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Vukusic S, Rollot F, Casey R, Pique J, Marignier R, Mathey G, Edan G, Brassat D, Ruet A, De Sèze J, Maillart E, Zéphir H, Labauge P, Derache N, Lebrun-Frenay C, Moreau T, Wiertlewski S, Berger E, Moisset X, Rico-Lamy A, Stankoff B, Bensa C, Thouvenot E, Heinzlef O, Al-Khedr A, Bourre B, Vaillant M, Cabre P, Montcuquet A, Wahab A, Camdessanché JP, Tourbah A, Guennoc AM, Hankiewicz K, Patry I, Nifle C, Maubeuge N, Labeyrie C, Vermersch P, Laplaud DA. Progressive Multifocal Leukoencephalopathy Incidence and Risk Stratification Among Natalizumab Users in France. JAMA Neurol 2020; 77:94-102. [PMID: 31479149 DOI: 10.1001/jamaneurol.2019.2670] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance Risk of developing progressive multifocal leukoencephalopathy (PML) is the major barrier to using natalizumab for patients with multiple sclerosis (MS). To date, the association of risk stratification with PML incidence has not been evaluated. Objective To describe the temporal evolution of PML incidence in France before and after introduction of risk minimization recommendations in 2013. Design, Setting, and Participants This observational study used data in the MS registry OFSEP (Observatoire Français de la Sclérose en Plaques) collected between April 15, 2007, and December 31, 2016, by participating MS expert centers and MS-dedicated networks of neurologists in France. Patients with an MS diagnosis according to current criteria, regardless of age, were eligible, and those exposed to at least 1 natalizumab infusion (n = 6318) were included in the at-risk population. A questionnaire was sent to all centers, asking for a description of their practice regarding PML risk stratification. Data were analyzed in July 2018. Exposures Time from the first natalizumab infusion to the occurrence of PML, natalizumab discontinuation plus 6 months, or the last clinical evaluation. Main Outcomes and Measures Incidence was the number of PML cases reported relative to the person-years exposed to natalizumab. A Poisson regression model for the 2007 to 2016 period estimated the annual variation in incidence and incidence rate ratio (IRR), adjusted for sex and age at treatment initiation and stratified by period (2007-2013 and 2013-2016). Results In total, 6318 patients were exposed to natalizumab during the study period, of whom 4682 (74.1%) were female, with a mean (SD [range]) age at MS onset of 28.5 (9.1 [1.1-72.4]) years; 45 confirmed incident cases of PML were diagnosed in 22 414 person-years of exposure. The crude incidence rate for the whole 2007 to 2016 period was 2.00 (95% CI, 1.46-2.69) per 1000 patient-years. Incidence significantly increased by 45.3% (IRR, 1.45; 95% CI, 1.15-1.83; P = .001) each year before 2013 and decreased by 23.0% (IRR, 0.77; 95% CI, 0.61-0.97; P = .03) each year from 2013 to 2016. Conclusions and Relevance The results of this study suggest, for the first time, a decrease in natalizumab-associated PML incidence since 2013 in France that may be associated with a generalized use of John Cunningham virus serologic test results; this finding appears to support the continuation and reinforcement of educational activities and risk-minimization strategies in the management of disease-modifying therapies for multiple sclerosis.
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Affiliation(s)
- Sandra Vukusic
- Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France.,Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon/Bron, France.,Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR5292, Lyon, France
| | - Fabien Rollot
- Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Hospices Civils de Lyon, Lyon, France.,EDMUS Foundation, Lyon/Bron, France
| | - Romain Casey
- Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Hospices Civils de Lyon, Lyon, France.,EDMUS Foundation, Lyon/Bron, France
| | - Julie Pique
- Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France.,Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon/Bron, France
| | - Romain Marignier
- Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France.,Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon/Bron, France.,Centre des Neurosciences de Lyon, FLUID Team, INSERM 1028 et CNRS UMR5292, Lyon, France
| | - Guillaume Mathey
- Department of Neurology, Nancy University Hospital, Nancy, France.,Université de Lorraine, EA 4360 APEMAC, Vandoeuvre-Lès-Nancy, Nancy, France
| | - Gilles Edan
- CHU Pontchaillou, CIC1414 INSERM, Rennes, France
| | - David Brassat
- Department of Neurology, CHU de Toulouse, Toulouse, France
| | - Aurélie Ruet
- University of Bordeaux, Bordeaux, France.,INSERM U1215, Neurocentre Magendie, Bordeaux, France.,CHU de Bordeaux, CIC Bordeaux CIC1401, Bordeaux, France
| | - Jérôme De Sèze
- Clinical Investigation Center, Department of Neurology, CHU de Strasbourg, INSERM 1434, Strasbourg, France
