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Alruwaili M, Al-kuraishy HM, Alexiou A, Papadakis M, ALRashdi BM, Elhussieny O, Saad HM, Batiha GES. Pathogenic Role of Fibrinogen in the Neuropathology of Multiple Sclerosis: A Tale of Sorrows and Fears. Neurochem Res 2023; 48:3255-3269. [PMID: 37442896 PMCID: PMC10514123 DOI: 10.1007/s11064-023-03981-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023]
Abstract
Multiple sclerosis (MS) is an autoimmune demyelinating neurodegenerative disease of the central nervous system (CNS) due to injury of the myelin sheath by immune cells. The clotting factor fibrinogen is involved in the pathogenesis of MS by triggering microglia and the progress of neuroinflammation. Fibrinogen level is correlated with MS severity; consequently, inhibition of the fibrinogen cascade may reduce MS neuropathology. Thus, this review aimed to clarify the potential role of fibrinogen in the pathogenesis of MS and how targeting of fibrinogen affects MS neuropathology. Accumulation of fibrinogen in the CNS may occur independently or due to disruption of blood-brain barrier (BBB) integrity in MS. Fibrinogen acts as transduction and increases microglia activation which induces the progression of inflammation, oxidative stress, and neuronal injury. Besides, brain fibrinogen impairs the remyelination process by inhibiting the differentiation of oligodendrocyte precursor cells. These findings proposed that fibrinogen is associated with MS neuropathology through interruption of BBB integrity, induction of neuroinflammation, and demyelination with inhibition of the remyelination process by suppressing oligodendrocytes. Therefore, targeting of fibrinogen and/or CD11b/CD18 receptors by metformin and statins might decrease MS neuropathology. In conclusion, inhibiting the expression of CD11b/CD18 receptors by metformin and statins may decrease the pro-inflammatory effect of fibrinogen on microglia which is involved in the progression of MS.
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Affiliation(s)
- Mubarak Alruwaili
- Department of Internal Medicine, College of Medicine, Jouf University, Sakaka, Saudi Arabia
| | - Hayder M. Al-kuraishy
- Department of Pharmacology, Toxicology and Medicine, Medical Faculty, College of Medicine, Al-Mustansiriyah University, P.O. Box 14132, Baghdad, Iraq
| | - Athanasios Alexiou
- Department of Science and Engineering, Novel Global Community Educational Foundation, Hebersham, NSW 2770 Australia
- AFNP Med, 1030 Vienna, Austria
| | - Marios Papadakis
- Department of Surgery II, University Hospital Witten-Herdecke, University of Witten-Herdecke, Heusnerstrasse 40, 42283 Wuppertal, Germany
| | - Barakat M. ALRashdi
- Biology Department, College of Science, Jouf University, Sakaka, 41412 Saudi Arabia
| | - Omnya Elhussieny
- Department of Histology and Cytology, Faculty of Veterinary Medicine, Matrouh University, Marsa Matruh, 51744 Egypt
| | - Hebatallah M. Saad
- Department of Pathology, Faculty of Veterinary Medicine, Matrouh University, Marsa Matruh, 51744 Egypt
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, 22511 Egypt
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Casanova I, Domínguez-Mozo MI, De Torres L, Aladro-Benito Y, García-Martínez Á, Gómez P, Abellán S, De Antonio E, Álvarez-Lafuente R. MicroRNAs Associated with Disability Progression and Clinical Activity in Multiple Sclerosis Patients Treated with Glatiramer Acetate. Biomedicines 2023; 11:2760. [PMID: 37893133 PMCID: PMC10604830 DOI: 10.3390/biomedicines11102760] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023] Open
Abstract
MicroRNAs (miRNAs) are promising biomarkers in multiple sclerosis (MS). This study aims to investigate the association between a preselected list of miRNAs in serum with therapeutic response to Glatiramer Acetate (GA) and with the clinical evolution of a cohort of relapsing-remitting MS (RRMS) patients. We conducted a longitudinal study for 5 years, with cut-off points at 2 and 5 years, including 26 RRMS patients treated with GA for at least 6 months. A total of 6 miRNAs from a previous study (miR-9.5p, miR-126.3p, mir-138.5p, miR-146a.5p, miR-200c.3p, and miR-223.3p) were selected for this analysis. Clinical relapse, MRI activity, confirmed disability progression (CDP), alone or in combination (No Evidence of Disease Activity-3) (NEDA-3), and Expanded Disability Status Scale (EDSS), were studied. After multivariate regression analysis, miR-9.5p was associated with EDSS progression at 2 years (β = 0.23; 95% CI: 0.04-0.46; p = 0.047). Besides this, mean miR-138.5p values were lower in those patients with NEDA-3 at 2 years (p = 0.033), and miR-146a.5p and miR-126.3p were higher in patients with CDP progression at 2 years (p = 0.044 and p = 0.05 respectively. These results reinforce the use of microRNAs as potential biomarkers in multiple sclerosis. We will need more studies to corroborate these data and to better understand the role of microRNAs in the pathophysiology of this disease.
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Affiliation(s)
- Ignacio Casanova
- Department of Neurology, Torrejon University Hospital, 28850 Madrid, Spain; (I.C.); (L.D.T.); (P.G.); (S.A.)
- School of Medicine, Universidad Francisco de Vitoria, 28223 Madrid, Spain
| | - María I. Domínguez-Mozo
- Research Group in Environmental Factors of Neurodegenerative Diseases, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (Á.G.-M.); (R.Á.-L.)
| | - Laura De Torres
- Department of Neurology, Torrejon University Hospital, 28850 Madrid, Spain; (I.C.); (L.D.T.); (P.G.); (S.A.)
| | | | - Ángel García-Martínez
- Research Group in Environmental Factors of Neurodegenerative Diseases, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (Á.G.-M.); (R.Á.-L.)
| | - Patricia Gómez
- Department of Neurology, Torrejon University Hospital, 28850 Madrid, Spain; (I.C.); (L.D.T.); (P.G.); (S.A.)
- School of Medicine, Universidad Francisco de Vitoria, 28223 Madrid, Spain
| | - Sara Abellán
- Department of Neurology, Torrejon University Hospital, 28850 Madrid, Spain; (I.C.); (L.D.T.); (P.G.); (S.A.)
| | - Esther De Antonio
- Department of Radiology, Torrejon University Hospital, 28850 Madrid, Spain;
| | - Roberto Álvarez-Lafuente
- Research Group in Environmental Factors of Neurodegenerative Diseases, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (Á.G.-M.); (R.Á.-L.)
