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Nawar AA, Farid AM, Wally R, Tharwat EK, Sameh A, Elkaramany Y, Asla MM, Kamel WA. Efficacy and safety of stem cell transplantation for multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2024; 14:12545. [PMID: 38822024 PMCID: PMC11143245 DOI: 10.1038/s41598-024-62726-4] [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: 10/01/2023] [Accepted: 05/21/2024] [Indexed: 06/02/2024] Open
Abstract
Multiple sclerosis (MS) is a common autoimmune neurological disease affecting patients' motor, sensory, and visual performance. Stem Cell Transplantation (SCT) is a medical intervention where a patient is infused with healthy stem cells with the purpose of resetting their immune system. SCT shows remyelinating and immunomodulatory functions in MS patients, representing a potential therapeutic option. We conducted this systematic review and meta-analysis that included randomized control trials (RCTs) of SCT in MS patients to investigate its clinical efficacy and safety, excluding observational and non-English studies. After systematically searching PubMed, Web of Science, Scopus, and Cochrane Library until January 7, 2024, nine RCTs, including 422 patients, were eligible. We assessed the risk of bias (ROB) in these RCTs using Cochrane ROB Tool 1. Data were synthesized using Review Manager version 5.4 and OpenMeta Analyst software. We also conducted subgroup and sensitivity analyses. SCT significantly improved patients expanded disability status scale after 2 months (N = 39, MD = - 0.57, 95% CI [- 1.08, - 0.06], p = 0.03). SCT also reduced brain lesion volume (N = 136, MD = - 7.05, 95% CI [- 10.69, - 3.4], p = 0.0002). The effect on EDSS at 6 and 12 months, timed 25-foot walk (T25-FW), and brain lesions number was nonsignificant. Significant adverse events (AEs) included local reactions at MSCs infusion site (N = 25, RR = 2.55, 95% CI [1.08, 6.03], p = 0.034) and hematological disorders in patients received immunosuppression and autologous hematopoietic SCT (AHSCT) (N = 16, RR = 2.33, 95% CI [1.23, 4.39], p = 0.009). SCT can improve the disability of MS patients and reduce their brain lesion volume. The transplantation was generally safe and tolerated, with no mortality or significant serious AEs, except for infusion site reactions after mesenchymal SCT and hematological AEs after AHSCT. However, generalizing our results is limited by the sparse number of RCTs conducted on AHSCT. Our protocol was registered on PROSPERO with a registration number: CRD42022324141.
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Affiliation(s)
| | | | - Rim Wally
- Faculty of Dentistry, Suez Canal University, Ismailia, Egypt
| | - Engy K Tharwat
- Bioinformatics Group, Centre for Informatics Science, School of Information Technology and Computer Science, Nile University, Giza, Egypt
| | - Ahmed Sameh
- Biotechnology Department, Faculty of Science, Cairo University, Giza, Egypt
| | - Yomna Elkaramany
- Biotechnology Department, Faculty of Science, Cairo University, Giza, Egypt
| | | | - Walaa A Kamel
- Neurology Department, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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2
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Volz T, Sippel A, Fischbach F, Richter J, Willison AG, Häußler V, Heesen C. "A second birthday"? Experiences of persons with multiple sclerosis treated with autologous hematopoietic stem cell transplantation-a qualitative interview study. Front Neurol 2024; 15:1384551. [PMID: 38751886 PMCID: PMC11094363 DOI: 10.3389/fneur.2024.1384551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction and objective Autologous hematopoietic stem cell transplantation (aHSCT) is a promising treatment option for persons with multiple sclerosis (pwMS). Patients undergoing aHSCT face unique challenges in all aspects of life. In this study, we explored the lived experiences of pwMS undergoing aHSCT. Methods Semi-structured interviews of 12 pwMS treated with aHSCT were conducted using a maximum variation sampling strategy. Interviews were transcribed verbatim and analyzed thematically using inductive and deductive categories. Results Three major themes were identified: (1) preparing for aHSCT, (2) experiencing the procedure, and (3) post-treatment time. A difficult decision-making process, organizational effort, and funding difficulties characterized the preparation for transplantation. AHSCT was seen as a life-changing event accompanied by both psychological and physical stress, with an associated feeling of regaining control. The transplantation had a lasting positive effect on the lives of the interviewed pwMS. However, the early post-treatment time was characterized by successes and failures alike. Particularly the independently organized medical aftercare was perceived as challenging. Retrospective revaluation has led most pwMS to wish for earlier information provision about the treatment option of aHSCT during their treatment history. Conclusion AHSCT had a clear impact on patients' physical and psycho-social health, influencing their perception of life and its quality. Assessing and attending to unmet needs of patients before, during, and after transplantation may positively influence their experience of aHSCT.
