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Carnero Contentti E, Lopez PA, Patrucco L, Cristiano E, Miguez J, Silva B, Liwacki S, Tkachuk V, Balbuena ME, Vrech C, Deri N, Correale J, Marrodan M, Ysrraelit MC, Fiol M, Leguizamon F, Luetic G, Tavolini D, Mainella C, Zanga G, Burgos M, Hryb J, Barboza A, Lazaro L, Alonso R, Fernández Liguori N, Nadur D, Martinez A, Steinberg J, Carrá A, Alonso Serena M, Rojas JI. Traditional first-line treatment failure rates in neuromyelitis optica spectrum disorder patients included in the Argentinean registry (RelevarEM). Mult Scler Relat Disord 2024; 89:105771. [PMID: 39033591 DOI: 10.1016/j.msard.2024.105771] [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: 02/26/2024] [Revised: 05/29/2024] [Accepted: 07/14/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Immunosuppressive therapies as azathioprine (AZA), mycophenolate mofetil (MMF) and rituximab (RTX) are widely prescribed as first-line treatment to prevent relapses in NMOSD. However, the rate of response to these traditional therapies is unknown in Argentina. We aimed to describe and compare treatment failure rates in NMOSD patients included in the Argentinean MS and NMOSD registry (RelevarEM, NCT03375177). METHODS A retrospective cohort study was conducted in NMOSD patients included in RelevarEM (a nationwide, longitudinal, observational, non-mandatory registry of MS and NMOSD in Argentina). NMOSD patients were defined based on validate diagnostic criteria. Only NMOSD patients who received AZA or MMF for at least 6 months or RTX for at least 1 month were included. Patients who were receiving AZA, MMF, or RTX and then switched to another 1 of these 3 therapies were included if the above-mentioned criteria for each drug were fulfilled. Data on patient demographics, clinical, neuroradiological findings, and treatments administered were collected. Treatment failure was defined as any new attack/relapse that occurred despite immunosuppressive treatment. RESULTS We included 139 NMOSD patients who were receiving AZA (n = 105), MMF (n = 5) or RTX (n = 29) with a mean follow-up time of 41.3 ± 11.4 months and median of EDSS at treatment initiation of 3. We observed a reduction in the annualized relapse rate from pre-treatment to post-treatment of 51.1 %, 48.4 %, and 79.1 % respectively with a Hazard Risk relative to RTX (95 % CI) of 1.67 (1.34-3.54, p = 0.01) for AZA and 2.01 (1.86-4.43, p = 0.008) for MMF. AZA, MMF and RTX failure was observed in 45/105 (42.8 %), 2/5 (40 %) and 3/29 (10.3 %) patients, respectively. CONCLUSIONS Treatment failure rates were higher for AZA and MMF than RTX in Argentinean NMOSD patients in a real-world setting. High-efficacy treatment increases the opportunity to prevent attacks of NMOSD.
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Affiliation(s)
- Edgar Carnero Contentti
- Neuroimmunology Unit, Department of Neurosciences, Hospital Aleman, Buenos Aires, Argentina.
| | - Pablo A Lopez
- Neuroimmunology Unit, Department of Neurosciences, Hospital Aleman, Buenos Aires, Argentina
| | - Liliana Patrucco
- Centro Esclerosis Múltiple Buenos Aires (CEMBA)Buenos Aires, Argentina
| | - Edgardo Cristiano
- Centro Esclerosis Múltiple Buenos Aires (CEMBA)Buenos Aires, Argentina
| | - Jimena Miguez
- Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Berenice Silva
- Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Neurology Department, Hospital JM Ramos Mejia, Buenos Aires, Argentina
| | - Susana Liwacki
- Neurology Unit, Hospital Córdoba, Córdoba, Argentina; Clínica Universitaria Reina Fabiola, Córdoba, Argentina
| | - Verónica Tkachuk
- Neuroimmunology Unit, Neurology Department, Hospital de Clínicas, Buenos Aires, Argentina
| | - María E Balbuena
- Neuroimmunology Unit, Neurology Department, Hospital de Clínicas, Buenos Aires, Argentina
| | - Carlos Vrech
- Neurology Department, Sanatorio Allende, Córdoba, Argentina
| | - Norma Deri
- CENyR, Ciudad de Buenos Aires, Buenos Aires, Argentina
| | | | | | | | - Marcela Fiol
- Neurology Department, Fleni, Buenos Aires, Argentina
| | - Felisa Leguizamon
- Neurology Department, Hospital de Agudos Dr. Teodoro Álvarez, Buenos Aires, Argentina
| | - Geraldine Luetic
- Neurology Department, Instituto de Neurocienciencias, Rosario, Argentina
| | - Darío Tavolini
- Neurology Department, INECO Neurociencias Oroño, Santa Fe, Argentina
| | - Carolina Mainella
- Neurology Department, Hospital Español de Rosario, Santa Fe, Argentina
| | - Gisela Zanga
- Neurology Department, Unidad Asistencial César Milstein, Buenos Aires, Argentina
| | - Marcos Burgos
- Neurology Department, Hospital San Bernardo, Salta, Argentina
| | - Javier Hryb
- Neurology Department, Hospital de Agudos Dr. Carlos G. Durand, Buenos Aires, Argentina
| | - Andrés Barboza
- Neurology Department, Hospital Central de Mendoza, Mendoza, Argentina
| | - Luciana Lazaro
- Neurology Department, Sanatorio Guemes, Buenos Aires, Argentina
| | - Ricardo Alonso
- Neurology Department, Hospital JM Ramos Mejia, Buenos Aires, Argentina; Neurology Department, Sanatorio Guemes, Buenos Aires, Argentina
| | | | - Débora Nadur
