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Singer BA, Feng J, Chiong-Rivero H. Early use of high-efficacy therapies in multiple sclerosis in the United States: benefits, barriers, and strategies for encouraging adoption. J Neurol 2024; 271:3116-3130. [PMID: 38615277 PMCID: PMC11136864 DOI: 10.1007/s00415-024-12305-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Multiple sclerosis (MS) is characterized by progressive neuroinflammation and neurodegeneration from disease onset that, if left untreated, can result in the accumulation of irreversible neurological disability. Early intervention with high-efficacy therapies (HETs) is increasingly recognized as the best strategy to delay or mitigate disease progression from the earliest stages of the disease and to prevent long-term neurodegeneration. Although there is growing clinical and real-world evidence supporting early HET intervention, foregoing this strategy in favor of a traditional escalation approach prioritizing lower-efficacy disease-modifying therapies remains a common approach in clinical practice. This review explores potential health care professional- and patient-related barriers to the early use of HETs in patients with MS in the United States. Barriers can include regulatory and reimbursement restrictions; knowledge gaps and long-term safety concerns among health care professionals; and various individual, cultural, and societal factors affecting patients. Potential strategies for overcoming these barriers and encouraging early HET use are proposed.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA.
| | - Jenny Feng
- Ochsner Medical Center, New Orleans, LA, USA
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Aliyu M, Zohora FT, Ceylan A, Hossain F, Yazdani R, Azizi G. Immunopathogenesis of multiple sclerosis: molecular and cellular mechanisms and new immunotherapeutic approaches. Immunopharmacol Immunotoxicol 2024; 46:355-377. [PMID: 38634438 DOI: 10.1080/08923973.2024.2330642] [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: 09/21/2023] [Accepted: 03/09/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Multiple sclerosis (MS) is a central nervous system (CNS) demyelinating autoimmune disease with increasing global prevalence. It predominantly affects females, especially those of European descent. The interplay between environmental factors and genetic predisposition plays a crucial role in MS etiopathogenesis. METHODS We searched recent relevant literature on reputable databases, which include, PubMed, Embase, Web of Science, Scopus, and ScienceDirect using the following keywords: multiple sclerosis, pathogenesis, autoimmunity, demyelination, therapy, and immunotherapy. RESULTS Various animal models have been employed to investigate the MS etiopathogenesis and therapeutics. Autoreactive T cells within the CNS recruit myeloid cells through chemokine expression, leading to the secretion of inflammatory cytokines driving the MS pathogenesis, resulting in demyelination, gliosis, and axonal loss. Key players include T cell lymphocytes (CD4+ and CD8+), B cells, and neutrophils. Signaling dysregulation in inflammatory pathways and the immunogenetic basis of MS are essential considerations for any successful therapy to MS. Data indicates that B cells and neutrophils also have significant roles in MS, despite the common belief that T cells are essential. High neutrophil-to-lymphocyte ratios correlate with MS severity, indicating their contribution to disease progression. Dysregulated signaling pathways further exacerbate MS progression. CONCLUSION MS remains incurable, but disease-modifying therapies, monoclonal antibodies, and immunomodulatory drugs offer hope for patients. Research on the immunogenetics and immunoregulatory functions of gut microbiota is continuing to provide light on possible treatment avenues. Understanding the complex interplay between genetic predisposition, environmental factors, and immune dysregulation is critical for developing effective treatments for MS.
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Affiliation(s)
- Mansur Aliyu
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, International Campus, TUMS-IC, Tehran, Iran
- Department of Medical Microbiology, Faculty of Clinical Science, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Fatema Tuz Zohora
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
| | - Ayca Ceylan
- Medical Faculty, Department of Pediatrics, Division of Immunology and Allergy, Selcuk University, Konya, Turkey
| | - Fariha Hossain
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
| | - Reza Yazdani
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gholamreza Azizi
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
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van Pesch V, Hanganu AR, Sankari SE. Long-term follow up of alemtuzumab-treated patients: a retrospective study in a Belgian tertiary care center. Acta Neurol Belg 2024:10.1007/s13760-024-02542-9. [PMID: 38619747 DOI: 10.1007/s13760-024-02542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/23/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Pivotal studies have reported a significant proportion of patients achieving no evidence of disease activity (NEDA) after 2 cycles of treatment with alemtuzumab (ATZ), that can be maintained for several years. Long-term real-world evidence regarding ATZ as well as subsequent treatment trajectories is still scarce. OBJECTIVE To analyze the effectiveness and safety of ATZ-treated patients in a tertiary care Belgian center. METHODS A retrospective cohort study including 32 patients treated with ATZ between 2015 and 2021 was performed. RESULTS 32 patients received 2 ATZ courses with a mean follow-up (FU) duration of 5.6 years (range: 2.25-8.2). 21.75% patients were treatment naïve. 40.5% were previously treated with natalizumab or fingolimod. NEDA-3 was achieved in 61.3-85% of patients, with failure mostly attributed to recurrence of radiological disease activity. During FU, annualized relapse rates remained very low (0.06-0.14), disability improvement occurred in up to 40.5%, whereas disability worsening occurred in up to 13.5%. Retreatment risk was associated with younger age (< 45 years old, Odds Ratio 8.0, p = 0.02) and a higher number of previous DMTs (Hazard ratio 2.7, 95%CI 1.3-7.4, p = 0.02). Safety in our cohort was consistent with the known profile of ATZ. At the end of FU, 65.6% patients remained untreated after 2 or 3 courses of ATZ, while the remaining switched to anti-CD20 therapy or cladribine. CONCLUSION ATZ is a high efficacy therapy for active MS, providing long-term remission in a significant proportion of patients. Retreatment was more frequent in younger patients or patients having failed a higher number of previous DMTs.
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Affiliation(s)
- Vincent van Pesch
- Department of Neurology, Cliniques Universitaires Saint-Luc (Neurology), UCLouvain, Brussels, Belgium.
| | - Andreea-Raluca Hanganu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, Fundeni Clinical Institute, Bucharest, Romania
| | - Souraya El Sankari
- Department of Neurology, Cliniques Universitaires Saint-Luc (Neurology), UCLouvain, Brussels, Belgium
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Yamout B, Al-Jumah M, Sahraian MA, Almalik Y, Khaburi JA, Shalaby N, Aljarallah S, Bohlega S, Dahdaleh M, Almahdawi A, Khoury SJ, Koussa S, Slassi E, Daoudi S, Aref H, Mrabet S, Zeineddine M, Zakaria M, Inshasi J, Gouider R, Alroughani R. Consensus recommendations for diagnosis and treatment of Multiple Sclerosis: 2023 revision of the MENACTRIMS guidelines. Mult Scler Relat Disord 2024; 83:105435. [PMID: 38245998 DOI: 10.1016/j.msard.2024.105435] [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: 10/26/2023] [Revised: 12/21/2023] [Accepted: 01/06/2024] [Indexed: 01/23/2024]
Abstract
With evolving diagnostic criteria and the advent of new oral and parenteral therapies for Multiple Sclerosis (MS), most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and time and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of MS therapies is critical to maximize patient benefit. The current guidelines review the current diagnostic criteria for MS and the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, progressive MS, pediatric cases and pregnant women. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.
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Affiliation(s)
- B Yamout
- Neurology Institute and Multiple Sclerosis Center, Harley Street Medical Center, Abu Dhabi, United Arab Emirates.
| | - M Al-Jumah
- InterHealth hospital, Multiple Sclerosis Center, Riyadh, Saudi Arabia
| | - M A Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Y Almalik
- Division of Neurology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - J Al Khaburi
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - N Shalaby
- Neurology Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | | | - S Bohlega
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - A Almahdawi
- Consultant Neurologist, Neurology Unit, Baghdad Teaching Hospital, Medical City Complex, Iraq
| | - S J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - S Koussa
- Multiple Sclerosis Center, Geitaoui Lebanese University Hospital, Beirut, Lebanon
| | - E Slassi
- Hôpital Cheikh Khalifa Ibn Zaid, Casablanca, Morocco
| | - S Daoudi
- Hospital Center Nedir Mohamed, Faculty of Medicine, University Mouloud Mammeri Tizi-Ouzou, Algeria
| | - H Aref
- Neurology Department, Ain Shams University, Cairo, Egypt
| | - S Mrabet
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - M Zeineddine
- Middle East and North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS), Beirut, Lebanon
| | | | - J Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - R Gouider
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - R Alroughani
- Amiri Hospital, Arabian Gulf Street, Sharq, Kuwait
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Costa-Frossard França L, Meca Lallana V, Labiano-Fontcuberta A, Blasco R, Monreal E, Martínez Ginés ML, Aguirre C, Sabin Muñoz J, Sainz de la Maza S, Cuello JP, Díaz-Pérez C, Chico García JL, Lozano Ros A, Rodríguez Jorge F, Martínez Martínez S, García Domínguez JM. Real-World Retrospective Analysis of Alemtuzumab Outcomes in Relapsing-Remitting Multiple Sclerosis: The LEMCAM Study. CNS Drugs 2024; 38:231-238. [PMID: 38418770 PMCID: PMC10920415 DOI: 10.1007/s40263-024-01066-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Alemtuzumab is a high-efficacy treatment approved for relapsing-remitting multiple sclerosis (RRMS). Although clinical trials and observational studies are consistent in showing its efficacy and manageable safety profile, further studies under clinical practice conditions are needed to further support its clinical use. OBJECTIVE The aim of this observational retrospective study was to evaluate the effectiveness and safety of alemtuzumab to add to the current real-world evidence on the drug. METHODS A cohort of 115 adult patients with RRMS treated with alemtuzumab between 2014 and 2020 was retrospectively followed up in five centers in Spain. Analysis included annualized relapse rate (ARR), 6-month confirmed disability worsening (CDW), 6-month confirmed disability improvement (CDI), radiological activity, no evidence of disease activity (NEDA-3), and safety signals. Given the different follow-up periods among participants, ARR was calculated using the person-years method. CDI was defined as a ≥ 1.0-point decrease in Expanded Disability Status Scale (EDSS) score assessed in patients with a baseline EDSS score ≥ 2.0 confirmed 6 months apart. CDW was defined as a ≥ 1.0-point increase in EDSS score assessed in patients with a baseline EDSS score ≥ 1.0 (≥ 1.5 if baseline EDSS = 0), confirmed 6 months apart. RESULTS ARR decreased from 1.9 (95% confidence interval 1.60-2.33) in the year prior to alemtuzumab initiation to 0.28 (0.17-0.37) after 1 year of treatment (87% reduction), and to 0.22 (0.13-0.35) after the second year. Over the entire follow-up period, ARR was 0.24 (0.18-0.30). At year 1, 75% of patients showed no signs of magnetic resonance imaging (MRI) activity and 70% at year 5. One percent of patients experienced 6-month CDW at year 1, 2.6% at year 2, 7.4% at year 3, and no patients over years 4 and 5. A total of 7.7% of patients achieved 6-month CDI in year 1, 3.6% in year 2, and maintained it at years 3 and 4. Most patients achieved annual NEDA-3: year 1, 72%; year 2, 79%; year 3, 80%; year 4, 89%; year 5, 75%. Infusion-related reactions were observed in 95% of patients and infections in 74%. Thyroid disorders occurred in 30% of patients, and only three patients developed immune thrombocytopenia. No cases of progressive multifocal leukoencephalopathy were reported. CONCLUSIONS This study shows that alemtuzumab reduced the relapse rate and disability worsening in real-world clinical practice, with many patients achieving and sustaining NEDA-3 over time. The safety profile of alemtuzumab was consistent with previous findings, and no new or unexpected safety signals were observed. As this was an observational and retrospective study, the main limitation of not having all variables comprehensively available for all patients should be considered when interpreting results.