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Windfeld-Mathiasen J, Horwitz H, Andersen JB, Framke E, Gade C, Andersen JT, Magyari M. Interferon-beta exposure in-utero and the risk of infections in early childhood. Mult Scler Relat Disord 2023; 77:104867. [PMID: 37423048 DOI: 10.1016/j.msard.2023.104867] [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: 05/02/2023] [Revised: 06/09/2023] [Accepted: 06/29/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Knowledge within the field of multiple sclerosis treatment during pregnancy is vital to ensure the most optimal clinical practice. Immunomodulatory treatment in pregnancy could in theory affect the normal development and maturation of the immune system of the fetus with a potential increased risk of infections, consequently. We therefore set out to investigate whether exposure to interferon-beta in utero affected the risk of acquiring infections in early childhood. METHODS This retrospective matched cohort study utilized data from the Danish Multiple Sclerosis Registry linked with national Danish registries to identify all children born of mothers with MS in Denmark from 1998 to 2018. The study included 510 children exposed to interferon-beta in utero. The children were matched 1:1 on various of demographic characteristics with children born to mothers with untreated MS and 1:3 with children born to mothers without MS. Each child was followed for up to five years. Using individual-level data, we investigated all-cause mortality, rate of hospital admissions due to infections, and redeemed prescriptions of antibiotics. The primary statistical model applied was a negative binomial regression analysis. RESULTS We found no differences in childhood mortality, for hospital admissions the rate ratio compared to healthy controls was 0.79 (0.62-1.00). Regarding antibiotic prescriptions, the results were similar (RR 1.00 (0.90-1.11). Furthermore, we found no certain dose-response relationship between interferon-beta exposure duration and hospital admission rate (P = 0.47) or redeemed antibiotic prescription (P = 0.71). CONCLUSION Exposure to interferon-beta during gestation has little to no impact on the risk of acquiring significant infections during the first five years of childhood.
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Affiliation(s)
- Josefine Windfeld-Mathiasen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, Copenhagen 2400, Denmark; Danish Multiple Sclerosis Registry, Department of Neurology, University Hospital-Rigshospitalet, Glostrup, Copenhagen, Denmark.
| | - Henrik Horwitz
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, Copenhagen 2400, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Johanna Balslev Andersen
- Danish Multiple Sclerosis Registry, Department of Neurology, University Hospital-Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Elisabeth Framke
- Danish Multiple Sclerosis Registry, Department of Neurology, University Hospital-Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Christina Gade
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, Copenhagen 2400, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Jon Trærup Andersen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, Copenhagen 2400, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Registry, Department of Neurology, University Hospital-Rigshospitalet, Glostrup, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
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Muzio L, Ghirelli A, Agosta F, Martino G. Novel therapeutic approaches for motor neuron disease. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:523-537. [PMID: 37620088 DOI: 10.1016/b978-0-323-98817-9.00027-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease that leads to the neurodegeneration and death of upper and lower motor neurons (MNs). Although MNs are the main cells involved in the process of neurodegeneration, a growing body of evidence points toward other cell types as concurrent to disease initiation and propagation. Given the current absence of effective therapies, the quest for other therapeutic targets remains open and still challenges the scientific community. Both neuronal and extra-neuronal mechanisms of cellular stress and damage have been studied and have posed the basis for the development of novel therapies that have been investigated on both animal models and humans. In this chapter, a thorough review of the main mechanisms of cellular damage and the respective therapeutic attempts targeting them is reported. The main areas covered include neuroinflammation, protein aggregation, RNA metabolism, and oxidative stress.
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Affiliation(s)
- Luca Muzio
- San Raffaele Scientific Institute, Division of Neuroscience, InsPE, Milan, Italy
| | - Alma Ghirelli
- San Raffaele Scientific Institute, Division of Neuroscience, InsPE, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Federica Agosta
- San Raffaele Scientific Institute, Division of Neuroscience, InsPE, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gianvito Martino
- San Raffaele Scientific Institute, Division of Neuroscience, InsPE, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Dominguez-Mozo MI, Casanova I, De Torres L, Aladro-Benito Y, Perez-Perez S, Garcia-Martínez A, Gomez P, Abellan S, De Antonio E, Lopez-De-Silanes C, Alvarez-Lafuente R. microRNA Expression and Its Association With Disability and Brain Atrophy in Multiple Sclerosis Patients Treated With Glatiramer Acetate. Front Immunol 2022; 13:904683. [PMID: 35774792 PMCID: PMC9239306 DOI: 10.3389/fimmu.2022.904683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMicroRNAs are small non-coding RNA that regulate gene expression at a post-transcriptional level affecting several cellular processes including inflammation, neurodegeneration and remyelination. Different patterns of miRNAs expression have been demonstrated in multiple sclerosis compared to controls, as well as in different courses of the disease. For these reason they have been postulated as promising biomarkers candidates in multiple sclerosis.Objectiveto correlate serum microRNAs profile expression with disability, cognitive functioning and brain volume in patients with remitting-relapsing multiple sclerosis.Methodscross-sectional study in relapsing-remitting multiple sclerosis patients treated with glatiramer acetate. Disability was measured with Expanded Disability Status Scale (EDSS) and cognitive function was studied with Symbol Digit Modalities Test (SDMT). Brain volume was analyzed with automatic software NeuroQuant®.ResultsWe found an association between miR.146a.5p (rs:0.434, p=0.03) and miR.9.5p (rs:0.516, p=0.028) with EDSS; and miR-146a.5p (rs:-0.476, p=0.016) and miR-126.3p (rs:-0.528, p=0.007) with SDMT. Regarding to the brain volume, miR.9.5p correlated with thalamus (rs:-0.545, p=0.036); miR.200c.3p with pallidum (rs:-0.68, p=0.002) and cerebellum (rs:-0.472, p=0.048); miR-138.5p with amygdala (rs:0.73, p=0.016) and pallidum (rs:0.64, p=0.048); and miR-223.3p with caudate (rs:0.46, p=0.04).ConclusionsThese data support the hypothesis of microRNA as potential biomarkers in this disease. More studies are needed to validate these results and to better understand the role of microRNAs in the pathogenesis, monitoring and therapeutic response of multiple sclerosis.
