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Mariottini A, Nozzoli C, Carli I, Landi F, Gigli V, Repice AM, Ipponi A, Cecchi M, Boncompagni R, Saccardi R, Massacesi L. Cost and effectiveness of autologous haematopoietic stem cell transplantation and high-efficacy disease-modifying therapies in relapsing-remitting multiple sclerosis. Neurol Sci 2024; 45:3379-3387. [PMID: 38277051 PMCID: PMC11176212 DOI: 10.1007/s10072-024-07308-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/04/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Autologous haematopoietic stem cell transplantation (AHSCT) is a highly effective one-off treatment for relapsing-remitting multiple sclerosis (RR-MS), potentially representing an optimal front-loading strategy for costs. OBJECTIVE Exploring cost/effectiveness of AHSCT and high-efficacy disease-modifying treatments (HE-DMTs) in RR-MS, estimating costs at our centre in Italy, where National Health Service (NHS) provides universal health coverage. METHODS Costs (including drugs, inpatient/outpatient management) for treatment with AHSCT and HE-DMTs were calculated as NHS expenditures over 2- and 5-year periods. Cost-effectiveness for each treatment was estimated as "cost needed to treat" (CNT), i.e. expense to prevent relapses, progression, or disease activity (NEDA) in one patient over n-years, retrieving outcomes from published studies. RESULTS Costs of AHSCT and HE-DMTs were similar over 2 years, whereas AHSCT was cheaper than most HE-DMTs over 5 years (€46 600 vs €93 800, respectively). When estimating cost-effectiveness of treatments, over 2 years, mean CNT of HE-DMTs for NEDA was twofold that of AHSCT, whereas it was similar for relapses and disability. Differences in CNT were remarkable over 5 years, especially for NEDA, being mean CNT of HE-DMTs €382 800 vs €74 900 for AHSCT. CONCLUSIONS AHSCT may be highly cost-effective in selected aggressive RR-MS. Besides priceless benefits for treated individuals, cost-savings generated by AHSCT may contribute to improving healthcare assistance at a population level.
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Affiliation(s)
- Alice Mariottini
- Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy.
- Department of Neurology 2 and Tuscan Region Multiple Sclerosis Referral Centre, Careggi University Hospital, Florence, Italy.
| | - Chiara Nozzoli
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Ilaria Carli
- Hospital Management, UOC Controllo Direzionale, Careggi University Hospital, Florence, Italy
| | - Filippo Landi
- Hospital Management, UOC Controllo Direzionale, Careggi University Hospital, Florence, Italy
| | - Valentina Gigli
- Hospital Management, UOC Controllo Direzionale, Careggi University Hospital, Florence, Italy
| | - Anna Maria Repice
- Department of Neurology 2 and Tuscan Region Multiple Sclerosis Referral Centre, Careggi University Hospital, Florence, Italy
| | | | - Michele Cecchi
- Hospital Pharmacy, Careggi University Hospital, Florence, Italy
| | - Riccardo Boncompagni
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Riccardo Saccardi
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Luca Massacesi
- Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
- Department of Neurology 2 and Tuscan Region Multiple Sclerosis Referral Centre, Careggi University Hospital, Florence, Italy
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2
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Singer BA, Feng J, Chiong-Rivero H. Early use of high-efficacy therapies in multiple sclerosis in the United States: benefits, barriers, and strategies for encouraging adoption. J Neurol 2024; 271:3116-3130. [PMID: 38615277 PMCID: PMC11136864 DOI: 10.1007/s00415-024-12305-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Multiple sclerosis (MS) is characterized by progressive neuroinflammation and neurodegeneration from disease onset that, if left untreated, can result in the accumulation of irreversible neurological disability. Early intervention with high-efficacy therapies (HETs) is increasingly recognized as the best strategy to delay or mitigate disease progression from the earliest stages of the disease and to prevent long-term neurodegeneration. Although there is growing clinical and real-world evidence supporting early HET intervention, foregoing this strategy in favor of a traditional escalation approach prioritizing lower-efficacy disease-modifying therapies remains a common approach in clinical practice. This review explores potential health care professional- and patient-related barriers to the early use of HETs in patients with MS in the United States. Barriers can include regulatory and reimbursement restrictions; knowledge gaps and long-term safety concerns among health care professionals; and various individual, cultural, and societal factors affecting patients. Potential strategies for overcoming these barriers and encouraging early HET use are proposed.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA.
