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Yamout B, Alroughani R, Inshasi J, Farouk S, Abdulla F, Al-Jarki NY, Alasmi A, Al Fahad S, Alkhabouri J, Al-Saffar K, Benedetti B, Canibano B, Deleu D, Hassan A, Sarathchandran P, Shatila A, Abouelnaga M, Thakre M, Szolics M, Boshra A. Practical Recommendations from the Gulf Region on the Therapeutic Use of Cladribine Tablets for the Management of Relapsing Multiple Sclerosis: Impact of the Latest Real-World Evidence on Clinical Practice. Neurol Ther 2024; 13:1321-1335. [PMID: 39097537 PMCID: PMC11393234 DOI: 10.1007/s40120-024-00650-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 07/22/2024] [Indexed: 08/05/2024] Open
Abstract
Cladribine tablets (CladT), like alemtuzumab, acts as an immune reconstitution therapy. However, CladT is administered orally (alemtuzumab is given by infusion) and without the potential for serious side effects that limit the therapeutic use of alemtuzumab in multiple sclerosis (MS). Treatment with CladT, given initially as short courses of treatment 1 year apart, provides years of freedom from MS disease activity in responders to treatment. The appearance of mild or moderate MS disease activity after the initial 2 years of treatment may prompt careful follow-up or a further course of CladT, depending on the nature of the activity and individual circumstances. The appearance of severe MS disease activity requires a switch to an alternative high-efficacy disease-modifying treatment (DMT). The accumulating data from CladT-treated people with MS in real-world studies, including those with follow-up durations extending for years beyond the initial treatment, have demonstrated long-term freedom from MS disease activity in a good proportion of patients. This clinical experience has also confirmed that treatment with CladT is generally safe and well tolerated. The best time to prescribe a high-efficacy DMT is the subject of debate, with evidence that earlier versus later use of such agents may provide more effective long-term protection from disability progression. High-efficacy DMTs have traditionally been reserved for use in people with MS and high disease activity on presentation or breakthrough disease on one or more DMTs, as per the current product labels. The latest evidence from real-world studies suggests that CladT is effective and safe in DMT-naïve patients, including those with shorter disease duration.
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Affiliation(s)
- Bassem Yamout
- Neurology Institute and Multiple Sclerosis Center, Harley Street Medical Center, Abu Dhabi, United Arab Emirates
| | - Raed Alroughani
- Division of Neurological, Department of Medicine, Amiri Hospital, Arabian Gulf Street, 13001, Sharq, Kuwait.
| | - Jihad Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - Samar Farouk
- Department of Neurology, Ibn Sina Hospital, Safat, Kuwait
- Department of Neurology and Psychiatry, Minia University, Minya, Egypt
| | - Fatema Abdulla
- Neuroscience Department, Ministry of Health, Manama, Kingdom of Bahrain
| | | | - Abdulla Alasmi
- Neurology Unit, Department of Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Sarmad Al Fahad
- Neurology Department, Neurospinal Hospital, Baghdad Medical College, Dubai, United Arab Emirates
| | | | - Khalid Al-Saffar
- Department of Neurology, Medcare Hospital Al Safa, Dubai, United Arab Emirates
| | | | | | - Dirk Deleu
- Neurology Medical Clinic, Tawam Hospital, Abu Dhabi, United Arab Emirates
| | - Ali Hassan
- Neurology Department, Al Qassimi Hospital, EHS, Sharjah, United Arab Emirates
| | | | - Ahmed Shatila
- Neurology Department, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Mohammad Abouelnaga
- Neurology Department, Zayed Military Hospital, Abu Dhabi, United Arab Emirates
| | - Mona Thakre
- Neurology Department, Al Zahra Hospital, Dubai, United Arab Emirates
| | - Miklos Szolics
- Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
- Department of Medicine, CMHS, Abu Dhabi, United Arab Emirates
| | - Amir Boshra
- Merck Serono Middle East FZ-Ltd, An Affiliate of Merck KGaA, Dubai, United Arab Emirates
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Manni A, Oggiano F, Palazzo C, Panetta V, Gargano CD, Mangialardi V, Guerra T, Iaffaldano A, Caputo F, Iaffaldano P, Ruggieri M, Trojano M, Paolicelli D. Clinical and biological predictors of Cladribine effectiveness in Multiple Sclerosis: A real-world, single Centre study considering a two-year interval from year-2 dosing. J Neurol Sci 2024; 462:123070. [PMID: 38850773 DOI: 10.1016/j.jns.2024.123070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