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Affiliation(s)
- María I Dominguez-Mozo
- Research Group in Environmental Factors of Neurodegenerative Diseases, Health Research Institute Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Ignacio Casanova
- Department of Neurology, Hospital Universitario de Torrejón, Madrid, Spain
- School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Laura De Torres
- Department of Neurology, Hospital Universitario de Torrejón, Madrid, Spain
| | | | - Silvia Perez-Perez
- Research Group in Environmental Factors of Neurodegenerative Diseases, Health Research Institute Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Angel Garcia-Martínez
- Research Group in Environmental Factors of Neurodegenerative Diseases, Health Research Institute Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Patricia Gomez
- Department of Neurology, Hospital Universitario de Torrejón, Madrid, Spain
- School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Sara Abellan
- Department of Neurology, Hospital Universitario de Torrejón, Madrid, Spain
| | - Esther De Antonio
- Department of Radiology, Hospital Universitario de Torrejón, Madrid, Spain
| | - Carlos Lopez-De-Silanes
- Department of Neurology, Hospital Universitario de Torrejón, Madrid, Spain
- School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Roberto Alvarez-Lafuente
- Research Group in Environmental Factors of Neurodegenerative Diseases, Health Research Institute Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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Abstract
PURPOSE OF REVIEW To provide the latest evidence and treatment advances of multiple sclerosis in women of childbearing age prior to conception, during pregnancy and postpartum. RECENT FINDINGS Recent changes permitting interferon beta (IFN-β) use in pregnancy and breastfeeding has broadened the choices of disease modifying treatments (DMTs) for patients with high relapse rates. Natalizumab may also be continued until 34 weeks of pregnancy for patients requiring persisting treatment. Drugs with a known potential of teratogenicity such as fingolimod or teriflunomide should be avoided and recommended wash-out times for medications such as cladribine, alemtuzumab or ocrelizumab should be considered. Teriflunomide and fingolimod are not recommended during breastfeeding, however, glatiramer acetate and IFN-β are considered to be safe. SUMMARY The evidence of potential fetotoxicities and adverse pregnancy outcomes associated with DMTs is increasing, although more research is needed to evaluate the safety of drugs and to track long-term health outcomes for the mother and the child.
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Affiliation(s)
- Guoda Varytė
- Clinic of Obstetrics and Gynaecology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Simone IL, Tortorella C, Ghirelli A. Influence of Pregnancy in Multiple Sclerosis and Impact of Disease-Modifying Therapies. Front Neurol 2021; 12:697974. [PMID: 34276545 PMCID: PMC8280312 DOI: 10.3389/fneur.2021.697974] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/26/2021] [Indexed: 01/25/2023] Open
Abstract
Purpose of this Review: This article is a systematic review on the influence pregnancy has on multiple sclerosis and the resulting impact of disease-modifying therapies. Findings: Multiple sclerosis predominantly affects young women with a clinical onset most often during the child-bearing age. The impact of multiple sclerosis and disease-modifying therapies on fertility, pregnancy, fetal outcome, and breastfeeding is a pivotal topic when it comes to clinical practice. The introduction of disease-modifying therapies has changed not only the natural history of the disease but also the perspective of pregnancy in women with multiple sclerosis. Family planning requires careful consideration, especially because many disease-modifying drugs are contraindicated during pregnancy. In this article, we review current evidence collected from published literature and drug-specific pregnancy registers on the use of disease-modifying therapies. Additionally, we discuss safety profiles for each drug and correlate them to both risk for the exposed fetus and risk for the mothers interrupting treatments when seeking pregnancy.
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Affiliation(s)
- Isabella Laura Simone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Alma Ghirelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
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Song Z, Khaw YM, Pacheco LA, Tseng KY, Tan Z, Cai K, Ponnusamy E, Cheng J, Inoue M. Induction of a higher-ordered architecture in glatiramer acetate improves its biological efficiency in an animal model of multiple sclerosis. Biomater Sci 2020; 8:5271-5281. [PMID: 32744547 DOI: 10.1039/d0bm00957a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Glatiramer acetate (GA), a linear random copolypeptide, is a first-line treatment for multiple sclerosis (MS). A major concern, however, is that GA treatment is associated with adverse effects and poor patient adherence due to the need for frequent injections. Here we describe improved performance of the polymeric drug, even at low doses with less-frequent injections, through the modification of its architecture into a star-shaped GA (sGA). In a sGA, multiple GAs are covalently linked onto a core, which greatly changes their properties such as molecular weight, size, and shape. The spherical sGA is retained longer in the body after intraperitoneal injection, and is more readily internalized by RAW 264.7 macrophage cells and bone marrow-derived dendritic cells than GA. In C57BL/6 mice induced with experimental autoimmune encephalitis, a mouse model for MS, sGA treatment exerts disease amelioration effect that is significantly better than that of GA despite a lower dose and less frequent injection. Moreover, spinal cord pathologies of demyelination and leukocyte infiltration are dramatically less pronounced in the sGA treatment condition compared to the GA treatment condition. Thus, we propose that sGA with a higher-ordered architecture offers an attractive and potentially viable treatment option for MS patients.
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Affiliation(s)
- Ziyuan Song
- Department of Comparative Biosciences, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA. and Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA.
| | - Yee Ming Khaw
- Department of Comparative Biosciences, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA. and University of Illinois at Urbana-Champaign, Neuroscience Program, 405 North Matthews Avenue, Urbana, Illinois 61801, USA
| | - Lazaro A Pacheco
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA.
| | - Kuan-Ying Tseng
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA.
| | - Zhengzhong Tan
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA.
| | - Kaimin Cai
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA.
| | | | - Jianjun Cheng
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA.
| | - Makoto Inoue
- Department of Comparative Biosciences, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA. and University of Illinois at Urbana-Champaign, Neuroscience Program, 405 North Matthews Avenue, Urbana, Illinois 61801, USA
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Andersen JB, Magyari M. Pharmacotherapeutic considerations in women with multiple sclerosis. Expert Opin Pharmacother 2020; 21:1591-1602. [PMID: 32521172 DOI: 10.1080/14656566.2020.1774554] [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: 01/01/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronically progressive disease of the central nervous system. The relapsing form of the disease predominantly affects women with onset between the ages 20 to 40 years. Therefore, timing, choice, and treatment options should take pregnancy planning into consideration to accommodate both the needs and safety of the mother and health of the fetus. AREAS COVERED In this review, the authors discuss and summarize the recent evidence of different pharmacotherapeutic possibilities in the treatment of women with MS. EXPERT OPINION There is evidence that disease modifying therapy reduces the risk of relapses and diminishes disability progression in people with relapsing MS. The disease is often diagnosed in the childbearing years, and thus pregnancy planning can possibly be a part of the pharmacotherapeutic considerations. The management of women planning pregnancy requires a balancing of risks. The clinician must consider the risks related to treatment discontinuation versus the risk of exposing the developing fetus to drugs that are potential fetotoxic. Randomized controlled trials of medication safety - if used during pregnancy, are prohibited for ethical reasons; hence, the evidence is continuously gathered from observational data, post-authorization studies and pregnancy registries.
