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Ruggieri S, Prosperini L, Al-Araji S, Annovazzi PO, Bisecco A, Ciccarelli O, De Stefano N, Filippi M, Fleischer V, Evangelou N, Enzinger C, Gallo A, Garjani A, Groppa S, Haggiag S, Khalil M, Lucchini M, Mirabella M, Montalban X, Pozzilli C, Preziosa P, Río J, Rocca MA, Rovira A, Stromillo ML, Zaffaroni M, Tortorella C, Gasperini C. Assessing treatment response to oral drugs for multiple sclerosis in real-world setting: a MAGNIMS Study. J Neurol Neurosurg Psychiatry 2024; 95:142-150. [PMID: 37775266 DOI: 10.1136/jnnp-2023-331920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/09/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The assessment of treatment response is a crucial step for patients with relapsing-remitting multiple sclerosis on disease-modifying therapies (DMTs). We explored whether a scoring system developed within the MAGNIMS (MRI in Multiple Sclerosis) network to evaluate treatment response to injectable drugs can be adopted also to oral DMTs. METHODS A multicentre dataset of 1200 patients who started three oral DMTs (fingolimod, teriflunomide and dimethyl fumarate) was collected within the MAGNIMS network. Disease activity after the first year was classified by the 'MAGNIMS' score based on the combination of relapses (0-≥2) and/or new T2 lesions (<3 or ≥3) on brain MRI. We explored the association of this score with the following 3-year outcomes: (1) confirmed disability worsening (CDW); (2) treatment failure (TFL); (3) relapse count between years 1 and 3. The additional value of contrast-enhancing lesions (CELs) and lesion location was explored. RESULTS At 3 years, 160 patients experienced CDW: 12% of them scored '0' (reference), 18% scored '1' (HR=1.82, 95% CI 1.20 to 2.76, p=0.005) and 37% scored '2' (HR=2.74, 95% CI 1.41 to 5.36, p=0.003) at 1 year. The analysis of other outcomes provided similar findings. Considering the location of new T2 lesions (supratentorial vs infratentorial/spinal cord) and the presence of CELs improved the prediction of CDW and TFL, respectively, in patients with minimal MRI activity alone (one or two new T2 lesions). CONCLUSIONS Early relapses and substantial MRI activity in the first year of treatment are associated with worse short-term outcomes in patients treated with some of the oral DMTs.
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Affiliation(s)
- Serena Ruggieri
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Luca Prosperini
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | - Sarmad Al-Araji
- Department of Neuroinflammation, Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Pietro Osvaldo Annovazzi
- Neuroimmunology Unit-Multiple Sclerosis Center, Hospital of Gallarate, ASST della Valle Olona, Gallarate, Italy
| | - Alvino Bisecco
- Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Olga Ciccarelli
- Department of Neuroinflammation, Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- National Institute for Health Research Biomedical Research Centre, University College London Hospitals, London, UK
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Massimo Filippi
- Neurology Unit and Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Vinzenz Fleischer
- Department of Neurology and Neuroimaging Center (NIC) of the Focus Program Translational Neuroscience (FTN), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Nikos Evangelou
- Mental Health & Clinical Neuroscience Unit, University of Nottingham, Nottingham, UK
- Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria
- Department of Radiology (Division of Neuroradiology, Vascular and Interventional Radiology), Medical University of Graz, Graz, Austria
| | - Antonio Gallo
- Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Afagh Garjani
- Mental Health & Clinical Neuroscience Unit, University of Nottingham, Nottingham, UK
- Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sergiu Groppa
- Department of Neurology and Neuroimaging Center (NIC) of the Focus Program Translational Neuroscience (FTN), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Shalom Haggiag
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | - Michael Khalil
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Matteo Lucchini
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di ricerca Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimiliano Mirabella
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di ricerca Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Xavier Montalban
- Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Carlo Pozzilli
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Preziosa
- Neurology Unit and Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Jordi Río
- Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Maria A Rocca
- Neurology Unit and Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Alex Rovira
- Section of Neuroradiology, Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria L Stromillo
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Mauro Zaffaroni
- Neuroimmunology Unit-Multiple Sclerosis Center, Hospital of Gallarate, ASST della Valle Olona, Gallarate, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | - Claudio Gasperini
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
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Gold R, Barnett M, Chan A, Feng H, Fujihara K, Giovannoni G, Montalbán X, Shi FD, Tintoré M, Xue Q, Yang C, Zhou H. Clinical use of dimethyl fumarate in multiple sclerosis treatment: an update to include China, using a modified Delphi method. Ther Adv Neurol Disord 2023; 16:17562864231180734. [PMID: 37465201 PMCID: PMC10350766 DOI: 10.1177/17562864231180734] [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: 12/20/2022] [Accepted: 05/20/2023] [Indexed: 07/20/2023] Open
Abstract
Dimethyl fumarate (DMF) is a widely used oral disease-modifying therapy for multiple sclerosis (MS). Its efficacy and safety profiles are supported by over a decade of experience. Differences exist between Asia and Europe/United States in the prevalence and characteristics of MS; most data for DMF are derived from populations outside Asia. DMF was recently (2021) approved for use in China. The objectives of this review were to evaluate the evidence for DMF's profile, to provide an update to healthcare providers on current knowledge surrounding its use and to assess the relevance of existing data to use in China. This study used a modified Delphi method based on the insights of a scientific Steering Committee (SC), with a structured literature review conducted to assess the data of DMF. The literature review covered all papers in English (from 01 January 2011 to 21 February 2022) that include 'dimethyl fumarate' and 'multiple sclerosis', and their MeSH terms, on PubMed, supplemented by EMBASE and Citeline searches. Papers were categorized by topic and assessed for relevance and quality, before being used to formulate statements summarizing the literature on each subject. SC members voted on/revised statements, requiring ⩾80% agreement and ⩽10% disagreement for inclusion. Statements not reaching this level were discussed further until agreement was reached or until there was agreement to remove the statement. A total of 1030 papers were retrieved and used to formulate the statements and evidence summaries considered by the SC members. A total of 45 statements were agreed by the SC members. The findings support the positive efficacy and safety profile of DMF in treating patients with MS. Limited Chinese patient data are an ongoing consideration; however, based on current evidence, the statements are considered applicable to both the global and Chinese populations. DMF is a valuable addition to address unmet MS treatment needs in China. Registration: Not applicable.
