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Okazaki T, Kodama D, Yamadera M, Sugiyama Y, Tsuji H, Nishida F, Ooka Y, Nakamichi K, Hashikawa K, Yanagihara T. [Progressive multifocal leukoencephalopathy in a patient with rheumatoid arthritis under salazosulfapyridine treatment]. Rinsho Shinkeigaku 2021; 61:833-838. [PMID: 34789625 DOI: 10.5692/clinicalneurol.cn-001622] [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: 11/05/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare opportunistic infection caused by JC virus (JCV) activation. We report an 85-years old man who had been diagnosed to have rheumatoid arthritis (RA) 1.5 years prior to diagnosis of PML, and had been treated with salazosulfapyridine (SASP). He developed weakness of the left upper limb, which progressed gradually for two months. A neurological examination on admission revealed severe palsy of the left upper limb without sensory disturbance, cognitive decline or gait disturbance. Brain MRI revealed white matter lesions in the right frontal lobe around the precentral gyrus. Cerebrospinal fluid (CSF) examination and peripheral lymphocyte counts were normal. HIV was ruled out serologically. There were no findings suggestive of malignancy. We suspected PML and stopped SASP. JCV-DNA was detected in CSF. There were enlarged nuclei positive with VP-1 immunostaining in the brain biopsy materials. Thus, the diagnosis of PML was definitive. Paralysis of the left upper limb began to improve one week after discontinuing SASP. Treatment with mefloquine and mirtazapine was initiated, but he developed severe interstitial pneumonia, which might be caused by mefloquine. Therefore, he underwent rehabilitation without medication. JCV-DNA became undetectable and white matter lesions decreased 6 months later. Paralysis improved and he had no problem with activities of daily living a year later. The risk factor for PML has changed over the last decade, and drugs such as biologics became significant risk factors for patients with autoimmune diseases. There are reports suggesting that systemic lupus erythematosus (SLE) and RA themselves might be independent risk factors for PML. Although there is no previous report of SASP inducing PML, SASP might be the culprit in our case. However, there is another possibility that SAPS and RA worked synergistically for the onset of PML.
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Affiliation(s)
| | | | | | | | | | | | - Yoko Ooka
- Department of Neurology, Osaka Police Hospital
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases
| | | | - Takehiko Yanagihara
- Department of Neurology, Osaka Police Hospital.,Osaka Neurological Research Institute
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Villa E, Sarquis T, de Grazia J, Núñez R, Alarcón P, Villegas R, Guevara C. Rheumatoid meningitis: A systematic review and meta-analysis. Eur J Neurol 2021; 28:3201-3210. [PMID: 33966315 DOI: 10.1111/ene.14904] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Rheumatoid meningitis (RM) is a neurological complication of rheumatoid arthritis (RA). Current evidence is based on case reports and partial reviews. METHODS This is a systematic review and meta-analysis following the PRISMA statement. The aim is to describe the characteristics of the disease, including clinical, imaging and laboratory findings, treatment, outcomes and prognosis reported in the literature. RESULTS In all, 103 studies with 130 cases were included. RM affected adults with an average age of 62 years, with or without a previous RA diagnosis. RA activity and time with the disease were associated with a worse prognosis. Most common clinical manifestations were transient focal neurological signs (64.6%), systemic symptoms (51.3%), episodic headache (50.4%) and neuropsychiatric alterations (47.7%). Joint manifestations were present in only 27.4% of cases. Brain magnetic resonance imaging showed unilateral or bilateral involvement, predominantly frontoparietal. Both pachymeninges and leptomeninges were affected, the latter more frequently (82.88%). The laboratory findings included increased levels of rheumatoid factor (89.71%), anti-cyclic citrullinated peptide (89.47%), C-reactive protein (82.54%) and erythrocyte sedimentation rate (81.81%). Cerebrospinal fluid analysis showed an increase in the protein level (76.14%), with pleocytosis (85.19%) of mononuclear predominance (89.19%). Biopsy was performed in 72.52% of the patients. Corticosteroid pulse therapy was the main induction therapy. Disease relapse occurred in 31.17% of patients, whilst 54.54% had a full recovery. CONCLUSIONS Rheumatoid meningitis must be considered in adult patients with or without RA diagnosis, high-dose corticosteroid induction therapy should be installed and maintenance therapy plays a key role. It is not recommended to use anti-TNF as an induction therapy. Nowadays, RM has a significantly better outcome. These findings may aid clinicians in timely RM diagnosis and treatment, thus improving its outcomes.