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Affiliation(s)
- Johanna B Andersen
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark.,Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark
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Ciplea AI, Langer-Gould A, Stahl A, Thiel S, Queisser-Wahrendorf A, Gold R, Hellwig K. Safety of potential breast milk exposure to IFN-β or glatiramer acetate: One-year infant outcomes. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/4/e757. [PMID: 32434802 PMCID: PMC7251509 DOI: 10.1212/nxi.0000000000000757] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/19/2020] [Indexed: 01/05/2023]
Abstract
Objective To determine whether potential breast milk exposure to interferon-beta (IFN-β) or glatiramer acetate (GA) is safe for the infant. Methods We identified 74 infants born to 69 women with MS who breastfed under IFN-β (n = 39), GA (n = 34), or both (n = 1). Women had been enrolled into the German Multiple Sclerosis and Pregnancy Registry during pregnancy. Data were obtained from standardized, telephone-administered questionnaires completed by the mother during pregnancy and at 1, 3, 6, and 12 months postpartum and the infant's take-home medical record. Results The median duration of exposed breastfeeding was 8.5 months (wide interquartile range: 4.9–12.7 months). Physical growth curves during the first year of life were consistent with national, sex-specific growth curves. Median body measurements were consistent with national medians. Most children (n = 71, 96%) had normal motor and language development. Gross motor delay was reported in 3 children, of whom 1 remained delayed at last follow-up (3.9 years old) and 2 were normal by 0.9 and 4.1 years old. The proportion of children hospitalized at least once (girls n = 2, 7%, and boys n = 6, 14%) and the proportion of children with at least one episode of systemic antibiotic use during the first year of life (girls n = 7, 23%, and boys n = 8, 18%) are consistent with national averages. Conclusion Potential breast milk exposure to IFN-β or GA did not increase the risk of common adverse infant outcomes in the first year of life. Taken together with the benefits of breastfeeding and low biological plausibility of risk, women with MS who wish to resume IFN-β or GA postpartum can be encouraged to breastfeed.
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Affiliation(s)
- Andrea Ines Ciplea
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Annette Langer-Gould
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Anna Stahl
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Sandra Thiel
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Annette Queisser-Wahrendorf
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Ralf Gold
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Kerstin Hellwig
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany.
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Canibaño B, Deleu D, Mesraoua B, Melikyan G, Ibrahim F, Hanssens Y. Pregnancy-related issues in women with multiple sclerosis: an evidence-based review with practical recommendations. J Drug Assess 2020; 9:20-36. [PMID: 32128285 PMCID: PMC7034025 DOI: 10.1080/21556660.2020.1721507] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 01/21/2020] [Indexed: 12/18/2022] Open
Abstract
Objective: To review the current evidence regarding pregnancy-related issues in multiple sclerosis (MS) and to provide recommendations specific for each of them. Research design and methods: A systematic review was performed based on a comprehensive literature search. Results: MS has no effect on fertility, pregnancy or fetal outcomes, and pregnancies do not affect the long-term disease course and accumulation of disability. There is a potential risk for relapse after use of gonadotropin-releasing hormone agonists during assisted reproduction techniques. At short-term, pregnancy leads to a reduction of relapses during the third trimester, followed by an increased risk of relapses during the first three months postpartum. Pregnancies in MS are not per se high risk pregnancies, and MS does not influence the mode of delivery or anesthesia unless in the presence of significant disability. MRI is not contraindicated during pregnancy; however, gadolinium contrast media should be avoided whenever possible. It is safe to use pulse dose methylprednisolone infusions to manage acute disabling relapses during pregnancy and breastfeeding. However, its use during the first trimester of pregnancy is still controversial. Women with MS should be encouraged to breastfeed with a possible favorable effect of exclusive breastfeeding. Disease-modifying drugs can be classified according to their potential for pregnancy-associated risk and impact on fetal outcome. Interferon beta (IFNβ) and glatiramer acetate (GA) may be continued until pregnancy is confirmed and, after consideration of the individual risk-benefit if continued, during pregnancy. The benefit of continuing natalizumab during the entire pregnancy may outweigh the risk of recurring disease activity, particularly in women with highly active MS. GA and IFNβ are considered safe during breastfeeding. The use of natalizumab during pregnancy or lactation requires monitoring of the newborn. Conclusions: This review provides current evidence and recommendations for counseling and management of women with MS preconception, during pregnancy and postpartum.
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Affiliation(s)
- Beatriz Canibaño
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Dirk Deleu
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Boulenouar Mesraoua
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Gayane Melikyan
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Faiza Ibrahim
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Yolande Hanssens
- Clinical Services Unit, Pharmacy, Hamad Medical Corporation, Doha, Qatar
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12
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Burkill S, Vattulainen P, Geissbuehler Y, Sabido Espin M, Popescu C, Suzart-Woischnik K, Hillert J, Artama M, Verkkoniemi-Ahola A, Myhr KM, Cnattingius S, Korhonen P, Montgomery S, Bahmanyar S. The association between exposure to interferon-beta during pregnancy and birth measurements in offspring of women with multiple sclerosis. PLoS One 2019; 14:e0227120. [PMID: 31887199 PMCID: PMC6936848 DOI: 10.1371/journal.pone.0227120] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/11/2019] [Indexed: 01/12/2023] Open
Abstract
Background Interferon-beta (IFN-beta) is a commonly used treatment for multiple sclerosis (MS). Current guidelines recommend cessation of treatment during pregnancy, however the results of past studies on the safety of prenatal exposure to IFN-beta have been conflicting. A large scale study of a population of MS women is therefore warranted. Objectives To assess whether, among those born to women with MS, infants prenatally exposed to IFN-beta show evidence of smaller size at birth relative to infants which were not prenatally exposed to any MS disease modifying drugs. Methods Swedish and Finnish register data was used. Births to women with MS in Sweden and Finland between 2005–2014 for which a birth measurement for weight, height, and head circumference was available were included. The exposure window was from 6 months prior to LMP to the end of pregnancy. Results In Sweden, 411 pregnancies were identified as exposed to IFN-beta during the exposure window, and 835 pregnancies were counted as unexposed to any MS DMD. The corresponding numbers for Finland were 232 and 331 respectively. Infants prenatally exposed to interferon-beta were on average 28 grams heavier (p = 0.17), 0.01 cm longer (p = 0.95), and had head circumferences 0.14 cm larger (p = 0.13) in Sweden. In Finland, infants were 50 grams lighter (p = 0.27), 0.02 cm shorter (p = 0.92) and had head circumferences 0.22 cm smaller (p = 0.15) relative to those unexposed. Conclusions This study provides evidence that exposure to IFN-beta during pregnancy does not influence birth weight, length, or head circumference.