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Affiliation(s)
- Timo Volz
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Anna Sippel
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Felix Fischbach
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Department of Neurology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Johanna Richter
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Alice Grizzel Willison
- Department of Neurology, Medical Faculty University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Vivien Häußler
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Department of Neurology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Christoph Heesen
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Department of Neurology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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3
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Ross LA, Stropp LM, Cohen JA. Autologous Hematopoietic Stem Cell Transplantation to Treat Multiple Sclerosis. Neurol Clin 2024; 42:165-184. [PMID: 37980114 DOI: 10.1016/j.ncl.2023.06.002] [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: 11/20/2023]
Abstract
In aggregate, the available data suggest autologous hematopoietic stem cell transplantation (AHSCT) has potent, durable efficacy to treat relapsing multiple sclerosis (MS). Safety issues and financial costs are significant but largely associated with the procedure itself. AHSCT is a reasonable option for patients with highly active relapsing MS and an inadequate response to the available disease therapies. The key question is where to place AHSCT in the overall relapsing MS algorithm relative to other high-efficacy therapies. Ongoing randomized trials will better characterize the benefit and risk of AHSCT compared with currently available high-efficacy disease therapies.
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Affiliation(s)
- Lindsay A Ross
- Mellen Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Lisa M Stropp
- Mellen Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jeffrey A Cohen
- Mellen Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Peterson S, Jalil A, Beard K, Kakara M, Sriwastava S. Updates on efficacy and safety outcomes of new and emerging disease modifying therapies and stem cell therapy for Multiple Sclerosis: A review. Mult Scler Relat Disord 2022; 68:104125. [PMID: 36057173 DOI: 10.1016/j.msard.2022.104125] [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: 05/10/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022]
Abstract
Multiple Sclerosis (MS) is a chronic neurodegenerative autoimmune disorder of the central nervous system (CNS) and the most common cause of serious physical disability in working-age adults. Drug development and research in this field have rapidly evolved over the past two decades, leading to the broad array of treatment options available today. These disease-modifying therapies (DMTs) work through distinct mechanisms of action and exhibit varying safety and efficacy profiles to help manage symptoms and reduce exacerbations in MS patients. Our extensive understanding of this condition has also led to novel approaches, such as the discovery of specific biomarkers that allow us to monitor the therapeutic response towards DMTs. The development of new DMTs continues to progress quickly today, and it can be difficult for clinicians to remain up to date on the most recent advancements and new treatment options for their patients. In this comprehensive review, we provide an outline of current MS medications in the pipeline including emerging DMTs and stem cell therapy, as well as the unique characteristics of these medications, including their indications, pharmacokinetic effects, and the relevant advancements.
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Affiliation(s)
- Sarah Peterson
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA; Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Amaris Jalil
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Katherine Beard
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Mihir Kakara
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, PA, USA; Depratment of Neurology, Wayne State University, Detroit, MI, USA
| | - Shitiz Sriwastava
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA; Depratment of Neurology, Wayne State University, Detroit, MI, USA; West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA; Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA.
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von Niederhäusern V, Ruder J, Ghraichy M, Jelcic I, Müller AM, Schanz U, Martin R, Trück J. B-Cell Reconstitution After Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:9/6/e200027. [PMID: 36229189 PMCID: PMC9562041 DOI: 10.1212/nxi.0000000000200027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Autologous hematopoietic stem cell transplantation (aHSCT) is increasingly used to treat aggressive forms of multiple sclerosis (MS). This procedure is believed to result in an immune reset and restoration of a self-tolerant immune system. Immune reconstitution has been extensively studied for T cells, but only to a limited extent for B cells. As increasing evidence suggests an important role of B cells in MS pathogenesis, we sought here to better understand reconstitution and the extent of renewal of the B-cell system after aHSCT in MS. METHODS Using longitudinal multidimensional flow cytometry and immunoglobulin heavy chain (IgH) repertoire sequencing following aHSCT with BCNU + Etoposide + Ara-C + Melphalan anti-thymocyte globulin, we analyzed the B-cell compartment in a cohort of 20 patients with MS in defined intervals before and up to 1 year after aHSCT and compared these findings with data from healthy controls. RESULTS Total B-cell numbers recovered within 3 months and increased above normal levels 1 year after transplantation, successively shifting from a predominantly transitional to a naive immune phenotype. Memory subpopulations recovered slowly and remained below normal levels with reduced repertoire diversity 1 year after transplantation. Isotype subclass analysis revealed a proportional shift toward IgG1-expressing cells and a reduction in IgG2 cells. Mutation analysis of IgH sequences showed that highly mutated memory B cells and plasma cells may transiently survive conditioning while the analysis of sequence cluster overlap, variable (IGHV) and joining (IGHJ) gene usage and repertoire diversity suggested a renewal of the late posttransplant repertoire. In patients with early cytomegalovirus reactivation, reconstitution of naive and memory B cells was delayed. DISCUSSION Our detailed characterization of B-cell reconstitution after aHSCT in MS indicates a reduced reactivation potential of memory B cells up to 1 year after transplantation, which may leave patients susceptible to infection, but may also be an important aspect of its mechanism of action.