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Affiliation(s)
- Ralf Gold
- Department of Neurology, Ruhr University Bochum, Bochum 44791, Germany
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney and Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew Chan
- Department of Neurology, Inselspital (Bern University Hospital), University of Bern, Bern, Switzerland
| | - Huiyu Feng
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Gavin Giovannoni
- Department of Neurology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Xavier Montalbán
- Neurology Department, Multiple Sclerosis Center of Catalonia (Cemcat), Vall d’Hebron University Hospital, Barcelona, Spain
| | - Fu-Dong Shi
- Department of Neurology, Institute of Neuroimmunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Mar Tintoré
- Neurology Department, Multiple Sclerosis Center of Catalonia (Cemcat), Vall d’Hebron University Hospital, Barcelona, Spain
| | - Qun Xue
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chunsheng Yang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Gonzalez-Martinez A, Patel R, Healy BC, Lokhande H, Paul A, Saxena S, Polgar-Turcsanyi M, Weiner HL, Chitnis T. miRNA 548a-3p as biomarker of NEDA-3 at 2 years in multiple sclerosis patients treated with fingolimod. J Neuroinflammation 2023; 20:131. [PMID: 37254147 DOI: 10.1186/s12974-023-02811-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/19/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a disabling autoimmune demyelinating disorder affecting young people and causing significant disability. In the last decade, different microRNA (miRNA) expression patterns have been associated to several treatment response therapies such as interferon and glatiramer acetate. Nowadays, there is increasing interest in the potential role of miRNA as treatment response biomarkers to the most recent oral and intravenous treatments. In this study, we aimed to evaluate serum miRNAs as biomarkers of No Evidence of Disease Activity (NEDA-3) at 2 years in patients with relapsing remitting MS (RRMS) treated with fingolimod. MAIN BODY A Discovery cohort of 31 RRMS patients treated with fingolimod were identified from the CLIMB study and classified as No Evidence of Disease Activity (NEDA-3) or Evidence of Disease Activity (EDA-3) after 2 years on treatment. Levels of miRNA expression were measured at 6 months using human serum miRNA panels and compared in EDA-3 and NEDA-3 groups using the Wilcoxon rank sum test. A set of differentially expressed miRNA was further validated in an independent cohort of 22 fingolimod-treated patients. We found that 548a-3p serum levels were higher levels in fingolimod-treated patients classified as NEDA-3, compared to the EDA-3 group in both the Discovery (n = 31; p = 0.04) and Validation (n = 22; p = 0.03) cohorts 6 months after treatment initiation; miR-548a-3p provided an AUC of 0.882 discriminating patients with NEDA-3 at 2 years in the Validation cohort. CONCLUSION Our results show differences in miR-548a-3p expression at 6 months after fingolimod start in patients with MS with NEDA-3 at 2 years. These results provide class III evidence of the use of miR-548a-3p as biomarker of NEDA-3 in patients with fingolimod.
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Affiliation(s)
- Alicia Gonzalez-Martinez
- Department of Neurology, Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Brigham and Women's Hospital, 60 Fenwood Road, 9002K, Boston, MA, 02115, USA
| | - Rohit Patel
- Department of Neurology, Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Brigham and Women's Hospital, 60 Fenwood Road, 9002K, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Brian C Healy
- Harvard Medical School, Boston, MA, 02115, USA
- Department of Neurology, Brigham MS Center, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Hrishikesh Lokhande
- Department of Neurology, Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Brigham and Women's Hospital, 60 Fenwood Road, 9002K, Boston, MA, 02115, USA
| | - Anu Paul
- Department of Neurology, Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Brigham and Women's Hospital, 60 Fenwood Road, 9002K, Boston, MA, 02115, USA
| | - Shrishti Saxena
- Department of Neurology, Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Brigham and Women's Hospital, 60 Fenwood Road, 9002K, Boston, MA, 02115, USA
| | - Mariann Polgar-Turcsanyi
- Department of Neurology, Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Brigham and Women's Hospital, 60 Fenwood Road, 9002K, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Howard L Weiner
- Harvard Medical School, Boston, MA, 02115, USA
- Department of Neurology, Brigham MS Center, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Tanuja Chitnis
- Department of Neurology, Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Brigham and Women's Hospital, 60 Fenwood Road, 9002K, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, 02115, USA.
- Department of Neurology, Brigham MS Center, Brigham and Women's Hospital, Boston, MA, 02115, USA.
