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Gold R, Schlegel E, Elias-Hamp B, Albert C, Schmidt S, Tackenberg B, Xiao J, Schaak T, Salmen HC. Incidence and mitigation of gastrointestinal events in patients with relapsing-remitting multiple sclerosis receiving delayed-release dimethyl fumarate: a German phase IV study (TOLERATE). Ther Adv Neurol Disord 2018; 11:1756286418768775. [PMID: 29707040 PMCID: PMC5912264 DOI: 10.1177/1756286418768775] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/26/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Gastrointestinal (GI) events are common adverse events (AEs) associated with delayed-release dimethyl fumarate (DMF), an approved treatment for relapsing–remitting multiple sclerosis (RRMS). The objective of the TOLERATE study was to evaluate GI tolerability and GI mitigation via symptomatic therapies in patients initiating DMF in a real-world clinical setting in Germany. Methods: TOLERATE was a multicentre, open-label, single-arm study performed at 25 German sites. Endpoints were frequency, severity, duration (all primary) and mitigation of GI-related events (secondary). Patients were instructed to take DMF according to the prescribing information for up to 12 weeks and to document GI events and intake of GI-symptomatic therapy on numerical rating scales, using eDiaries. Results: A total of 211 patients were included in the safety population (71% female; mean age 40 ± 11 years). Of these, 185 patients (87.7%) reported GI-related events, out of which nearly half received GI-symptomatic therapy (84/185; 45.4%). The most frequently reported GI events were upper abdominal pain, flatulence and nausea. GI-related events peaked during the first 3 weeks of therapy and rapidly decreased thereafter. The severity of GI events over 12 weeks according to the Modified Overall Gastrointestinal Symptom Scale were mild to moderate in the majority of patients reporting GI-related events and taking symptomatic GI medication (53.6%). Only 10% of all patients discontinued study treatment due to AEs in general, while 6.6% discontinued due to GI-related events. The severity of GI-related events decreased over time in patients who received symptomatic treatment with one or more medications (e.g. acid secretion blockers, antidiarrhoeals or antiemetics). Conclusion: Gastrointestinal events associated with delayed-release DMF were mainly mild to moderate in severity. Prevalence of GI events peaked during the first 3 weeks of therapy and rapidly faded thereafter. Although 44.9% of patients experiencing GI events used common GI symptomatic therapies, only 6.6% of patients discontinued DMF because of GI events, suggesting that GI events could be managed well with common symptomatic therapy.
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Affiliation(s)
- Ralf Gold
- Katholisches Klinikum Bochum St. Josef-Hospital, Neurological Clinic, Bochum University, Gudrunstraße 56, 44791 Bochum, Germany
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Alifirova VM, Bisaga GN, Boyko AN, Bryukhov VV, Davydovskay MV, Zakharova MN, Zakharova EV, Malkova NA, Popova EV, Salogub GN, Sivertseva SA, Troshina EA, Khachanova NV, Schmidt TE. Clinical recommendations on the use of alemtuzumab (lemtrada). Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:115-126. [DOI: 10.17116/jnevro201711722115-126] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Wicks P, Brandes D, Park J, Liakhovitski D, Koudinova T, Sasane R. Preferred features of oral treatments and predictors of non-adherence: two web-based choice experiments in multiple sclerosis patients. Interact J Med Res 2015; 4:e6. [PMID: 25749630 PMCID: PMC4376178 DOI: 10.2196/ijmr.3776] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 01/21/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Oral disease modifying therapies (DMTs) for multiple sclerosis (MS) differ in efficacy, tolerability, and safety. OBJECTIVE We sought to understand how these attributes impact patient preference and predicted DMT non-adherence among oral-naïve MS patients. METHODS Adult MS patients from the "PatientsLikeMe" Web-based health data-sharing platform completed a discrete choice exercise where they were asked to express their preference for one of three hypothetical oral DMTs, each with a certain combination of levels of tested attributes. Another Web-based exercise tested a number of possible drivers of non-adherence, mainly side effects. Data from an MS clinic were used to adjust for sample bias. Respondents' preferences were analyzed using Hierarchical Bayesian estimation. RESULTS A total of 319 patients completed all questions. Most respondents were female (77.7%, 248/319) with mean age 48 years (SD 10). Liver toxicity was the attribute that emerged as the most important driver of patient preference (25.8%, relative importance out of 100%), followed by severe side effects (15.3%), delay to disability progression (10.7%), and common side effects (10.4%). The most important drivers of predicted non-adherence were frequency of daily dosing (17.4% out of 100%), hair thinning (14.8%), use during pregnancy (14.1%), severe side effects (13.8%), and diarrhea (13.0%). CONCLUSIONS Understanding the important concerns expressed by patients may help health care providers to understand and educate their patients more completely about these concerns. This knowledge may therefore improve both choices of appropriate therapy and adherence to therapy over time.