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Affiliation(s)
- Valentin von Niederhäusern
- From the Division of Immunology and Children's Research Center (V.N., M.G., J.T.), University Children's Hospital Zurich, University of Zurich; Neuroimmunology and MS Research Section (J.R., I.J., R.M.), Department of Neurology, University Hospital Zurich, University of Zurich; and Department of Medical Oncology and Hematology (A.M.M., U.S.), University Hospital Zurich
| | - Josefine Ruder
- From the Division of Immunology and Children's Research Center (V.N., M.G., J.T.), University Children's Hospital Zurich, University of Zurich; Neuroimmunology and MS Research Section (J.R., I.J., R.M.), Department of Neurology, University Hospital Zurich, University of Zurich; and Department of Medical Oncology and Hematology (A.M.M., U.S.), University Hospital Zurich
| | - Marie Ghraichy
- From the Division of Immunology and Children's Research Center (V.N., M.G., J.T.), University Children's Hospital Zurich, University of Zurich; Neuroimmunology and MS Research Section (J.R., I.J., R.M.), Department of Neurology, University Hospital Zurich, University of Zurich; and Department of Medical Oncology and Hematology (A.M.M., U.S.), University Hospital Zurich
| | - Ilijas Jelcic
- From the Division of Immunology and Children's Research Center (V.N., M.G., J.T.), University Children's Hospital Zurich, University of Zurich; Neuroimmunology and MS Research Section (J.R., I.J., R.M.), Department of Neurology, University Hospital Zurich, University of Zurich; and Department of Medical Oncology and Hematology (A.M.M., U.S.), University Hospital Zurich
| | - Antonia Maria Müller
- From the Division of Immunology and Children's Research Center (V.N., M.G., J.T.), University Children's Hospital Zurich, University of Zurich; Neuroimmunology and MS Research Section (J.R., I.J., R.M.), Department of Neurology, University Hospital Zurich, University of Zurich; and Department of Medical Oncology and Hematology (A.M.M., U.S.), University Hospital Zurich
| | - Urs Schanz
- From the Division of Immunology and Children's Research Center (V.N., M.G., J.T.), University Children's Hospital Zurich, University of Zurich; Neuroimmunology and MS Research Section (J.R., I.J., R.M.), Department of Neurology, University Hospital Zurich, University of Zurich; and Department of Medical Oncology and Hematology (A.M.M., U.S.), University Hospital Zurich
| | - Roland Martin
- From the Division of Immunology and Children's Research Center (V.N., M.G., J.T.), University Children's Hospital Zurich, University of Zurich; Neuroimmunology and MS Research Section (J.R., I.J., R.M.), Department of Neurology, University Hospital Zurich, University of Zurich; and Department of Medical Oncology and Hematology (A.M.M., U.S.), University Hospital Zurich
| | - Johannes Trück
- From the Division of Immunology and Children's Research Center (V.N., M.G., J.T.), University Children's Hospital Zurich, University of Zurich; Neuroimmunology and MS Research Section (J.R., I.J., R.M.), Department of Neurology, University Hospital Zurich, University of Zurich; and Department of Medical Oncology and Hematology (A.M.M., U.S.), University Hospital Zurich.
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6
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Autologous Hematopoietic Stem-Cell Transplantation in Multiple Sclerosis: A Systematic Review and Meta-Analysis. Neurol Ther 2022; 11:1553-1569. [PMID: 35902484 PMCID: PMC9333355 DOI: 10.1007/s40120-022-00389-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/14/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION In 1995, the use of autologous hematopoietic stem-cell transplantation (AHSCT), which was previously used to treat hematological tumors, was introduced for severe autoimmune diseases such as multiple sclerosis (MS). AHSCT has proven its safety over the past few years due to technical advances and careful patient selection in transplant centers. While most studies have reported that AHSCT led to decreased Expanded Disability Status Scale (EDSS) scores, some patients reported increased EDSS scores following the procedure. Given the contradictory results, we aimed to conduct a comprehensive systematic review and meta-analysis to investigate the efficacy and safety of AHSCT. METHODS PubMed, Web of Science, and Scopus were searched in March 2022 using a predefined search strategy. We included cohort studies, clinical trials, case-control studies, and case series that investigated the efficacy or safety of AHSCT in patients with MS. PICO in the present study was defined as follows: problem or study population (P): patients with MS; intervention (I): AHSCT; comparison (C): none; outcome (O): efficacy and safety. RESULTS After a two-step review process, 50 studies with a total of 4831 patients with MS were included in our study. Our analysis showed a significant decrease in EDSS score after treatment (standardized mean difference [SMD]: -0.48, 95% CI -0.75, -0.22). Moreover, the annualized relapse rate was also significantly reduced after AHSCT compared to the pretreatment period (SMD: -1.58, 95% CI -2.34, -0.78). The pooled estimate of progression-free survival after treatment was 73% (95% CI 69%, 77). Furthermore, 81% of patients with MS who received AHSCT remained relapse-free (95% CI 76%, 86%). Investigating event-free survival, which reflects the absence of any disease-related event, showed a pooled estimate of 63% (95% CI 54%, 73%). Also, the MRI activity-free survival was 89% (95% CI 84%) among included studies with low heterogeneity. New MRI lesions seem to appear in nearly 8% of patients who underwent AHSCT (95% CI 4%, 12%). Our meta-analysis showed that 68% of patients with MS experience no evidence of disease activity (NEDA) after AHSCT (95% CI 59%, 77). The overall survival after transplantation was 94% (95% CI 91%, 96%). In addition, 4% of patients died from transplant-related causes (95% CI 2%, 6%). CONCLUSION Current data encourages a broader application of AHSCT for treating patients with MS while still considering proper patient selection and transplant methods. In addition, with increasing knowledge and expertise in the field of stem-cell therapy, AHSCT has become a safer treatment approach for MS.
