the relevance of 1 g of RTX as maintenance therapy and the fact that 2 g of RTX is generally an overtreatment in inflammatory neurological diseases.
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Affiliation(s)
- Celso Rual
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France
| | - Damien Biotti
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France; Infinity, INSERM UMR1291 - CNRS UMR5051, University Toulouse III, Toulouse Cedex 3, F-31024, France
| | - Zoe Lepine
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France
| | - Adrien Delourme
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France
| | - Juliette Le Berre
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France
| | - Emmanuel Treiner
- Laboratory of Immunology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France; Infinity, INSERM UMR1251, University Toulouse III, Toulouse Cedex 3, F-31024, France
| | - Jonathan Ciron
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France; Infinity, INSERM UMR1291 - CNRS UMR5051, University Toulouse III, Toulouse Cedex 3, F-31024, France.
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17
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Zhao D, Zhao C, Lu J, Han Y, Sun T, Ren K, Ma C, Zhang C, Li H, Guo J. Efficacy and safety of repeated low-dose rituximab therapy in relapsing-remitting multiple sclerosis: A retrospective case series study. Mult Scler Relat Disord 2023; 70:104518. [PMID: 36657326 DOI: 10.1016/j.msard.2023.104518] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/09/2023] [Accepted: 01/13/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Rituximab (RTX) is an extensively used off-label drug for multiple sclerosis (MS), whereas the induction and maintenance regimens vary widely among studies. Few data are available on efficacy and safety of repeated low-dose RTX therapy in MS patients. OBJECTIVE This study aimed to evaluate the efficacy and safety of repeated low-dose RTX therapy for relapsing-remitting MS (RRMS), the most common form of MS affecting approximately 85% of patients. METHODS Nine RRMS patients were enrolled and the medical records were retrospectively reviewed. RTX at 100 mg per week for three consecutive weeks was used as induction therapy. Maintenance therapy was reinfusions of RTX at 100 mg every 6 months during the first year, followed by 100 mg every 6 to 12 months. Main outcome measures included annualized relapse rate (ARR), expanded disability status scale (EDSS) score, and T2 lesion burden on MRI for evaluating the efficacy of low-dose RTX regimen. Meanwhile, adverse events (AEs) were recorded to assess the safety of repeated RTX infusions. RESULTS All patients were females with an average onset age of 25.4 ± 6.7 years. The median disease duration before the first RTX infusion was 56 (range, 3-108) months and the median follow-up period was 30 (range, 15-40) months. No relapses were recorded in all patients after RTX therapy. Repeated low-dose RTX therapy resulted in a dramatic reduction of median ARR (pre-RTX vs post-RTX, 1.1 vs 0, p = 0.012), median EDSS score (2.0 vs 0, p = 0.007), and the number of T2 lesions on MRI (35.6 ± 18.0 vs 29.4 ± 18.1, p = 0.001). A total of 35 episodes of AEs occurred during repeated low-dose RTX therapy, and all of them were mild and transient. CONCLUSION Repeated low-dose RTX therapy is cost-effective for RRMS patients and shows a good safety profile. It may be a promising option for those having no access or poor response to first-line disease-modified drugs (DMDs), particularly in low- or middle-income countries.
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Affiliation(s)
- Daidi Zhao
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China
| | - Cong Zhao
- Department of Neurology, Air Force Medical Center of PLA, Beijing 100142, China
| | - Jiarui Lu
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China
| | - Yu Han
- Department of Radiology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China
| | - Tangna Sun
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China
| | - Kaixi Ren
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China
| | - Chao Ma
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China
| | - Chao Zhang
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China
| | - Hongzeng Li
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China.
| | - Jun Guo
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an 710038, China.