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Affiliation(s)
- Sarah Burkill
- Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | | | | | | | | | | | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Miia Artama
- National Institute for Health and Welfare, Helsinki, Finland
| | | | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Sven Cnattingius
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | | | - Scott Montgomery
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology and Biostatistics School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Shahram Bahmanyar
- Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Rommer PS, Milo R, Han MH, Satyanarayan S, Sellner J, Hauer L, Illes Z, Warnke C, Laurent S, Weber MS, Zhang Y, Stuve O. Immunological Aspects of Approved MS Therapeutics. Front Immunol 2019; 10:1564. [PMID: 31354720 PMCID: PMC6637731 DOI: 10.3389/fimmu.2019.01564] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 06/24/2019] [Indexed: 12/21/2022] Open
Abstract
Multiple sclerosis (MS) is the most common neurological immune-mediated disease leading to disability in young adults. The outcome of the disease is unpredictable, and over time, neurological disabilities accumulate. Interferon beta-1b was the first drug to be approved in the 1990s for relapsing-remitting MS to modulate the course of the disease. Over the past two decades, the treatment landscape has changed tremendously. Currently, more than a dozen drugs representing 1 substances with different mechanisms of action have been approved (interferon beta preparations, glatiramer acetate, fingolimod, siponimod, mitoxantrone, teriflunomide, dimethyl fumarate, cladribine, alemtuzumab, ocrelizumab, and natalizumab). Ocrelizumab was the first medication to be approved for primary progressive MS. The objective of this review is to present the modes of action of these drugs and their effects on the immunopathogenesis of MS. Each agent's clinical development and potential side effects are discussed.
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Affiliation(s)
- Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ron Milo
- Department of Neurology, Barzilai University Medical Center, Ashkelon, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - May H. Han
- Neuroimmunology Division, Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, United States
| | - Sammita Satyanarayan
- Neuroimmunology Division, Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, United States
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität, Munich, Germany
| | - Larissa Hauer
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University of Köln, Cologne, Germany
| | - Sarah Laurent
- Department of Neurology, Medical Faculty, University of Köln, Cologne, Germany
| | - Martin S. Weber
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Yinan Zhang
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Olaf Stuve
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität, Munich, Germany
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Neurology Section, VA North Texas Health Care System, Medical Service Dallas, VA Medical Center, Dallas, TX, United States
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14
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Zettl UK, Hecker M, Aktas O, Wagner T, Rommer PS. Interferon β-1a and β-1b for patients with multiple sclerosis: updates to current knowledge. Expert Rev Clin Immunol 2018; 14:137-153. [DOI: 10.1080/1744666x.2018.1426462] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Uwe Klaus Zettl
- Department of Neurology, Neuroimmunology Section, University of Rostock, Rostock, Germany
| | - Michael Hecker
- Department of Neurology, Neuroimmunology Section, University of Rostock, Rostock, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Torsten Wagner
- Department of Medical Affairs, Merck KGaA, Darmstadt, Germany
| | - Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Thöne J, Thiel S, Gold R, Hellwig K. Treatment of multiple sclerosis during pregnancy - safety considerations. Expert Opin Drug Saf 2017; 16:523-534. [PMID: 28333552 DOI: 10.1080/14740338.2017.1311321] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Women with multiple sclerosis (MS) are treated early in the disease course with disease modifying therapies (DMT). Updated information is needed on pregnancy outcomes of DMT-exposed pregnancies and the effect of the drug withdrawal on MS disease activity. Areas covered: In this review, we will cover the most important updated management strategies in planning a pregnancy when having MS. Expert opinion: MS itself does not increase the risk of adverse pregnancy outcomes and does not negatively influence the long-term course of the disease. As MS became a treatable disease, management of DMTs before, during and after pregnancy is important. This requires updated knowledge on safety of DMTs as well as data of the effect on disease activity after drug withdrawal. A special challenge is the handling of women with highly active MS, as pregnancy might not be powerful enough to suppress the risk of rebound relapses. Exclusive breastfeeding is an option for many women who want to do so, but in cases of high disease activity and those women who do not want to breastfeed, early reintroduction of MS therapies should be considered.
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Affiliation(s)
- Jan Thöne
- a Department of Neurology , University Hospital Essen , Essen , Germany
| | - Sandra Thiel
- b Department of Neurology, St. Josef-Hospital , Ruhr-University Bochum , Bochum , Germany
| | - Ralf Gold
- b Department of Neurology, St. Josef-Hospital , Ruhr-University Bochum , Bochum , Germany
| | - Kerstin Hellwig
- b Department of Neurology, St. Josef-Hospital , Ruhr-University Bochum , Bochum , Germany
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16
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Thiel S, Langer-Gould A, Rockhoff M, Haghikia A, Queisser-Wahrendorf A, Gold R, Hellwig K. Interferon-beta exposure during first trimester is safe in women with multiple sclerosis-A prospective cohort study from the German Multiple Sclerosis and Pregnancy Registry. Mult Scler 2016; 22:801-9. [PMID: 26920382 DOI: 10.1177/1352458516634872] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 01/31/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Available data suggest that pregnancy exposure to interferon-beta might result in lower mean birth weight and preterm birth. OBJECTIVE To determine the effect of interferon-beta exposure during pregnancy on pregnancy outcomes in multiple sclerosis patients. METHODS We compared the pregnancy outcomes of women exposed to interferon-beta with pregnancies unexposed to disease-modifying therapies. Women were enrolled into the German Multiple Sclerosis and Pregnancy Registry. A standardized questionnaire was administered during pregnancy and postpartum. Detailed information on course of multiple sclerosis and pregnancy, concomitant medications, delivery, and outcome of pregnancy was obtained. RESULTS We collected data on 251 pregnancies exposed to interferon-beta and 194 unexposed to disease-modifying therapies. In all, 246 (98.01%) women discontinued interferon-beta treatment during first trimester. No differences regarding mean birth weight (exposed: 3272.28 ± 563.61 g; unexposed: 3267.46 ± 609.81 g), mean birth length (exposed: 50.73 ± 3.30 cm; unexposed: 50.88 ± 3.45 cm), preterm birth (p = 0.187), spontaneous abortion (p = 0.304), and congenital anomalies (p = 0.197) were observed between the two groups. CONCLUSIONS Interferon-beta exposure during early pregnancy does not influence the mean birth weight, risk of preterm birth, or other adverse pregnancy outcomes. Our study provides further reassurance that interferon-beta treatment can be safely continued up until women become pregnant.