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Baeva ME, Metz LM, Greenfield J, Camara-Lemarroy CR. Simple Parameters from Complete Blood Count Predict Lymphopenia, Adverse Effects and Efficacy in People with MS treated with Dimethyl Fumarate. Mult Scler Relat Disord 2023; 74:104699. [PMID: 37031552 DOI: 10.1016/j.msard.2023.104699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/28/2023] [Accepted: 04/02/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Dimethyl fumarate (DMF) is a first-line oral therapy for relapsing-remitting multiple sclerosis (RRMS). This retrospective study aims to determine the utility of routine complete blood counts (CBC) in predicting lymphopenia, adverse effects and efficacy in a real-world clinical setting. METHODS The Calgary Multiple Sclerosis (MS) Clinic manages over 1800 people with MS on disease-modifying therapies (DMT). Data of patients with relapsing-remitting MS (pwMS) who initiated DMF between July 1, 2013 and December 31, 2014 were included. Patients were followed for one year. DMT use is carefully monitored and pwMS need a screening CBC and have regular CBCs done at follow-up. Demographic, clinical, MRI and relapse information are collected prospectively in a clinic database. We analyzed CBCs at baseline and month 3. RESULTS We identified 139 pwMS in the study period who started DMF. Median follow-up time on-drug was 12 (0.16-12) months. In our study, 15.8% of pwMS developed lymphopenia grade 2 or higher. Baseline lymphocyte counts and older age were significant predictors of lymphopenia. Higher baseline eosinophil counts predicted flushing/gastrointestinal adverse effects, and higher baseline monocyte counts were predictive of breakthrough disease activity. Neutrophil and platelet to lymphocyte ratios, markers that have been associated with overall mortality in the general population, were increased at month 3. CONCLUSIONS Routinely obtained CBCs during the screening and monitoring of people with MS starting DMF offer clinically useful information and generate interesting hypotheses. Age and baseline lymphocyte counts are reinforced as clinically useful predictors of lymphopenia. Our novel findings that baseline eosinophil and monocyte counts could offer insights into usual adverse effects and efficacy, respectively, should be further investigated as a potentially new set of biomarkers.
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Lorrey SJ, Waibl Polania J, Wachsmuth LP, Hoyt-Miggelbrink A, Tritz ZP, Edwards R, Wolf DM, Johnson AJ, Fecci PE, Ayasoufi K. Systemic immune derangements are shared across various CNS pathologies and reflect novel mechanisms of immune privilege. Neurooncol Adv 2023; 5:vdad035. [PMID: 37207119 PMCID: PMC10191195 DOI: 10.1093/noajnl/vdad035] [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] [Indexed: 05/21/2023] Open
Abstract
Background The nervous and immune systems interact in a reciprocal manner, both under physiologic and pathologic conditions. Literature spanning various CNS pathologies including brain tumors, stroke, traumatic brain injury and de-myelinating diseases describes a number of associated systemic immunologic changes, particularly in the T-cell compartment. These immunologic changes include severe T-cell lymphopenia, lymphoid organ contraction, and T-cell sequestration within the bone marrow. Methods We performed an in-depth systematic review of the literature and discussed pathologies that involve brain insults and systemic immune derangements. Conclusions In this review, we propose that the same immunologic changes hereafter termed 'systemic immune derangements', are present across CNS pathologies and may represent a novel, systemic mechanism of immune privilege for the CNS. We further demonstrate that systemic immune derangements are transient when associated with isolated insults such as stroke and TBI but persist in the setting of chronic CNS insults such as brain tumors. Systemic immune derangements have vast implications for informed treatment modalities and outcomes of various neurologic pathologies.
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Affiliation(s)
- Selena J Lorrey
- Department of Immunology, Duke University, Durham, NC, USA
- Brain Tumor Immunotherapy Program, Duke University, Durham, NC, USA
| | - Jessica Waibl Polania
- Brain Tumor Immunotherapy Program, Duke University, Durham, NC, USA
- Department of Pathology, Duke University, Durham, NC, USA
| | - Lucas P Wachsmuth
- Brain Tumor Immunotherapy Program, Duke University, Durham, NC, USA
- Department of Pathology, Duke University, Durham, NC, USA
- Medical Scientist Training Program, Duke University, Durham, NC, USA
| | - Alexandra Hoyt-Miggelbrink
- Brain Tumor Immunotherapy Program, Duke University, Durham, NC, USA
- Department of Pathology, Duke University, Durham, NC, USA
| | | | - Ryan Edwards
- Brain Tumor Immunotherapy Program, Duke University, Durham, NC, USA
| | - Delaney M Wolf
- Department of Immunology, Mayo Clinic, Rochester, MN, USA
| | | | - Peter E Fecci
- Department of Immunology, Duke University, Durham, NC, USA
- Brain Tumor Immunotherapy Program, Duke University, Durham, NC, USA
- Department of Pathology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
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Ferret-Sena V, Capela C, Macedo A, Salgado AV, Derudas B, Staels B, Sena A. Fingolimod treatment modulates PPARγ and CD36 gene expression in women with multiple sclerosis. Front Mol Neurosci 2022; 15:1077381. [PMID: 36590913 PMCID: PMC9797671 DOI: 10.3389/fnmol.2022.1077381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
Fingolimod is an oral immunomodulatory drug used in the treatment of multiple sclerosis (MS) that may change lipid metabolism. Peroxisome proliferator-activated receptors (PPAR) are transcription factors that regulate lipoprotein metabolism and immune functions and have been implicated in the pathophysiology of MS. CD36 is a scavenger receptor whose transcription is PPAR regulated. The objective of this study was to evaluate whether fingolimod treatment modifies PPAR and CD36 gene expression as part of its action mechanisms. Serum lipoprotein profiles and PPAR and CD36 gene expression levels in peripheral leukocytes were analysed in 17 female MS patients before and at 6 and 12 months after fingolimod treatment initiation. Clinical data during the follow-up period of treatment were obtained. We found that fingolimod treatment increased HDL-Cholesterol and Apolipoprotein E levels and leukocyte PPARγ and CD36 gene expression. No correlations were found between lipid levels and variations in PPARγ and CD36 gene expression. PPARγ and CD36 variations were significantly correlated during therapy and in patients free of relapse and stable disease. Our results suggest that PPARγ and CD36-mediated processes may contribute to the mechanisms of action of fingolimod in MS. Further studies are required to explore the relation of the PPARγ/CD36 pathway to the clinical efficacy of the drug and its involvement in the pathogenesis of the disease.