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Sharrack B, Petrie J, Coles A, Snowden JA. Is stem cell transplantation safe and effective in multiple sclerosis? BMJ 2022; 377:e061514. [PMID: 35680142 DOI: 10.1136/bmj-2020-061514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Basil Sharrack
- Department of Neurology and Sheffield NIHR Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust and University of Sheffield, Sheffield, UK
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK
| | - Jennifer Petrie
- Department of Neurology and Sheffield NIHR Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust and University of Sheffield, Sheffield, UK
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK
| | - Alasdair Coles
- Department of Neurology and Sheffield NIHR Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust and University of Sheffield, Sheffield, UK
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK
| | - John A Snowden
- Department of Neurology and Sheffield NIHR Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust and University of Sheffield, Sheffield, UK
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK
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Patti F, Chisari CG, Toscano S, Arena S, Finocchiaro C, Cimino V, Milone G. Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis Patients: Monocentric Case Series and Systematic Review of the Literature. J Clin Med 2022; 11:jcm11040942. [PMID: 35207216 PMCID: PMC8875789 DOI: 10.3390/jcm11040942] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 02/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory and immune-mediated disease of the central nervous system (CNS), commonly affecting young adults and potentially associated with life-long disability. About 14 disease-modifying treatments (DMTs) are currently approved for the treatment of MS. However, despite the use of highly effective therapies, some patients exhibit a highly active disease with an aggressive course from onset and a higher risk of long-term disability accrual. In the last few years, several retrospective studies, clinical trials, meta-analyses and systematic reviews have investigated autologous hematopoietic stem cell transplantation (AHSCT) as a possible therapeutic option in order to address this unmet clinical need. These studies demonstrated that AHSCT is a highly efficacious and relatively safe therapeutic option for the treatment of highly active MS. Particularly, over recent years, the amount of evidence has grown, with significant improvements in the development of patient selection criteria, choice of the most suitable transplant technique and clinical experience. In this paper, we present six patients who received AHSCT in our MS center and we systematically reviewed recent evidence about the long-term efficacy and safety of AHSCT and the placement of AHSCT in the rapidly evolving therapeutic armamentarium for MS.
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Affiliation(s)
- Francesco Patti
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Clara Grazia Chisari
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Simona Toscano
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Sebastiano Arena
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Chiara Finocchiaro
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Vincenzo Cimino
- IRCCS Centro Neurolesi “Bonino Pulejo”, 98124 Messina, Italy;
| | - Giuseppe Milone
- Hematology and Bone Marrow Transplant Unit, Azienda Policlinico-Vittorio Emanuele, 95124 Catania, Italy;
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Freeman L, Longbrake EE, Coyle PK, Hendin B, Vollmer T. High-Efficacy Therapies for Treatment-Naïve Individuals with Relapsing-Remitting Multiple Sclerosis. CNS Drugs 2022; 36:1285-1299. [PMID: 36350491 PMCID: PMC9645316 DOI: 10.1007/s40263-022-00965-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/11/2022]
Abstract
There are > 18 distinct disease-modifying therapy (DMT) options covering 10 mechanisms of action currently approved by the US Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis (RRMS). Given the multitude of available treatment options, and recent international consensus guidelines offering differing recommendations, there is broad heterogeneity in how the DMTs are used in clinical practice. Choosing a DMT for newly diagnosed patients with MS is currently a topic of significant debate in MS care. Historically, an escalation approach to DMT was used for newly diagnosed patients with RRMS. However, the evidence for clinical benefits of early treatment with high-efficacy therapies (HETs) in this population is emerging. In this review, we provide an overview of the DMT options and MS treatment strategies, and discuss the clinical benefits of HETs (including ofatumumab, ocrelizumab, natalizumab, alemtuzumab, and cladribine) in the early stages of MS, along with safety concerns associated with these DMTs. By minimizing the accumulation of neurological damage early in the disease course, early treatment with HETs may enhance long-term clinical outcomes over the lifetime of the patient.