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Affiliation(s)
- Sandra Thiel
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany/Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | - Milena Rockhoff
- Department of Neurology, St. Josef Hospital, Ruhr University, Bochum, Bochum, Germany
| | - Aiden Haghikia
- Department of Neurology, St. Josef Hospital, Ruhr University, Bochum, Bochum, Germany
| | | | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr University, Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University, Bochum, Bochum, Germany
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17
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Almas S, Vance J, Baker T, Hale T. Management of Multiple Sclerosis in the Breastfeeding Mother. Mult Scler Int 2016; 2016:6527458. [PMID: 26966579 PMCID: PMC4757692 DOI: 10.1155/2016/6527458] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/30/2015] [Accepted: 12/31/2015] [Indexed: 12/12/2022] Open
Abstract
Multiple Sclerosis (MS) is an autoimmune neurological disease characterized by inflammation of the brain and spinal cord. Relapsing-Remitting MS is characterized by acute attacks followed by remission. Treatment is aimed at halting these attacks; therapy may last for months to years. Because MS disproportionately affects females and commonly begins during the childbearing years, clinicians treat pregnant or nursing MS patients. The intent of this review is to perform an in-depth analysis into the safety of drugs used in breastfeeding women with MS. This paper is composed of several drugs used in the treatment of MS and current research regarding their safety in breastfeeding including immunomodulators, immunosuppressants, monoclonal antibodies, corticosteroids, and drugs used for symptomatic treatment. Typically, some medications are large polar molecules which often do not pass into the milk in clinically relevant amounts. For this reason, interferon beta is likely safe for the infant when given to a breastfeeding mother. However, other drugs with particularly dangerous side effects may not be recommended. While treatment options are available and some data from clinical studies does exist, there continues to be a need for investigation and ongoing review of the medications used in breastfeeding mothers.
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Affiliation(s)
- Saneea Almas
- Department of Pediatrics, School of Medicine, Texas Tech University Health Sciences Center, 1400 Wallace Boulevard, Amarillo, TX 79106, USA
| | - Jesse Vance
- Infant Risk Center, Texas Tech University Health Sciences Center, 1400 Wallace Boulevard, Amarillo, TX 79106, USA
| | - Teresa Baker
- Department of Obstetrics & Gynecology, School of Medicine, Texas Tech University Health Sciences Center, 1400 Coulter Street, Amarillo, TX 79106, USA
| | - Thomas Hale
- Department of Pediatrics, School of Medicine, Texas Tech University Health Sciences Center, 1400 Wallace Boulevard, Amarillo, TX 79106, USA
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18
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Herbstritt S, Langer-Gould A, Rockhoff M, Haghikia A, Queisser-Wahrendorf A, Gold R, Hellwig K. Glatiramer acetate during early pregnancy: A prospective cohort study. Mult Scler 2016; 22:810-6. [PMID: 26754804 DOI: 10.1177/1352458515623366] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/29/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Only limited data are available on whether glatiramer acetate exposure during pregnancy has an effect on perinatal outcome. OBJECTIVE To determine the effect of glatiramer acetate exposure during pregnancy on pregnancy outcomes in women with multiple sclerosis. METHODS We compared the outcome of pregnancies of women with multiple sclerosis exposed to glatiramer acetate with pregnancies unexposed to disease-modifying therapies. Women were enrolled into the German Multiple Sclerosis and Pregnancy registry. A standardized questionnaire was administered during pregnancy and postpartum. Detailed information on course of multiple sclerosis and pregnancy, concomitant medications, labor, delivery, and outcome of pregnancy was obtained. RESULTS We collected data on 246 multiple sclerosis pregnancies, 151 exposed to glatiramer acetate and 95 unexposed to disease-modifying therapies during pregnancy. Three (2.2%) congenital anomalies occurred in the exposed and 6 (6.7%) in the control group. We did not observe an increase in other adverse pregnancy or delivery outcomes including spontaneous abortions, preterm birth, Cesarean sections, or reduced birth weight in the exposed group. CONCLUSION Our data provide further evidence that glatiramer acetate exposure during the first trimester of pregnancy appears safe and without teratogenic effect. These findings provide important additive knowledge to better counsel women with multiple sclerosis in planning a pregnancy.
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Affiliation(s)
- Sandra Herbstritt
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany/Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich Heine University, Duesseldorf, Germany
| | | | - Milena Rockhoff
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Aiden Haghikia
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | | | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
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Hegen H, Auer M, Deisenhammer F. Pharmacokinetic considerations in the treatment of multiple sclerosis with interferon-β. Expert Opin Drug Metab Toxicol 2015; 11:1803-19. [PMID: 26419922 DOI: 10.1517/17425255.2015.1094055] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Interferon-β (IFNβ) is well established as a disease-modifying treatment for patients with multiple sclerosis. Several preparations of the biopharmaceutical are available differing in protein structure, formulation, dose as well as frequency and route of administration. Recently, a pegylated form of IFNβ has been marketed. AREAS COVERED Following a PubMed database search, we provide an overview of what is presently known about the pharmacokinetics (PK) of IFNβ including its absorption, distribution, metabolism and elimination. Also, we discuss the association with clinically relevant issues such as treatment efficacy, adverse events and anti-drug antibodies. EXPERT OPINION IFNβ has a bioavailability of ∼ 30% after subcutaneous or intramuscular administration, shows peak serum concentrations within several hours, has a half-life of < 1 day and is eliminated by a renal and hepatic pathway. PK parameters do not substantially differ between the types of IFNβ and routes of administration; only pegylation of IFNβ results in substantially increased and prolonged PK. Although no clinical dose-effect relationship could be established, there is an association of IFNβ dose with magnetic resonance imaging outcome parameters. Furthermore, there is an association of IFNβ serum levels with the occurrence of adverse events and anti-drug antibodies.
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Affiliation(s)
- Harald Hegen
- a 1 Innsbruck Medical University, Department of Neurology , Innsbruck, Austria
| | - Michael Auer
- a 1 Innsbruck Medical University, Department of Neurology , Innsbruck, Austria
| | - Florian Deisenhammer
- b 2 Innsbruck Medical University, Department of Neurology, Neuroimmunology Laboratory , Innsbruck, Austria +43 5 12 50 42 42 64 ; +43 5 12 50 42 42 66 ;
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20
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Affiliation(s)
- Hans-Peter Hartung
- Department of Neurology, Heinrich-Heine-University, D-40225 Düsseldorf, Germany.