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18
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Starvaggi Cucuzza C, Longinetti E, Ruffin N, Evertsson B, Kockum I, Jagodic M, Al Nimer F, Frisell T, Piehl F. Sustained Low Relapse Rate With Highly Variable B-Cell Repopulation Dynamics With Extended Rituximab Dosing Intervals in Multiple Sclerosis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200056. [PMID: 36411076 PMCID: PMC9749930 DOI: 10.1212/nxi.0000000000200056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/16/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVES B cell-depleting therapies are highly effective in relapsing-remitting multiple sclerosis (RRMS) but are associated with increased infection risk and blunted humoral vaccination responses. Extension of dosing intervals may mitigate such negative effects, but its consequences on MS disease activity are yet to be ascertained. The objective of this study was to determine clinical and neuroradiologic disease activity, as well as B-cell repopulation dynamics, after implementation of extended rituximab dosing in RRMS. METHODS We conducted a prospective observational study in a specialized-care, single-center setting, including patients with RRMS participating in the COMBAT-MS and MultipleMS observational drug trials, who had received at least 2 courses of rituximab (median follow-up 4.2 years, range 0.1-8.9 years). Using Cox regression, hazard ratios (HRs) of clinical relapse and/or contrast-enhancing lesions on MRI were calculated in relation to time since last dose of rituximab. RESULTS A total of 3,904 dose intervals were accumulated in 718 patients and stratified into 4 intervals: <8, ≥8 to 12, ≥12 to 18, and ≥18 months. We identified 24 relapses of which 20 occurred within 8 months since previous infusion and 4 with intervals over 8 months. HRs for relapse when comparing ≥8 to 12, ≥12 to 18, and ≥18 months with <8 months since last dose were 0.28 (95% CI 0.04-2.10), 0.38 (95% CI 0.05-2.94), and 0.89 (95% CI 0.20-4.04), respectively, and thus nonsignificant. Neuroradiologic outcomes mirrored relapse rates. Dynamics of total B-cell reconstitution varied considerably, but median total B-cell counts reached lower level of normal after 12 months and median memory B-cell counts after 16 months. DISCUSSION In this prospective cohort of rituximab-treated patients with RRMS exposed to extended dosing intervals, we could not detect a relation between clinical or neuroradiologic disease activity and time since last infusion. Total B- and memory B-cell repopulation kinetics varied considerably. These findings, relevant for assessing risk-mitigation strategies with anti-CD20 therapies in RRMS, suggest that relapse risk remains low with extended infusion intervals. Further studies are needed to investigate the relation between B-cell repopulation dynamics and adverse event risks associated with B-cell depletion.
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Affiliation(s)
- Chiara Starvaggi Cucuzza
- From the Department of Clinical Neuroscience (C.S.C., E.L., N.R., B.E., I.K., M.J., F.A.N., F.P.), Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine (C.S.C., N.R., I.K., M.J., F.A.N., F.P.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (B.E., F.P.), Karolinska University Hospital, Stockholm, Sweden; Center for Neurology (C.S.C., I.K., M.J., F.A.N., F.P.), Academic Specialist Center, Stockholm, Sweden; and Clinical Epidemiology Division (T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Elisa Longinetti
- From the Department of Clinical Neuroscience (C.S.C., E.L., N.R., B.E., I.K., M.J., F.A.N., F.P.), Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine (C.S.C., N.R., I.K., M.J., F.A.N., F.P.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (B.E., F.P.), Karolinska University Hospital, Stockholm, Sweden; Center for Neurology (C.S.C., I.K., M.J., F.A.N., F.P.), Academic Specialist Center, Stockholm, Sweden; and Clinical Epidemiology Division (T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Nicolas Ruffin