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Affiliation(s)
- Eduardo Villa
- Department of Neurology and Neurosurgery, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Teresita Sarquis
- Department of Neurology and Neurosurgery, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - José de Grazia
- Department of Radiology, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - René Núñez
- Department of Radiology, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Pablo Alarcón
- Genetic Section, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Rodrigo Villegas
- Program in Biostatistics, School of Public Health, Universidad de Chile, Santiago, Chile
| | - Carlos Guevara
- Department of Neurology and Neurosurgery, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
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3
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Complications neurologiques de l’infection par le virus JC : revue générale. Rev Med Interne 2021; 42:177-185. [DOI: 10.1016/j.revmed.2020.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/28/2020] [Accepted: 08/27/2020] [Indexed: 12/11/2022]
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4
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Bonek R, Guenter W, Jałowiński R, Karbicka A, Litwin A, Maciejowski M, Zajdel R, Petit V, Rejdak K. JC Virus Seroprevalence and JCVAb Index in Polish Multiple Sclerosis Treatment-Naïve Patients. J Clin Med 2020; 9:E3867. [PMID: 33261210 PMCID: PMC7759948 DOI: 10.3390/jcm9123867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 11/17/2022] Open
Abstract
Multiple sclerosis (MS) treatment with new agents is associated with the risk of the development of progressive multifocal leukoencephalopathy (PML). The seropositivity and a high index of anti-John Cunningham virus (JCV) antibodies are some of the risk factors for PML development. The aim of this study was to assess the seroprevalence of anti-JCVAb and JCVAb index (AI), as well as its correlations with demographic and clinical characteristics in treatment-naïve Polish MS patients. This is a multicenter, prospective, and cross-sectional study involving 665 MS patients. The overall prevalence of anti-JCVAb was 65.3%, while 63.1% of seropositive patients had an index level of >1.5. The seroprevalence was shown to increase along with the patient's age. Except for age, the prevalence of anti-JCVAb was not associated with demographic or clinical data. No correlations between the index levels and the demographic or clinical data were observed. In Poland, the seroprevalence of anti-JCVAb in treatment-naïve MS patients is one of the highest in Europe. The majority of seropositive patients had an anti-JCV antibody level denoting a high-risk category. This means that we need further studies to be conducted on the individualization of MS treatment in order to provide patients with an appropriate therapeutic safety level.
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Affiliation(s)
- Robert Bonek
- Department of Neurology and Clinical Neuroimmunology, Regional Specialist Hospital, 86-300 Grudziadz, Poland
- Foundation Supporting Development of Neurology and Clinical Neuroimmunology MoA, 85-654 Bydgoszcz, Poland
| | - Wojciech Guenter
- Department of Clinical Neuropsychology, Nicolaus Copernicus University, 87-100 Torun, Poland, and Collegium Medicum, 85-094 Bydgoszcz, Poland;
| | - Robert Jałowiński
- Department of Neurology, Regional Hospital, 71-455 Szczecin, Poland; (R.J.); (A.K.)
| | - Anna Karbicka
- Department of Neurology, Regional Hospital, 71-455 Szczecin, Poland; (R.J.); (A.K.)
| | - Anna Litwin
- Department of Neurology, Regional Hospital, 10-561 Olsztyn, Poland;
| | | | - Radosław Zajdel
- Chair of Business Informatics, University of Lodz, 90-214 Lodz, Poland;
| | - Veronique Petit
- Department of Neurology, Medical University of Lublin, 20-090 Lublin, Poland; (V.P.); (K.R.)
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, 20-090 Lublin, Poland; (V.P.); (K.R.)
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Simopoulou T, Tsimourtou V, Katsiari C, Vlychou M, Bogdanos DP, Sakkas LI. Progressive multifocal leukoencephalopathy in a patient with systemic sclerosis treated with methotrexate: A case report and literature review. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2020; 5:NP1-NP6. [PMID: 35382519 PMCID: PMC8922622 DOI: 10.1177/2397198320926883] [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: 02/19/2020] [Accepted: 04/14/2020] [Indexed: 08/10/2023]
Abstract
Reactivation of viruses occurs in autoimmune disorders in the setting of certain immunosuppressive drugs. We describe a 54-year-old female with systemic sclerosis and extensive cutaneous calcinosis who had been treated with methotrexate for 18 months and presented with headache and neurological deficits. She was diagnosed with progressive multifocal leukoencephalopathy, a rare disease caused by JC virus. Methotrexate was discontinued and mirtazapine plus mefloquine were added. The patient showed a slow recovery and five years later she had complete resolution of progressive multifocal leukoencephalopathy clinical manifestations. Calcinosis had a limited response to various agents and severely affected daily activities of the patient. This case report, highlights the importance of clinical suspicion for progressive multifocal leukoencephalopathy in every patient with immune-mediated disease, even on weak immunosuppressant, who presents with central nervous system manifestations and also the unmet therapeutic need for systemic sclerosis-associated calcinosis.