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Affiliation(s)
| | - Virginia Meca Lallana
- Demyelinating Diseases Unit, Neurology Service, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Rosario Blasco
- Neuroimmunology Unit, Neurology Service, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Enric Monreal
- Department of Neurology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- IRYCIS (Ramón y Cajal Institute for Health Research), Madrid, Spain
- REEM (Spanish Network of Multiple Sclerosis), Universidad de Alcalá, Madrid, Spain
| | | | - Clara Aguirre
- Demyelinating Diseases Unit, Neurology Service, Hospital Universitario La Princesa, Madrid, Spain
| | - Julia Sabin Muñoz
- Neuroimmunology Unit, Neurology Service, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Susana Sainz de la Maza
- Department of Neurology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- IRYCIS (Ramón y Cajal Institute for Health Research), Madrid, Spain
- REEM (Spanish Network of Multiple Sclerosis), Universidad de Alcalá, Madrid, Spain
| | - Juan Pablo Cuello
- Department of Neurology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Carolina Díaz-Pérez
- Demyelinating Diseases Unit, Neurology Service, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Alberto Lozano Ros
- Department of Neurology, Hospital Universitario Gregorio Marañón, Madrid, Spain
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Puthenparampil M, Gaggiola M, Miscioscia A, Mauceri VA, De Napoli F, Zanotelli G, Anglani M, Nosadini M, Sartori S, Perini P, Rinaldi F, Gallo P. Alemtuzumab following natalizumab is more effective in adult-onset than paediatric-onset multiple sclerosis. Ther Adv Neurol Disord 2023; 16:17562864231177196. [PMID: 37808246 PMCID: PMC10559704 DOI: 10.1177/17562864231177196] [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: 02/10/2023] [Accepted: 05/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Paediatric-onset multiple sclerosis (POMS) therapeutic approach derives from of adult-onset multiple sclerosis (AOMS) tailored algorithms. Objectives To evaluate in a common clinical scenario the efficacy and safety of alemtuzumab (ALZ) in POMS and AOMS. Methods All patients switching from natalizumab (NTZ) to ALZ for safety concerns (high anti-John Cunningham Virus Antibody Index value, anti-JCV Index) were enrolled in this single-centre, retrospective, case-control open-label study. Results Ten POMS and 27 AOMS were followed up for 51.3 months. After month 12, we found a lower risk of clinical or radiological relapses among AOMS patients and among patients with older age at ALZ (both p < 0.05). Survival analysis revealed an increased risk of relapse in POMS compared with AOMS (logrank p = 0.00498) and patients starting ALZ before age 22.75 years than the elder ones (logrank p = 0.0018). Survival analysis did not disclose any difference between AOMS and POMS (logrank p = 0.27) in terms of progression independent of any relapse activity (PIRA). In addition, no evidence of relapse-associated worsening was observed. Autoimmune events were reported by 5 AOMS and no POMS (29.4% versus 0.0%, p = 0.057), and survival analysis was not significant (logrank p = 0.0786). Conclusion ALZ seems more effective in AOMS than in POMS following NTZ. These findings underrate ALZ effectiveness when shifting from NTZ in POMS.
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Affiliation(s)
- Marco Puthenparampil
- Multiple Sclerosis Centre, Clinica Neurologica, Dipartimento di Neuroscienze, Università degli Studi di Padova, Via Giustiniani 5, 35128 Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Marta Gaggiola
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Alessandro Miscioscia
- Department of Neurosciences, University of Padua, Padova, Italy
- Padua Neuroscience Centre, University of Padua, Padova, Italy
| | - Valentina Annamaria Mauceri
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Federica De Napoli
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Giovanni Zanotelli
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | | | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute ‘Città della Speranza’, Padova, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute ‘Città della Speranza’, Padova, Italy
| | - Paola Perini
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Francesca Rinaldi
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Paolo Gallo
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
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Edan G, Le Page E. Escalation Versus Induction/High-Efficacy Treatment Strategies for Relapsing Multiple Sclerosis: Which is Best for Patients? Drugs 2023; 83:1351-1363. [PMID: 37725259 PMCID: PMC10582148 DOI: 10.1007/s40265-023-01942-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
After more than 2 decades of recommending an escalating strategy for the treatment of most patients with multiple sclerosis, there has recently been considerable interest in the use of high-efficacy therapies in the early stage of the disease. Early intervention with induction/high-efficacy disease-modifying therapy may have the best risk-benefit profile for patients with relapsing-remitting multiple sclerosis who are young and have active disease, numerous focal T2 lesions on spinal and brain magnetic resonance imaging, and no irreversible disability. Although we have no curative treatment, at least seven classes of high-efficacy drugs are available, with two main strategies. The first strategy involves the use of high-efficacy drugs (e.g., natalizumab, sphingosine 1-phosphate receptor modulators, or anti-CD20 drugs) to achieve sustained immunosuppression. These can be used as a first-line therapy in many countries. The second strategy entails the use of one of the induction drugs (short-term use of mitoxantrone, alemtuzumab, cladribine, or autologous hematopoietic stem cell transplant) that are mainly recommended as a second-line or third-line treatment in patients with very active or aggressive multiple sclerosis disease. Early sustained immunosuppression exposes patients to heightened risks of infection and cancer proportionate to cumulative exposure, and induction drugs expose patients to similar risks during the initial post-treatment period, although these risks decrease over time. Their initial potential safety risks should now be revisited, taking account of long-term data and some major changes in their regimens: natalizumab with the long-term monitoring of John Cunningham virus; use of monthly courses of mitoxantrone with maximum cumulative doses of 36-72 mg/m2, followed by a safer disease-modifying drug; cladribine with only 2-weekly treatment courses required in years 1 and 2 and no systematic treatment for the following 2 years; alemtuzumab, whose safety and clinical impacts have now been documented for more than 6 years after the last infusion; and autologous haematopoietic stem cell transplant, which dramatically reduces transplantation-related mortality with a new regimen and guidelines. Escalation and induction/high-efficacy treatments need rigorous magnetic resonance imaging monitoring. Monitoring over the first few years, using the MAGNIMS score or American Academy of Neurology guidelines, considerably improves prediction accuracy and facilitates the selection of patients with relapsing-remitting multiple sclerosis requiring aggressive treatment.
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Affiliation(s)
- Gilles Edan
- Empenn IRISA Research Group, INSERM Clinical Investigation Center, Pontchaillou University Hospital, Rennes, France.
| | - Emmanuelle Le Page
- Neurology Department, INSERM Clinical Investigation Center, Pontchaillou University Hospital, Rennes, France
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Sandgren S, Novakova L, Nordin A, Axelsson M, Malmeström C, Zetterberg H, Lycke J. A five-year observational prospective mono-center study of the efficacy of alemtuzumab in a real-world cohort of patients with multiple sclerosis. Front Neurol 2023; 14:1265354. [PMID: 37808497 PMCID: PMC10551138 DOI: 10.3389/fneur.2023.1265354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/01/2023] [Indexed: 10/10/2023] Open
Abstract
Background Alemtuzumab (ALZ) is a pulsed immune reconstitution therapy for multiple sclerosis (MS). Objective To assess basic characteristics, therapeutic effects, and prognostic biomarkers on clinical and imaging parameters of disease activity for relapsing-remitting MS (RRMS) patients selected for ALZ, in a real-world long-term setting. Methods Fifty-one RRMS patients [female = 31; mean age 36 (standard deviation 7.1) years; median expanded disability status scale (EDSS) 2 (interquartile range (IQR) 1.5)] initiating ALZ treatment, were consecutively included. Patients were assessed at baseline and thereafter annually for 5 years with clinical measures, symbol digit modality test (SDMT), and magnetic resonance imaging (MRI). Concentrations of glial fibrillary acidic protein (GFAP), reflecting astrogliosis, and neurofilament light (NfL), reflecting axonal damage, were measured in cerebrospinal fluid (CSF) and serum samples collected at baseline and after 2 years in CSF, and annually in serum. Control subjects were symptomatic controls (SCs, n = 27), who were examined at baseline and after 5 years without evidence of neurological disease. Results While the mean annualized relapse rate was significantly reduced from baseline at each year of follow-up, disability was essentially maintained at a median EDSS of 1.5 and IQR between 1.13 and 2.25. New MRI activity was recorded in 26 patients (53%) over 5 years. The proportion of patients who achieved no evidence of disease activity (NEDA-3), 6-months confirmed disability worsening (CDW), and 6-months confirmed disability improvement (CDI) at 5 years were 33, 31, and 31%, respectively. The SDMT score was reduced for patients (p < 0.001), but unchanged for SCs. ALZ treatment did not change GFAP levels, whereas there was a significant decrease for RRMS patients in median CSF and serum NfL levels at follow-up [CSF month 24: 456 pg./mL (IQR 285.4) (p = 0.05); serum month 24: 6.7 pg/mL (IQR 4.7) (p < 0.01); serum month 60: 7.2 pg/mL (IQR 4.7) (p < 0.01)], compared to baseline [CSF: 1014 pg/mL (IQR 2832.5); serum 8.6 pg/mL (IQR 17.4)]. Conclusion In this real-world mono-center population, we observed a progression-free survival of 69%, cumulative NEDA-3 of 33%, and reduced NfL levels, over a five-year follow-up. This confirms ALZ as an effective pulsed immune reconstitution therapy that significantly reduces neuro axonal loss, and therefore has the potential to reduce long-term neurological disability. ALZ did not appear to affect astrogliosis.