- From the Department of Clinical Neuroscience (C.S.C., E.L., N.R., B.E., I.K., M.J., F.A.N., F.P.), Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine (C.S.C., N.R., I.K., M.J., F.A.N., F.P.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (B.E., F.P.), Karolinska University Hospital, Stockholm, Sweden; Center for Neurology (C.S.C., I.K., M.J., F.A.N., F.P.), Academic Specialist Center, Stockholm, Sweden; and Clinical Epidemiology Division (T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Björn Evertsson
- From the Department of Clinical Neuroscience (C.S.C., E.L., N.R., B.E., I.K., M.J., F.A.N., F.P.), Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine (C.S.C., N.R., I.K., M.J., F.A.N., F.P.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (B.E., F.P.), Karolinska University Hospital, Stockholm, Sweden; Center for Neurology (C.S.C., I.K., M.J., F.A.N., F.P.), Academic Specialist Center, Stockholm, Sweden; and Clinical Epidemiology Division (T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Kockum
- From the Department of Clinical Neuroscience (C.S.C., E.L., N.R., B.E., I.K., M.J., F.A.N., F.P.), Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine (C.S.C., N.R., I.K., M.J., F.A.N., F.P.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (B.E., F.P.), Karolinska University Hospital, Stockholm, Sweden; Center for Neurology (C.S.C., I.K., M.J., F.A.N., F.P.), Academic Specialist Center, Stockholm, Sweden; and Clinical Epidemiology Division (T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Maja Jagodic
- From the Department of Clinical Neuroscience (C.S.C., E.L., N.R., B.E., I.K., M.J., F.A.N., F.P.), Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine (C.S.C., N.R., I.K., M.J., F.A.N., F.P.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (B.E., F.P.), Karolinska University Hospital, Stockholm, Sweden; Center for Neurology (C.S.C., I.K., M.J., F.A.N., F.P.), Academic Specialist Center, Stockholm, Sweden; and Clinical Epidemiology Division (T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Faiez Al Nimer
- From the Department of Clinical Neuroscience (C.S.C., E.L., N.R., B.E., I.K., M.J., F.A.N., F.P.), Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine (C.S.C., N.R., I.K., M.J., F.A.N., F.P.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (B.E., F.P.), Karolinska University Hospital, Stockholm, Sweden; Center for Neurology (C.S.C., I.K., M.J., F.A.N., F.P.), Academic Specialist Center, Stockholm, Sweden; and Clinical Epidemiology Division (T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- From the Department of Clinical Neuroscience (C.S.C., E.L., N.R., B.E., I.K., M.J., F.A.N., F.P.), Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine (C.S.C., N.R., I.K., M.J., F.A.N., F.P.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (B.E., F.P.), Karolinska University Hospital, Stockholm, Sweden; Center for Neurology (C.S.C., I.K., M.J., F.A.N., F.P.), Academic Specialist Center, Stockholm, Sweden; and Clinical Epidemiology Division (T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- From the Department of Clinical Neuroscience (C.S.C., E.L., N.R., B.E., I.K., M.J., F.A.N., F.P.), Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine (C.S.C., N.R., I.K., M.J., F.A.N., F.P.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (B.E., F.P.), Karolinska University Hospital, Stockholm, Sweden; Center for Neurology (C.S.C., I.K., M.J., F.A.N., F.P.), Academic Specialist Center, Stockholm, Sweden; and Clinical Epidemiology Division (T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
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19