OBJECTIVES Cladribine tablets (CLAD) for adult patients with highly active relapsing multiple sclerosis (RMS) have been available in Italy since 2018. We aimed to assess predictors of no-evidence-of-disease-activity-3 (NEDA-3) status after 24 months of the last dose of CLAD. RESULTS We included 88 patients (70.5% female, mean age at CLAD start 35.4 ± 11.4). Eighteen patients were treatment naïve, 48 switched to CLAD from a First line Disease Modifying Drug (DMD), and 22 from Second line DMDs. All patients were observed for a median follow-up time of 2.4 (1-4) years after the last dose of CLAD. Forty-nine patients (55.7%) showed NEDA at the last available follow-up. Naïve patients (p = 0.001), those with a lower number of previous DMDs (p < 0.001) and, even though not significantly, those switching from first line DMDs (p = 0.069) were more likely NEDA3 at the last available follow-up. In a subgroup of 30 patients (34%), Serum Light Neurofilaments (sNFL) levels showed a decrease from baseline to the 24 months of follow-up, statistically significant from baseline to the sixth month, and from the first to the second year detection. sNFL levels at 12th month showed a strong inverse correlation with the time to NEDA3 loss. CONCLUSIONS Our experience provides information for the 2-years after the last dose of CLAD, confirming a higher effectiveness of CLAD when placed early in the treatment algorithm. Given the ongoing expansion of the therapeutic landscape in MS, sNfL could support individualized decision-making, used as blood-based biomarker for CLAD responses in clinical practice.
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Affiliation(s)
- A Manni
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy.
| | - F Oggiano
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy.
| | - C Palazzo
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy.
| | - V Panetta
- L'altrastatistica srl -Consultancy & Training- Biostatistics office, Rome, Cap 00174, Italy.
| | - C D Gargano
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy.
| | - V Mangialardi
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
| | - T Guerra
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
| | - A Iaffaldano
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
| | - F Caputo
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
| | - P Iaffaldano
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy.
| | - M Ruggieri
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy.
| | - M Trojano
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy.
| | - D Paolicelli
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy.
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Ciron J, Bourre B, Castelnovo G, Guennoc AM, De Sèze J, Ben-Amor AF, Savarin C, Vermersch P. Holistic, Long-Term Management of People with Relapsing Multiple Sclerosis with Cladribine Tablets: Expert Opinion from France. Neurol Ther 2024; 13:503-518. [PMID: 38488979 PMCID: PMC11136930 DOI: 10.1007/s40120-024-00589-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/09/2024] [Indexed: 03/17/2024] Open
Abstract
Cladribine tablets (CladT) has been available for therapeutic use in France since March 2021 for the management of highly active relapsing multiple sclerosis (RMS). This high-efficacy disease-modifying therapy (DMT) acts as an immune reconstitution therapy. In contrast to most high-efficacy DMTs, which act via continuous immunosuppression, two short courses of oral treatment with CladT at the beginning of years 1 and 2 of treatment provide long-term control of MS disease activity in responders to treatment, without the need for any further pharmacological treatment for several years. Although the labelling for CladT does not provide guidance beyond the initial treatment courses, real-world data on the therapeutic use of CladT from registries of previous clinical trial participants and patients treated in routine practice indicate that MS disease activity is controlled for a period of years beyond this time for a substantial proportion of patients. Moreover, this clinical experience has provided useful information on how to initiate and manage treatment with CladT. In this article we, a group of expert neurologists from France, provide recommendations on the initiation of CladT in DMT-naïve patients, how to switch from existing DMTs to CladT for patients with continuing MS disease activity, how to manage patients during the first 2 years of treatment and finally, how to manage patients with or without MS disease activity in years 3, 4 and beyond after initiating treatment with CladT. We believe that optimisation of the use of CladT beyond its initial courses of treatment will maximise the benefits of this treatment, especially early in the course of MS when suppression of focal inflammation in the CNS is a clinical priority to limit MS disease progression.