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Affiliation(s)
- Sofia Sandgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lenka Novakova
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Nordin
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Markus Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Clas Malmeström
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Laboratory for Clinical Immunology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, University College London (UCL) Queen Square Institute of Neurology, London, United Kingdom
- UK Dementia Research Institute at University College London (UCL), London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, Hong Kong SAR, China
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Hecker M, Fitzner B, Boxberger N, Putscher E, Engelmann R, Bergmann W, Müller M, Ludwig-Portugall I, Schwartz M, Meister S, Dudesek A, Winkelmann A, Koczan D, Zettl UK. Transcriptome alterations in peripheral blood B cells of patients with multiple sclerosis receiving immune reconstitution therapy. J Neuroinflammation 2023; 20:181. [PMID: 37533036 PMCID: PMC10394872 DOI: 10.1186/s12974-023-02859-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 07/25/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic, inflammatory and neurodegenerative disease that leads to irreversible damage to the brain and spinal cord. The goal of so-called "immune reconstitution therapies" (IRTs) is to achieve long-term disease remission by eliminating a pathogenic immune repertoire through intense short-term immune cell depletion. B cells are major targets for effective immunotherapy in MS. OBJECTIVES The aim of this study was to analyze the gene expression pattern of B cells before and during IRT (i.e., before B-cell depletion and after B-cell repopulation) to better understand the therapeutic effects and to identify biomarker candidates of the clinical response to therapy. METHODS B cells were obtained from blood samples of patients with relapsing-remitting MS (n = 50), patients with primary progressive MS (n = 13) as well as healthy controls (n = 28). The patients with relapsing MS received either monthly infusions of natalizumab (n = 29) or a pulsed IRT with alemtuzumab (n = 15) or cladribine (n = 6). B-cell subpopulation frequencies were determined by flow cytometry, and transcriptome profiling was performed using Clariom D arrays. Differentially expressed genes (DEGs) between the patient groups and controls were examined with regard to their functions and interactions. We also tested for differences in gene expression between patients with and without relapse following alemtuzumab administration. RESULTS Patients treated with alemtuzumab or cladribine showed on average a > 20% lower proportion of memory B cells as compared to before IRT. This was paralleled by profound transcriptome shifts, with > 6000 significant DEGs after adjustment for multiple comparisons. The top DEGs were found to regulate apoptosis, cell adhesion and RNA processing, and the most highly connected nodes in the network of encoded proteins were ESR2, PHB and RC3H1. Higher mRNA levels of BCL2, IL13RA1 and SLC38A11 were seen in patients with relapse despite IRT, though these differences did not pass the false discovery rate correction. CONCLUSIONS We show that B cells circulating in the blood of patients with MS undergoing IRT present a distinct gene expression signature, and we delineated the associated biological processes and gene interactions. Moreover, we identified genes whose expression may be an indicator of relapse risk, but further studies are needed to verify their potential value as biomarkers.
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Affiliation(s)
- Michael Hecker
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany.
| | - Brit Fitzner
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Nina Boxberger
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Elena Putscher
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Robby Engelmann
- Clinic III (Hematology, Oncology and Palliative Medicine), Special Hematology Laboratory, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Wendy Bergmann
- Core Facility for Cell Sorting and Cell Analysis, Rostock University Medical Center, Schillingallee 70, 18057, Rostock, Germany
| | - Michael Müller
- Core Facility for Cell Sorting and Cell Analysis, Rostock University Medical Center, Schillingallee 70, 18057, Rostock, Germany
| | | | - Margit Schwartz
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Stefanie Meister
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Ales Dudesek
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Alexander Winkelmann
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Dirk Koczan
- Institute of Immunology, Rostock University Medical Center, Schillingallee 70, 18057, Rostock, Germany
| | - Uwe Klaus Zettl
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
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10
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Voigt I, Inojosa H, Wenk J, Akgün K, Ziemssen T. Building a monitoring matrix for the management of multiple sclerosis. Autoimmun Rev 2023; 22:103358. [PMID: 37178996 DOI: 10.1016/j.autrev.2023.103358] [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: 04/27/2023] [Accepted: 05/09/2023] [Indexed: 05/15/2023]
Abstract
Multiple sclerosis (MS) has a longitudinal and heterogeneous course, with an increasing number of therapy options and associated risk profiles, leading to a constant increase in the number of parameters to be monitored. Even though important clinical and subclinical data are being generated, treating neurologists may not always be able to use them adequately for MS management. In contrast to the monitoring of other diseases in different medical fields, no target-based approach for a standardized monitoring in MS has been established yet. Therefore, there is an urgent need for a standardized and structured monitoring as part of MS management that is adaptive, individualized, agile, and multimodal-integrative. We discuss the development of an MS monitoring matrix which can help facilitate data collection over time from different dimensions and perspectives to optimize the treatment of people with MS (pwMS). In doing so, we show how different measurement tools can combined to enhance MS treatment. We propose to apply the concept of patient pathways to disease and intervention monitoring, not losing track of their interrelation. We also discuss the use of artificial intelligence (AI) to improve the quality of processes, outcomes, and patient safety, as well as personalized and patient-centered care. Patient pathways allow us to track the patient's journey over time and can always change (e.g., when there is a switch in therapy). They therefore may assist us in the continuous improvement of monitoring in an iterative process. Improving the monitoring process means improving the care of pwMS.
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Affiliation(s)
- Isabel Voigt
- Center of Clinical Neuroscience, Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Hernan Inojosa
- Center of Clinical Neuroscience, Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Judith Wenk
- Center of Clinical Neuroscience, Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Katja Akgün
- Center of Clinical Neuroscience, Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany.
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11
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Costa GD, Comi G. A safety review of current monoclonal antibodies used to treat multiple sclerosis. Expert Opin Drug Saf 2023; 22:1011-1024. [PMID: 37314699 DOI: 10.1080/14740338.2023.2224556] [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: 02/16/2023] [Accepted: 06/08/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system. Monoclonal antibodies (mAbs) have shown efficacy in reducing MS relapse rates, disease progression, and brain lesion activity. AREAS COVERED This article reviews the literature on the use of mAbs for the treatment of MS, including their mechanisms of action, clinical trial data, safety profiles, and long-term outcomes. The review focuses on the three main categories of mAbs used in MS: alemtuzumab, natalizumab, and anti-CD20 drugs. A literature search was conducted using relevant keywords and guidelines and reports from regulatory agencies were reviewed. The search covered studies published from inception to 31 December 202231 December 2022. The article also discusses the potential risks and benefits of these therapies, including their effects on infection rates, malignancies, and vaccination efficacy. EXPERT OPINION Monoclonal antibodies have revolutionized the treatment of MS, but safety concerns must be considered, particularly with regards to infection rates, malignancy risk, and vaccination efficacy. Clinicians must weigh the potential benefits and risks of mAbs on an individual patient basis, taking into account factors such as age, disease severity, and comorbidities. Ongoing monitoring and surveillance are essential to ensure the long-term safety and effectiveness of monoclonal antibody therapies in MS.
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Affiliation(s)
| | - Giancarlo Comi
- Vita-Salute San Raffaele University, Milan, Italy
- Multiple Sclerosis Center, Casa di Cura Igea, Milan, Italy
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12
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López-Real AM, Gonzalez I, Solar DM, Oterino A, Costa E, Pato A, Llaneza MA, García-Estévez DA, Rodriguez-Regal A, Rodriguez M, Peña J. Alemtuzumab treatment in real clinical practice: Experience in a multicenter cohort. Mult Scler Relat Disord 2023; 75:104762. [PMID: 37229800 DOI: 10.1016/j.msard.2023.104762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Alemtuzumab is a highly effective treatment for relapsing remitting multiple sclerosis (RRMS), but in recent years safety-related concerns had emerged due to description of novel serious side effects not registered in CARE-MS I and CARE-MS II phase 3 studies, nor in TOPAZ extension study. Data about alemtuzumab use in real clinical practice are limited and based mainly on retrospective studies with small sample sizes. Therefore, more information about effectiveness and safety of alemtuzumab in this context is needed. METHODS A multicenter observational prospective study to investigate effectivity and safety of alemtuzumab in a real-world setting was performed. Primary endpoints were the change in annualized relapse rate (ARR), and in disability measured by EDSS score. Secondary endpoints were the cumulative probability of confirmed 6-month disability improvement and worsening. Disability worsening and disability improvement were considered when the EDSS score was increased or decreased, respectively, in 1 point if baseline EDSS score was <5.0, or in 0.5 point if baseline EDSS score was ≥5.5, confirmed over 6 months. Other secondary endpoint was the proportion of patients who achieved NEDA-3 status (absence of clinical relapses, disability EDSS progression, and MRI disease activity as depicted by new/enlarging T2 lesions or Gadolinium enhancing T1 lesions). Adverse events also were recorded. RESULTS A total of 195 RRMS patients (70% female) who started alemtuzumab treatment were included. Mean of follow-up was 2.38 years. Alemtuzumab significantly reduced the annualized relapse rate from baseline with risk reductions of 86%, 83.5%, and 84%, at 12, 24, and 36 months of follow-up respectively (Friedman test, p-value < 0.05 for all comparisons). Alemtuzumab also significantly reduced EDSS score over one and two years after starting alemtuzumab treatment (Friedman test, p-value<0.001 for both comparisons). A high proportion of patients presented confirmed 6-month stability or disability improvement (92%, 82%, and 79%, over 1, 2 and 3 years of follow-up respectively). The proportion of patients who retained NEDA-3 status at 12, 24 and 36 months were 61%, 49%, and 42%, respectively. Baseline characteristics associated with a lower probability of achieving NEDA-3 were younger age, sex female, high ARR, elevated number of previous treatments, and switch from a second line therapy. Infusion related reactions were the most frequent adverse event observed. The most common infections were urinary tract infections (50%), and upper respiratory tract infections (19%) over the 3 years of follow- up. Secondary thyroid autoimmunity was developed in 18.5% of patients. CONCLUSION Alemtuzumab has demonstrated in real clinical practice high effectiveness in controlling multiple sclerosis activity, and no unexpected adverse events were observed.