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Smith JB, Gonzales EG, Li BH, Langer-Gould A. Analysis of Rituximab Use, Time Between Rituximab and SARS-CoV-2 Vaccination, and COVID-19 Hospitalization or Death in Patients With Multiple Sclerosis. JAMA Netw Open 2022; 5:e2248664. [PMID: 36576740 PMCID: PMC9857265 DOI: 10.1001/jamanetworkopen.2022.48664] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Rituximab and other B-cell-depleting therapies blunt humoral responses to SARS-CoV-2 vaccines, particularly when the vaccine is administered within 6 months of an infusion. Whether this translates into an increased risk of hospitalization or death from COVID-19 is unclear. OBJECTIVES To examine whether rituximab treatment is associated with an increased risk of hospitalization for COVID-19 among SARS-CoV-2-vaccinated persons with multiple sclerosis (MS) and whether delaying vaccination more than 6 months after rituximab treatment is associated with decreased risk. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used Kaiser Permanente Southern California's electronic health record to identify individuals from January 1, 2020, to February 15, 2022, who had MS and who had been vaccinated against SARS-CoV-2. EXPOSURES Rituximab treatment compared with disease-modifying therapies (DMTs) that do not interfere with vaccine efficacy or being untreated (no or other DMT group). Among rituximab-treated patients, the exposure was receiving at least 1 vaccine dose more than 6 months after their last infusion compared with receiving all vaccine doses 6 months or less since their last infusion. MAIN OUTCOMES AND MEASURES The main outcome was hospitalization due to COVID-19 infection. The odds of infection resulting in hospitalization following SARS-CoV-2 vaccination were adjusted for race and ethnicity, advanced MS-related disability; vaccine type; booster dose; and, among rituximab-treated only analyses, cumulative rituximab dose and dose at last infusion. Exposures, outcomes, and covariates were collected from the electronic health record. RESULTS Among 3974 SARS-CoV-2-vaccinated people with MS (mean [SD] age, 55.3 [15] years; 2982 [75.0%] female; 103 [2.6%] Asian or Pacific Islander; 634 [16.0%] Black; 953 [24.0%] Hispanic; 2269 [57.1%] White; and 15 [0.3%] other race or ethnicity), rituximab-treated patients (n = 1516) were more likely to be hospitalized (n = 27) but not die (n = 0) compared with the 2458 individuals with MS receiving no or other DMTs (n = 7 and n = 0, respectively; adjusted odds ratio [aOR] for hospitalization, 7.33; 95% CI, 3.05-17.63). Receiving messenger RNA (mRNA) SARS-CoV-2 vaccine (aOR, 0.36; 95% CI, 0.15-0.90; P = .03) and receiving a booster vaccination (aOR, 0.31; 95% CI, 0.15-0.64; P = .002) were independently associated with a decreased risk of hospitalization for COVID-19. Among vaccinated rituximab-treated individuals with MS, receiving any vaccination dose more than 6 months after the last rituximab infusion was associated with a reduced risk of COVID-19 hospitalization (aOR, 0.22; 95% CI, 0.10-0.49). CONCLUSIONS AND RELEVANCE This cohort study's findings suggest that rituximab-treated people with MS should be strongly encouraged to receive mRNA SARS-CoV-2 vaccines and boosters more than 6 months after their last rituximab infusion whenever possible. The low absolute risk of hospitalization for COVID-19 among mRNA-vaccinated individuals with MS should not preclude use of rituximab, which has marked efficacy, cost, and convenience advantages over other DMTs.
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Affiliation(s)
- Jessica B. Smith
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena
| | - Edlin G. Gonzales
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena
| | - Bonnie H. Li
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena
| | - Annette Langer-Gould
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles
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20
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Lycke J, Svenningsson A. Long-term treatment with anti-CD20 monoclonal antibodies is untenable because of risk: Commentary. Mult Scler 2022; 28:1177-1178. [PMID: 35678609 PMCID: PMC9189590 DOI: 10.1177/13524585221101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jan Lycke
- J Lycke Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå stråket 7, Sahlgrenska University Hospital, Gothenburg 415 45, Sweden.