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Affiliation(s)
- Léorah Freeman
- Department of Neurology, Dell Medical School, The University of Texas at Austin, 1601 Trinity St, Austin, TX, 78701, USA.
| | | | - Patricia K. Coyle
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Barry Hendin
- Banner, University Medicine Neurosciences Clinic, Phoenix, AZ USA
| | - Timothy Vollmer
- Department of Neurology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
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Roudsari PP, Alavi-Moghadam S, Rezaei-Tavirani M, Goodarzi P, Tayanloo-Beik A, Sayahpour FA, Larijani B, Arjmand B. The Outcome of Stem Cell-Based Therapies on the Immune Responses in Rheumatoid Arthritis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1326:159-186. [PMID: 32926346 DOI: 10.1007/5584_2020_581] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Rheumatoid arthritis as a common autoimmune inflammatory disorder with unknown etiology can affect 0.5-1% of adults in developed countries. It involves more than just the patient's joints and can be accompanied by several comorbidities and affect cardiovascular, pulmonary, and some other systems of the human body. Although cytokine-mediated pathways are mentioned to have a central role in RA pathogenesis, adaptive and innate immune systems and intracellular signaling pathways all have important roles in this process. Non-steroidal anti-inflammatory drugs, glucocorticoids, conventional disease-modifying anti-rheumatic drugs, and biological agents are some mentioned medications used for RA. They are accompanied by some adverse effects and treatment failures which elucidates the needing for novel and more powerful therapeutic approaches. Stem cell-based therapies and their beneficial effects on therapeutic processes of different diseases have been founded so far. They can be an alternative and promising therapeutic approach for RA, too; due to their effects on immune responses of the disease. This review, besides some explanations about RA characteristics, addresses the outcome of the stem cell-based therapies including mesenchymal stem cell transplantation and hematopoietic stem cell transplantation for RA and explains their effects on the disease improvement.
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Affiliation(s)
- Peyvand Parhizkar Roudsari
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepideh Alavi-Moghadam
- Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Parisa Goodarzi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Tayanloo-Beik
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Forough Azam Sayahpour
- Department of Stem Cells and Developmental Biology, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical sciences, Tehran, Iran
| | - Babak Arjmand
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. .,Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
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11
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Hartung DM. Economics of Multiple Sclerosis Disease-Modifying Therapies in the USA. Curr Neurol Neurosci Rep 2021; 21:28. [PMID: 33948740 DOI: 10.1007/s11910-021-01118-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Multiple sclerosis (MS) is a prevalent and debilitating neuroinflammatory disease associated with a significant economic burden. Direct healthcare costs, which can average $70,000 a year, have risen rapidly over the last decade and are driven by the escalating cost of disease-modifying therapies (DMTs). Despite a growing number of DMTs, annual increases in price for most DMTs have commonly exceeded 10% over the last 15 years. The high cost of MS DMTs has created economic hardships for patients in terms of high out-of-pocket costs and insurance company-induced barriers. Although generic versions of glatiramer acetate and dimethyl fumarate have provided some lower cost options, the median annual price for branded products currently exceeds $90,000. The goal of this paper is to examine the economic landscape of MS DMTs in the USA. RECENT FINDINGS Recent economic analyses have provided new insights into the relative value of DMTs. Robust economic modeling studies suggest that costs per quality-adjusted life-year for most DMTs exceed commonly endorsed thresholds for what is considered a reasonable value in the USA. Because of higher efficacy and lower net costs, ocrelizumab and alemtuzumab are considered the best value. It is likely that generic versions of dimethyl fumarate and glatiramer acetate are also economically attractive. DMTs provide clinical benefit for patients with MS; however, their high cost can be a financial burden and impede access. High DMT prices are the principal reason why cost-effectiveness studies have indicated the economic value of most DMTs is questionable.
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Affiliation(s)
- Daniel M Hartung
- College of Pharmacy, Oregon State University, 2730 SW Moody Ave CL5CP, Portland, OR, 97201-5042, USA.
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12
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Mariottini A, De Matteis E, Muraro PA. Haematopoietic Stem Cell Transplantation for Multiple Sclerosis: Current Status. BioDrugs 2021; 34:307-325. [PMID: 32166703 DOI: 10.1007/s40259-020-00414-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is a treatment option for aggressive forms of multiple sclerosis (MS) that has been derived from haematological indications and repurposed for treatment of refractory autoimmune diseases. In the present review, a search for clinical studies on AHSCT was performed on the PubMed website and ClinicalTrials.gov databases. Papers were selected according to the following criteria: text written in English language, publication date between 2014 and August 2019, and reports including more than five patients. Prospective randomised and uncontrolled trials and retrospective case series were reviewed to examine the safety and efficacy of the procedure. Treatment protocols, pathological data and economic aspects of AHSCT were also succinctly covered. Growing evidence suggests that long-term suppression of inflammatory activity with stabilization or improvement of disability can be achieved in a high proportion of properly selected patients. More sophisticated outcome measures recently adopted, including effect on brain atrophy and disease biomarkers, are giving further insight into the effectiveness of transplant. The risks of the procedure have decreased to levels that can be considered acceptable for treatment of individuals with aggressive forms of MS. Careful selection of patients with an expected good benefit/risk profile, which is maximal when AHSCT is performed in early phases of the disease, and the expertise of transplant centres are critical to the success of treatment. Higher efficacy of AHSCT than with conventional treatments has recently been demonstrated by one randomised trial and further evidence is awaited from ongoing and planned trials comparing AHSCT with the most effective disease-modifying therapeutic agents.
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Affiliation(s)
- Alice Mariottini
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | - Eleonora De Matteis
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Centre for Experimental Neurological Therapies, Sapienza University, Rome, Italy
| | - Paolo A Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.