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21
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Cocco E, Marrosu MG. The current role of mitoxantrone in the treatment of multiple sclerosis. Expert Rev Neurother 2014; 14:607-16. [PMID: 24834466 DOI: 10.1586/14737175.2014.915742] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Mitoxantrone is an immunosuppressive drug approved for aggressive relapsing and progressive multiple sclerosis. In recent years, its use has decreased due to the risk of severe adverse events and the introduction of novel therapies, such as natalizumab or fingolimod. Mitoxantrone is effective in reducing inflammatory activity by decreasing the number of relapses and MRI lesions and simultaneously decreasing the worsening of disability. Apart from its role as a second/third-line therapy, some studies suggest its use as an induction therapy. However, mitoxantrone use is limited because of its potential risk of severe adverse events, such as cardiotoxicity and the induction of therapy-related acute leukemia. Genetic markers are on evaluation to predict side effects and therapeutic efficacy, which is consistent with the direction of personalized treatment. Considering its efficacy and the potential risks, mitoxantrone use is limited to active patients after a careful, individualized evaluation of the risk/benefit balance.
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Affiliation(s)
- Eleonora Cocco
- Multiple Sclerosis Center, Department of Public Health, Clinical and molecular medicine, University of Cagliari, Cagliari, Italy
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Harari D, Abramovich R, Zozulya A, Smith P, Pouly S, Köster M, Hauser H, Schreiber G. Bridging the species divide: transgenic mice humanized for type-I interferon response. PLoS One 2014; 9:e84259. [PMID: 24416207 PMCID: PMC3887009 DOI: 10.1371/journal.pone.0084259] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/12/2013] [Indexed: 01/23/2023] Open
Abstract
We have generated transgenic mice that harbor humanized type I interferon receptors (IFNARs) enabling the study of type I human interferons (Hu-IFN-Is) in mice. These “HyBNAR” (Hybrid IFNAR) mice encode transgenic variants of IFNAR1 and IFNAR2 with the human extracellular domains being fused to transmembrane and cytoplasmic segments of mouse sequence. B16F1 mouse melanoma cells harboring the HyBNAR construct specifically bound Hu-IFN-Is and were rendered sensitive to Hu-IFN-I stimulated anti-proliferation, STAT1 activation and activation of a prototypical IFN-I response gene (MX2). HyBNAR mice were crossed with a transgenic strain expressing the luciferase reporter gene under the control of the IFN-responsive MX2 promoter (MX2-Luciferase). Both the HyBNAR and HyBNAR/MX2-Luciferase mice were responsive to all Hu-IFN-Is tested, inclusive of IFNα2A, IFNβ, and a human superagonist termed YNSα8. The mice displayed dose-dependent pharmacodynamic responses to Hu-IFN-I injection, as assessed by measuring the expression of IFN-responsive genes. Our studies also demonstrated a weak activation of endogenous mouse interferon response, especially after high dose administration of Hu-IFNs. In sharp contrast to data published for humans, our pharmacodynamic readouts demonstrate a very short-lived IFN-I response in mice, which is not enhanced by sub-cutaneous (SC) injections in comparison to other administration routes. With algometric differences between humans and mice taken into account, the HyBNAR mice provides a convenient non-primate pre-clinical model to advance the study of human IFN-Is.
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Affiliation(s)
- Daniel Harari
- Department of Biological Chemistry, The Weizmann Institute of Science, Rehovot, Israel
- * E-mail: daniel@ (DH); (GS)
| | - Renne Abramovich
- Department of Biological Chemistry, The Weizmann Institute of Science, Rehovot, Israel
| | - Alla Zozulya
- MS Platform, Merck-Serono, (a division of Merck KGaA), Geneva, Switzerland
| | - Paul Smith
- MS Platform, Merck-Serono, (a division of Merck KGaA), Geneva, Switzerland
| | - Sandrine Pouly
- MS Platform, Merck-Serono, (a division of Merck KGaA), Geneva, Switzerland
| | - Mario Köster
- Helmholtz Centre for Infection Research, Dept. Gene Regulation and Differentiation, Braunschweig, Germany
| | - Hansjörg Hauser
- Helmholtz Centre for Infection Research, Dept. Gene Regulation and Differentiation, Braunschweig, Germany
| | - Gideon Schreiber
- Department of Biological Chemistry, The Weizmann Institute of Science, Rehovot, Israel
- * E-mail: daniel@ (DH); (GS)
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Lu E, Wang BW, Guimond C, Synnes A, Sadovnick AD, Dahlgren L, Traboulsee A, Tremlett H. Safety of disease-modifying drugs for multiple sclerosis in pregnancy: current challenges and future considerations for effective pharmacovigilance. Expert Rev Neurother 2013; 13:251-60; quiz 261. [PMID: 23448215 DOI: 10.1586/ern.13.12] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
When contemplating a pregnancy, women treated for multiple sclerosis (MS) with a disease-modifying drug must decide to discontinue their medication before conception or risk exposing their unborn child to potential drug toxicity. Few studies exist as reference for patients and physicians, and of those available, the majority are less than ideal due to real-world constraints, ethical issues and methodological shortcomings. The authors provide a brief summary of existing animal and human data with current recommendations regarding the safety of IFN-β, glatiramer acetate, natalizumab, mitoxantrone, fingolimod and teriflunomide during pregnancy and lactation in women with MS. We also assess the quality, strengths and limitations of the existing studies including challenges with study design. The investigation of outcomes such as spontaneous abortion and congenital anomalies are highlighted with potential methodological improvements for future studies on drug safety in pregnancy suggested. The authors explore the pharmacokinetics and pharmacodynamics of the MS disease-modifying drugs for their possible mechanistic role in fetal harm and discuss the potential role of clinical trials. Future pharmacovigilance studies should continue to pursue multicenter collaboration with an emphasis on appropriate study design.
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Affiliation(s)
- Ellen Lu
- Department of Medicine, Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Hartung HP, Haas J, Meergans M, Tracik F, Ortler S. [Interferon-β1b in multiple sclerosis therapy: more than 20 years clinical experience]. DER NERVENARZT 2013; 84:679-704. [PMID: 23669866 DOI: 10.1007/s00115-013-3781-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The introduction of interferon-β1b in 1993 in the USA and 2 years later in Europe made it possible for the first time to alter the course of the disease in patients with relapsing-remitting multiple sclerosis (MS). Subsequently, interferon-β1b was approved for the treatment of patients with active secondary progressive MS (1999) and early relapsing-remitting MS following a first demyelinating event (clinically isolated syndrome, CIS) (2006). Here we provide an overview of the clinical experience gathered during more than 20 years of interferon-β use focusing on long-term efficacy and safety and the impact of early initiation of treatment. Furthermore, the following aspects will be discussed: putative mechanisms of action of interferon-β, indications for a disease-modifying therapy, clinical relevance of neutralizing antibodies, importance of adherence in MS therapy, high versus low frequency therapy, combination therapies with interferon-β and safety of interferon-β in children and adolescents with MS and during pregnancy.