| | - Anders Svenningsson
- Department of Clinical Sciences and Department of Neurology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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21
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Dorcet G, Migné H, Biotti D, Bost C, Lerebours F, Ciron J, Treiner E. Early B cells repopulation in multiple sclerosis patients treated with rituximab is not predictive of a risk of relapse or clinical progression. J Neurol 2022; 269:5443-5453. [PMID: 35652942 PMCID: PMC9159933 DOI: 10.1007/s00415-022-11197-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/12/2022] [Accepted: 05/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND It is currently unknown whether early B cell reconstitution (EBR) in MS patients under rituximab is associated with a risk of relapse or progression. OBJECTIVES Analyzing EBR in rituximab-treated patients and its putative association with clinical findings. METHODS Prospective lymphocytes immunophenotyping was performed in a monocentric cohort of MS patients treated by rituximab for 2 years. EBR was defined when B cells concentration was > 5 cells/mm3. B cell subsets were retrospectively associated with clinical data. Clinical and radiological monitoring included relapses, EDSS (Expanded Disability Status Scale), SDMT (Symbol Digit Modalities Test), and MRI. RESULTS 182 patients were analyzed (61 remitting-relapsing and 121 progressive-active). 38.5% experienced EBR at least once, but very few (7/182) showed systematic reconstitution. Most patients remained stable upon treatment, regardless of the occurrence of EBR. Dynamics of B cell reconstitution featured increased naïve/transitional B cells, and decreased memory subsets. Homeostasis of the B cell compartment differed at baseline between patients experiencing or not EBR upon treatment. In patients with EBR, reciprocal dynamics of transitional and pro-inflammatory double-negative B cell subsets was associated with better response to rituximab treatment. CONCLUSION EBR is common in rituximab-treated MS patients and is not associated with clinical disease activity. EBR in the peripheral blood may reflect regulatory immunological phenomena in subgroup of patients.
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Affiliation(s)
- Guillaume Dorcet
- Department of Neurology, CRC-SEP, University Hospital of Toulouse, Toulouse, France.,INSERM U1291-CNRS 5051, INFINITy, Toulouse, France
| | - Hugo Migné
- Immunology Laboratory, Biology Department, University Hospital of Toulouse, Toulouse, France
| | - Damien Biotti
- Department of Neurology, CRC-SEP, University Hospital of Toulouse, Toulouse, France.,INSERM U1291-CNRS 5051, INFINITy, Toulouse, France
| | - Chloé Bost
- INSERM U1291-CNRS 5051, INFINITy, Toulouse, France.,Immunology Laboratory, Biology Department, University Hospital of Toulouse, Toulouse, France
| | - Fleur Lerebours
- Department of Neurology, CRC-SEP, University Hospital of Toulouse, Toulouse, France
| | - Jonathan Ciron
- Department of Neurology, CRC-SEP, University Hospital of Toulouse, Toulouse, France.,INSERM U1291-CNRS 5051, INFINITy, Toulouse, France
| | - Emmanuel Treiner
- INSERM U1291-CNRS 5051, INFINITy, Toulouse, France. .,Immunology Laboratory, Biology Department, University Hospital of Toulouse, Toulouse, France.
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22
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Moreira A, Munteis E, Vera A, Macías Gómez A, Bertrán Recasens B, Rubio Pérez MÁ, Llop M, Martínez-Rodríguez JE. Delayed B cell repopulation after rituximab treatment in multiple sclerosis patients with expanded adaptive NK cells. Eur J Neurol 2022; 29:2015-2023. [PMID: 35247022 PMCID: PMC9310749 DOI: 10.1111/ene.15312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/23/2022] [Accepted: 02/25/2022] [Indexed: 11/29/2022]
Abstract
Background and purpose The aim was to evaluate whether adaptive NKG2C+ natural killer (NK) cells, characterized by enhanced antibody‐dependent cell cytotoxicity (ADCC), may influence time to B cell repopulation after rituximab treatment in multiple sclerosis (MS) patients. Methods This was a prospective observational study of MS patients treated with rituximab monitoring peripheral B cells for repeated doses. B cell repopulation was defined as CD19+ cells above 2% of total lymphocytes, classifying cases according to the median time of B cell repopulation as early or late (≤9 months, >9 months, respectively). Basal NK cell immunophenotype and in vitro ADCC responses induced by rituximab were assessed by flow cytometry. Results B cell repopulation in 38 patients (24 relapsing–remitting MS [RRMS]; 14 progressive MS) was classified as early (≤9 months, n = 19) or late (>9 months, n = 19). RRMS patients with late B cell repopulation had higher proportions of NKG2C+ NK cells compared to those with early repopulation (24.7% ± 16.2% vs. 11.3% ± 10.4%, p < 0.05), and a direct correlation between time to B cell repopulation and percentage of NKG2C+ NK cells (R 0.45, p < 0.05) was observed. RRMS cases with late repopulation compared with early repopulation had a higher secretion of tumor necrosis factor α and interferon γ by NK cells after rituximab‐dependent NK cell activation. The NK cell immunophenotype appeared unrelated to B cell repopulation in progressive MS patients. Conclusions Adaptive NKG2C+ NK cells in RRMS may be associated with delayed B cell repopulation after rituximab, a finding probably related to enhanced depletion of B cells exerted by NK‐cell‐mediated ADCC, pointing to the use of personalized regimens with anti‐CD20 monoclonal antibody therapy in some patients.