- Neuroimmunology Unit, Neurology Department, Hospital de Clínicas, Buenos Aires, Argentina
| | - Alejandra Martinez
- Neurology Department, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Judith Steinberg
- Neurology Department, Private office, Lujan, Buenos Aires, Argentina
| | - Adriana Carrá
- Neurology Department, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Marina Alonso Serena
- Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan I Rojas
- Centro Esclerosis Múltiple Buenos Aires (CEMBA)Buenos Aires, Argentina
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Cobo-Calvo Á, Gómez-Ballesteros R, Orviz A, Díaz Sánchez M, Boyero S, Aguado-Valcarcel M, Sepúlveda M, Rebollo P, López-Laiz P, Maurino J, Téllez Lara N. Therapeutic inertia in the management of neuromyelitis optica spectrum disorder. Front Neurol 2024; 15:1341473. [PMID: 38450077 PMCID: PMC10915282 DOI: 10.3389/fneur.2024.1341473] [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: 11/20/2023] [Accepted: 02/02/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction and objective Limited information is available on how neurologists make therapeutic decisions in neuromyelitis optica spectrum disorder (NMOSD), especially when new treatments with different mechanisms of action, administration, and safety profile are being approved. Decision-making can be complex under this uncertainty and may lead to therapeutic inertia (TI), which refers to lack of treatment initiation or intensification when therapeutic goals are not met. The study aim was to assess neurologists' TI in NMOSD. Methods An online, cross-sectional study was conducted in collaboration with the Spanish Society of Neurology. Neurologists answered a survey composed of demographic characteristics, professional background, and behavioral traits. TI was defined as the lack of initiation or intensification with high-efficacy treatments when there is evidence of disease activity and was assessed through five NMOSD aquaporin-4 positive (AQP4+) simulated case scenarios. A multivariate logistic regression analysis was used to determine the association between neurologists' characteristics and TI. Results A total of 78 neurologists were included (median interquartile range [IQR] age: 36.0 [29.0-46.0] years, 55.1% male, median [IQR] experience managing demyelinating conditions was 5.2 [3.0-11.1] years). The majority of participants were general neurologists (59.0%) attending a median (IQR) of 5.0 NMOSD patients (3.0-12.0) annually. Thirty participants (38.5%) were classified as having TI. Working in a low complexity hospital and giving high importance to patient's tolerability/safety when choosing a treatment were predictors of TI. Conclusion TI is a common phenomenon among neurologists managing NMOSD AQP4+. Identifying TI and implementing specific intervention strategies may be critical to improving therapeutic decisions and patient care.
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Affiliation(s)
- Álvaro Cobo-Calvo
- Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Aida Orviz
- Department of Neurology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - María Díaz Sánchez
- Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Sabas Boyero
- Department of Neurology, Hospital Universitario Cruces, Bilbao, Spain
| | | | - María Sepúlveda
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | | | | | - Nieves Téllez Lara
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Carlsson O, Jonsson DI, Brundin L, Iacobaeus E. Relapses and Serious Infections in Patients with Neuromyelitis Optica Spectrum Disorder Treated with Rituximab: A Swedish Single-Center Study. J Clin Med 2024; 13:355. [PMID: 38256489 PMCID: PMC10816065 DOI: 10.3390/jcm13020355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare immune-mediated relapsing-remitting disease of the central nervous system. The usage of rituximab, as relapse-preventive therapy, in NMOSD is common. We performed a single-center retrospective cohort study to assess the risk of relapses and severe infectious events (SIEs) in rituximab-treated NMOSD patients. This study included 24 aquaporin-4 IgG+ (AQP4+), 8 myelin-oligodendrocyte-protein IgG+ (MOG+), and 10 double-seronegative NMOSD patients. Relapses were observed in 50% of all patients during a mean treatment time of 4.0 (range: 0.5-8.25) years. The incidence risk ratio (IRR) of relapse was three times higher in MOG+ compared to AQP4+ patients (IRR: 3.0, 95% confidence interval (CI); 1.2-7.7). SIEs occurred in 40% of all patients during follow-up. AQP4+ patients conferred an increased risk of SIEs compared to MOG+ patients (IRR; 5.3, 95% CI; 1.2-24.3). Incomplete CD19+ B-lymphocyte suppression was not correlated with relapse risk (hazard ratio; 1.9, 95% CI; 0.7-5.2), and there was no correlation between IgG-levels and SIE risk (odds ratio; 2.0, 95% CI; 0.8-4.8). In conclusion, considerable risks of both relapses and SIEs were observed in NMOSD patients exposed to rituximab, which underlines the need for close clinical vigilance of disease activity and infections during treatment.