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Affiliation(s)
- Theodora Simopoulou
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Vana Tsimourtou
- Department of Neurology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christina Katsiari
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Marianna Vlychou
- Department of Radiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Lazaros I Sakkas
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Anada M, Tohyama M, Oda Y, Kamoshima Y, Amino I, Nakano F, Miyazaki Y, Akimoto S, Minami N, Kikuchi S, Terae S, Niino M. Progressive Multifocal Leukoencephalopathy during Tocilizumab Treatment for Rheumatoid Arthritis. Intern Med 2020; 59:2053-2059. [PMID: 32448834 PMCID: PMC7492111 DOI: 10.2169/internalmedicine.4431-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A 61-year-old woman was diagnosed with rheumatoid arthritis 12 years ago and received multiple treatment regimens before achieving symptomatic stability with methotrexate plus tocilizumab, a humanized monoclonal antibody against the IL-6 receptor, about 2 years prior to the current presentation. Sixteen months after tocilizumab initiation, she exhibited dysarthria and disorientation; five months later, she was hospitalized with movement difficulties. Her neurological symptoms deteriorated thereafter, accompanied by enlarged cerebral white matter lesions on magnetic resonance imaging. A biopsy of the right frontal lesion confirmed progressive multifocal leukoencephalopathy (PML). While several therapeutic monoclonal antibodies have been linked to PML, this is the first case associated with tocilizumab.
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Affiliation(s)
- Mamiko Anada
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | | | - Yoshitaka Oda
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Japan
| | - Yuuta Kamoshima
- Department of Neurosurgery, Sapporo Azabu Neurosurgical Hospital, Japan
| | - Itaru Amino
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Fumihito Nakano
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Yusei Miyazaki
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Sachiko Akimoto
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Seiji Kikuchi
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Satoshi Terae
- Department of Diagnostic Radiology, Sapporo City General Hospital, Japan
| | - Masaaki Niino
- Department of Clinical Research, National Hospital Organization Hokkaido Medical Center, Japan
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Inshasi JS, Almadani A, Fahad SA, Noori SI, Alsaadi T, Shakra M, Shatila AO, Zein TM, Boshra A. High-efficacy therapies for relapsing-remitting multiple sclerosis: implications for adherence. An expert opinion from the United Arab Emirates. Neurodegener Dis Manag 2020; 10:257-266. [PMID: 32438857 DOI: 10.2217/nmt-2020-0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The number of disease-modifying treatments (DMDs) for relapsing-remitting multiple sclerosis has increased. DMDs differ not only in their efficacy and safety/tolerability, but also in the treatment burden of, associated with their initiation, route/frequency of administration, maintenance treatment and monitoring. High-efficacy DMDs bring the prospect of improved suppression of relapses and progression of disability, but may have serious safety issues, and burdensome long-term monitoring. Studies of patient preferences in this area have focused on side effects, efficacy and route of administration. Adherence to DMDs is often suboptimal in relapsing-remitting multiple sclerosis and there is a need to understand more about how the complex therapeutic and administration profiles of newer DMDs interact with these barriers to support optimal adherence to therapy.
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Affiliation(s)
- Jihad Said Inshasi
- MS Section, Rashid Hospital & Dubai Medical College, Dubai Health Authority (DHA), Dubai, UAE
| | - Abubaker Almadani
- Rashid Hospital & Dubai Medical College, Dubai health Authority (DHA), Dubai, UAE
| | - Sarmad Al Fahad
- Neurology Department, Neurospinal Hospital, Baghdad Medical College, Dubai, UAE
| | | | - Taoufik Alsaadi
- Neurology Department, American Center for Psychiatry & Neurology, Dubai, UAE
| | - Mustafa Shakra
- Department of Neurology, Sheikh Khalifa Medical City, Abu Dhabi, UAE
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Kartau M, Sipilä JOT, Auvinen E, Palomäki M, Verkkoniemi-Ahola A. Progressive Multifocal Leukoencephalopathy: Current Insights. Degener Neurol Neuromuscul Dis 2019; 9:109-121. [PMID: 31819703 PMCID: PMC6896915 DOI: 10.2147/dnnd.s203405] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/14/2019] [Indexed: 12/20/2022] Open
Abstract
Cases of PML should be evaluated according to predisposing factors, as these subgroups differ by incidence rate, clinical course, and prognosis. The three most significant groups at risk of PML are patients with hematological malignancies mostly previously treated with immunotherapies but also untreated, patients with HIV infection, and patients using monoclonal antibody (mAb) treatments. Epidemiological data is scarce and partly conflicting, but the distribution of the subgroups appears to have changed. While there is no specific anti-JCPyV treatment, restoration of the immune function is the most effective approach to PML treatment. Research is warranted to determine whether immune checkpoint inhibitors could benefit certain PML subgroups. There are no systematic national or international records of PML diagnoses or a risk stratification algorithm, except for MS patients receiving natalizumab (NTZ). These are needed to improve PML risk assessment and to tailor better prevention strategies.