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Affiliation(s)
- Antía Moreira
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.,Hospital Universitari d'Igualada, Barcelona, Spain
| | - Elvira Munteis
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.,Departament de Medicina, Universitat de Barcelona, Spain
| | - Andrea Vera
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Adrián Macías Gómez
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Bernat Bertrán Recasens
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Miguel Ángel Rubio Pérez
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Mireia Llop
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Jose E Martínez-Rodríguez
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
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23
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van Kempen ZLE, Toorop AA, Sellebjerg F, Giovannoni G, Killestein J. Extended dosing of monoclonal antibodies in multiple sclerosis. Mult Scler 2021; 28:2001-2009. [PMID: 34949134 DOI: 10.1177/13524585211065711] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the past two decades, treatment options for patients with multiple sclerosis (MS) have increased exponentially. In the current therapeutic landscape, "no evidence of MS disease activity" is within reach in many of our patients. Minimizing risks of complications, improving treatment convenience, and decreasing health care costs are goals that are yet to be reached. One way to optimize MS therapy is to implement personalized or extended interval dosing. Monoclonal antibodies are suitable candidates for personalized dosing (by therapeutic drug monitoring) or extended interval dosing. An increasing number of studies are performed and underway reporting on altered dosing intervals of anti-α4β1-integrin treatment (natalizumab) and anti-CD20 treatment (ocrelizumab, rituximab, and ofatumumab) in MS. In this review, current available evidence regarding personalized and extended interval dosing of monoclonal antibodies in MS is discussed with recommendations for future research and clinical practice.
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Affiliation(s)
- Zoé LE van Kempen
- MS Center Amsterdam, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
| | - Alyssa A Toorop
- MS Center Amsterdam Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gavin Giovannoni
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Joep Killestein
- MS Center Amsterdam Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
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24
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Rico A, Ninove L, Maarouf A, Boutiere C, Durozard P, Demortiere S, Saba Villarroel PM, Amroun A, Fourié T, de Lamballerie X, Pelletier J, Audoin B. Determining the best window for BNT162b2 mRNA vaccination for SARS-CoV-2 in patients with multiple sclerosis receiving anti-CD20 therapy. Mult Scler J Exp Transl Clin 2021; 7:20552173211062142. [PMID: 34925877 PMCID: PMC8673883 DOI: 10.1177/20552173211062142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
We studied the serologic response to the BNT162b2 mRNA vaccine at four weeks after the second dose in patients with RRMS treated with rituximab with extended-interval dosing (n = 26). At four weeks, 73% of patients were seropositive. No patient without B cells at the first dose (n = 4) was seropositive. Four of seven (57%) patients with B-cell proportion >0% and ≤5% were seropositive. All patients with B-cell proportion >5% (n = 15) were seropositive. In all patients, quantitative ELISA measures after vaccination were correlated with B-cell counts measured before vaccination. In patients receiving rituximab, seropositivity after BNT162b2 mRNA vaccination emerged only after B-cell repopulation.