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Affiliation(s)
- Véronique Ferret-Sena
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Monte de Caparica, Portugal
| | - Carlos Capela
- Departamento de Neurologia, Hospital Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Ana Macedo
- Keypoint Consultora Científica, Algés, Portugal,Departamento de Ciências Biomédicas e Medicina (DCBM), Universidade do Algarve, Faro, Portugal
| | | | - Bruno Derudas
- Inserm, CHU Lille, Institut Pasteur de Lille, University of Lille, Lille, France
| | - Bart Staels
- Inserm, CHU Lille, Institut Pasteur de Lille, University of Lille, Lille, France
| | - Armando Sena
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Monte de Caparica, Portugal,Departamento de Neurologia, Hospital Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal,*Correspondence: Armando Sena,
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Bollo L, Caputo F, Paolicelli D, Trojano M, Iaffaldano P. Interdisciplinary approach to opportunistic infections: staphylococcal meningitis in a patient with multiple sclerosis on treatment with dimethyl fumarate. Intern Emerg Med 2022; 17:1845-1847. [PMID: 35486330 PMCID: PMC9051806 DOI: 10.1007/s11739-022-02989-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Luca Bollo
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Francesca Caputo
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Pietro Iaffaldano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy.
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The Effects of Phellodendron Decoction on Wound Healing of Anal Fistula after Anal Fistulotomy. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:7363006. [PMID: 36016687 PMCID: PMC9396417 DOI: 10.1155/2022/7363006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/26/2022] [Accepted: 07/04/2022] [Indexed: 11/18/2022]
Abstract
Objective To analyze the therapeutic effect of Compound Phellodendron decoction on wounds after anal fistulotomy. Methods 100 patients with anal fistula who underwent anal fistulotomy from April 2019 to April 2021 were included in the study group and control group according to the random number table method. 50 patients in the study group were treated with Compound Phellodendron decoction by fumigation and sitting bath, while warm water replaced Compound Phellodendron decoction in the control group. Perianal pain, wound edema, and exudation were scored on postoperative days 3 and 7, and wound healing time was recorded. Interleukin-2(IL-2), IL-5, IL-6, and IL-12 were measured via a double-antibody sandwich enzyme-linked immunosorbent assay. Hematoxylin-eosin (HE) staining and immunofluorescence were used to quantitatively analyze the capillary number and CD4+ and CD8+ lymphocytes in granulation tissue on postoperative days 7. Results The scores of pain, edema, and exudation in 2 groups on postoperative day 7 were lower than those on the 3rd postoperative day. Compared with the control group, the pain, edema, and exudation scores in the study group were decreased, and the wound healing time was shortened; the expressions of IL-2 and IL-12 in the study group were significantly increased, while the expressions of IL-5 and IL-6 were decreased; the number of capillaries and CD4+ lymphocytes in the study group was increased, while the number of CD8+ lymphocytes was decreased. Conclusion Compound Phellodendron decoction had efficacy in promoting wound healing, reducing complications, and changing lymphocyte aggregation and alleviating local inflammatory response.
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Ravn J, Jensen HB, Kant M, Andersen PB, Góra MK, Sejbæk T. Risk factors for development of lymphopenia in dimethyl fumarate-treated patients with multiple sclerosis. Mult Scler Relat Disord 2022; 67:104081. [DOI: 10.1016/j.msard.2022.104081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 04/30/2022] [Accepted: 07/28/2022] [Indexed: 10/31/2022]
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Abstract
PURPOSE OF REVIEW Increasingly, therapeutic strategy in multiple sclerosis (MS) is informed by imaging and laboratory biomarkers, in addition to traditional clinical factors. Here, we review aspects of monitoring the efficacy and risks of disease-modifying therapy (DMT) with both conventional and emerging MRI and laboratory measures. RECENT FINDINGS The adoption of consensus-driven, stable MRI acquisition protocols and artificial intelligence-based, quantitative image analysis is heralding an era of precision monitoring of DMT efficacy. New MRI measures of compartmentalized inflammation, neuro-degeneration and repair complement traditional metrics but require validation before use in individual patients. Laboratory markers of brain cellular injury, such as neurofilament light, are robust outcomes in DMT efficacy trials; their use in clinical practice is being refined. DMT-specific laboratory monitoring for safety is critical and may include lymphocytes, immunoglobulins, autoimmunity surveillance, John Cunningham virus serology and COVID-19 vaccination seroresponse. SUMMARY A biomarker-enhanced monitoring strategy has immediate clinical application, with growing evidence of long-term reductions in disability accrual when both clinically symptomatic and asymptomatic inflammatory activity is fully suppressed; and amelioration of the risks associated with therapy. Emerging MRI and blood-based measures will also become important tools for monitoring agents that target the innate immune system and promote neuro-repair.