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Affiliation(s)
- Marge Kartau
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Jussi OT Sipilä
- Department of Neurology, Siun Sote, North Carelia Central Hospital, Joensuu, Finland
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland
- Clinical Neurosciences, University of Turku, Turku, Finland
| | - Eeva Auvinen
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Palomäki
- Neuroradiology, HUS Medical Imaging Center, Helsinki, Finland
| | - Auli Verkkoniemi-Ahola
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
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Tavakolpour S, Alesaeidi S, Darvishi M, GhasemiAdl M, Darabi-Monadi S, Akhlaghdoust M, Elikaei Behjati S, Jafarieh A. A comprehensive review of rituximab therapy in rheumatoid arthritis patients. Clin Rheumatol 2019; 38:2977-2994. [PMID: 31367943 DOI: 10.1007/s10067-019-04699-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/15/2022]
Abstract
Rituximab (RTX) is an approved treatment for rheumatoid arthritis (RA) patients that do not respond adequately to disease-modifying antirheumatic drugs. However, different new concerns, such as efficacy, optimum dose, safety issues, prediction of response to RTX, and pregnancy outcomes have attracted a lot of attention. The PubMed database was systematically reviewed for the last published articles, new findings, and controversial issues regarding RTX therapy in RA using "Rheumatoid arthritis" AND "rituximab" keywords, last updated on June 18, 2019. From 1812 initial recorders, 162 studies met the criteria. Regarding the optimum dose, low-dose RTX therapy (2 × 500 mg) seems as effective as standard dose (2 × 1000 mg), safer, and more cost-effective. The most common reported safety challenges included de novo infections, false negative serologic tests of viral infections, reactivation of chronic infections, interfering with vaccination outcome, and development of de novo psoriasis. Other less reported side effects are infusion reactions, nervous system disorders, and gastrointestinal disorders. Lower exposure to other biologics, presence of some serological markers (e.g., anti-RF, anti-CCP, IL-33, ESR), specific variations in FCGR3A, FCGR2A, TGFβ1, IL6, IRF5, BAFF genes, and also EBV-positivity could be used to predict response to RTX. Although there is no evidence of the teratogenic effect of RTX, it is recommended that women do not expose themselves to RTX at least 6 months before the conception. Only a reversible reduction of B cell-count in the offspring may be the pregnancy-related outcome. Although RTX is an effective therapeutic option for RA, more studies on optimum doses, prevention of RTX-related side effects, prediction of RTX response, and safety during the pregnancy are required.
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Affiliation(s)
- Soheil Tavakolpour
- Pharmaceutical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Samira Alesaeidi
- Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), department of aerospace and subaquatic medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Mojtaba GhasemiAdl
- Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Meisam Akhlaghdoust
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | - Arash Jafarieh
- Amir'Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Farley S, Gottesman MH, Friedman-Urevich S, Ye J, Shen M, Grueneberg D, Martone L, Calixte R. Anti-John Cunningham virus antibody index levels in multiple sclerosis patients treated with rituximab, fingolimod, and dimethyl fumarate. Surg Neurol Int 2019; 10:59. [PMID: 31528397 PMCID: PMC6743681 DOI: 10.25259/sni-4-2019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Progressive multifocal leukoencephalopathy (PML), a potentially fatal demyelinating disease caused by the John Cunningham virus (JCV), can occur as a complication of treatment with rituximab, fingolimod, and dimethyl fumarate. The primary objective of this study was to determine changes in anti-JCV antibody index values in multiple sclerosis (MS) patients treated with these three medications. Second, we explored the relationship between absolute lymphocyte count (ALC), anti-JCV antibody index values, and various patient characteristics. Methods: In this retrospective chart review, we evaluated changes in JCV serology and ALC in 172 MS patients treated with fingolimod, rituximab, or dimethyl fumarate (2013–2016). Only those with known anti-JCV antibody and ALC values before starting the study medications were included. Subsequent values were obtained on an ad hoc basis throughout the study. Results: There was a significant decrease in anti-JCV antibody index values in patients treated with fingolimod and rituximab (P = 0.03 and P = 0.014, respectively). A non-significant decreasing trend in anti-JCV antibody index values occurred in patients treated with dimethyl fumarate. Notably, there was no relationship between ALC and anti-JCV antibody index values for patients treated with rituximab, fingolimod, or dimethyl fumarate. Conclusions: Anti-JCV antibody index values significantly decreased in MS patients treated with fingolimod and rituximab; however, this did not occur with dimethyl fumarate. Fingolimod and rituximab may impair the humoral response to the JCV. Nevertheless, a declining anti-JCV antibody index in MS patients treated with fingolimod or rituximab should not necessarily be interpreted as correlating with a decreased risk for PML.