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Affiliation(s)
- Audrey Rico
- Department of Neurology, Aix-Marseille University, University Hospital of Marseille, Marseille, France
| | - Laetitia Ninove
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207), Marseille, France
| | - Adil Maarouf
- Department of Neurology, Aix-Marseille University, University Hospital of Marseille, Marseille, France
| | - Clémence Boutiere
- Department of Neurology, Aix-Marseille University, University Hospital of Marseille, Marseille, France
| | - Pierre Durozard
- Department of Neurology, Aix-Marseille University, University Hospital of Marseille, Marseille, France
| | - Sarah Demortiere
- Department of Neurology, Aix-Marseille University, University Hospital of Marseille, Marseille, France
| | | | - Abdennour Amroun
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207), Marseille, France
| | - Toscane Fourié
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207), Marseille, France
| | - Xavier de Lamballerie
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207), Marseille, France
| | - Jean Pelletier
- Department of Neurology, Aix-Marseille University, University Hospital of Marseille, Marseille, France
| | - Bertrand Audoin
- Department of Neurology, Aix-Marseille University, University Hospital of Marseille, Marseille, France
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25
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Disanto G, Sacco R, Bernasconi E, Martinetti G, Keller F, Gobbi C, Zecca C. Association of Disease-Modifying Treatment and Anti-CD20 Infusion Timing With Humoral Response to 2 SARS-CoV-2 Vaccines in Patients With Multiple Sclerosis. JAMA Neurol 2021; 78:1529-1531. [PMID: 34554185 DOI: 10.1001/jamaneurol.2021.3609] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Giulio Disanto
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Rosaria Sacco
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Enos Bernasconi
- Department of Medicine, Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.,University of Geneva, Geneva, Switzerland
| | - Gladys Martinetti
- Institute of Laboratory Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Franco Keller
- Institute of Laboratory Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Claudio Gobbi
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Chiara Zecca
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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26
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Abstract
BACKGROUND Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off-label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high-income countries where on-label disease-modifying treatments (DMTs) are available. OBJECTIVES: To assess beneficial and adverse effects of rituximab as 'first choice' and as 'switching' for adults with MS. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and trial registers for completed and ongoing studies on 31 January 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) and controlled non-randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with MS. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. We used the Cochrane Collaboration's tool for assessing risk of bias. We rated the certainty of evidence using GRADE for: disability worsening, relapse, serious adverse events (SAEs), health-related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching', relapsing or progressive MS, comparison versus placebo or another DMT, and RCTs or NRSIs. MAIN RESULTS We included 15 studies (5 RCTs, 10 NRSIs) with 16,429 participants of whom 13,143 were relapsing MS and 3286 progressive MS. The studies were one to two years long and compared rituximab as 'first choice' with placebo (1 RCT) or other DMTs (1 NRSI), rituximab as 'switching' against placebo (2 RCTs) or other DMTs (2 RCTs, 9 NRSIs). The studies were conducted worldwide; most originated from high-income countries, six from the Swedish MS register. Pharmaceutical companies funded two studies. We identified 14 ongoing studies. Rituximab as 'first choice' for relapsing MS Rituximab versus placebo: no studies met eligibility criteria for this comparison. Rituximab versus other DMTs: one NRSI compared rituximab with interferon beta or glatiramer acetate, dimethyl fumarate, natalizumab, or fingolimod in active relapsing MS at 24 months' follow-up. Rituximab likely results in a large reduction in relapses compared with interferon beta or glatiramer acetate (hazard ratio (HR) 0.14, 95% confidence interval (CI) 0.05 to 0.39; 335 participants; moderate-certainty evidence). Rituximab may reduce relapses compared with dimethyl fumarate (HR 0.29, 95% CI 0.08 to 1.00; 206 participants; low-certainty evidence) and natalizumab (HR 0.24, 95% CI 0.06 to 1.00; 