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Affiliation(s)
| | - I Gonzalez
- Complejo Hospitalario Universitario de Vigo, Spain
| | - D M Solar
- Hospital Universitario Cabueñes, Spain
| | - A Oterino
- Hospital Universitario Marqués de Valdecilla, Spain
| | - E Costa
- Complejo Hospitalario Universitario de Santiago de Compostela, Spain
| | - A Pato
- Hospital Rivera Povisa. Vigo, Spain
| | - M A Llaneza
- Complejo Hospitalario Universitario de Ferrol, Spain
| | | | | | - M Rodriguez
- Hospital Universitario Lucus Augusti. Lugo, Spain
| | - J Peña
- Hospital Universitario San Agustín. Avilés, Spain
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13
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Eichau S, López Ruiz R, Ruíz de Arcos M, Ruiz-Peña JL, Navarro G, Calleja MÁ, Moreno-Amador JL, Dotor García-Soto J. Results of treatment with alemtuzumab in a Spanish cohort of patients with multiple sclerosis in the real world: The RealMS study. Front Neurol 2023; 14:1112193. [PMID: 36998778 PMCID: PMC10044139 DOI: 10.3389/fneur.2023.1112193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/30/2023] [Indexed: 03/16/2023] Open
Abstract
Background Alemtuzumab (ALZ) is a humanized monoclonal antibody approved for the treatment of patients with highly active relapsing-remitting multiple sclerosis (RRMS) administered in two annual courses. The objective of this study was to describe the effectiveness and safety data of ALZ and to report the health resource utilization in patients receiving this treatment. Methods In this retrospective, non-interventional study, information was retrieved from patients' medical charts at one center in Spain. Included patients were ≥18 years old, and ALZ treatment was initiated between 1 March 2015 and 31 March 2019, according to routine clinical practice and local labeling. Results Of 123 patients, 78% were women. The mean (standard deviation, SD) age of patients at diagnosis was 40.3 (9.1) years, and the mean time since diagnosis was 13.8 (7.3) years. Patients were previously treated with a median (interquartile range; IQR) number of two (2.0-3.0) disease-modifying treatments (DMTs). Patients were treated with ALZ for a mean (SD) of 29.7 (13.8) months. ALZ reduced the annualized relapse rate (ARR) (1.5 before vs. 0.05 after; p < 0.001) and improved the median EDSS (4.63 before vs. 4.00 after; p < 0.001). Most (90.2%) patients were relapse-free while receiving ALZ. The mean number of gadolinium-enhancing [Gd+] T1 lesions was reduced (1.7 before vs. 0.1 after; p < 0.001), and the mean number of T2 hyperintense lesions was maintained (35.7 before vs. 35.4 after; p = 0.392). A total of 27 (21.9%) patients reported 29 autoimmune diseases: hyperthyroidism (12), hypothyroidism (11), idiopathic thrombocytopenic purpura (ITP) (3), alopecia areata (1), chronic urticaria (1), and vitiligo (1). The mean number of health resources (outpatient visits, emergency room visits, hospital admissions, and tests performed in the hospital) used while patients were treated with ALZ progressively decreased from year 1 to year 4, except for a slight increase at year 2 of outpatient visits. Conclusion The ReaLMS study provides real-world evidence that ALZ can promote clinical and magnetic resonance imaging disease remission, as well as disability improvement in patients with MS, despite several prior DMT failures. The ALZ safety profile was consistent with data available from clinical trials and other real-world studies. Healthcare resource use was reduced throughout the treatment period.
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Affiliation(s)
- Sara Eichau
- Multiple Sclerosis Unit, Neurology Service, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Rocío López Ruiz
- Multiple Sclerosis Unit, Neurology Service, Hospital Universitario Virgen Macarena, Seville, Spain
| | - María Ruíz de Arcos
- Multiple Sclerosis Unit, Neurology Service, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Juan Luis Ruiz-Peña
- Multiple Sclerosis Unit, Neurology Service, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Guillermo Navarro
- Multiple Sclerosis Unit, Neurology Service, Hospital Universitario Virgen Macarena, Seville, Spain
| | | | | | - Julio Dotor García-Soto
- Multiple Sclerosis Unit, Neurology Service, Hospital Universitario Virgen Macarena, Seville, Spain
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14
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Wilken J, Traboulsee A, Nelson F, Ionete C, Kolind S, Fratto T, Kane R, Gandhi R, Rawlings AM, Roesch N, Ozog MA, DeLuca J. Longitudinal assessment of neurocognitive function in people with relapsing multiple sclerosis initiating alemtuzumab in routine clinical practice: LEM-COG study results. Mult Scler Relat Disord 2023; 73:104677. [PMID: 37028124 DOI: 10.1016/j.msard.2023.104677] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/21/2023] [Accepted: 03/26/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Alemtuzumab is effective in reducing relapse rate and disability, but limited data exist on its effect on cognitive function in relapsing multiple sclerosis (RMS). The present study assessed neurocognitive function and safety associated with alemtuzumab treatment in RMS. METHODS This longitudinal, single-arm, prospective study included people with RMS (aged 25-55 years) who were treated with alemtuzumab in clinical practice in the United States of America and Canada. The first participant was enrolled in December 2016. The primary endpoint was the change from baseline to post-baseline (month [M] 12/24) in MS-COGnitive (MS-COG) composite score. Secondary endpoints included Paced Auditory Serial Addition Test (PASAT), Symbol Digit Modalities Test (SDMT), Brief Visuospatial Memory Test-Revised (BVMT-R), Selective Reminding Test (SRT), Controlled Oral Word Association Test (COWAT), and Automated Neuropsychological Assessment Metrics (ANAM) scores. Depression and fatigue were assessed using Hamilton Rating Scale-Depression (HAM-D) and Fatigue Severity Scale (FSS)/Modified Fatigue Impact Scale (MFIS), respectively. Magnetic resonance imaging (MRI) parameters were assessed when available. Safety was assessed throughout the study. Descriptive statistics were used for the pre-specified statistical analyses. Since the study was terminated early (November 2019) because of operational and resource difficulties, post hoc analyses for statistical inference were performed among participants who had a baseline value and at least one complete post-baseline assessment for cognitive parameters, fatigue, or depression. RESULTS Of the 112 participants enrolled, 39 were considered as the primary analysis population at M12. At M12, a mean change of 0.25 (95% confidence interval [CI]: 0.04, 0.45; p = 0.0049; effect size [ES]: 0.39) was observed in the MS-COG composite score. Improvements were observed in processing speed (based on PASAT and SDMT; p < 0.0001; ES: 0.62), as well as in individual PASAT, SDMT and COWAT scores. An improvement was also noted in HAM-D (p = 0.0054; ES: -0.44), but not in fatigue scores. Among MRI parameters, decreases in burden of disease volume (BDV; ES: -0.12), new gadolinium-enhancing lesions (ES: -0.41) and newly active lesions (ES: -0.07) were observed at M12. About 92% of participants showed stable or improved cognitive status at M12. There were no new safety signals reported in the study. The most common adverse events (≥10% of participants) were headache, fatigue, nausea, insomnia, urinary tract infection, pain in extremity, chest discomfort, anxiety, dizziness, arthralgia, flushing, and rash. Hypothyroidism (3.7%) was the most frequent adverse event of special interest. CONCLUSION The findings from this study suggest that alemtuzumab has a positive impact on cognitive function with significant improvements in processing speed and depression in people with RMS over a period of 12 months. The safety profile of alemtuzumab was consistent with previous studies.
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15
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Rispoli MG, D'Apolito M, Pozzilli V, Tomassini V. Lessons from immunotherapies in multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 193:293-311. [PMID: 36803817 DOI: 10.1016/b978-0-323-85555-6.00013-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
The improved understanding of multiple sclerosis (MS) neurobiology alongside the development of novel markers of disease will allow precision medicine to be applied to MS patients, bringing the promise of improved care. Combinations of clinical and paraclinical data are currently used for diagnosis and prognosis. The addition of advanced magnetic resonance imaging and biofluid markers has been strongly encouraged, since classifying patients according to the underlying biology will improve monitoring and treatment strategies. For example, silent progression seems to contribute significantly more than relapses to overall disability accumulation, but currently approved treatments for MS act mainly on neuroinflammation and offer only a partial protection against neurodegeneration. Further research, involving traditional and adaptive trial designs, should strive to halt, repair or protect against central nervous system damage. To personalize new treatments, their selectivity, tolerability, ease of administration, and safety must be considered, while to personalize treatment approaches, patient preferences, risk-aversion, and lifestyle must be factored in, and patient feedback used to indicate real-world treatment efficacy. The use of biosensors and machine-learning approaches to integrate biological, anatomical, and physiological parameters will take personalized medicine a step closer toward the patient's virtual twin, in which treatments can be tried before they are applied.
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Affiliation(s)
- Marianna G Rispoli
- Institute for Advanced Biomedical Technologies (ITAB) and Department of Neurosciences, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy; MS Centre, SS. Annunziata University Hospital, Chieti, Italy
| | - Maria D'Apolito
- Institute for Advanced Biomedical Technologies (ITAB) and Department of Neurosciences, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy; MS Centre, SS. Annunziata University Hospital, Chieti, Italy
| | - Valeria Pozzilli
- Institute for Advanced Biomedical Technologies (ITAB) and Department of Neurosciences, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy; MS Centre, SS. Annunziata University Hospital, Chieti, Italy
| | - Valentina Tomassini
- Institute for Advanced Biomedical Technologies (ITAB) and Department of Neurosciences, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy; MS Centre, SS. Annunziata University Hospital, Chieti, Italy.
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16
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Abstract
The multiple sclerosis (MS) neurotherapeutic landscape is rapidly evolving. New disease-modifying therapies (DMTs) with improved efficacy and safety, in addition to an expanding pipeline of agents with novel mechanisms, provide more options for patients with MS. While treatment of MS neuroinflammation is well tailored in the existing DMT armamentarium, concerted efforts are currently underway for identifying neuropathological targets and drug discovery for progressive MS. There is also ongoing research to develop agents for remyelination and neuroprotection. Further insights are needed to guide DMT initiation and sequencing as well as to determine the role of autologous stem cell transplantation in relapsing and progressive MS. This review provides a summary of these updates.
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Affiliation(s)
- Moein Amin
- Cleveland Clinic, Department of Neurology, Cleveland, OH 44195, USA
| | - Carrie M Hersh
- Cleveland Clinic, Lou Ruvo Center for Brain Health, Las Vegas, NV 89106, USA
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17
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Yang JH, Rempe T, Whitmire N, Dunn-Pirio A, Graves JS. Therapeutic Advances in Multiple Sclerosis. Front Neurol 2022; 13:824926. [PMID: 35720070 PMCID: PMC9205455 DOI: 10.3389/fneur.2022.824926] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system that causes significant disability and healthcare burden. The treatment of MS has evolved over the past three decades with development of new, high efficacy disease modifying therapies targeting various mechanisms including immune modulation, immune cell suppression or depletion and enhanced immune cell sequestration. Emerging therapies include CNS-penetrant Bruton's tyrosine kinase inhibitors and autologous hematopoietic stem cell transplantation as well as therapies aimed at remyelination or neuroprotection. Therapy development for progressive MS has been more challenging with limited efficacy of current approved agents for inactive disease and older patients with MS. The aim of this review is to provide a broad overview of the current therapeutic landscape for MS.