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Affiliation(s)
- Stephen Farley
- Department of Pharmacy, NYU Winthrop Hospital, Mineola, NY
| | | | | | - Janin Ye
- New York University, New York, NY
| | - Mark Shen
- Department of Pharmacy, NYU Winthrop Hospital, Mineola, NY
| | | | | | - Rose Calixte
- Department of Biostatistics, NYU Winthrop Hospital, Mineola, NY, USA
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11
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Nosaki Y, Ohyama K, Watanabe M, Yokoi T, Nakamichi K, Saijo M, Miura Y, Iwai K. Simultaneous Development of Progressive Multifocal Leukoencephalopathy and Cryptococcal Meningitis during Methotrexate and Infliximab Treatment. Intern Med 2019; 58:2703-2709. [PMID: 31527369 PMCID: PMC6794173 DOI: 10.2169/internalmedicine.2570-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by reactivation of the JC virus under an immunosuppressed state. This condition carries a high risk of cryptococcal meningitis. We herein report a 65-year-old woman who simultaneously developed PML and cryptococcal meningitis and presented with bilateral sixth nerve palsy. She had been treated with methotrexate and infliximab for rheumatoid arthritis. Her symptoms improved with antifungal drug treatment and discontinuation of immunosuppression therapy. Although concurrent PML and cryptococcal meningitis is rare, it should be considered in immunosuppressed patients.
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Affiliation(s)
- Yasunobu Nosaki
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Ken Ohyama
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Maki Watanabe
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Takamasa Yokoi
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Japan
| | - Masayuki Saijo
- Department of Virology 1, National Institute of Infectious Diseases, Japan
| | - Yoshiharu Miura
- Department of Neurology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Japan
| | - Katsushige Iwai
- Department of Neurology, Toyohashi Municipal Hospital, Japan
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12
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Palleria C, Iannone L, Leporini C, Citraro R, Manti A, Caminiti M, Gigliotti P, Grembiale RD, L’Andolina M, Muccari G, Naturale MD, Olivo D, Pagano Mariano G, Pellegrini R, Varcasia G, Abdalla K, Russo E, Ursini F, De Sarro G. Implementing a simple pharmacovigilance program to improve reporting of adverse events associated with biologic therapy in rheumatology: Preliminary results from the Calabria Biologics Pharmacovigilance Program (CBPP). PLoS One 2018; 13:e0205134. [PMID: 30356301 PMCID: PMC6200211 DOI: 10.1371/journal.pone.0205134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/19/2018] [Indexed: 01/01/2023] Open
Abstract
Introduction Post-marketing surveillance activities (namely pharmacovigilance) are crucial to favor the early detection of unexpected adverse events (AEs) and/or serious adverse reactions (SAEs). Indeed, spontaneous reporting of AEs has been demonstrated to underestimate the number of events in different clinical settings. Aim of the present study is to report the preliminary data of a Regional (Calabria, Italy) Pharmacovigilance Program (CBPP) aimed at improving AEs’ reporting associated with biologics use in rheumatology. Materials and methods We developed a simple, cost-effective pharmacovigilance program based on regular training sessions for physicians (stimulated reporting), periodical phone calls by a clinical pharmacologist aimed at identifying new events and stimulating self-awareness and encouraging reporting to the physician during the subsequent follow-up visit for minor AEs. To test this approach, all consecutive patients undergoing treatment with one biologic agent at eight rheumatology centers during a two-years period were invited to participate. Collected AEs were compared to the number of AEs spontaneously reported for the same molecules in the same centers before starting the protocol. Results During the study period, 399 patients (245 females; mean age: 58 ± 11 years) were started on treatment with biologics for active RA (n = 211, 52.9%), PsA (n = 119, 29.8%) or AS (n = 69, 17.3%) at eight rheumatology centers. A total of 125 AEs (31.3%) and 9 SAEs (2.3%) were reported during the two-years study period. In the control cohort (comprising 368 consecutive patients started on treatment with bDMARDs during a two-years period before CBPP study) only 42 (11.4%) AEs and no SAEs were reported (p < 0.0001). The most common AEs were injection site reactions and skin disorders. Conclusions In conclusion, our study provides further evidence of a critical role of active pharmacovigilance in detection, reporting and analysis of AEs in rheumatology.