170 participants; low-certainty evidence). It may make little or no difference on relapse compared with fingolimod (HR 0.26, 95% CI 0.04 to 1.69; 137 participants; very low-certainty evidence). The study reported no deaths over 24 months. The study did not measure disability worsening, SAEs, HRQoL, and common infections. Rituximab as 'first choice' for progressive MS One RCT compared rituximab with placebo in primary progressive MS at 24 months' follow-up. Rituximab likely results in little to no difference in the number of participants who have disability worsening compared with placebo (odds ratio (OR) 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate-certainty evidence). Rituximab may result in little to no difference in recurrence of relapses (OR 0.60, 95% CI 0.18 to 1.99; 439 participants; low-certainty evidence), SAEs (OR 1.25, 95% CI 0.71 to 2.20; 439 participants; low-certainty evidence), common infections (OR 1.14, 95% CI 0.75 to 1.73; 439 participants; low-certainty evidence), cancer (OR 0.50, 95% CI 0.07 to 3.59; 439 participants; low-certainty evidence), and mortality (OR 0.25, 95% CI 0.02 to 2.77; 439 participants; low-certainty evidence). The study did not measure HRQoL. Rituximab versus other DMTs: no studies met eligibility criteria for this comparison. Rituximab as 'switching' for relapsing MS One RCT compared rituximab with placebo in relapsing MS at 12 months' follow-up. Rituximab may decrease recurrence of relapses compared with placebo (OR 0.38, 95% CI 0.16 to 0.93; 104 participants; low-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to placebo on SAEs (OR 0.90, 95% CI 0.28 to 2.92; 104 participants; very low-certainty evidence), common infections (OR 0.91, 95% CI 0.37 to 2.24; 104 participants; very low-certainty evidence), cancer (OR 1.55, 95% CI 0.06 to 39.15; 104 participants; very low-certainty evidence), and mortality (OR 1.55, 95% CI 0.06 to 39.15; 104 participants; very low-certainty evidence). The study did not measure disability worsening and HRQoL. Five NRSIs compared rituximab with other DMTs in relapsing MS at 24 months' follow-up. The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to interferon beta or glatiramer acetate on disability worsening (HR 0.86, 95% CI 0.52 to 1.42; 1 NRSI, 853 participants; very low-certainty evidence). Rituximab likely results in a large reduction in relapses compared with interferon beta or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 NRSI, 1383 participants; moderate-certainty evidence); and fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 NRSI, 256 participants; moderate-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to natalizumab on relapses (HR 1.0, 95% CI 0.2 to 5.0; 1 NRSI, 153 participants; very low-certainty evidence). Rituximab likely increases slightly common infections compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 NRSI, 5477 participants; moderate-certainty evidence); and compared with natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 NRSIs, 5001 participants; moderate-certainty evidence). Rituximab may increase slightly common infections compared with fingolimod (OR 1.26, 95% CI 0.90 to 1.77; 3 NRSIs, 5187 participants; low-certainty evidence). It may make little or no difference compared with ocrelizumab (OR 0.02, 95% CI 0.00 to 0.40; 1 NRSI, 472 participants; very low-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab on mortality compared with fingolimod (OR 5.59, 95% CI 0.22 to 139.89; 1 NRSI, 136 participants; very low-certainty evidence) and natalizumab (OR 6.66, 95% CI 0.27 to 166.58; 1 NRSI, 153 participants; very low-certainty evidence). The included studies did not measure SAEs, HRQoL, and cancer. AUTHORS' CONCLUSIONS For preventing relapses in relapsing MS, rituximab as 'first choice' and as 'switching' may compare favourably with a wide range of approved DMTs. A protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab for progressive MS. The evidence is uncertain about the effect of rituximab on SAEs. They are relatively rare in people with MS, thus difficult to study, and they were not well reported in studies. There is an increased risk of common infections with rituximab, but absolute risk is small. Rituximab is widely used as off-label treatment in people with MS; however, randomised evidence is weak. In the absence of randomised evidence, remaining uncertainties on beneficial and adverse effects of rituximab for MS might be clarified by making real-world data available.
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Affiliation(s)
- Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Jera Kruja
- Neurology, UHC Mother Theresa, University of Medicine, Tirana, Albania
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
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