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Affiliation(s)
- Paul Wicks
- PatientsLikeMe, Cambridge, MA, United States.
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Babij R, Perumal JS. Comparative efficacy of alemtuzumab and established treatment in the management of multiple sclerosis. Neuropsychiatr Dis Treat 2015; 11:1221-9. [PMID: 26056453 PMCID: PMC4445870 DOI: 10.2147/ndt.s60518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Alemtuzumab is the newest disease-modifying therapy approved for the treatment of relapsing multiple sclerosis. Alemtuzumab is an anti-CD52 targeted antibody that causes lysis of T and B lymphocytes, monocytes, natural killer cells, macrophages, and dendritic cells. Following its administration, a prolonged T-cell lymphopenia results with emergence of a reconstituted immune system that differs in its composition from that pretreatment. In clinical trials, alemtuzumab has shown impressive efficacy with regard to clinical and radiological outcomes in relapsing multiple sclerosis, along with sustained long-term beneficial effects, and it is attractive for its once-yearly administration. Despite this, the occurrence of serious secondary autoimmune disorders, infections, and a potential risk of malignancy necessitates a careful evaluation of risks versus benefits for an individual patient prior to its use. The requirement of patient commitment to the intense mandatory monitoring program is also a factor to be considered when incorporating alemtuzumab into the treatment regimen.
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Affiliation(s)
- Rachel Babij
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Jai S Perumal
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
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Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The September 2013 monograph topics are trametinib, simeprevir, paroxetine mesylate, and empagliflozin. The DUE/MUE is on aripiprazole.
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Affiliation(s)
| | - Terri L Levien
- Clinical Associate Professor of Pharmacotherapy, Drug Information Center, Washington State University, Spokane, Washington
| | - Danial E Baker
- Director, Drug Information Center, and Professor of Pharmacy Practice, College of Pharmacy, Washington State University Spokane, PO Box 1495, Spokane, Washington 99210-1495. The authors indicate no relationships that could be perceived as a conflict of interest
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6
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Aharoni R. New findings and old controversies in the research of multiple sclerosis and its model experimental autoimmune encephalomyelitis. Expert Rev Clin Immunol 2014; 9:423-40. [DOI: 10.1586/eci.13.21] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Yin QQ, Liu CX, Wu YL, Wu SF, Wang Y, Zhang X, Hu XJ, Pu JX, Lu Y, Zhou HC, Wang HL, Nie H, Sun HD, Chen GQ. Preventive and Therapeutic Effects of Adenanthin on Experimental Autoimmune Encephalomyelitis by Inhibiting NF-κB Signaling. THE JOURNAL OF IMMUNOLOGY 2013; 191:2115-25. [DOI: 10.4049/jimmunol.1203546] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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8
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Pravica V, Markovic M, Cupic M, Savic E, Popadic D, Drulovic J, Mostarica-Stojkovic M. Multiple sclerosis: individualized disease susceptibility and therapy response. Biomark Med 2013; 7:59-71. [PMID: 23387485 DOI: 10.2217/bmm.12.113] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Multiple sclerosis (MS) is a heterogeneous disease in which diverse genetic, pathological and clinical backgrounds lead to variable therapy response. Accordingly, MS care should be tailored to address disease traits unique to each person. At the core of personalized management is the emergence of new knowledge, enabling optimized treatment and disease-modifying therapies. This overview analyzes the promise of genetic and nongenetic biomarkers in advancing decision-making algorithms to assist diagnosis or in predicting the disease course and therapy response in any given MS patient.