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Barbieri MA, Sorbara EE, Battaglia A, Cicala G, Rizzo V, Spina E, Cutroneo PM. Adverse Drug Reactions with Drugs Used in Multiple Sclerosis: An Analysis from the Italian Pharmacovigilance Database. Front Pharmacol 2022; 13:808370. [PMID: 35281926 PMCID: PMC8904918 DOI: 10.3389/fphar.2022.808370] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/10/2022] [Indexed: 12/14/2022] Open
Abstract
Given the importance of inflammation at the onset of multiple sclerosis (MS), therapy is mainly based on the use of anti-inflammatory drugs including disease modifying therapies (DMTs). Considering the recent approval of some DMTs, pharmacovigilance becomes a fundamental tool for the acquisition of new safety data. The aim of the study was to analyze adverse drug reactions (ADRs) related to the use of drugs approved for MS. All national publicly-available aggregated ADR reports recorded from 2002 to 2020 into the Reports of Adverse Reactions of Medicines (RAM) system and all complete Sicilian data reported into the Italian spontaneous reporting system (SRS) database having as suspected drugs interferon β-1a (IFN β-1a), interferon β-1b (IFN β-1b), peginterferon β-1a (PEG-IFN β-1a), glatiramer acetate (GA), natalizumab (NTZ), fingolimod (FNG), teriflunomide (TRF), dimethyl fumarate (DMF), alemtuzumab (Alem), ocrelizumab (OCZ), or cladribine (Cladr), were collected. Descriptive analyses of national, publicly-available aggregated data and full-access regional data were performed to assess demographic characteristics and drug-related variables followed by a more in-depth analysis of all Sicilian ADRs with a case-by-case assessment and a disproportionality analysis of unexpected ADRs. A total of 13,880 national reports have been collected from 2002 to 2020: they were mainly not serious ADRs (67.9% vs. 26.1%) and related to females (71.7% vs. 26.3%) in the age group 18–65 years (76.5%). The most reported ADRs were general and administration site conditions (n = 6,565; 47.3%), followed by nervous (n = 3,090; 22.3%), skin (n = 2,763; 19.9%) and blood disorders (n = 2,180; 15.7%). Some unexpected Sicilian ADRs were shown, including dyslipidemia for FNG (n = 10; ROR 28.5, CI 14.3–59.6), NTZ (n = 5; 10.3, 4.1–25.8), and IFN β-1a (n = 4; 8.7, 3.1–24.1), abortion and alopecia for NTZ (n = 9; 208.1, 73.4–590.1; n = 3; 4.9, 1.5–15.7), and vitamin D deficiency for GA (n = 3; 121.2, 30.9–475.3). Moreover, breast cancer with DMF (n = 4, 62.8, 20.5–191.9) and hypothyroidism with Cladr (n = 3; 89.2, 25.9–307.5) were also unexpected. The reporting of drugs-related ADRs in MS were mostly reported in the literature, but some unknown ADRs were also found. However, further studies are necessary to increase the awareness about the safety profiles of new drugs on the market.
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Affiliation(s)
| | | | - Alessandro Battaglia
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Cicala
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vincenzo Rizzo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Paola Maria Cutroneo
- Sicilian Regional Pharmacovigilance Centre, University Hospital of Messina, Messina, Italy
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12
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Sainzde la Maza S, Muñoz JS, Pilode la Fuente B, Thuissard I, Andreu‑Vázquez C, Sánchez-Seco VG, Salgado-Cámara P, Costa-Frossard L, Monreal E, Ayuso-Peralta L, García-Vasco L, García‑Domínguez JM, Martínez-Ginés ML, Fernández CM, Díaz-Díaz J, Oreja-Guevara C, Gómez‑Moreno M, Martín H, Rubio-Flores L, Blasco MR, Villar-Guimerans LM, Aladro Y. Early predictive risk factors for dimethyl fumarate-associated lymphopenia in patients with multiple sclerosis. Mult Scler Relat Disord 2022; 59:103669. [DOI: 10.1016/j.msard.2022.103669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/16/2022] [Accepted: 02/03/2022] [Indexed: 11/16/2022]
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13
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Huh SY, Kim SH, Kim KH, Kwon YN, Kim SM, Kim SW, Shin HY, Chung YH, Min JH, So J, Lim YM, Kim KK, Kim NH, Nam TS, Kang SY, Oh J, Oh SI, Sohn E, Kim HJ. Safety and Temporal Pattern of the Lymphocyte Count During Fingolimod Therapy in Patients With Multiple Sclerosis: Real-World Korean Experience. J Clin Neurol 2022; 18:663-670. [DOI: 10.3988/jcn.2022.18.6.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- So-Young Huh
- Department of Neurology, College of Medicine, Kosin University, Busan, Korea
| | - Su-Hyun Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Ki Hoon Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Young Nam Kwon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sung-Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Seung Woo Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Yeon Hak Chung
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju-Hong Min
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungmin So
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Min Lim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwang-Kuk Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Nam-Hee Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Tai-Seung Nam
- Department of Neurology, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Sa-Yoon Kang
- Department of Neurology, Jeju National University School of Medicine, Jeju, Korea
| | - Jeeyoung Oh
- Department of Neurology, Konkuk University Medical Center, Seoul, Korea
| | - Seong-il Oh
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Eunhee Sohn
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
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14
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Koska V, Förster M, Brouzou K, Arat E, Albrecht P, Aktas O, Küry P, Meuth SG, Kremer D. Case Report: Persisting Lymphopenia During Neuropsychiatric Tumefactive Multiple Sclerosis Rebound Upon Fingolimod Withdrawal. Front Neurol 2021; 12:785180. [PMID: 34777236 PMCID: PMC8585856 DOI: 10.3389/fneur.2021.785180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Fingolimod (FTY) is a disease modifying therapy for relapsing remitting multiple sclerosis (RRMS) which can lead to severe lymphopenia requiring therapy discontinuation in order to avoid adverse events. However, this can result in severe disease reactivation occasionally presenting with tumefactive demyelinating lesions (TDLs). TDLs, which are thought to originate from a massive re-entry of activated lymphocytes into the central nervous system, are larger than 2 cm in diameter and may feature mass effect, perifocal edema, and gadolinium enhancement. In these cases, it can be challenging to exclude important differential diagnoses for TDLs such as progressive multifocal leukoencephalopathy (PML) or other opportunistic infections. Here, we present the case of a 26-year-old female patient who suffered a massive rebound with TDLs following FTY discontinuation with primarily neuropsychiatric symptoms despite persisting lymphopenia. Two cycles of seven plasmaphereses each were necessary to achieve remission and ocrelizumab was used for long-term stabilization.