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13
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Bertolotto A, Martire S, Mirabile L, Capobianco M, De Gobbi M, Cilloni D. Autologous Hematopoietic Stem Cell Transplantation (AHSCT): Standard of Care for Relapsing-Remitting Multiple Sclerosis Patients. Neurol Ther 2020; 9:197-203. [PMID: 32548740 PMCID: PMC7606396 DOI: 10.1007/s40120-020-00200-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Indexed: 12/24/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) has been used in the treatment of highly active multiple sclerosis (MS) for over two decades. It has been demonstrated to be highly efficacious in relapsing-remitting (RR) MS patients failing to respond to disease-modifying drugs (DMDs). AHSCT guarantees higher rates of no evidence of disease activity (NEDA) than those achieved with any other DMDs, but it is also associated with greater short-term risks which have limited its use. In the 2019 updated EBMT and ASBMT guidelines, which review the clinical evidence of AHSCT in MS, AHSCT indication for highly active RRMS has changed from "clinical option" to "standard of care". On this basis, AHSCT must be proposed on equal footing with second-line DMDs to patients with highly active RRMS, instead of being considered as a last resort after failure of all available treatments. The decision-making process requires a close collaboration between transplant hematologists and neurologists and a full discussion of risk-benefit of AHSCT and alternative treatments. In this context, we propose a standardized protocol for decision-making and informed consent process.
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Affiliation(s)
- Antonio Bertolotto
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy.
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy.
| | - Serena Martire
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy
| | - Luca Mirabile
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy
| | - Marco Capobianco
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy
| | - Marco De Gobbi
- SSD Terapia oncoematologica intensiva e trapianto CSE, AOU San Luigi Gonzaga, Dipartimento di Scienze Cliniche e Biologiche, University of Turin, Turin, Italy
| | - Daniela Cilloni
- SSD Terapia oncoematologica intensiva e trapianto CSE, AOU San Luigi Gonzaga, Dipartimento di Scienze Cliniche e Biologiche, University of Turin, Turin, Italy
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14
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Jakimovski D, Vaughn CB, Eckert S, Zivadinov R, Weinstock-Guttman B. Long-term drug treatment in multiple sclerosis: safety success and concerns. Expert Opin Drug Saf 2020; 19:1121-1142. [PMID: 32744073 DOI: 10.1080/14740338.2020.1805430] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The portfolio of multiple sclerosis (MS) disease modifying treatments (DMTs) has significantly expanded over the past two decades. Given the lifelong use of MS pharmacotherapy, understanding their long-term safety profiles is essential in determining suitable and personalized treatment. AREAS COVERED In this narrative review, we summarize the short-, mid-, and long-term safety profile of currently available MS DMTs categories. In addition to the initial trial findings, safety outcomes derived from long-term extension studies (≥5-20 years) and safety-based prescription programs have been reviewed. In order to better understand the risk-benefit ratio for each particular DMT group, a short description of the DMT-based efficacy outcomes has been included. EXPERT OPINION Long-term extension trials, large observational studies and real-world databases allow detection of rare and potentially serious adverse events. Two-year-long trials are unable to fully capture the positive and negative effects of immune system modulation and reconstitution. DMT-based monitoring programs can provide greater insights regarding safe use of MS medications in different patient populations and clinical settings. During the process of shared DMT decision, both MS care providers and their patients should be aware of an ever-expanding number of drug-based adverse events and their influence on the risk-benefit analysis.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo, NY, USA
| | - Caila B Vaughn
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
| | - Svetlana Eckert
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo, NY, USA.,Translational Imaging Center at Clinical Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Stat37$e University of New York , Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
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15
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Baker D, Amor S, Kang AS, Schmierer K, Giovannoni G. The underpinning biology relating to multiple sclerosis disease modifying treatments during the COVID-19 pandemic. Mult Scler Relat Disord 2020; 43:102174. [PMID: 32464584 PMCID: PMC7214323 DOI: 10.1016/j.msard.2020.102174] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND SARS-CoV-2 viral infection causes COVID-19 that can result in severe acute respiratory distress syndrome (ARDS), which can cause significant mortality, leading to concern that immunosuppressive treatments for multiple sclerosis and other disorders have significant risks for both infection and ARDS. OBJECTIVE To examine the biology that potentially underpins immunity to the SARS-Cov-2 virus and the immunity-induced pathology related to COVID-19 and determine how this impinges on the use of current disease modifying treatments in multiple sclerosis. OBSERVATIONS Although information about the mechanisms of immunity are scant, it appears that monocyte/macrophages and then CD8 T cells are important in eliminating the SARS-CoV-2 virus. This may be facilitated via anti-viral antibody responses that may prevent re-infection. However, viral escape and infection of leucocytes to promote lymphopenia, apparent CD8 T cell exhaustion coupled with a cytokine storm and vascular pathology appears to contribute to the damage in ARDS. IMPLICATIONS In contrast to ablative haematopoietic stem cell therapy, most multiple-sclerosis-related disease modifying therapies do not particularly target the innate immune system and few have any major long-term impact on CD8 T cells to limit protection against COVID-19. In addition, few block the formation of immature B cells within lymphoid tissue that will provide antibody-mediated protection from (re)infection. However, adjustments to dosing schedules may help de-risk the chance of infection further and reduce the concerns of people with MS being treated during the COVID-19 pandemic.