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Affiliation(s)
- Vera Pravica
- Institute of Microbiology & Immunology, School of Medicine, University of Belgrade, Belgrade, Serbia.
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Vargas WS, Perumal JS. Fingolimod and cardiac risk: latest findings and clinical implications. Ther Adv Drug Saf 2013; 4:119-24. [PMID: 25083256 PMCID: PMC4110865 DOI: 10.1177/2042098613481023] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Fingolimod is an oral medication approved for the treatment of relapsing multiple sclerosis (MS). It is unique compared with other approved disease-modifying therapies for MS in that it is the first oral agent and it has a novel mechanism of action. In clinical trials and postmarket use, it demonstrates clear therapeutic efficacy. However, it is associated with certain risks including cardiac concerns. The recent reports of cardiac events potentially associated with the drug prompted a regulatory agencies review of the use of fingolimod for MS in the USA and Europe. After completion of their review, the US Food and Drug Administration and the European Medicines Agency concluded that its benefits outweighed the risks. However, certain recommendations were made for appropriate patient selection for fingolimod and for more cautious first-dose monitoring. We review the use of fingolimod for MS in light of the recently reported potential cardiac risks. We conclude that with appropriate patient selection and careful monitoring, it appears to have a favorable benefits/risks profile and can be a valuable treatment option for relapsing MS. Continued postmarketing surveillance and data from the extension phase of its clinical trials will be very important in understanding the long-term efficacy and safety of fingolimod and to help determine its place in the treatment algorithm for multiple sclerosis.
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Affiliation(s)
- Wendy S Vargas
- Weill Cornell Medical College - Neurology, New York, NY, USA
| | - Jai S Perumal
- Weill Cornell Medical College - Neurology, 1305 York Avenue, New York, NY 10021, USA
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10
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van Horssen J, de Vries HE. Dimethyl fumarate: a novel oral front-line therapy for multiple sclerosis treatment. FUTURE NEUROLOGY 2013. [DOI: 10.2217/fnl.13.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Owing to their immunomodulatory effects and safety profile, fumaric acid esters, such as dimethyl fumarate, are being investigated for the treatment of relapsing–remitting multiple sclerosis. BG-12, an oral formulation of dimethyl fumarate, is rapidly metabolized into its bioactive compound monomethyl fumarate, which displays both anti-inflammatory and neuroprotective properties in animal and in vitro studies. Although the mechanisms underlying the cytoprotective properties of fumaric acid esters are not fully elucidated, evidence is emerging that they act on immunomodulatory and antioxidant pathways. Clinical trials provide compelling evidence for the clinical efficacy of BG-12 in the treatment of relapsing–remitting multiple sclerosis, and have demonstrated that oral administration of BG-12 is well tolerated and markedly reduced the annualized relapse rate, the numbers of gadolinium-enhancing lesions and the number of black holes. Based on its favorable safety, tolerability and neuroprotective properties, BG-12 represents an excellent oral disease-modifying drug in the treatment of multiple sclerosis.
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Affiliation(s)
- Jack van Horssen
- Department of Molecular Cell Biology & Immunology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Helga E de Vries
- Department of Molecular Cell Biology & Immunology, VU University Medical Center, Amsterdam, The Netherlands
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Gebregiworgis T, Massilamany C, Gangaplara A, Thulasingam S, Kolli V, Werth MT, Dodds ED, Steffen D, Reddy J, Powers R. Potential of urinary metabolites for diagnosing multiple sclerosis. ACS Chem Biol 2013; 8:684-90. [PMID: 23369377 PMCID: PMC3631445 DOI: 10.1021/cb300673e] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A definitive diagnostic test for multiple sclerosis (MS) does not exist; instead physicians use a combination of medical history, magnetic resonance imaging, and cerebrospinal fluid analysis (CSF). Significant effort has been employed to identify biomarkers from CSF to facilitate MS diagnosis; however, none of the proposed biomarkers have been successful to date. Urine is a proven source of metabolite biomarkers and has the potential to be a rapid, noninvasive, inexpensive, and efficient diagnostic tool for various human diseases. Nevertheless, urinary metabolites have not been extensively explored as a source of biomarkers for MS. We demonstrate that urinary metabolites have significant promise for monitoring disease-progression, and response to treatment in MS patients. NMR analysis of urine permitted the identification of metabolites that differentiate experimental autoimmune encephalomyelitis (EAE)-mice (prototypic disease model for MS) from healthy and MS drug-treated EAE mice.