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Affiliation(s)
- Valeria Koska
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Moritz Förster
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Katja Brouzou
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Ercan Arat
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Philipp Albrecht
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Patrick Küry
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - David Kremer
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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15
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Chu L, Balusha A, Casserly C, Berger W, Morrow SA. Relationship between lymphopenia and disease activity in persons with multiple sclerosis treated with dimethyl fumarate. Mult Scler Relat Disord 2021; 57:103384. [DOI: 10.1016/j.msard.2021.103384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/02/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
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16
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Fingolimod as a first- or second-line treatment in a mini-series of young Hellenic patients with adolescent-onset multiple sclerosis: focus on immunological data. Neurol Sci 2021; 43:2641-2649. [PMID: 34596776 DOI: 10.1007/s10072-021-05623-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Pediatric onset multiple sclerosis(POMS) is characterized by a highly active profile, often warranting treatment with high efficacy disease-modulating therapies (DMTs). Fingolimod, an oral sphingosine-1-phosphate receptor modulator, is the first Food and Drug Administration (FDA)- and European Medicines Agency (EMA)-approved DMT for the treatment of POMS. OBJECT Our aim is to present real-world data of seven fingolimod-treated POMS-patients, recruited in a single MS center in Greece. METHODS Clinical and imaging/laboratory data from 7 Hellenic patients fulfilling the International Pediatric Multiple Sclerosis Study Group (IPMSSG) criteria for POMS diagnosis, who have received fingolimod treatment, were selected. Human leukocyte antigen (HLA) genotyping was performed with standard low-resolution sequence-specific oligonucleotide techniques. RESULTS Three patients were treatment-naïve adolescents who received fingolimod as first-line treatment. Two experienced ongoing clinical and radiological disease activity and have been switched to natalizumab. The remaining cases were post-adolescent adults with POMS, where the vast majority experienced total/near-total disease remission. Fingolimod was generally well-tolerated. Two patients with high disease activity carried the HLA-DRB1*03 allele, while five patients were carriers of at least one of the HLA-DRB1*04, HLA-DRB1*13, and HLA-DRB1*14 alleles, which when not combined with HLA-DRB1*03 showed a trend towards a more favorable clinical course. Fingolimod responders showed a trend towards increased CD(16-56)+NK cell counts in immunophenotyping assays. CONCLUSIONS Our preliminary results support that response of POMS patients to fingolimod may be partially dependent on age and previous DMT, with younger and treatment-naïve patients presenting worse outcomes. The role of immunogenetics and immunophenotyping in personalized treatment warrants investigation in larger and more diverse populations.
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17
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Scotto R, Reia A, Buonomo AR, Moccia M, Viceconte G, Pisano E, Zappulo E, Brescia Morra V, Gentile I. Risk of invasive fungal infections among patients treated with disease modifying treatments for multiple sclerosis: a comprehensive review. Expert Opin Drug Saf 2021; 20:925-936. [PMID: 33880975 DOI: 10.1080/14740338.2021.1918673] [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] [Indexed: 12/12/2022]
Abstract
Introduction: Disease modifying treatments are commonly used in the treatment of multiple sclerosis. As different opportunistic infections have been reported, concerns are also raised regarding the risk of invasive fungal infections.Areas covered: Both clinical trials and observational studies on safety and efficacy of diseases modifying treatment for multiple sclerosis were reviewed and data regarding the occurrence of invasive fungal infections were reported. Papers evaluating the following drugs were reviewed: rituximab, ocrelizumab, alemtuzumab, fingolimod, natalizumab, dimethyl fumarate, interferon, glatiramer acetate, cladribine, teriflunomide.Expert opinion: Overall, the occurrence of invasive fungal infections was low, with most infective events reported among patients treated with monoclonal antibodies and fingolimod. Aspergillosis and cryptococcal meningitidis were the most representative fungal infections. Although not common, these infections may be difficult to diagnose and their fatality rate is often high. For this reason, screening protocols for fungal infections must be implemented in the clinical practice when managing patients with MS.