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Affiliation(s)
- Jennifer H. Yang
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
- *Correspondence: Jennifer H. Yang
| | - Torge Rempe
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Natalie Whitmire
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Anastasie Dunn-Pirio
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Jennifer S. Graves
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
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18
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Krajnc N, Bsteh G, Berger T, Mares J, Hartung HP. Monoclonal Antibodies in the Treatment of Relapsing Multiple Sclerosis: an Overview with Emphasis on Pregnancy, Vaccination, and Risk Management. Neurotherapeutics 2022; 19:753-773. [PMID: 35378683 PMCID: PMC8978776 DOI: 10.1007/s13311-022-01224-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/10/2023] Open
Abstract
Monoclonal antibodies have become a mainstay in the treatment of patients with relapsing multiple sclerosis (RMS) and provide some benefit to patients with primary progressive MS. They are highly precise by specifically targeting molecules displayed on cells involved in distinct immune mechanisms of MS pathophysiology. They not only differ in the target antigen they recognize but also by the mode of action that generates their therapeutic effect. Natalizumab, an [Formula: see text]4[Formula: see text]1 integrin antagonist, works via binding to cell surface receptors, blocking the interaction with their ligands and, in that way, preventing the migration of leukocytes across the blood-brain barrier. On the other hand, the anti-CD52 monoclonal antibody alemtuzumab and the anti-CD20 monoclonal antibodies rituximab, ocrelizumab, ofatumumab, and ublituximab work via eliminating selected pathogenic cell populations. However, potential adverse effects may be serious and can necessitate treatment discontinuation. Most importantly, those are the risk for (opportunistic) infections, but also secondary autoimmune diseases or malignancies. Monoclonal antibodies also carry the risk of infusion/injection-related reactions, primarily in early phases of treatment. By careful patient selection and monitoring during therapy, the occurrence of these potentially serious adverse effects can be minimized. Monoclonal antibodies are characterized by a relatively long pharmacologic half-life and pharmacodynamic effects, which provides advantages such as permitting infrequent dosing, but also creates disadvantages regarding vaccination and family planning. This review presents an overview of currently available monoclonal antibodies for the treatment of RMS, including their mechanism of action, efficacy and safety profile. Furthermore, we provide practical recommendations for risk management, vaccination, and family planning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Mares
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
- Brain and Mind Center, University of Sydney, Sydney, Australia.
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Inojosa H, Proschmann U, Akgün K, Ziemssen T. The need for a strategic therapeutic approach: multiple sclerosis in check. Ther Adv Chronic Dis 2022; 13:20406223211063032. [PMID: 35070250 PMCID: PMC8777338 DOI: 10.1177/20406223211063032] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/10/2021] [Indexed: 12/18/2022] Open
Abstract
Multiple sclerosis (MS) is the most common chronic autoimmune neurological disease. Its therapeutic management has drastically evolved in the recent years with the development of specific disease-modifying therapies (DMTs). Together with the established injectables, oral and intravenous alternatives are now available for MS patients with significant benefits to modulate the disease course. Certain drugs present with a higher efficacy than the others, profiles and frequencies of adverse events differentiate as well. Thus due to the several and different treatment alternatives, the therapeutic approach adopted by neurologists requires a tactical focus for a targeted, timed, and meaningful treatment decision. An integration of rational and emotional control with proper communication skills is necessary for shared decision-making with patients. In this perspective paper, we reinforce the necessary concept of strategic MS treatment approach using all available therapies based on scientific evidence and current experience. We apply a didactic analogy to the strategic game chess. The opening with oriented attack (i.e. already in early disease stages as clinical isolated syndrome), a correct choice of chess pieces to move (i.e. among the several DMTs), a re-assessment reaction to different scenarios (e.g. sustained disease activity, adverse events, and family planning) and the advantage of real-world data are discussed to try the best approach to ultimately successfully approach the best personalized MS treatment.
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Affiliation(s)
- Hernan Inojosa
- Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Undine Proschmann
- Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Katja Akgün
- Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstr. 74, 01307 Dresden, Germany
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20
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Ruck T, Barman S, Schulte-Mecklenbeck A, Pfeuffer S, Steffen F, Nelke C, Schroeter CB, Willison A, Heming M, Müntefering T, Melzer N, Krämer J, Lindner M, Riepenhausen M, Gross CC, Klotz L, Bittner S, Muraro PA, Schneider-Hohendorf T, Schwab N, Meyer zu Hörste G, Goebels N, Meuth SG, Wiendl H. OUP accepted manuscript. Brain 2022; 145:1711-1725. [PMID: 35661859 PMCID: PMC9166548 DOI: 10.1093/brain/awac064] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/04/2022] [Accepted: 01/27/2022] [Indexed: 11/12/2022] Open
Abstract
Alemtuzumab is a monoclonal antibody that causes rapid depletion of CD52-expressing immune cells. It has proven to be highly efficacious in active relapsing–remitting multiple sclerosis; however, the high risk of secondary autoimmune disorders has greatly complicated its use. Thus, deeper insight into the pathophysiology of secondary autoimmunity and potential biomarkers is urgently needed. The most critical time points in the decision-making process for alemtuzumab therapy are before or at Month 12, where the ability to identify secondary autoimmunity risk would be instrumental. Therefore, we investigated components of blood and CSF of up to 106 multiple sclerosis patients before and after alemtuzumab treatment focusing on those critical time points. Consistent with previous reports, deep flow cytometric immune-cell profiling (n = 30) demonstrated major effects on adaptive rather than innate immunity, which favoured regulatory immune cell subsets within the repopulation. The longitudinally studied CSF compartment (n = 18) mainly mirrored the immunological effects observed in the periphery. Alemtuzumab-induced changes including increased numbers of naïve CD4+ T cells and B cells as well as a clonal renewal of CD4+ T- and B-cell repertoires were partly reminiscent of haematopoietic stem cell transplantation; in contrast, thymopoiesis was reduced and clonal renewal of T-cell repertoires after alemtuzumab was incomplete. Stratification for secondary autoimmunity did not show clear immununological cellular or proteomic traits or signatures associated with secondary autoimmunity. However, a restricted T-cell repertoire with hyperexpanded T-cell clones at baseline, which persisted and demonstrated further expansion at Month 12 by homeostatic proliferation, identified patients developing secondary autoimmune disorders (n = 7 without secondary autoimmunity versus n = 5 with secondary autoimmunity). Those processes were followed by an expansion of memory B-cell clones irrespective of persistence, which we detected shortly after the diagnosis of secondary autoimmune disease. In conclusion, our data demonstrate that (i) peripheral immunological alterations following alemtuzumab are mirrored by longitudinal changes in the CSF; (ii) incomplete T-cell repertoire renewal and reduced thymopoiesis contribute to a proautoimmune state after alemtuzumab; (iii) proteomics and surface immunological phenotyping do not identify patients at risk for secondary autoimmune disorders; (iv) homeostatic proliferation with disparate dynamics of clonal T- and B-cell expansions are associated with secondary autoimmunity; and (v) hyperexpanded T-cell clones at baseline and Month 12 may be used as a biomarker for the risk of alemtuzumab-induced autoimmunity.
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Affiliation(s)
- Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
- Correspondence to: PD Dr. med. Tobias Ruck Department of Neurology with Institute of Translational Neurology University Hospital Muenster Albert-Schweitzer-Campus 1 D-48149 Muenster, Germany E-mail:
| | - Sumanta Barman
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Falk Steffen
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany
| | - Christopher Nelke
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Christina B. Schroeter
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Alice Willison
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Michael Heming
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Thomas Müntefering
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Julia Krämer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Maren Lindner
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Marianne Riepenhausen
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Catharina C. Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany
| | - Paolo A. Muraro
- Department of Brain Sciences, Imperial College London, London, UK
| | - Tilman Schneider-Hohendorf
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Gerd Meyer zu Hörste
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Norbert Goebels
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
- Correspondence may also be addressed to: Univ.-Prof. Prof. h.c. Dr. med. Heinz Wiendl E-mail:
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21
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Coles AJ, Jones JL, Vermersch P, Traboulsee A, Bass AD, Boster A, Chan A, Comi G, Fernández Ó, Giovannoni G, Kubala Havrdova E, LaGanke C, Montalban X, Oreja-Guevara C, Piehl F, Wiendl H, Ziemssen T. Autoimmunity and long-term safety and efficacy of alemtuzumab for multiple sclerosis: Benefit/risk following review of trial and post-marketing data. Mult Scler 2021; 28:842-846. [PMID: 34882037 PMCID: PMC8978465 DOI: 10.1177/13524585211061335] [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] [Indexed: 11/17/2022]
Abstract
Does preexisting or treatment-emergent autoimmunity increase the risk of
subsequent autoimmune disease in individuals with relapsing-remitting multiple
sclerosis (MS) after alemtuzumab? In the extended phase 2/3 trials, 34/96
(35.4%) patients with and 395/1120 (35.3%) without preexisting autoimmunity
developed non-MS autoimmunity. Thyroid autoimmunity after alemtuzumab courses 1
or 2 did not increase subsequent non-thyroid autoimmune adverse events.
Therefore, autoimmune disease before or after alemtuzumab treatment does not
predict autoimmunity after further courses, so should not preclude adequate
alemtuzumab dosing to control MS. Finally, post-marketing safety data contribute
toward a full record of the alemtuzumab benefit/risk profile for the MS
field.
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Affiliation(s)
- Alasdair J Coles
- Department of Clinical Neuroscience, School of Medicine, University of Cambridge, Cambridge, UK
| | - Joanne L Jones
- Department of Clinical Neuroscience, School of Medicine, University of Cambridge, Cambridge, UK
| | - Patrick Vermersch
- Univ. Lille, INSERM UMR-S1172-Lille Neuroscience et Cognition, CHU Lille, FHU Precise, Lille, France
| | | | - Ann D Bass
- Neurology Center of San Antonio, San Antonio, TX, USA
| | | | - Andrew Chan
- Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Óscar Fernández
- Fundacion IMABIS, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Gavin Giovannoni
- Barts and The London School of Medicine, Queen Mary University of London, London, UK
| | - Eva Kubala Havrdova
- Department of Neurology, First Medical Faculty, Charles University, Prague, Czech Republic
| | | | - Xavier Montalban
- Department of Neurology-Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, IdISSC, Madrid, Spain/Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Fredrik Piehl
- Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology Carl Gustav Carus University Hospital, Dresden University of Technology, Dresden, Germany
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22
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Wang C, Barton J, Kyle K, Ly L, Barnett Y, Hartung HP, Reddel SW, Beadnall H, Taha M, Klistorner A, Barnett MH. Multiple sclerosis: structural and functional integrity of the visual system following alemtuzumab therapy. J Neurol Neurosurg Psychiatry 2021; 92:1319-1324. [PMID: 34187865 DOI: 10.1136/jnnp-2021-326164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/02/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate potential neuroprotective and pro-remyelinating effects of alemtuzumab in multiple sclerosis (MS), using the visual pathway as a model. METHODS We monitored clinical, multifocal visual evoked potential (mfVEP) and MRI outcomes in 30 patients commencing alemtuzumab for relapsing MS, and a reference group of 20 healthy controls (HCs), over 24 months. Change in mfVEP latency was the primary endpoint; change in optic radiation (OR) lesion diffusion metrics and Mars letter contrast sensitivity over the course of the study were secondary endpoints. RESULTS In patients, we observed a mean shortening of mfVEP latency of 1.21 ms over the course of the study (95% CI 0.21 to 2.21, p=0.013), not altered by correction for age, gender, disease duration or change in OR T2 lesion volume. Mean mfVEP latency in the HC group increased over the course of the study by 0.72 ms (not significant). Analysis of chronic OR T2 lesions (patients) showed an increase in normalised fractional anisotropy and axial diffusivity between baseline and 24 months (both p<0.01). Mean Mars letter contrast sensitivity was improved at 24 months vs baseline (p<0.001), and driven by an early improvement, in both patients and HC. CONCLUSION We found evidence of partial lesion remyelination after alemtuzumab therapy, indicating either natural restoration in the context of a 'permissive' local milieu; or potentially an independent, pro-reparative mechanism of action. The visual system presents a unique opportunity to study function-structure specific effects of therapy and inform the design of future phase 2 MS remyelination trials.