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Affiliation(s)
- Caterina Palleria
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
| | - Luigi Iannone
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
| | - Christian Leporini
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
| | - Rita Citraro
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
| | - Antonia Manti
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
| | - Maurizio Caminiti
- Associazione Calabrese per la Ricerca in Reumatologia (ACRR), Catanzaro, Italy
- Rheumatology Unit, Grande Ospedale Metropolitano “Bianchi-Melacrino-Morelli”, Reggio Calabria, Italy
| | - Pietro Gigliotti
- Associazione Calabrese per la Ricerca in Reumatologia (ACRR), Catanzaro, Italy
- Rheumatology Outpatient Clinic, Azienda Ospedaliera Provinciale Cosenza, Cosenza, Italy
| | - Rosa Daniela Grembiale
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
| | - Massimo L’Andolina
- Associazione Calabrese per la Ricerca in Reumatologia (ACRR), Catanzaro, Italy
- Rheumatology Outpatient Clinic, Azienda Sanitaria Provinciale Vibo Valentia, Vibo Valentia, Italy
| | - Giuseppe Muccari
- Associazione Calabrese per la Ricerca in Reumatologia (ACRR), Catanzaro, Italy
- Rheumatology Outpatient Clinic, Azienda Ospedaliera “Pugliese-Ciaccio”, Catanzaro, Italy
| | - Maria Diana Naturale
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
| | - Domenico Olivo
- Associazione Calabrese per la Ricerca in Reumatologia (ACRR), Catanzaro, Italy
- Rheumatology Outpatient Clinic, Azienda Sanitaria Provinciale Crotone, Crotone, Italy
| | - Giuseppa Pagano Mariano
- Associazione Calabrese per la Ricerca in Reumatologia (ACRR), Catanzaro, Italy
- Rheumatology Unit, Grande Ospedale Metropolitano “Bianchi-Melacrino-Morelli”, Reggio Calabria, Italy
| | - Roberta Pellegrini
- Associazione Calabrese per la Ricerca in Reumatologia (ACRR), Catanzaro, Italy
- Rheumatology Unit, Azienda Ospedaliera “SS Annunziata”, Cosenza, Italy
| | - Giuseppe Varcasia
- Associazione Calabrese per la Ricerca in Reumatologia (ACRR), Catanzaro, Italy
- Rheumatology Unit, Ospedale Castrovillari, Castrovillari, Italy
| | - Karim Abdalla
- Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
| | - Emilio Russo
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
- * E-mail:
| | - Francesco Ursini
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
- Associazione Calabrese per la Ricerca in Reumatologia (ACRR), Catanzaro, Italy
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13
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Mulero P, Midaglia L, Montalban X. Ocrelizumab: a new milestone in multiple sclerosis therapy. Ther Adv Neurol Disord 2018; 11:1756286418773025. [PMID: 29774057 PMCID: PMC5952271 DOI: 10.1177/1756286418773025] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 03/16/2018] [Indexed: 12/31/2022] Open
Abstract
B cells play a central role in the pathogenesis of multiple sclerosis (MS): they are involved in the activation of pro-inflammatory T cells, secretion of pro-inflammatory cytokines and production of autoantibodies directed against myelin. Hence, the use of B cell-depleting monoclonal antibodies as therapy for autoimmune diseases, including MS, has increased in recent years. Previous results with rituximab, the first therapeutic B cell-depleting chimeric monoclonal antibody that showed efficacy in MS clinical trials, encouraged researchers to evaluate the efficacy of a humanized anti-CD20 antibody, ocrelizumab, in MS. A large phase II clinical trial in patients with relapsing-remitting MS (RRMS) designed to explore the effects of two doses of ocrelizumab (600 mg and 2000 mg) compared with placebo showed a pronounced effect on radiological and relapse-related outcomes. These results were confirmed in two phase III trials (OPERA I and II) that compared the efficacies of ocrelizumab with interferon beta-1a in patients with relapsing MS, and showed decreased annualized relapse rates (46% in OPERA I and 47% in OPERA II), as well as fewer numbers of gadolinium-enhanced lesions on magnetic resonance imaging (MRI) scans (94% in OPERA I and 95% in OPERA II). Notably, ocrelizumab is the first drug to lower rates of clinical and MRI-evidenced progression in patients with primary progressive MS (PPMS). The phase III trial (ORATORIO) in patients with PPMS met its primary efficacy endpoint: the percentage of patients with 12-week confirmed disability progression was significantly lower in the active treatment group (32.9%) than in patients receiving placebo (39.3%). In March 2017, this evidence led the US Food and Drug Administration to approve the licence for ocrelizumab (Ocrevus®) as a treatment for MS, as the first treatment approved for PPMS and as the first monoclonal antibody for secondary progressive MS.