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Affiliation(s)
- Olof Carlsson
- Department of Clinical Neuroscience, Karolinska Institute, 171 64 Solna, Sweden; (O.C.); (D.I.J.); (L.B.)
- Department of Neurology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Dagur Ingi Jonsson
- Department of Clinical Neuroscience, Karolinska Institute, 171 64 Solna, Sweden; (O.C.); (D.I.J.); (L.B.)
- Department of Neurophysiology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Lou Brundin
- Department of Clinical Neuroscience, Karolinska Institute, 171 64 Solna, Sweden; (O.C.); (D.I.J.); (L.B.)
- Department of Neurology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Ellen Iacobaeus
- Department of Clinical Neuroscience, Karolinska Institute, 171 64 Solna, Sweden; (O.C.); (D.I.J.); (L.B.)
- Department of Neurology, Karolinska University Hospital, 171 76 Stockholm, Sweden
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Okuda DT, Moog TM, McCreary M, Cook K, Burgess KW, Smith AD. Treatment transitions in neuromyelitis optica spectrum disorder increase risk for disease advancement. Mult Scler Relat Disord 2023; 79:105041. [PMID: 37804767 DOI: 10.1016/j.msard.2023.105041] [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: 07/06/2023] [Revised: 08/14/2023] [Accepted: 09/28/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND People with neuromyelitis optica spectrum disorder (PwNMOSD) commonly switch between disease modifying therapies, yet the consequence of transitions remains unknown. We aimed to understand if treatment transitions due to medical, non-medical, and tolerability reasons were related to disease progression. METHODS A retrospective study of medical records for PwNMOSD was performed between 2008 and 2022. A comprehensive clinical timeline was created for each person including details related to treatment history and associated clinical and radiological outcomes (i.e., hospital admission, relapses, and MRI advancement). If a transition occurred, the reason for the switch was categorized as being due to medical, non-medical, or tolerability issues. A proportional hazards model was created, and the assumptions were tested based on weighted residuals. RESULTS The cohort included 164 aquaporin-4 IgG positive NMOSD subjects with 89 (79 female; median disease duration (range) = 10.1 years (y) (1.7-32.8)) people switching therapies at least once (once: 42; twice: 26; three times: 12; four times: 6; 5 or more times: 3). A similar amount of higher efficacy therapies was used by PwNMOSD that switched due to a non-medical/tolerability or a medical-related reason. The results of the recurrent event survival analysis revealed that after an initial transition due to non-medical/tolerability reasons, the risk of a hospital admission, relapse, and MRI advancement decreases by 40.3 % (p = 0.005), 53.1 % (p = 0.002), and 65.9 % (p = 0.005), respectively. However, with each additional discontinuation due to non-medical/tolerability reasons, the risk of hospitalization increased by 25.2 % (p = 0.0003) and risk for MRI advancement increased by 41.9 % (p = 0.03). For transitions due to medical reasons, a significant increased risk of MRI advancement by 32.2 % (p = 0.005) for the first switch was identified with no associated observed risk with each additional discontinuation (p = 0.33). Within the first six months after stopping a medication due to non-medical/tolerability reasons, the rate of starting a new medication was less (p<0.0001) when compared to a discontinuation due to a medical-related event. CONCLUSIONS The risk associated with the time course of treatment transitions for people with NMOSD may assist in transforming the way healthcare providers bridge the gap between therapies and the approach to the timing of a switch. These data highlight additional factors that may be equatable to the efficacy of prescribed treatments in the prevention of acute neurological events.
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Affiliation(s)
- Darin T Okuda
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA; Revert Health Inc., Coppell, TX, USA.
| | - Tatum M Moog
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Morgan McCreary
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karin Cook
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katy W Burgess
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alexander D Smith
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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