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Affiliation(s)
- Chenyu Wang
- Sydney Neuroimaging Analysis Centre, Camperdown, New South Wales, Australia.,Brain and Mind Centre, The University of Sydney, Camperdown, New South Wales, Australia
| | - Joshua Barton
- Brain and Mind Centre, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kain Kyle
- Sydney Neuroimaging Analysis Centre, Camperdown, New South Wales, Australia.,Brain and Mind Centre, The University of Sydney, Camperdown, New South Wales, Australia
| | - Linda Ly
- Sydney Neuroimaging Analysis Centre, Camperdown, New South Wales, Australia
| | - Yael Barnett
- Sydney Neuroimaging Analysis Centre, Camperdown, New South Wales, Australia.,Radiology Department, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Hans-Peter Hartung
- Brain and Mind Centre, The University of Sydney, Camperdown, New South Wales, Australia.,Clinic for Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Stephen W Reddel
- Brain and Mind Centre, The University of Sydney, Camperdown, New South Wales, Australia
| | - Heidi Beadnall
- Brain and Mind Centre, The University of Sydney, Camperdown, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Marinda Taha
- Brain and Mind Centre, The University of Sydney, Camperdown, New South Wales, Australia
| | - Alexander Klistorner
- Sydney Neuroimaging Analysis Centre, Camperdown, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Harry Barnett
- Sydney Neuroimaging Analysis Centre, Camperdown, New South Wales, Australia .,Brain and Mind Centre, The University of Sydney, Camperdown, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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23
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Gabelić T, Barun B, Adamec I, Krbot Skorić M, Habek M. Product review on MAbs (alemtuzumab and ocrelizumab) for the treatment of multiple sclerosis. Hum Vaccin Immunother 2021; 17:4345-4362. [PMID: 34668842 DOI: 10.1080/21645515.2021.1969850] [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] [Indexed: 01/03/2023] Open
Abstract
Traditionally, the management of active relapsing remitting MS was based on the, so-called, maintenance therapy, which is characterized by continuous treatment with particular disease modifying therapy (DMT), and a return of disease activity when the drug is discontinued. Another approach is characterized by a short treatment course of a DMT, which is hypothesized to act as an immune reconstitution therapy (IRT), with the potential to protect against relapses for years after a short course of treatment. Introduction of monoclonal antibodies in the treatment of MS has revolutionized MS treatment in the last decade. However, given the increasingly complex landscape of DMTs approved for MS, people with MS and neurologists are constantly faced with the question which DMT is the most appropriate for the given patient, a question we still do not have an answer to. In this product review, we will discuss the first DMT that acts as IRT, an anti-CD52 monoclonal antibody alemtuzumab and an anti CD20 monoclonal antibody, ocrelizumab that has the potential to act as an IRT, but is administered continuously. Special emphasis will be given on safety in the context of COVID-19 pandemics and vaccination strategies.
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Affiliation(s)
- Tereza Gabelić
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Barbara Barun
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Adamec
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Magdalena Krbot Skorić
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia
| | - Mario Habek
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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24
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Russo CV, Saccà F, Frau J, Annovazzi P, Signoriello E, Bonavita S, Grasso R, Clerico M, Cordioli C, Laroni A, Capobianco M, Torri Clerici V, Sartori A, Cavalla P, Maniscalco GT, La Gioia S, Caleri F, Giugno A, Iodice R, Carotenuto A, Cocco E, Fenu G, Zaffaroni M, Baroncini D, Lus G, Gallo A, De Mercanti SF, Lapucci C, Di Francescantonio V, Brambilla L, Sormani MP, Signori A. A real-world study of alemtuzumab in a cohort of Italian patients. Eur J Neurol 2021; 29:257-266. [PMID: 34558755 PMCID: PMC9293282 DOI: 10.1111/ene.15121] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/16/2021] [Accepted: 09/19/2021] [Indexed: 01/02/2023]
Abstract
Background and purpose Real‐world data on alemtuzumab are limited and do not provide evidence of its effectiveness after various disease‐modifying therapies (DMTs). Our aim was to provide real‐world data on the impact of clinical variables and previous DMTs on clinical response to alemtuzumab. Methods Sixteen Italian multiple sclerosis centers retrospectively included patients who started alemtuzumab from January 2015 to December 2018, and recorded demographics, previous therapies, washout duration, relapses, Expanded Disability Status Scale (EDSS) score, and magnetic resonance imaging data. Negative binomial regression models were used to assess the effect of factors on annualized relapse (ARR) after alemtuzumab initiation. Results We studied 322 patients (mean age 36.8 years, median EDSS score 3, median follow‐up 1.94 years). Previous treatments were: fingolimod (106), natalizumab (80), first‐line oral agents (56), first‐line injectables (interferon/glatiramer acetate; 30), and other drugs (15). Thirty‐five patients were treatment‐naïve. The pre‐alemtuzumab ARR was 0.99 and decreased to 0.13 during alemtuzumab treatment (p < 0.001). The number of previous‐year relapses was associated with alemtuzumab ARR (adjusted risk ratio [RR] 1.38, p = 0.009). Progression‐free survival was 94.5% after 1 year, and 89.2% after 2 years of alemtuzumab treatment. EDSS score improvement occurred in 13.5% after 1 year, and 20.6% after 2 years. Re‐baselining patients after 6 months of alemtuzumab treatment, led to no evidence of disease activity status in 71.6% after 1 year and 58.9% after 2 years. Conclusions Alemtuzumab decreases ARR independent of previous therapy, including patients with disease activity during natalizumab treatment. Overall, 90% of patients showed no disease progression, and 20% an improvement after 2 years of alemtuzumab.
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Affiliation(s)
| | - Francesco Saccà
- NSRO Department, University of Naples Federico II, Napoli, Italy
| | - Jessica Frau
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna); Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Pietro Annovazzi
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | | | | | | | - Marinella Clerico
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Torino, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Center, ASST Spedali Civili di Brescia, Montichiari Hospital, Montichiari, Italy
| | - Alice Laroni
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research (CEBR) and IRCCS San Martino-IST, University of Genova, Genova, Italy
| | - Marco Capobianco
- SC Neurologia e Centro di Riferimento Regionale SM - AOU S. Luigi, Orbassano, Torino, Italy
| | - Valentina Torri Clerici
- Neuro-Immunology and Neuromuscolar Diseases Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milano, Italy
| | - Arianna Sartori
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, ASUGI, University of Trieste, Trieste, Italy
| | - Paola Cavalla
- MS Center, City of Health & Science University Hospital, Torino, Italy
| | | | - Sara La Gioia
- Centro Sclerosi Multipla, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Francesca Caleri
- Neurology Department, F. Tappeiner Hospital Meran (BZ) of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Alessia Giugno
- Institute of Neurology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Rosa Iodice
- NSRO Department, University of Naples Federico II, Napoli, Italy
| | | | - Eleonora Cocco
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna); Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Giuseppe Fenu
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna); Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | - Damiano Baroncini
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | - Giacomo Lus
- University of Campania Luigi Vanvitelli, Napoli, Italy
| | - Antonio Gallo
- University of Campania "Luigi Vanvitelli", Napoli, Italy
| | | | - Caterina Lapucci
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research (CEBR) and IRCCS San Martino-IST, University of Genova, Genova, Italy
| | | | - Laura Brambilla
- Neuro-Immunology and Neuromuscolar Diseases Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milano, Italy
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genova, Genova, Italy
| | - Alessio Signori
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genova, Genova, Italy
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25
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Ziemssen T, Hoffmann F, Richter S, Engelmann U, White R. Alemtuzumab in a Large Real-Life Cohort: Interim Baseline Data of the TREAT-MS Study. Front Neurol 2021; 12:620758. [PMID: 34421780 PMCID: PMC8375470 DOI: 10.3389/fneur.2021.620758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
The non-interventional long-Term study foR obsErvAtion of Treatment with alemtuzumab in active relapsing-remitting MS (TREAT-MS) study collects the so far largest real-life cohort regarding utilization, long-term effectiveness, and safety of alemtuzumab, a humanized monoclonal antibody directed against the cell surface glycoprotein CD52, in adult patients with active relapsing-remitting multiple sclerosis (RRMS). An interim analysis of baseline parameters at inclusion of a non-interventional real-world study about alemtuzumab in Germany including previous multiple sclerosis (MS) medication utilization, MS activity, severity, and duration, as well as comorbidities was performed. Of the 883 patients, 71.6% were women. Mean age was 35.7 ± 9.2 years, time since first MS symptoms (=disease duration) is 8.0 ± 6.8 years, and Expanded Disability Status Scale (EDSS) is 2.7 ± 1.8 points (range, 0.0-7.5 points). The number of relapses in the 12 and 24 months prior to inclusion were 1.6 ± 1.2 and 2.2 ± 1.8, respectively. Of the patients, 14.4% were treatment naive, while for the majority, a wide spectrum of MS disease-modifying treatments (DMTs) and treatment sequences were documented. Overall, interferon beta (IFN-beta) was reported most frequently (52.4%), followed by fingolimod (35.2%), natalizumab (34.9%), and glatiramer acetate (28.9%). Patients with longer disease duration and higher EDSS had a higher number of previous DMTs. Compared to the pivotal phase 2/3 studies, RRMS patients starting alemtuzumab treatment had a longer disease duration in real-world conditions. There was variety of different treatment sequences before the final switch to alemtuzumab. In the future, linking these treatment sequences or other baseline characteristics with effectiveness and safety outcomes might be useful to support treatment decisions. Registered at Paul-Ehrlich-Institut under NIS 281.