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Affiliation(s)
- Patricia Mulero
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Luciana Midaglia
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Xavier Montalban
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitario Vall d’Hebron, Edif. Antiga EUI, Pl 2, Barcelona, 08035, SpainDivision of Neurology, University of Toronto, 190 Elizabet Street R. Fraser Elliott Building, 3-805, Toronto, ON, Canada
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14
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Bononi I, Mazzoni E, Pietrobon S, Manfrini M, Torreggiani E, Rossini M, Lotito F, Guerra G, Rizzo P, Martini F, Tognon M. Serum IgG antibodies from healthy subjects up to 100 years old react to JC polyomavirus. J Cell Physiol 2018; 233:5513-5522. [PMID: 29323725 DOI: 10.1002/jcp.26457] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/05/2018] [Indexed: 12/17/2022]
Abstract
JC polyomavirus (JCPyV) was identified in 1971 in the brain tissue of a patient (J.C.) affected by the progressive multifocal leukoencephalopathy (PML). JCPyV encodes for the oncoproteins large T antigen (Tag) and small t-antigen (tag). These oncoproteins are responsible of the cell transformation and tumorigenesis in experimental animals. JCPyV is ubiquitous in human populations. After the primary infection, which is usually asymptomatic, JCPyV remains lifelong in the host in a latent phase. Its reactivation may occur in heathy subjects and immunocompromised patients. Upon reactivation, JCPyV could reach (i) the CNS inducing the PML, (ii) the kidney of transplant patients causing the organ rejection. Association between JCPyV, which is a small DNA tumor virus, and gliomas and colorectal carcinomas has been published. In the present investigation, we report on a new indirect ELISA with two specific synthetic peptides mimicking JCPyV VP1 immunogenic epitopes to detect specific serum IgG antibodies against JCPyV. Serum samples of healthy subjects (n = 355) ranging 2-100 years old, were analyzed by this new indirect ELISA. The linear peptides VP1 K and VP1 N resemble the natural JCPyV VP1 capsidic epitopes constituting a docking site for serum antibodies. Data from this innovative immunologic assay indicate that the overall prevalence of JCPyV-VP1 antibodies in healthy subjects is at 39%. The innovative indirect ELISA with JCPyV VP1 mimotopes seems to be a useful method to detect specific IgG antibodies against this virus, without cross-reactivity with the closely related SV40 and BKPyV polyomaviruses.
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Affiliation(s)
- Ilaria Bononi
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Elisa Mazzoni
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Silvia Pietrobon
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Manfrini
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Elena Torreggiani
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Marika Rossini
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Francesca Lotito
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Giovanni Guerra
- Clinical Laboratory Analysis, University Hospital of Ferrara, Ferrara, Italy
| | - Paola Rizzo
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Fernanda Martini
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Mauro Tognon
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, School of Medicine, University of Ferrara, Ferrara, Italy
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15
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Paz SPC, Branco L, Pereira MADC, Spessotto C, Fragoso YD. Systematic review of the published data on the worldwide prevalence of John Cunningham virus in patients with multiple sclerosis and neuromyelitis optica. Epidemiol Health 2018; 40:e2018001. [PMID: 29370683 PMCID: PMC5900441 DOI: 10.4178/epih.e2018001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/05/2018] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES John Cunningham virus (JCV) is a polyoma virus that infects humans, mainly in childhood or adolescence, and presents no symptomatic manifestations. JCV can cause progressive multifocal leukoencephalopathy (PML) in immunosuppressed individuals, including those undergoing treatment for multiple sclerosis (MS) and neuromyelitis optica (NMO). PML is a severe and potentially fatal disease of the brain. The prevalence of JCV antibodies in human serum has been reported to be between 50.0 and 90.0%. The aim of the present study was to review worldwide data on populations of patients with MS and NMO in order to establish the rates of JCV seropositivity in these individuals. METHODS The present review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and used the following search terms: “JCV” OR “JC virus” AND “multiple sclerosis” OR “MS” OR “NMO” OR “neuromyelitis optica” AND “prevalence.” These terms were searched for both in smaller and in larger clusters of words. The databases searched included PubMed, MEDLINE, SciELO, LILACS, Google Scholar, and Embase. RESULTS After the initial selection, 18 papers were included in the review. These articles reported the prevalence of JCV antibodies in the serum of patients with MS or NMO living in 26 countries. The systematic review identified data on 29,319 patients with MS/NMO and found that 57.1% of them (16,730 individuals) were seropositive for the anti-JCV antibody (range, 40.0 to 69.0%). CONCLUSIONS The median worldwide prevalence of JCV among adults with MS or NMO was found to be 57.1%.