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Affiliation(s)
- H-P Hartung
- Neurologische Klinik im UKD, Medizinische Fakultät, Heinrich-Heine Universität, Moorenstr. 5, 40225 Düsseldorf, Deutschland.
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Hu X, Miller L, Richman S, Hitchman S, Glick G, Liu S, Zhu Y, Crossman M, Nestorov I, Gronke RS, Baker DP, Rogge M, Subramanyam M, Davar G. A Novel PEGylated Interferon Beta-1a for Multiple Sclerosis: Safety, Pharmacology, and Biology. J Clin Pharmacol 2013; 52:798-808. [DOI: 10.1177/0091270011407068] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Glatiramer acetate triggers PI3Kδ/Akt and MEK/ERK pathways to induce IL-1 receptor antagonist in human monocytes. Proc Natl Acad Sci U S A 2010; 107:17692-7. [PMID: 20876102 DOI: 10.1073/pnas.1009443107] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Glatiramer acetate (GA), an immunomodulator used in multiple sclerosis (MS) therapy, induces the production of secreted IL-1 receptor antagonist (sIL-1Ra), a natural inhibitor of IL-1β, in human monocytes, and in turn enhances sIL-1Ra circulating levels in MS patients. GA is a mixture of peptides with random Glu, Lys, Ala, and Tyr sequences of high polarity and hydrophilic nature that is unlikely to cross the blood-brain barrier. In contrast, sIL-1Ra crosses the blood-brain barrier and, in turn, may mediate GA anti-inflammatory activities within the CNS by counteracting IL-1β activities. Here we identify intracellular signaling pathways induced by GA that control sIL-1Ra expression in human monocytes. By using kinase knockdown and specific inhibitors, we demonstrate that GA induces sIL-1Ra production via the activation of PI3Kδ, Akt, MEK1/2, and ERK1/2, demonstrating that both PI3Kδ/Akt and MEK/ERK pathways rule sIL-1Ra expression in human monocytes. The pathways act in parallel upstream glycogen synthase kinase-3α/β (GSK3α/β), the knockdown of which enhances sIL-1Ra production. Together, our findings demonstrate the existence of signal transduction triggered by GA, further highlighting the mechanisms of action of this drug in MS.
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Niino M, Hirotani M, Miyazaki Y, Sasaki H. Memory and naïve B-cell subsets in patients with multiple sclerosis. Neurosci Lett 2009; 464:74-8. [PMID: 19666086 DOI: 10.1016/j.neulet.2009.08.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 07/28/2009] [Accepted: 08/03/2009] [Indexed: 10/20/2022]
Abstract
Memory and naïve B cells are considered to play distinct roles in immune regulation. However, the roles of memory and naïve B-cell subsets in multiple sclerosis (MS) have not yet been elucidated. In this study, we examined whether memory and naïve B-cell subsets differ between patients with MS and healthy subjects and whether interferon beta (IFNbeta)-1b can affect these subsets in patients with MS. We also studied these subsets in relapsing and remitting stages of MS. Subjects included 31 patients with relapsing-remitting MS in the remitting stage, of which 15 were treated with IFNbeta-1b and 16 were not treated, and 22 healthy control subjects. For 11 of the 16 untreated patients, blood samples were also obtained in the relapsing stage. Expression of CD5, CD80, CD86, CCR5, CXCR3, CD11a, and CD49d in memory and naïve B cells in blood samples was examined by flow cytometry. The percentages of CD86(+) cells and CCR5(+) cells in the naïve B-cell subset were significantly higher in untreated patients than in control subjects or IFNbeta-treated patients. In patients with MS, the percentages of CD86(+) cells and CCR5(+) cells in the naïve B-cell subset and the percentage of CD5(+) cells in the memory B-cell subset were significantly greater in the remitting stage than in the relapsing stage. These results indicate that memory and naïve B-cell subsets, especially CD86(+) naïve B cells, CCR5(+) naïve B cells, and CD5(+) memory B cells, might be useful in the study of the pathogenesis of and therapy for MS.
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Affiliation(s)
- Masaaki Niino
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
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Hartung HP. High-dose, high-frequency recombinant interferon beta-1a in the treatment of multiple sclerosis. Expert Opin Pharmacother 2009; 10:291-309. [PMID: 19236200 DOI: 10.1517/14656560802677882] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is at present no cure for multiple sclerosis (MS), and existing therapies are designed primarily to prevent lesion formation, decrease the rate and severity of relapses and delay the resulting disability by reducing levels of inflammation. OBJECTIVE The aim of this review was to assess the treatment of relapsing MS with particular focus on subcutaneous (s.c.) interferon (IFN) beta-1a. METHOD The literature on IFN beta-1a therapy of MS was reviewed based on a PubMed search (English-language publications from 1990) including its pharmacodynamics and pharmacokinetics, clinical efficacy in relapsing MS as shown in placebo-controlled studies and in comparative trials, efficacy in secondary progressive MS, safety and tolerability, and the impact of neutralizing antibodies. CONCLUSION The literature suggests that high-dose, high-frequency s.c. IFN beta-1a offers an effective option for treating patients with relapsing MS, with proven long-term safety and tolerability, and has a favourable benefit-to-risk ratio compared with other forms of IFN beta.
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Affiliation(s)
- Hans-Peter Hartung
- Heinrich-Heine-University, Department of Neurology, Moorenstreet 5, D-40225 Düsseldorf, Germany.
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Weinstock-Guttman B, Ramanathan M, Zivadinov R. Interferon-beta treatment for relapsing multiple sclerosis. Expert Opin Biol Ther 2008; 8:1435-47. [PMID: 18694361 DOI: 10.1517/14712598.8.9.1435] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recombinant forms of IFN-beta were the first therapeutic intervention found to be effective at interfering with the course of multiple sclerosis (MS), a chronic and debilitating disease affecting the CNS in young adults. OBJECTIVE/METHODS To examine the application of IFN-beta to MS treatment by a review of relevant literature. RESULTS The different IFN-beta products available are similar in their clinical effects. However, the response to IFN-beta therapy is only partial and the most efficient individual-specific dose, route and frequency of administration are not elucidated fully. The mechanism of action of IFN-beta in MS is also not understood fully but its immunomodulatory effects are probably more important than its anti-proliferative and antiviral activities. CONCLUSIONS Although new therapeutic approaches are being sought to better treat MS, IFN-beta remains one of the most recognized and approved worldwide therapeutic options for this disease.
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Affiliation(s)
- Bianca Weinstock-Guttman
- The Jacobs Neurological Institute, Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
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