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Affiliation(s)
- Tjalf Ziemssen
- Department of Neurology, Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Frank Hoffmann
- Klinik für Neurologie, Krankenhaus Martha-Maria Halle-Doelau, Halle (Saale), Germany
| | - Stephan Richter
- Zentrum für Neurologie und Psychiatrie, MIND, Stuttgart, Germany
| | - Ulrich Engelmann
- Medical Affairs, Sanofi-Aventis Deutschland GmbH, Neu-Isenburg, Germany
| | - Robin White
- Medical Affairs, Sanofi-Aventis Deutschland GmbH, Neu-Isenburg, Germany
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26
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Rauma I, Mustonen T, Seppä JM, Ukkonen M, Männikkö M, Verkkoniemi-Ahola A, Kartau M, Saarinen JT, Luostarinen L, Simula S, Ryytty M, Ahmasalo R, Sipilä JOT, Pieninkeroinen I, Tapiola T, Remes AM, Kuusisto H. Safety of alemtuzumab in a nationwide cohort of Finnish multiple sclerosis patients. J Neurol 2021; 269:824-835. [PMID: 34255182 PMCID: PMC8782800 DOI: 10.1007/s00415-021-10664-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 12/05/2022]
Abstract
Background Alemtuzumab is an effective disease-modifying therapy (DMT) for highly active multiple sclerosis (MS). However, safety concerns limit its use in clinical practice. Objectives To evaluate the safety of alemtuzumab in a nationwide cohort of Finnish MS patients. Methods In this retrospective case series study, we analyzed the data of all but two MS patients who had received alemtuzumab in Finland until 2019. Data were systematically collected from patient files. Results Altogether 121 patients were identified, most of whom had received previous DMTs (82.6%). Median follow-up time after treatment initiation was 30.3 months and exceeded 24 months in 78 patients. Infusion-associated reactions (IARs) were observed in 84.3%, 57.3%, and 57.1% of patients during alemtuzumab courses 1–3, respectively. Serious adverse events (SAEs) were observed in 32.2% of patients, serious IARs in 12.4% of patients, and SAEs other than IARs in 23.1% of patients. Autoimmune adverse events were observed in 30.6% of patients. One patient died of hemophagocytic lymphohistiocytosis, and one patient died of pneumonia. A previously unreported case of thrombotic thrombocytopenic purpura was documented. Conclusions SAEs were more frequent in the present cohort than in previous studies. Even though alemtuzumab is a highly effective therapy for MS, vigorous monitoring with a long enough follow-up time is advised.
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Affiliation(s)
- Ilkka Rauma
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. .,Department of Neurology, Tampere University Hospital, Tampere, Finland. .,Department of Neurology, Seinäjoki Central Hospital, Seinäjoki, Finland.
| | - Tiina Mustonen
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Maritta Ukkonen
- Department of Neurology, Tampere University Hospital, Tampere, Finland
| | - Marianne Männikkö
- Department of Neurology, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Auli Verkkoniemi-Ahola
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Marge Kartau
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | | | - Liisa Luostarinen
- Department of Neurology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Sakari Simula
- Department of Neurology, Mikkeli Central Hospital, Mikkeli, Finland
| | - Mervi Ryytty
- Medical Research Center, Oulu University Hospital, Oulu, Finland.,Research Unit of Clinical Neuroscience, University of Oulu, Faculty of Medicine, Oulu, Finland
| | - Riitta Ahmasalo
- Department of Neurology, Lapland Central Hospital, Rovaniemi, Finland
| | - Jussi O T Sipilä
- Department of Neurology, North Karelia Central Hospital, Siun Sote, Joensuu, Finland.,Department of Clinical Neurosciences, University of Turku, Turku, Finland
| | | | - Tero Tapiola
- Department of Neurology, South Karelia Central Hospital, Lappeenranta, Finland
| | - Anne M Remes
- Medical Research Center, Oulu University Hospital, Oulu, Finland.,Research Unit of Clinical Neuroscience, University of Oulu, Faculty of Medicine, Oulu, Finland
| | - Hanna Kuusisto
- Department of Neurology, Tampere University Hospital, Tampere, Finland.,Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kanta-Häme Central Hospital, Hämeenlinna, Finland
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27
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Borriello G, Ianniello A, Toosy AT. Alopecia Universalis Occurring after Alemtuzumab Treatment for Multiple Sclerosis. A Two-Year Follow-Up of Two Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147338. [PMID: 34299789 PMCID: PMC8305636 DOI: 10.3390/ijerph18147338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 12/12/2022]
Abstract
Alopecia Universalis (AU) is the most severe form of Alopecia Areata and is caused by cytotoxic T-cells reacting with follicular autoantigens, producing complete loss of scalp and body hair. Alemtuzumab is a highly efficacious monoclonal antibody used in the treatment of Multiple Sclerosis (MS), but it causes secondary autoimmunity in up to 40% of patients. Many factors are believed to contribute to this process, but pathogenic mechanisms are not well clear. To date, three cases of AU after treatment with Alemtuzumab have been reported. In this paper we report the cases of two patients who developed AU 12 months after the second cycle of Alemtuzumab, with a review of the literature. One year after the end of the second cycle, two female patients in their thirties experienced complete hair loss. The first case was temporally associated with a significant drop in vitamin D (VD) levels. The second case was accompanied by joint swelling. Both patients had thyroid alterations and showed no hair regrowth after a 2-year follow-up. AU must be considered among the secondary autoimmune manifestations of Alemtuzumab treatment. We emphasize the need for appropriate patient screening and thorough clinical surveillance for factors predisposing patients to secondary autoimmunity.
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Affiliation(s)
- Giovanna Borriello
- MS Center, S. Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy;
| | - Antonio Ianniello
- MS Center, S. Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy;
- Correspondence:
| | - Ahmed T Toosy
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, University College London (UCL), London WC1E 6BT, UK;
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28
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Hunter SF, Aburashed RA, Alroughani R, Chan A, Dive D, Eichau S, Kantor D, Kim HJ, Lycke J, Macdonell RAL, Pozzilli C, Scott T, Sharrack B, Wiendl H, Chung L, Daizadeh N, Baker DP, Vermersch P. Confirmed 6-Month Disability Improvement and Worsening Correlate with Long-term Disability Outcomes in Alemtuzumab-Treated Patients with Multiple Sclerosis: Post Hoc Analysis of the CARE-MS Studies. Neurol Ther 2021; 10:803-818. [PMID: 34165694 PMCID: PMC8571457 DOI: 10.1007/s40120-021-00262-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/03/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction In the 2-year CARE-MS trials (NCT00530348; NCT00548405) in patients with relapsing–remitting multiple sclerosis, alemtuzumab showed superior efficacy versus subcutaneous interferon beta-1a. Efficacy was maintained in two consecutive extensions (NCT00930553; NCT02255656). This post hoc analysis compared disability outcomes over 9 years among alemtuzumab-treated patients according to whether they experienced confirmed disability improvement (CDI) or worsening (CDW) or neither CDI nor CDW. Methods CARE-MS patients were randomized to receive two alemtuzumab courses (12 mg/day; 5 days at baseline; 3 days at 12 months), with additional as-needed 3-day courses in the extensions. CDI or CDW were defined as ≥ 1.0-point decrease or increase, respectively, in Expanded Disability Status Scale (EDSS) score from core study baseline confirmed over 6 months, assessed in patients with baseline EDSS score ≥ 2.0. Improved or stable EDSS scores were defined as ≥ 1-point decrease or ≤ 0.5-point change (either direction), respectively, from core study baseline. Functional systems (FS) scores were also assessed. Results Of 511 eligible patients, 43% experienced CDI and 34% experienced CDW at any time through year 9 (patients experiencing both CDI and CDW were counted in each individual group); 29% experienced neither CDI nor CDW. At year 9, patients with CDI had a −0.58-point mean EDSS score change from baseline; 88% had stable or improved EDSS scores. Improvements occurred across all FS, primarily in sensory, pyramidal, and cerebellar domains. Patients with CDW had a +1.71-point mean EDSS score change; 16% had stable or improved EDSS scores. Patients with neither CDI nor CDW had a −0.10-point mean EDSS score change; 98% had stable or improved EDSS scores. Conclusion CDI achievement at any point during the CARE-MS studies was associated with improved disability at year 9, highlighting the potential of alemtuzumab to change the multiple sclerosis course. Conversely, CDW at any point was associated with worsened disability at year 9. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-021-00262-3.
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Affiliation(s)
- Samuel F Hunter
- Advanced Neurosciences Institute, 101 Forrest Crossing Blvd., Franklin, TN, 37064, USA.
| | - Rany A Aburashed
- Institute for Neurosciences and Multiple Sclerosis, Owosso, MI, USA
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Andrew Chan
- Department of Neurology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Seville, Spain
| | - Daniel Kantor
- Florida Atlantic University, Boca Raton, FL, USA.,Nova Southeastern University, Fort Lauderdale, FL, USA.,Penn Center for Global Health, Philadelphia, PA, USA
| | - Ho Jin Kim
- Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Richard A L Macdonell
- Austin Health and Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Carlo Pozzilli
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Thomas Scott
- Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, PA, USA
| | - Basil Sharrack
- Sheffield NIHR Neuroscience BRC and Sheffield Teaching Hospitals, Sheffield, UK
| | | | | | | | | | - Patrick Vermersch
- Univ. Lille, INSERM U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
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29
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Stangel M, Becker V, Elias-Hamp B, Havla J, Grothe C, Pul R, Rau D, Richter S, Schmidt S. Oral pulsed therapy of relapsing multiple sclerosis with cladribine tablets - expert opinion on issues in clinical practice. Mult Scler Relat Disord 2021; 54:103075. [PMID: 34261026 DOI: 10.1016/j.msard.2021.103075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Oral cladribine is the first oral pulsed therapy licensed for relapsing multiple sclerosis (RMS). Three years after the introduction into the European market, we evaluated practical aspects in the use of cladribine tablets, incorporating the experience gained in routine clinical practice and real-world studies. METHODS Based on a structured review process, a panel of nine neurologists experienced in MS therapy discussed salient statements regarding the use of cladribine tables. For each statement the level of evidence was determined according to the levels of evidence recommended by the Centre for Evidence-Based Medicine, Oxford. The strength of each expert statement was then evaluated by means of a linear scale from 1 (very strong rejection) to 9 (very strong approval). Votes were collected by a formalized blinded process. Consent was considered to be reached if at least 75% of the experts agreed on a particular statement (i.e. voted for 7-9 points on the linear scale). RESULTS . Statements include efficacy in early RMS, risk of side effects and infections, vaccination, pregnancy, and monitoring requirements. CONCLUSION The consented recommendations summarize the practical experience inthe use of cladribine tablets in a real-world setting. These may provide guidance for unanswered questions arising with the introduction of new treatments such as cladribine tablets.
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Affiliation(s)
- Martin Stangel
- Klinik für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
| | - Veit Becker
- Neurologische Praxis Eppendorf, Kümmellstr. 1, D-20249 Hamburg, Germany.
| | - Birte Elias-Hamp
- Birte Elias-Hamp, Praxis für Neurologie und Psychiatrie, Bengelsdorfstr. 5, D-22179 Hamburg, Germany.