| | - Elisabeth Maillart
- Department of Neurology, Assistance Publique des Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Hélène Zéphir
- LIRIC (Lille Inflammation Research International Center), University of Lille, CHU de Lille, INSERM UMR995, Lille, France
| | - Pierre Labauge
- CHU de Montpellier, MS Unit, Montpellier, France.,University of Montpellier (MUSE), Montpellier, France
| | | | | | - Thibault Moreau
- Department of Neurology, CHU de Dijon, EA4184, Dijon, France
| | - Sandrine Wiertlewski
- CHU de Nantes, Service de Neurologie, CIC015 INSERM, Nantes, France.,INSERM CR1064, Nantes, France
| | - Eric Berger
- Department of Neurology, CHU de Besançon, Besançon, France
| | - Xavier Moisset
- Department of Neurology, Neuro-Dol, CHU Clermont-Ferrand, Université Clermont Auvergne, INSERM U1107, Clermont-Ferrand, France
| | - Audrey Rico-Lamy
- Pôle de Neurosciences Cliniques, Service de Neurologie, APHM, Hôpital de la Timone, Marseille, France.,CRMBM UMR 7339, CNRS, Aix-Marseille Université, Marseille, France
| | - Bruno Stankoff
- Brain and Spine Institute, Sorbonne Universités, UPMC Paris 06, ICM, Hôpital de la Pitié Salpêtrière, INSERM UMR S 1127, CNRS UMR 7225, Paris, France.,Department of Neurology, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Caroline Bensa
- Department of Neurology, Fondation Rothschild, Paris, France
| | - Eric Thouvenot
- Department of Neurology, CHU de Nîmes, Nîmes, France.,Institut de Génomique Fonctionnelle, UMR5203, INSERM 1191, Université de Montpellier, Montpellier, France
| | | | | | | | | | - Philippe Cabre
- Department of Neurology, CHU de la Martinique, Fort-de-France, France
| | - Alexis Montcuquet
- Department of Neurology, CHU de Limoges, Hôpital Dupuytren, Limoges, France
| | - Abir Wahab
- Department of Neurology, Assistance Publique des Hôpitaux de Paris, Hôpital Henri Mondor, Université Paris Est, Créteil, France
| | | | - Ayman Tourbah
- Department of Neurology, CHU de Reims, Faculté de Médecine de Reims, URCA, Reims, France.,LPN EA 2027 Université Paris 8, Saint-Denis, France
| | - Anne-Marie Guennoc
- Department of Neurology, CHU de Tours, Hôpital Bretonneau, CRC SEP, Tours, France
| | - Karolina Hankiewicz
- Department of Neurology, Hôpital Pierre Delafontaine, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Ivania Patry
- Department of Neurology, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | - Chantal Nifle
- Department of Neurology, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Nicolas Maubeuge
- Department of Neurology, CHU de Poitiers, Hôpital La Milétrie, Poitiers, France
| | - Céline Labeyrie
- Department of Neurology, CHU de Bicêtre, Le Kremlin-Bicêtre, France
| | - Patrick Vermersch
- LIRIC (Lille Inflammation Research International Center), University of Lille, CHU de Lille, INSERM UMR995, Lille, France
| | - David-Axel Laplaud
- CHU de Nantes, Service de Neurologie, CIC015 INSERM, Nantes, France.,INSERM CR1064, Nantes, France
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Grand'Maison F, Yeung M, Morrow SA, Lee L, Emond F, Ward BJ, Laneuville P, Schecter R. Sequencing of disease-modifying therapies for relapsing-remitting multiple sclerosis: a theoretical approach to optimizing treatment. Curr Med Res Opin 2018; 34:1419-1430. [PMID: 29583054 DOI: 10.1080/03007995.2018.1458023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Multiple sclerosis (MS) is a chronic disease which usually begins in young adulthood and is a lifelong condition. Individuals with MS experience physical and cognitive disability resulting from inflammation and demyelination in the central nervous system. Over the past decade, several disease-modifying therapies (DMTs) have been approved for the management of relapsing-remitting MS (RRMS), which is the most prevalent phenotype. The chronic nature of the disease and the multiple treatment options make benefit-risk-based sequencing of therapy essential to ensure optimal care. The efficacy and short- and long-term risks of treatment differ for each DMT due to their different mechanism of action on the immune system. While transitioning between DMTs, in addition to immune system effects, factors such as age, disease duration and severity, disability status, monitoring requirements, preference for the route of administration, and family planning play an important role. Determining a treatment strategy is therefore challenging as it requires careful consideration of the differences in efficacy, safety and tolerability, while at the same time minimizing risks of immune modulation. In this review, we discuss a sequencing approach for treating RRMS, with importance given to the long-term risks and individual preference when devising a treatment plan. Evidence-based strategies to counter breakthrough disease are also addressed.