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Affiliation(s)
| | | | | | | | - Yara Dadalti Fragoso
- Reference Center for Multiple Sclerosis, Santos, Brazil.,Department of Neurology, Universidade Metropolitana de Santos, Santos, Brazil
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16
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Auricchio F, Scavone C, Cimmaruta D, Di Mauro G, Capuano A, Sportiello L, Rafaniello C. Drugs approved for the treatment of multiple sclerosis: review of their safety profile. Expert Opin Drug Saf 2017; 16:1359-1371. [PMID: 28976217 DOI: 10.1080/14740338.2017.1388371] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic immune-mediated inflammatory disorder of the brain and spinal cord characterized by inflammation, demyelination, and axonal degeneration. Area covered: Even though the pharmacological armamentarium for MS treatment is considerably improved in the last 20 years, safety data especially for the second-line and innovative treatments are lacking. In order to analyze the safety profile of drugs used for the treatment of MS, a literature review of pre-marketing, post-marketing studies and case reports was performed. Expert opinion: Nowadays, the numerous drugs approved in the last years for the treatment of MS allow a better control of the disease and a better patient compliance. The main advantages of the new disease-modifying agents for MS (DMTs), in fact, derive from the new oral administration and the prolonged half-life with consequent improvement in compliance compared to first-line therapy which required subcutaneous administrations. However, DMTs can cause serious, sometimes life-threatening or fatal, drug adverse reactions. Due to the lack of safety data and given the recent marketing approval of the last DMTs for MS, observational studies and post-marketing surveillance activities will be necessary in order to improve the knowledge about the safety profile of these drugs and the improvement of their use in clinical practice.
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Affiliation(s)
- Fabiana Auricchio
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Cristina Scavone
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Daniela Cimmaruta
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Gabriella Di Mauro
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Annalisa Capuano
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Liberata Sportiello
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Concetta Rafaniello
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
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17
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Schioppo T, Ingegnoli F. Current perspective on rituximab in rheumatic diseases. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2891-2904. [PMID: 29042750 PMCID: PMC5633295 DOI: 10.2147/dddt.s139248] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The steadily increasing knowledge regarding pathogenetic mechanisms in autoimmune rheumatic diseases has paved the way to different therapeutic approaches. In particular, the market entry of biologics has dramatically modified the natural history of rheumatic chronic inflammatory diseases with a meaningful impact on patients’ quality of life. Among the wide spectrum of available biological treatments, rituximab (RTX), first used in the treatment of non-Hodgkin’s lymphoma, was later approved for rheumatoid arthritis and anti-neutrophil cytoplasmic antibodies-associated vasculitis. Nowadays, in rheumatology, RTX is also used with off-label indications in patients with systemic sclerosis, Sjögren’s syndrome and systemic lupus erythematosus. RTX is a monoclonal antibody directed to CD20 molecules expressed on the surfaces of pre-B and mature B lymphocytes. It acts by causing apoptosis of these cells with antibody- and complement-dependent cytotoxicity. As inflammatory responses to cell-associated immune complexes are key elements in the pathogenesis of several autoimmune rheumatic diseases, such an approach might be effective in these patients. In fact, RTX, by promoting the rapid and long-term depletion of circulating and lymphoid tissue-associated B cells, leads to a lower recruitment of these effector cells at sites of immune complex deposition, thus reducing inflammation and tissue damage. RTX is of the most interest to rheumatologists as it represents an important additional therapeutic approach. Thus, the advent in clinical practice of approved RTX biosimilars, such as CT-P10, may be of help in improving treatment access as well as in reducing costs.
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Affiliation(s)
- Tommaso Schioppo
- Department of Clinical Sciences and Community Health, Division of Rheumatology, ASST Pini, Università degli Studi di Milano, Milano, Italy
| | - Francesca Ingegnoli
- Department of Clinical Sciences and Community Health, Division of Rheumatology, ASST Pini, Università degli Studi di Milano, Milano, Italy
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18
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Bradshaw MJ, Cho TA, Chow FC. Central Nervous System Infections Associated with Immunosuppressive Therapy for Rheumatic Disease. Rheum Dis Clin North Am 2017; 43:607-619. [PMID: 29061246 DOI: 10.1016/j.rdc.2017.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients on immunosuppressive therapy for rheumatic diseases are at increased risk of infection. Although infections of the central nervous system (CNS) are less common compared with other sites, patients on broadly immunosuppressive and biologic immunomodulatory agents may be susceptible to more severe, disseminated forms of infection, including of the CNS. Certain key principles regarding infection risk apply across immunosuppressive therapies, including increased risk with higher doses and longer duration of therapy and with combination therapy. Providers should be aware of the CNS infection risk related to immunosuppressant use to help guide best practices for screening and prophylaxis.
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Affiliation(s)
- Michael J Bradshaw
- Partners Multiple Sclerosis Center, Brigham and Women's Hospital and Massachusetts General Hospital, 60 Fenwood Road, 4th floor, Boston, MA 02115, USA
| | - Tracey A Cho
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Felicia C Chow
- Department of Neurology and Division of Infectious Diseases, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, Building 1, Room 101, San Francisco, CA 94110, USA.
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