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, and Data Integration for Future Medicine (DIFUTURE) consortium, LMU Hospital, Ludwig-Maximilians Universität München, Munich, Germany.
| | - Christoph Grothe
- GFO-Kliniken Troisdorf, Wilhelm-Busch-Straße 9, D-53840 Troisdorf, Germany.
| | - Refik Pul
- Klinik für Neurologie am Universitätsklinikum in Essen, Hufelandstr. 55, D-45147 Essen, Germany.
| | - Daniela Rau
- Nervenfachärztliche Gemeinschaftspraxis in Ulm, Pfauengasse 8, D-89073 Ulm, Germany.
| | - Stephan Richter
- MIND-MVZ Stuttgart, Charlottenstr. 14, D-70182 Stuttgart, Germany.
| | - Stephan Schmidt
- Neurologische Gemeinschaftspraxis Bonn, Gesundheitszentrum St. Johannes, Kölnstr. 54, D-53111 Bonn, Germany.
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30
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Coles AJ, Arnold DL, Bass AD, Boster AL, Compston DAS, Fernández Ó, Havrdová EK, Nakamura K, Traboulsee A, Ziemssen T, Jacobs A, Margolin DH, Huang X, Daizadeh N, Chirieac MC, Selmaj KW. Efficacy and safety of alemtuzumab over 6 years: final results of the 4-year CARE-MS extension trial. Ther Adv Neurol Disord 2021; 14:1756286420982134. [PMID: 34035833 PMCID: PMC8072102 DOI: 10.1177/1756286420982134] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/09/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In the 2-year CARE-MS I and II trials, alemtuzumab 12 mg administered on 5 consecutive days at core study baseline and on 3 consecutive days 12 months later significantly improved outcomes versus subcutaneous interferon beta-1a (SC IFNB-1a) in relapsing-remitting multiple sclerosis patients. Here, we present the final 6-year CARE-MS extension trial results (CAMMS03409), and compare outcomes over 6 years in patients randomized to both treatment groups at core study baseline. METHODS Over a 4-year extension, alemtuzumab patients (alemtuzumab-only) received as-needed additional alemtuzumab (⩾12 months apart) for disease activity after course 2. SC IFNB-1a patients who entered the extension discontinued SC IFNB-1a and received 2 alemtuzumab 12 mg courses (IFN-alemtuzumab), followed by additional, as-needed, alemtuzumab. RESULTS Through year 6, 63% of CARE-MS I and 50% of CARE-MS II alemtuzumab-only patients received neither additional alemtuzumab nor other disease-modifying therapy, with lasting suppression of disease activity, improved disability, and slowing of brain volume loss (BVL). In CARE-MS I patients (treatment-naive; less disability; shorter disease duration), disease activity and BVL were significantly reduced in IFN-alemtuzumab patients, similar to alemtuzumab-only patients at year 6. Among CARE-MS II patients (inadequate response to prior treatment; more disability; longer disease duration), alemtuzumab significantly improved clinical and magnetic resonance imaging outcomes, including BVL, in IFN-alemtuzumab patients; however, disability outcomes were less favorable versus alemtuzumab-only patients. Safety profiles, including infections and autoimmunities, following alemtuzumab were similar between treatment groups. CONCLUSION This study demonstrates the high efficacy of alemtuzumab over 6 years, with a similar safety profile between treatment groups. CLINICALTRIALSGOV IDENTIFIERS NCT00530348; NCT00548405; NCT00930553.
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Affiliation(s)
- Alasdair J. Coles
- Department of Clinical Neurosciences, University
of Cambridge, Box 165, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
| | - Douglas L. Arnold
- NeuroRx Research, Montréal, Québec, Canada
- Department of Neurology and Neurosurgery,
Montréal Neurological Institute, McGill University, Montréal, Québec,
Canada
| | - Ann D. Bass
- Neurology Center of San Antonio, San Antonio,
TX, USA
| | | | | | - Óscar Fernández
- Instituto de Investigación Biomédica de Málaga
(IBIMA), Málaga, Spain
| | - Eva Kubala Havrdová
- Department of Neurology and Center for Clinical
Neuroscience, First Medical Faculty, Charles University, Prague, Czech
Republic
| | - Kunio Nakamura
- Department of Biomedical Engineering, Cleveland
Clinic, Cleveland, OH, USA
| | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav
Carus University Hospital, Dresden, Germany
| | - Alan Jacobs
- Immunovant, Inc., New York, NY, USA
- Sanofi, Cambridge, MA, USA
| | | | - Xiaobi Huang
- Sanofi, Cambridge, MA, USA
- Biogen, Cambridge, MA, USA
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31
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Abstract
PURPOSE OF REVIEW Using highly effective (HE) compounds right from the beginning of disease-modifying immunotherapy (DMT) in people with multiple sclerosis (pwMS) has gained popularity among clinicians and pwMS alike. We discuss the most recent evidence supporting this approach, and whether any of the associated risks should stop us adopting it as a default strategy. RECENT FINDINGS With the addition of injectable ofatumumab, and the two oral sphingosine one phosphate modulators siponimod and ozanimod, ten HE DMTs are now available for pwMS, though variation in licensing status and cost may limit their use in some healthcare environments. Real World evidence based on large MS registry data suggests the superiority of early HE DMT over a slow treatment escalation approach; delaying HE DMT leads to more rapid and often irreversible disability accrual. Mechanistically, B-cell depletion, particularly memory B-cell suppression, is a common denominator closely associated with DMT efficacy. SUMMARY The concept that HE DMTs are necessarily associated with a high risk of adverse effects, is no longer supported by the evidence. The rather predictable and manageable risk profile of most HE DMTs should lower the threshold for clinicians to discuss such treatment with pwMS as a first line approach.
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32
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Bose G, Freedman MS. Recent advances and remaining questions of autologous hematopoietic stem cell transplantation in multiple sclerosis. J Neurol Sci 2021; 421:117324. [PMID: 33497951 DOI: 10.1016/j.jns.2021.117324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/29/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
The judicious use of autologous hematopoietic stem cell transplantation (AHSCT) for MS requires understanding the potential benefits, identifying the most appropriate patient, and acknowledging the risks and differences between different protocols. Recently, AHSCT for MS is occurring more frequently, with a better safety profile than earlier studies. This review assesses recently published studies to determine the advances that have been made and remaining questions that future studies are poised to answer. We included studies from January 2016 to November 2020 with 20 or more patients. The benefits of AHSCT, including "no evidence of disease activity", functional and patient-reported outcomes, novel biomarkers such as brain atrophy or neurofilament light chain, and cost-effectiveness were assessed. The patient selection, treatment protocols, and safety outcomes differ between reports. The overall efficacy of AHSCT is better than standard treatments. Younger patients with highly active disease have greater chance for improvement, while patients who have comorbidities, failed more treatments, and are transitioning to a more progressive phase may not respond as well to AHSCT. The safety profiles for all AHSCT protocols is improving, however the durability of treatment response may not be the same for all protocols. The goal of AHSCT is to stop disease activity, avoid worsening disability, and obviate the need for further disease-modifying treatment, while improving patient quality of life and minimizing treatment-related risk. Results from currently enrolling randomized controlled trials, as well as ongoing registries, will provide more evidence for the safe and appropriate use of AHSCT.
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Affiliation(s)
- Gauruv Bose
- University of Ottawa, The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada.
| | - Mark S Freedman
- University of Ottawa, The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital General Campus, 501 Smyth Road, Box 606, Ottawa, ON K1H 8L6, Canada.
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33
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The Disease-Modifying Therapies of Relapsing-Remitting Multiple Sclerosis and Liver Injury: A Narrative Review. CNS Drugs 2021; 35:861-880. [PMID: 34319570 PMCID: PMC8354931 DOI: 10.1007/s40263-021-00842-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 02/08/2023]
Abstract
In this narrative review, we analyze pre-registration and post-marketing data concerning hepatotoxicity of all disease-modifying therapies (DMTs) available for the treatment of relapsing-remitting multiple sclerosis, including beta interferon, glatiramer acetate, fingolimod, teriflunomide, dimethyl fumarate, cladribine, natalizumab, alemtuzumab, and ocrelizumab. We review the proposed causal mechanisms described in the literature and we also address issues like use of DMTs in patients with viral hepatitis or liver cirrhosis. Most data emerged in the post-marketing phase by reports to national pharmacovigilance agencies and published case reports or case series. Serious liver adverse events are rare, but exact incidence is largely unknown, as are predictive factors. Unfortunately, none of the DMTs currently available for the treatment of multiple sclerosis is free of potential hepatic toxic effects. Cases of acute liver failure have been reported for beta-interferon, fingolimod, natalizumab, alemtuzumab, and ocrelizumab by different mechanisms (idiosyncratic reaction, autoimmune hepatitis, or viral reactivation). Patients with multiple sclerosis should be informed about possible hepatic side effects of their treatment. Most cases of liver injury are idiosyncratic and unpredictable. The specific monitoring schedule for each DMT has been reviewed and the clinician should be ready to recognize clinical symptoms suggestive for liver injury. Not all DMTs are indicated in cirrhotic patients. For some DMTs, screening for hepatitis B virus and hepatitis C virus is required before starting treatment and a monitoring or antiviral prophylaxis schedule has been established. Beta interferon, glatiramer acetate, natalizumab, and alemtuzumab are relatively contraindicated in autoimmune hepatitis due to the risk of disease exacerbation.
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34
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Abstract
Alemtuzumab (Lemtrada®) is an anti-CD52 monoclonal antibody approved in the EU for the treatment of highly active relapsing-remitting multiple sclerosis (RRMS). In phase 3 trials in patients with active RRMS, intravenous alemtuzumab was more effective than subcutaneous interferon β-1a in terms of decreasing relapse rates (in treatment-naïve or -experienced patients) and disability progression (treatment-experienced patients). Treatment benefits were maintained over up to 9 years of follow-up, with ≈ 50% of patients not requiring retreatment. The efficacy of alemtuzumab in patients with highly active disease was generally similar to that in the overall population. Alemtuzumab has an acceptable tolerability profile, with infusion-associated reactions, infections and autoimmunity being the main safety and tolerability issues. Current evidence indicates that alemtuzumab is an effective treatment option for adults with highly active RRMS, with an acceptable safety and tolerability profile and convenient treatment regimen.
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Affiliation(s)
- Yahiya Y Syed
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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35
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Systemic erythematous lupus after treatment of multiple sclerosis with alemtuzumab. Mult Scler Relat Disord 2020; 46:102589. [PMID: 33296985 DOI: 10.1016/j.msard.2020.102589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/10/2020] [Accepted: 10/18/2020] [Indexed: 11/20/2022]
Abstract
Alemtuzumab is a humanized monoclonal antibody targeting CD52 protein that has shown great efficacy in the treatment of relapsing remitting multiple sclerosis and is associated with prolonged remission of the disease. Although it is highly effective, alemtuzumab can lead to serious adverse advents among which the most common are secondary autoimmune diseases. We present a patient who was treated with alemtuzumab for relapsing remitting multiple sclerosis. Her disease remained stable in a follow-up period of over ten years. However, during the follow-up period she developed thyroiditis one year, as well as systemic erythematous lupus seven years after the last alemtuzumab infusion, a disease not previously associated with alemtuzumab administration.
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