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Affiliation(s)
- R Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - A Reia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - A R Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - M Moccia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - G Viceconte
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - E Pisano
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - E Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - V Brescia Morra
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - I Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
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18
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Lower lymphocyte counts and older age are associated with reduced multiple sclerosis disease activity during dimethyl fumarate treatment. Mult Scler Relat Disord 2021; 49:102781. [PMID: 33524927 DOI: 10.1016/j.msard.2021.102781] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 01/12/2021] [Accepted: 01/16/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND delayed-release dimethyl fumarate (DMF) is a disease modifying therapy for relapsing-remitting multiple sclerosis (MS) with antioxidant and anti-inflammatory properties. The drug causes lymphocyte count reduction, which can lead to lymphopenia development during treatment. This is an important safety issue, due to infectious risk, mainly progressive multifocal leukoencephalopathy (PML). If the lymphocyte count influences the response to treatment is still a matter of debate, as there are contrasting contrasting data in the literature. Considering this, we aimed to identify DMF induced lymphopenia risk factors and to evaluate lymphopenia impact on MS disease activity in a real world setting. METHODS a retrospective study on 135 MS patients receiving DMF with a mean treatment duration of 32.3±15.9 months was performed. Baseline and follow-up demographic, clinical, magnetic resonance imaging (MRI) and laboratory data were collected. RESULTS 44 patients (32.6%) developed lymphopenia, with 11 (8.1%) grade 1, 23 (17.0%) grade 2 and 10 (7.4 %) grade 3. Older age and lower basal absolute lymphocyte count were found to be associated with lymphopenia development on a binary regression model (p<0.001 and p=0.009). When compared with non lymphopenic+lymphopenia grade 1 patients, those experiencing lymphopenia grade 2+3 had longer disease activity free survival (p<0.001), fewer clinical relapses (p=0.005) and lower MRI disease activity (p≤0.001). On Cox regression model, older age and lymphopenia grade 2+3 were found to be protective factors against disease activity (HR=0.966; 95% C.I.=0.942-0.992; p=0.009 for age; HR=0.137; 95% C.I.=0.043-0.439; p=0.001 for lymphopenia grade 2+3) and MRI disease activity (HR=0.968; 95% C.I.=0.941-0.997; p=0.030 for age; HR=0.142; 95% C.I.=0.034-0.591; p=0.007 for lymphopenia grade 2+3). Only lymphopenia grade 2+3 was found to be a predictor of clinical relapses (HR=0.970; 95% C.I.=0.936-1.005; p=0.095 for age; HR=0.115; 95% C.I.=0.016-0.854; p=0.034 for lymphopenia grade 2+3), with a protective effect. CONCLUSION older age and lower basal lymphocyte count were found to be associated with lymphopenia development. Lymphopenia grade 2+3 and older age could be protective against clinical and radiologic disease activity during DMF treatment.
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19
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Dello Russo C, Scott KA, Pirmohamed M. Dimethyl fumarate induced lymphopenia in multiple sclerosis: A review of the literature. Pharmacol Ther 2020; 219:107710. [PMID: 33091427 DOI: 10.1016/j.pharmthera.2020.107710] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 12/13/2022]
Abstract
Dimethyl fumarate (DMF) is a first line medication for multiple sclerosis. It has a favourable safety profile, however, there is concern regarding the occurrence of moderate-severe and sustained lymphopenia and the associated risk of progressive multifocal leukoencephalopathy. We carried out an extensive literature review to understand the molecular mechanisms underlying this adverse reaction. Dynamic changes in certain components of the immune system are likely to be important for the therapeutic effects of DMF, including depletion of memory T cells and decrease in activated T cells together with expansion of naïve T cells. Similar modifications were reported for the B cell components. CD8+ T cells are particularly susceptible to DMF-induced cell death, with marked reductions observed in lymphopenic subjects. The reasons underlying such increased sensitivity are not known, nor it is known how expansion of other lymphocyte subsets occurs. Understanding the molecular mechanisms underlying DMF action is challenging: in vivo DMF is rapidly metabolized to monomethyl fumarate (MMF), a less potent immunomodulator in vitro. Pharmacokinetics indicate that MMF is the main active species in vivo. However, the relative importance of DMF and MMF in toxicity remains unclear, with evidence presented in favour of either of the compounds as toxic species. Pharmacogenetic studies to identify genetic predictors of DMF-induced lymphopenia are limited, with inconclusive results. A role of the gut microbiome in the pharmacological effects of DMF is emerging. It is clear that further investigations are necessary to understand the mechanisms of DMF-induced lymphopenia and devise preventive strategies. Periodic monitoring of absolute lymphocyte counts, currently performed in clinical practise, allows for the early detection of lymphopenia as a risk-minimization strategy.
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Affiliation(s)
- Cinzia Dello Russo
- MRC Centre for Drug Safety Science and Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, UK; Dept. of Healthcare Surveillance and Bioethics, Section of Pharmacology, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Kathryn Anne Scott
- MRC Centre for Drug Safety Science and Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- MRC Centre for Drug Safety Science and Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, UK.
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20
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Comi G, Dalla Costa G, Moiola L. Newly approved agents for relapsing remitting multiple sclerosis: how real-world evidence compares with randomized clinical trials? Expert Rev Neurother 2020; 21:21-34. [PMID: 33043718 DOI: 10.1080/14737175.2021.1829478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION In recent years, many treatment options have become available for relapsing remitting MS. Randomized clinical trials and real-world studies are complementary sources of information, and together have the potential to offer a comprehensive understanding of the safety and efficacy profiles of each drug, a critical factor for a personalized management of the disease. AREAS COVERED In this review, the authors provide an up-to-date review of both RCTs and real-world studies assessing the safety and efficacy profiles of recently developed disease-modifying drugs for relapsing remitting MS. These include fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab and ocrelizumab. EXPERT OPINION From the authors' review of the literature, the efficacy profiles resulted from RCTs were confirmed by observational studies with regard to the disease-modifying drugs considered. The magnitude of the effects on annualized relapse rates and MRI active lesions was generally even larger in the observational studies compared to RCTs. From the safety point of view, observational studies revealed new adverse events, mostly in the area of bacterial and opportunistic infections, not seen in the relative registration programme. This is a very important gain because it allows to elaborate appropriate strategies to prevent and handle the risks.