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Affiliation(s)
- Jonathan Ciron
- Department of Neurology, Centre de Ressources et de Compétences Sclérose en Plaques (CRC-SEP), Toulouse University Hospital, Hôpital Pierre-Paul Riquet, Toulouse, France
- INSERM UMR1291, CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse III, Toulouse, France
| | | | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | | | - Jérôme De Sèze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Ali Frederic Ben-Amor
- Knowlepsy Investment, Marseille Innovation, Technopôle de Château-Gombert, Marseille, France
| | - Carine Savarin
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France.
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de Seze J, Dive D, Ayrignac X, Castelnovo G, Payet M, Rayah A, Gobbi C, Vermersch P, Zecca C. Narrative Review on the Use of Cladribine Tablets as Exit Therapy for Stable Elderly Patients with Multiple Sclerosis. Neurol Ther 2024; 13:519-533. [PMID: 38587749 PMCID: PMC11136913 DOI: 10.1007/s40120-024-00603-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
The number of ageing people with relapsing multiple sclerosis (RMS) is increasing. The efficacy of disease-modifying therapies (DMTs) for RMS declines with age. Also, older persons with MS may be more susceptible to infections, hospitalisations and malignancy. Aging people with MS have higher rates of comorbidities versus aged-matched controls, increasing the individual risk of disability. We review the therapeutic properties of cladribine tablets (CladT) in ageing people with RMS, with regard to their utility for allowing these individuals to cease continuous administration of a DMT (i.e. to act as an "exit therapy"). CladT is thought to be an immune reconstitution therapy, in that two short courses of oral treatment 1 year apart provide suppression of MS disease activity in responders that far outlasts the duration of treatment and post-treatment reductions in lymphocyte counts. Post hoc analyses, long-term follow-up of populations with RMS in randomised trials, and real-world evidence suggest that the efficacy of CladT is probably independent of age, although more data in the elderly are still needed. No clear adverse signals for lymphopenia or other adverse safety signals have emerged with increasing age, although immunosenescence in the setting of age-related "inflammaging" may predispose elderly patients to a higher risk of infections. Updating vaccination status is recommended, especially against pneumococci and herpes zoster for older patients, to minimise the risk of these infections. CladT may be a useful alternative treatment for ageing people with MS who often bear a burden of multiple comorbidities and polypharmacy and who are more exposed to the adverse effects of continuous immunosuppressive therapy.
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Affiliation(s)
- Jerome de Seze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France.
| | - Dominique Dive
- Department of Neurology, Liège University Hospital, Liège, Belgium
| | - Xavier Ayrignac
- Department of Neurology, University of Montpellier, INM, INSERM, Montpellier University Hospital, Montpellier, France
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Marianne Payet
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Amel Rayah
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Claudio Gobbi
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Patrick Vermersch
- University of Lille, INSERM U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Chiara Zecca
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
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Deleu D, Garcia Canibano B, Elalamy O, Sayed Abdelmoneim M, Boshra A. Practical Guidance on the Use of Cladribine Tablets in the Management or Relapsing Multiple Sclerosis: Expert Opinion from Qatar. Degener Neurol Neuromuscul Dis 2023; 13:81-88. [PMID: 38105885 PMCID: PMC10725680 DOI: 10.2147/dnnd.s433459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
The increasing availability of high-efficacy disease-modifying therapies (DMT) for the management of relapsing multiple sclerosis (RMS) has increased the potential for individualised patient management but has added complexity to the design of treatment regimens. The long-term application of immune reconstitution therapy (IRT) is supported by an increasing database of real world studies that have added important information on the long-term safety and efficacy of this approach. Cladribine tablets (CladT) is an IRT given as two annual short courses of treatment, following which a majority of patients then demonstrate no significant MS disease activity over a period of years. Whether, and how, to treat patients beyond the first two years of treatment remains a matter for debate, as clinical evidence accumulates. We, a group of neurologists who manage people with RMS in Qatar, provide our expert consensus recommendations on the application and long-term management of CladT therapy based on our experience with treatment in the last 5 years. These include pragmatic recommendations for people with MS disease activity in years 3 and 4 (ie up to four years following first dose of CladT), and for people with or without MS disease activity in subsequent years. We believe our recommendations will help to ensure the optimal application of CladT-based IRT, with the potential benefit for the patient of achieving prolonged periods free of both MS disease symptoms and the burden of regular applications of immunosuppressive DMT.