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Key Words
- ace2, angiotensin converting enzyme two
- ards, acute respiratory distress syndrome
- asc, antibody secreting cells
- cns, central nervous system
- dmt, disease modifying therapies
- (hsct), haematopoietic stem cell therapy
- irt, immune reconstitution therapies
- ms, multiple sclerosis
- rbd, receptor binding domain
- rna, ribonucleic acid
- sars, severe acute respiratory syndrome
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Affiliation(s)
- David Baker
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom.
| | - Sandra Amor
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom; Pathology Department, VUmc, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Angray S Kang
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom; Centre for Oral Immunobiology and Regenerative Medicine, Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Klaus Schmierer
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
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16
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Lycke J, Lenhoff S. Intensive immunosuppression followed by autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420929467. [PMID: 32636931 PMCID: PMC7315665 DOI: 10.1177/1756286420929467] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/22/2020] [Indexed: 12/20/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) to treat multiple sclerosis (MS) has mostly been used in devastating cases as the last option to stop further neurological deterioration. However, evidence from several retrospective clinical trials indicates that young, less disabled patients with highly inflammatory active MS are the most likely to benefit from AHSCT, and after moving from high-intensity to nonmyeloablative procedures the tolerability of AHSCT has increased and its associated risk and mortality have declined considerably. Recent meta-analyses and randomized clinical trials show that AHSCT is more effective than currently approved disease-modifying therapies (DMTs), with suppression of disease activity in 70–90% of patients and long-term cessation of disease activity in two-thirds of treated patients. The rationale for AHSCT is to eliminate autoimmunity and achieve immune resetting by intense immunosuppression followed by infusion of autologous hematopoietic stem cells. Similar effects on the immune system have been suggested for cladribine and alemtuzumab treatment and, together with AHSCT, they constitute the induction or immune-reconstitution therapies for MS. Although, further randomized controlled trials of AHSCT for MS are needed, it has become clear that improved patient selection and lower intensity conditioning regimens have reduced AHSCT associated risks and mortality and strengthened the position of AHSCT among other DMTs. Do we have enough experience and scientific support for AHSCT in MS to move from an exclusive treatment for aggressive, treatment-resistant MS and acquire broader indications, similar to other effective DMTs?
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Affiliation(s)
- Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gröna stråket 11, 3 tr, Sahlgrenska University Hospital, Gothenburg, 415 45, Sweden
| | - Stig Lenhoff
- Department of Hematology, Oncology and Radiophysics, Skane University Hospital, Lund, Sweden
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17
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Lycke J, Axelsson M. Can multiple sclerosis be cured? A case of highly active relapsing multiple sclerosis treated with autologous hematopoietic stem-cell transplantation 13 years ago. Mult Scler Relat Disord 2020; 44:102253. [PMID: 32570177 DOI: 10.1016/j.msard.2020.102253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/30/2020] [Indexed: 11/24/2022]
Abstract
A 26-year-old man, with five years of highly active deteriorating relapsing multiple sclerosis (MS), unresponsive to conventional therapy, was treated with autologous hematopoietic stem-cell transplantation (AHSCT) 13 years ago. Since then the patient had no clinical or neuroradiological disease activity and disability progression was halted. Repeated analysis of CSF revealed reduced levels of inflammatory biomarkers and the neurofilament light protein level was normalized indicating no further axonal degeneration. The patient is socio-economic independent, is working full time, and has become a father. Measures of quality of life and cognition did not indicate further deterioration. Long-term follow-up has not shown any signs of active disease suggesting that AHSCT may be a cure for MS.
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Affiliation(s)
- Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Markus Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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18
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Immunological consequences of "immune reconstitution therapy" in multiple sclerosis: A systematic review. Autoimmun Rev 2020; 19:102492. [PMID: 32062028 DOI: 10.1016/j.autrev.2020.102492] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 10/30/2019] [Indexed: 02/07/2023]
Abstract
Immune reconstitution therapy (IRT) is an emerging concept for the treatment of multiple sclerosis (MS) that is given intermittently and can induce long-term remission of MS that is sustained in treatment-free periods. A systematic literature review was performed to identify and summarize current knowledge regarding the short- and long-term immunological consequences of different IRTs and CD20 depleting therapies on the cellular level in patients with MS. A total of 586 articles published between January 2010 and September 2019 were identified and screened; 44 studies met inclusion criteria for the review. All the treatments considered appeared to produce both qualitative and quantitative changes in the immune cell populations of patients with MS that resulted in a more anti-inflammatory immune profile. Autologous hematopoietic stem cell transplantation produced the longest-lasting and greatest effects on a wide range of immune cells. Many patients achieved prolonged depletion of the adaptive immune system when alemtuzumab and cladribine tablets were administered as short courses of therapy; however, a proportion of patients required retreatment to maintain these effects. Alemtuzumab may produce greater depletion of both CD4+ and CD8+ T cells than cladribine tablets, although both treatments similarly deplete B cells. Recovery of B cells before T cell recovery and hyperpopulation of B cells after alemtuzumab may contribute to secondary autoimmunity. Cladribine tablets had a greater effect on B cells than T cells, and no hyperpopulation of B cells was observed after treatment with cladribine tablets. Ocrelizumab and rituximab require regular repeated treatment every 6 months to maintain depletion of B and T cells. Effects of the drug treatments on the innate immune system were minor compared with those on the adaptive immune system. Additional characterization of the cellular changes occurring during IRT and CD20 depletion may lead to further improvement in the understanding of the pathogenesis of MS and the future development of therapies with even longer lasting effects. Although the treatments considered in this review improve quality of life and outcomes for patients with MS, a cure for this debilitating disease is not yet in sight.