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Affiliation(s)
| | - Michael Yeung
- b Clinical Neurosciences, Foothills Medical Centre , Calgary , Alberta , Canada
| | - Sarah A Morrow
- c London Health Sciences Center (LHSC), Western University , London , Ontario , Canada
| | - Liesly Lee
- d Department of Neurology , Sunnybrook Health Sciences Centre , Toronto , Ontario , Canada
| | - Francois Emond
- e CHU de Québec - hôpital de l'Enfant-Jésus , Quebec City , Quebec , Canada
| | - Brian J Ward
- f Department of Microbiology & Immunology , McGill University , Montreal , Quebec , Canada
| | - Pierre Laneuville
- g Department of Medicine , McGill University , Montreal , Quebec , Canada
| | - Robyn Schecter
- h Novartis Pharmaceuticals Canada Inc. , Dorval , Quebec , Canada
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Clavel G, Moulignier A, Semerano L. Progressive multifocal leukoencephalopathy and rheumatoid arthritis treatments. Joint Bone Spine 2017; 84:671-675. [PMID: 28323224 DOI: 10.1016/j.jbspin.2017.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 12/15/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system due to reactivation of the JC virus (JCV). PML is extremely uncommon despite the high prevalence of the virus in the general population. No specific treatment is available, and the prognosis is bleak. The diagnosis is based on brain imaging findings, detection of the JCV genome in cerebrospinal fluid samples and, in some cases, histological studies of the brain lesions. The pathophysiological mechanisms that drive the development of PML are incompletely understood. However, a consistent feature is the presence of a predisposing factor, most notably immunosuppression. The risk of developing PML varies with the underlying disease (e.g., HIV infection or autoimmune disease) and with the drugs used to treat them. Biologics have been ranked according to the risk of PML during their use. Natalizumab, a monoclonal antibody given to treat multiple sclerosis, is among the drugs associated with a high risk of PML. Patients given natalizumab are now closely monitored based on anti-JCV antibody titers and index values. In rheumatology, the expanding use of biologics has led to an increase in cases of PML, with rituximab being associated with the highest risk. Given the absence of specific recommendations, exhaustive registries and postmarketing observational studies are urgently needed to gauge the risk of PML according to the underlying disease and drug treatments, with the goal of defining optimal monitoring protocols.
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Affiliation(s)
- Gaëlle Clavel
- Service de médecine interne, Fondation A. de Rothschild, 25-29, rue Manin, 75019 Paris, France; Inserm UMR 1125, 74, rue Marcel-Cachin, 93017 Bobigny, France; Sorbonne Paris Cité, université Paris 13, 74, rue Marcel-Cachin, 93017 Bobigny, France.
| | | | - Luca Semerano
- Inserm UMR 1125, 74, rue Marcel-Cachin, 93017 Bobigny, France; Sorbonne Paris Cité, université Paris 13, 74, rue Marcel-Cachin, 93017 Bobigny, France; Service de rhumatologie, groupe hospitalier Avicenne Jean-Verdier-René-Muret, Assistance publique-Hopitaux de Paris (AP-HP), 93017 Bobigny, France
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Mondal S, Rangasamy SB, Ghosh S, Watson RL, Pahan K. Nebulization of RNS60, a Physically-Modified Saline, Attenuates the Adoptive Transfer of Experimental Allergic Encephalomyelitis in Mice: Implications for Multiple Sclerosis Therapy. Neurochem Res 2017; 42:1555-1570. [PMID: 28271325 DOI: 10.1007/s11064-017-2214-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/20/2017] [Accepted: 02/20/2017] [Indexed: 01/12/2023]
Abstract
Developing a new and effective therapeutic approach against multiple sclerosis (MS) is always an important area of research. RNS60 is a bioactive aqueous solution generated by subjecting normal saline to Taylor-Couette-Poiseuille flow under elevated oxygen pressure. Recently we have demonstrated that RNS60, administered through intraperitoneal injection, ameliorated clinical symptoms and disease progression of experimental allergic encephalomyelitis (EAE), an animal model of MS. Since the intravenous route is not preferred for treating a chronic condition, we tested if nebulization of RNS60 could attenuate the disease process of adoptively-transferred EAE in mice. Although we could not directly image RNS60 after nebulization, nebulized Alexa680 reached spleen, spinal cord and different parts of the brain. Nebulization of RNS60 starting from the acute phase attenuated clinical symptoms of relapsing-remitting EAE in female SJL/J mice. RNS60 nebulization also inhibited perivascular cuffing, maintained the integrity of blood-brain and blood-spinal cord barriers, suppressed inflammation, normalized the expression of myelin genes, and blocked demyelination in the CNS of EAE mice. On the immunomodulatory front, nebulization of RNS60 to EAE mice led to the enrichment of anti-autoimmune regulatory T cells (Tregs) and suppression of autoimmune Th17 cells. Together, these results suggest that nebulization of RNS60 may be used to control aberrant immune responses in MS and other autoimmune disorders.
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Affiliation(s)
- Susanta Mondal
- Department of Neurological Sciences, Rush University Medical Center, 1735 West Harrison St, Suite 310, Chicago, IL, 60612, USA
| | - Suresh B Rangasamy
- Department of Neurological Sciences, Rush University Medical Center, 1735 West Harrison St, Suite 310, Chicago, IL, 60612, USA
| | - Supurna Ghosh
- Revalesio Corporation, 1200 East D Street, Tacoma, WA, 98421, USA
| | - Richard L Watson
- Revalesio Corporation, 1200 East D Street, Tacoma, WA, 98421, USA
| | - Kalipada Pahan
- Department of Neurological Sciences, Rush University Medical Center, 1735 West Harrison St, Suite 310, Chicago, IL, 60612, USA.
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