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Affiliation(s)
- Giancarlo Comi
- Institute of Experimental Neurology of San Raffaele Hospital , Milan, Italy
| | - Gloria Dalla Costa
- Institute of Experimental Neurology of San Raffaele Hospital , Milan, Italy.,Vita-Salute San Raffaele University , Milan, Italy
| | - Lucia Moiola
- Institute of Experimental Neurology of San Raffaele Hospital , Milan, Italy.,Neurology Unit and MS Center, San Raffaele Hospital , Milan, Italy
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21
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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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22
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Kemmerer CL, Pernpeintner V, Ruschil C, Abdelhak A, Scholl M, Ziemann U, Krumbholz M, Hemmer B, Kowarik MC. Differential effects of disease modifying drugs on peripheral blood B cell subsets: A cross sectional study in multiple sclerosis patients treated with interferon-β, glatiramer acetate, dimethyl fumarate, fingolimod or natalizumab. PLoS One 2020; 15:e0235449. [PMID: 32716916 PMCID: PMC7384624 DOI: 10.1371/journal.pone.0235449] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022] Open
Abstract
Background Several disease modifying drugs (DMDs) have been approved for the treatment of multiple sclerosis (MS), however, little is known about their differential impact on peripheral blood (PB) B cell subsets. Methods We performed a cross sectional study on PB B cells in MS patients treated with interferon-β (n = 25), glatiramer acetate (n = 19), dimethyl fumarate (n = 15), fingolimod (n = 16) or natalizumab (n = 22), untreated MS patients (n = 20), and in patients with non-inflammatory neurological diseases (n = 12). Besides analyzing routine laboratory data, flow cytometry was performed to analyze naïve B cells (CD19+CD20+CD27-IgD+), non-class switched (CD19+CD20+CD27+IgD+) and class-switched memory B cells (CD19+CD20+CD27+IgD-), double negative B cells (CD19+CD20lowCD27-IgD-) and plasmablasts (CD19+CD20lowCD27+CD38++). Results Treatment associated changes were found for the overall B cell pool as well as for all B cell subsets. Natalizumab increased absolute numbers and percentage of all B cells mainly by expanding the memory B cell pool. Fingolimod decreased absolute numbers of all B cell subsets and the percentage of total B cells. Fingolimod, dimethyl fumarate and interferon-β treatments were associated with an increase in the fraction of naïve B cells while class switched and non-class switched memory B cells showed decreased percentages. Conclusion Our results highlight differential effects of DMDs on the PB B cell compartment. Across the examined treatments, a decreased percentage of memory B cells was found in dimethyl fumarate, interferon-β and fingolimod treated patients which might contribute to the drugs’ mode of action in MS. Further studies are necessary to decipher the exact role of B cell subsets during MS pathogenesis.
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Affiliation(s)
- C. L. Kemmerer
- Department of Neurology & Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - V. Pernpeintner
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - C. Ruschil
- Department of Neurology & Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - A. Abdelhak
- Department of Neurology & Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - M. Scholl
- Department of Neurology & Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - U. Ziemann
- Department of Neurology & Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - M. Krumbholz
- Department of Neurology & Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - B. Hemmer
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - M. C. Kowarik
- Department of Neurology & Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- * E-mail:
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Cohan S, Lucassen E, Smoot K, Brink J, Chen C. Sphingosine-1-Phosphate: Its Pharmacological Regulation and the Treatment of Multiple Sclerosis: A Review Article. Biomedicines 2020; 8:biomedicines8070227. [PMID: 32708516 PMCID: PMC7400006 DOI: 10.3390/biomedicines8070227] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/11/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
Sphingosine-1-phosphate (S1P), via its G-protein-coupled receptors, is a signaling molecule with important regulatory properties on numerous, widely varied cell types. Five S1P receptors (S1PR1-5) have been identified, each with effects determined by their unique G-protein-driven downstream pathways. The discovery that lymphocyte egress from peripheral lymphoid organs is promoted by S1P via S1PR-1 stimulation led to the development of pharmacological agents which are S1PR antagonists. These agents promote lymphocyte sequestration and reduce lymphocyte-driven inflammatory damage of the central nervous system (CNS) in animal models, encouraging their examination of efficacy in the treatment of multiple sclerosis (MS). Preclinical research has also demonstrated direct protective effects of S1PR antagonists within the CNS, by modulation of S1PRs, particularly S1PR-1 and S1PR-5, and possibly S1PR-2, independent of effects upon lymphocytes. Three of these agents, fingolimod, siponimod and ozanimod have been approved, and ponesimod has been submitted for regulatory approval. In patients with MS, these agents reduce relapse risk, sustained disability progression, magnetic resonance imaging markers of disease activity, and whole brain and/or cortical and deep gray matter atrophy. Future opportunities in the development of more selective and intracellular S1PR-driven downstream pathway modulators may expand the breadth of agents to treat MS.
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24
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Bhatia R, Srivastava MVP, Khurana D, Pandit L, Mathew T, Gupta S, Netravathi M, Nair SS, Singh G, Singhal BS. Consensus Statement On Immune Modulation in Multiple Sclerosis and Related Disorders During the COVID-19 Pandemic: Expert Group on Behalf of the Indian Academy of Neurology. Ann Indian Acad Neurol 2020; 23:S5-S14. [PMID: 32419748 PMCID: PMC7213028 DOI: 10.4103/0972-2327.282442] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022] Open
Abstract
Knowledge related to SARS-CoV-2 or 2019 novel coronavirus (2019-nCoV) is still emerging and rapidly evolving. We know little about the effects of this novel coronavirus on various body systems and its behaviour among patients with underlying neurological conditions, especially those on immunomodulatory medications. The aim of the present consensus expert opinion document is to appraise the potential concerns when managing our patients with underlying CNS autoimmune demyelinating disorders during the current COVID-19 pandemic.
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Affiliation(s)
- Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Lekha Pandit
- Department of Neurology, K.S. Hegde Medical Academy, Mangalore, Karnataka, India
| | - Thomas Mathew
- Department of Neurology, St John's Medical College, Bangalore, Karnataka, India
| | - Salil Gupta
- Department of Neurology, Command Hospital Air Force, Bangalore, Karnataka, India
| | - M Netravathi
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Sruthi S Nair
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Gagandeep Singh
- Department of Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Bhim S Singhal
- Department of Neurology, Bombay Hospital, Mumbai, Maharashtra, India
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