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Effect of autologous hematopoietic stem cell transplantation on multiple sclerosis and neuromyelitis optica spectrum disorder: a PRISMA-compliant meta-analysis. Bone Marrow Transplant 2020; 55:1928-1934. [PMID: 32020080 DOI: 10.1038/s41409-020-0810-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 12/29/2022]
Abstract
We should consider both the treatment effects and adverse effects of autologous hematopoietic stem cell transplantation (AHSCT) on multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). Articles exploring the effect and safety of AHSCT in the treatment of MS and NMOSD and published before December 2019 were identified from the following databases (PubMed, Web of Science, Medline, EMBASE, Cochrane and Google Scholar). The study used STATA 13.0 software to compute the efficacy outcomes. Finally, the meta-analysis included 27 studies (including 1626 MS and 31 NMOSD patients). Regarding the effect of AHSCT on MS, the computed PFS was 74%. Subgroup analyses showed that intermediate-intensity regimen caused PFS 73%. Low-intensity regimen resulted in PFS 85%. High-intensity regimen resulted in PFS 58%. Subgroup analyses indicated that relapsing remitting MS (RRMS), primary progressive MS (PPMS) and secondary progressive MS (SPMS) patients showed PFS 81%, 78% and 60%, respectively. Computed transplant-related mortality (TRM) in MS was 1%. Regarding effect of AHSCT on NMOSD, the computed PFS and TRM was 76% and 0%, respectively. In conclusion, the study supported that AHSCT showed long-term effect on MS and NMOSD patients with a high safety. Low- and intermediate-intensity regimens and RRMS patients showed optimal benefit from AHSCT.
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Autologous haematopoietic stem cell therapy for multiple sclerosis: a review for supportive care clinicians on behalf of the Autoimmune Diseases Working Party of the European Society for Blood and Marrow Transplantation. Curr Opin Support Palliat Care 2019; 13:394-401. [PMID: 31599815 PMCID: PMC6867671 DOI: 10.1097/spc.0000000000000466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW In this review, we summarize the recently published literature that demonstrates the efficacy and safety of autologous haematopoietic stem cell therapy (AHSCT) in multiple sclerosis (MS) and highlight the importance of supportive care required for the safe and well-tolerated delivery of AHSCT. RECENT FINDINGS MS is an autoimmune inflammatory and degenerative disorder of the central nervous system (CNS). In the majority of patients, the illness runs a relapsing remitting course (RRMS), culminating in a secondary progressive phase with gradual accumulation of fixed disabilities. Currently available disease-modifying therapies suppress CNS inflammation but have a limited effect on preventing disease progression for which there remains no effective therapy. Over the last two decades, there has been increasing evidence that AHSCT is a highly effective therapeutic strategy for treatment-resistant inflammatory types of MS, especially RRMS. Concerns about the safety of AHSCT in MS, usually a nonlife-threatening disease, have previously limited its use. However, AHSCT can now be delivered safely with major long-term benefits because of increasing transplant centre experience, judicious patient selection and good supportive care. SUMMARY MS is currently the fastest growing indication for AHSCT in Europe. Supportive care before, during and after the transplant period is key to the successful delivery of AHSCT.
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Autologous Hematopoietic Cell Transplantation in Multiple Sclerosis: Changing Paradigms in the Era of Novel Agents. Stem Cells Int 2019; 2019:5840286. [PMID: 31341484 PMCID: PMC6612973 DOI: 10.1155/2019/5840286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 04/22/2019] [Accepted: 06/13/2019] [Indexed: 12/29/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) is established as a standard of care for diseases ranging from hematological malignancies to other neoplastic pathologies and severe immunological deficiencies. In April 1995, our group performed the first AHSCT in progressive multiple sclerosis (MS). Since then, a plethora of studies have been published with encouraging but controversial results. Major challenges in the field include appropriate patient selection, improvements in AHSCT procedure, and timing of this treatment modality. Beyond AHSCT, several new intravenous or oral agents have been developed and approved over the last 20 years in MS. The emergence of multiple effective therapies for MS has created a challenging scenario for both treating physicians and patients. Novel cell-based therapies other than AHSCT are also currently investigated in MS patients with promising results. Our review is aimed at summarizing state-of-the-art knowledge on basic principles and results of AHSCT in MS and its role compared to novel agents.
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