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Affiliation(s)
- Dirk Deleu
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Osama Elalamy
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Amir Boshra
- Merck Serono Middle East FZ-Ltd., Dubai, UAE, an affiliate of Merck KGaA, Dubai, United Arab Emirates
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Inshasi J, Farouk S, Shatila A, Hassan A, Szolics M, Thakre M, Kayed D, Krieger D, Almadani A, Alsaadi T, Benedetti B, Mifsud V, Jacob A, Sayegh S, Boshra A, Alroughani R. Multicentre Observational Study of Treatment Satisfaction with Cladribine Tablets in the Management of Relapsing Multiple Sclerosis in the Arabian Gulf: The CLUE Study. Neurol Ther 2023; 12:1309-1318. [PMID: 37289421 PMCID: PMC10310633 DOI: 10.1007/s40120-023-00497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/10/2023] [Indexed: 06/09/2023] Open
Abstract
INTRODUCTION Inconvenient administration and side effects of some disease-modifying therapies (DMTs) for relapsing multiple sclerosis (RMS) can deter adherence. We evaluated treatment satisfaction with cladribine tablets (CladT) for RMS in the Arabian Gulf. METHODS This was a non-interventional, multicentre, prospective observational study in non-pregnant/lactating adults (aged ≥ 18 years) with RMS eligible for 1st treatment with CladT (EU labelling). The primary outcome was overall treatment satisfaction at 6 months (Treatment Satisfaction Questionnaire for Medication [TSQM]-14, v. 1.4), Global Satisfaction subscale. Secondary endpoints were TSQM-14 scores for convenience, satisfaction with side effects and satisfaction with effectiveness. Patients provided written informed consent. RESULTS Of 63 patients screened, 58 received CladT and 55 completed the study. Mean age was 33 ± 9 years; mean weight 73 ± 17 kg; 31% male/69% female; mostly from the United Arab Emirates (52%) or Kuwait (30%). All had RMS (mean 0.9 ± 1.1 relapses in the past year), mean Expanded Disability Status Scale (EDSS) 1.4 ± 1.2; 36% were DMT-naïve. Mean [95% CI] score was high for overall treatment satisfaction (77.8 [73.0-82.6]), ease of use (87.4 [83.7-91.0]), tolerability (94.2 [91.0-97.3]) and effectiveness (76.2 [71.6-80.7]). Scores were similar irrespective of DMT history, age, gender, relapse history or EDSS. No relapses or serious treatment-emergent adverse events (TEAE) occurred. Two severe TEAE occurred (fatigue, headache) and 16% reported lymphopenia (two cases of grade 3 lymphopenia). Absolute lymphocyte counts at baseline and 6 months were 2.2 ± 0.8 × 109/L and 1.3 ± 0.3 × 109/L, respectively. CONCLUSIONS Treatment satisfaction, ease of use, tolerability and patient-perceived effectiveness for CladT were high, irrespective of baseline demographics, disease characteristics and prior treatment.
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Affiliation(s)
- Jihad Inshasi
- Rashid Hospital and Dubai Medical College and Dubai Health Authority (DHA), P.O. Box 4545, Dubai, UAE.
| | - Samar Farouk
- Ibn Sina Hospital, Kuwait, Kuwait
- Faculty of Medicine, Minia University, Minia, Egypt
| | | | - Ali Hassan
- Tawam Hospital, Abu Dhabi, UAE
- College of Medicine and Health Science, United Arab Emirates University, Abu Dhabi, UAE
| | - Miklos Szolics
- Tawam Hospital, Abu Dhabi, UAE
- College of Medicine and Health Science, United Arab Emirates University, Abu Dhabi, UAE
| | | | | | | | - Abubaker Almadani
- Rashid Hospital and Dubai Medical College and Dubai Health Authority (DHA), P.O. Box 4545, Dubai, UAE
| | | | | | | | - Anu Jacob
- Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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