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Affiliation(s)
- Teklab Gebregiworgis
- Department of Chemistry, University of Nebraska-Lincoln, Lincoln, NE, 68588-0304
| | - Chandirasegaran Massilamany
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68588-0905
| | - Arunakumar Gangaplara
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68588-0905
| | - Sivasubramani Thulasingam
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68588-0905
| | - Venkata Kolli
- Department of Chemistry, University of Nebraska-Lincoln, Lincoln, NE, 68588-0304
| | - Mark T. Werth
- Department of Chemistry, Nebraska Wesleyan University, Lincoln NE 68504
| | - Eric D. Dodds
- Department of Chemistry, University of Nebraska-Lincoln, Lincoln, NE, 68588-0304
| | - David Steffen
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68588-0905
| | - Jay Reddy
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68588-0905
| | - Robert Powers
- Department of Chemistry, University of Nebraska-Lincoln, Lincoln, NE, 68588-0304
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12
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Abstract
Multiple sclerosis (MS) is a disease marked by focal demyelinating inflammatory plaques throughout the CNS. Neuro-ophthalmologic sequelae are common in MS and may arise from the disease itself or from treatment of the disease. Both afferent and efferent functions may be affected. Despite much progress, our understanding of the pathophysiology of MS, and the efficacy of our available treatments, remain inadequate. Here, we review the chief neuro-ophthalmologic abnormalities associated with MS and discuss the emerging diagnostic and therapeutic advances that are likely to further our understanding of MS and its treatment.
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Affiliation(s)
- Ryan D Walsh
- Departments of Neurology & Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 3 W Gates Building, Philadelphia, PA 19104, USA
| | - Collin M McClelland
- Departments of Neurology & Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 3 W Gates Building, Philadelphia, PA 19104, USA
| | - Steven L Galetta
- Departments of Neurology & Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 3 W Gates Building, Philadelphia, PA 19104, USA
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13
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Béraud D, Hathaway HA, Trecki J, Chasovskikh S, Johnson DA, Johnson JA, Federoff HJ, Shimoji M, Mhyre TR, Maguire-Zeiss KA. Microglial activation and antioxidant responses induced by the Parkinson's disease protein α-synuclein. J Neuroimmune Pharmacol 2012; 8:94-117. [PMID: 23054368 PMCID: PMC3582877 DOI: 10.1007/s11481-012-9401-0] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 09/06/2012] [Indexed: 12/29/2022]
Abstract
Parkinson’s disease (PD) is the second most common age-related neurodegenerative disorder typified by tremor, rigidity, akinesia and postural instability due in part to the loss of dopamine within the nigrostriatal system. The pathologic features of this disorder include the loss of substantia nigra dopamine neurons and attendant striatal terminals, the presence of large protein-rich neuronal inclusions containing fibrillar α-synuclein and increased numbers of activated microglia. Evidence suggests that both misfolded α-synuclein and oxidative stress play an important role in the pathogenesis of sporadic PD. Here we review evidence that α-synuclein activates glia inducing inflammation and that Nrf2-directed phase-II antioxidant enzymes play an important role in PD. We also provide new evidence that the expression of antioxidant enzymes regulated in part by Nrf2 is increased in a mouse model of α-synuclein overexpression. We show that misfolded α-synuclein directly activates microglia inducing the production and release of the proinflammatory cytokine, TNF-α, and increasing antioxidant enzyme expression. Importantly, we demonstrate that the precise structure of α-synuclein is important for induction of this proinflammatory pathway. This complex α-synuclein-directed glial response highlights the importance of protein misfolding, oxidative stress and inflammation in PD and represents a potential locus for the development of novel therapeutics focused on induction of the Nrf2-directed antioxidant pathway and inhibition of protein misfolding.
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Affiliation(s)
- Dawn Béraud
- Department of Neuroscience, Georgetown University Medical Center, NRB EP08, 3970 Reservoir Road NW, Washington, DC 20057, USA
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