| | - Jenny Feng
- Ochsner Medical Center, New Orleans, LA, USA
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3
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Amezcua L, Livingston T, Hayward B, Zhou J, Williams MJ. Impact of adherence to disease modifying therapies on long-term clinical and economic outcomes in multiple sclerosis: A claims analysis of real-world data. Mult Scler Relat Disord 2023; 77:104866. [PMID: 37487345 DOI: 10.1016/j.msard.2023.104866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 06/16/2023] [Accepted: 06/30/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic neurodegenerative inflammatory disease that requires long-term commitment to treatment for optimal outcomes. A variety of disease-modifying therapies (DMTs) are now available that reduce relapses and delay disease progression in people with MS. However, adherence remains a significant issue, with a variety of mental, physical, and emotional factors contributing to non-adherence. In a large number of studies, non-adherence has been associated with worse clinical outcomes (relapses and disease severity), a higher economic burden, and loss of work productivity. However, many of these studies were short-term (1-2 years) or cross-sectional studies; thus, more data are needed on the long-term clinical and economic impacts of DMT non-adherence. The objective of this study was to determine the longer-term impact of adherence to DMTs on disease activity and healthcare resource utilization (HCRU) in people with MS. The study hypothesis was that non-adherence to DMTs would be associated long-term with worse clinical outcomes and a higher economic burden. METHODS A retrospective administrative claims analysis of the US MarketScan® Commercial database (2011-2017) in individuals (18-65 years) with MS (based on International Classification of Disease coding) was conducted. Adherence was classified by proportion of days covered (PDC) ≥0.8 and non-adherence by PDC <0.8; sensitivity analyses helped further categorize as moderately (PDC ≥0.6-<0.8) or highly (PDC <0.6) non-adherent. Cohorts were matched using propensity score matching. Time to first relapse, annualized relapse rate (ARR), time to use of assistive devices (cane/walker or wheelchair), and annual HCRU (inpatient, emergency room [ER], outpatient, and MRI visits and costs) were compared between cohorts. RESULTS 10,248 MS cases were identified; 58% met adherence criteria, and 42% met non-adherence criteria. Mean follow-up from diagnosis or first DMT claim was 5.3 years. Adherent individuals had a longer time to first relapse (hazard ratio [HR] 0.83; 95% confidence interval [CI]: 0.77-0.90; p<0.0001), a lower ARR (0.13 vs. 0.18, respectively; rate ratio [RR] 0.75 [95% CI: 0.71-0.79]; p<0.0001), and longer lag times to cane/walker use (HR 0.79 [95% CI: 0.66-0.94]; p=0.0067) and wheelchair use (HR 0.68 [95% CI: 0.55-0.83]; p=0.0002) than non-adherent individuals. Adherent individuals had fewer annual inpatient and ER visits and lower total costs than those who were non-adherent (p<0.0001). Sensitivity analyses showed that differences in disease activity and HCRU were generally more pronounced between matched adherent and highly non-adherent pairs than between matched adherent and moderately non-adherent pairs. CONCLUSION Significant differences in MS disease activity and HCRU were observed based on adherence to DMTs. Our study underscores the negative impact of non-adherence to DMTs on long-term clinical and economic outcomes in MS.
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Affiliation(s)
- Lilyana Amezcua
- Department of Neurology, Keck School of Medicine, University of Southern California, USA.
| | | | - Brooke Hayward
- One Technology Place, EMD Serono, Inc., Rockland, MA, USA
| | - Jia Zhou
- One Technology Place, EMD Serono, Inc., Rockland, MA, USA
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4
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Filippi M, Danesi R, Derfuss T, Duddy M, Gallo P, Gold R, Havrdová EK, Kornek B, Saccà F, Tintoré M, Weber J, Trojano M. Early and unrestricted access to high-efficacy disease-modifying therapies: a consensus to optimize benefits for people living with multiple sclerosis. J Neurol 2022; 269:1670-1677. [PMID: 34626224 PMCID: PMC8501364 DOI: 10.1007/s00415-021-10836-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 02/05/2023]
Abstract
Early intervention with high-efficacy disease-modifying therapy (HE DMT) may be the best strategy to delay irreversible neurological damage and progression of multiple sclerosis (MS). In European healthcare systems, however, patient access to HE DMTs in MS is often restricted to later stages of the disease due to restrictions in reimbursement despite broader regulatory labels. Although not every patient should be treated with HE DMTs at the initial stages of the disease, early and unrestricted access to HE DMTs with a positive benefit-risk profile and a reasonable value proposition will provide the freedom of choice for an appropriate treatment based on a shared decision between expert physicians and patients. This will further optimize outcomes and facilitate efficient resource allocation and sustainability in healthcare systems and society.
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Affiliation(s)
- Massimo Filippi
- Neurology Unit, Neurorehabilitation Unit, Neurophysiology Service, and Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | | | | | - Martin Duddy
- The Newcastle Upon Tyne Hospitals, Newcastle upon Tyne, UK
| | | | - Ralf Gold
- Ruhr-Universität Bochum, Bochum, Germany
| | - Eva Kubala Havrdová
- Department of Neurology, First Medical Faculty, Charles University, Prague, Czech Republic
| | | | - Francesco Saccà
- Università Degli Studi Di Napoli 'Federico II', Naples, Italy
| | - Mar Tintoré
- MS Centre of Catalonia at the Hospital Vall d'Hebron, Barcelona, Spain
| | - Jörg Weber
- Klinikum Klagenfurt,, Klagenfurt am Wörthersee, Austria
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Patti F, Chisari CG, Toscano S, Arena S, Finocchiaro C, Cimino V, Milone G. Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis Patients: Monocentric Case Series and Systematic Review of the Literature. J Clin Med 2022; 11:jcm11040942. [PMID: 35207216 PMCID: PMC8875789 DOI: 10.3390/jcm11040942] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 02/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory and immune-mediated disease of the central nervous system (CNS), commonly affecting young adults and potentially associated with life-long disability. About 14 disease-modifying treatments (DMTs) are currently approved for the treatment of MS. However, despite the use of highly effective therapies, some patients exhibit a highly active disease with an aggressive course from onset and a higher risk of long-term disability accrual. In the last few years, several retrospective studies, clinical trials, meta-analyses and systematic reviews have investigated autologous hematopoietic stem cell transplantation (AHSCT) as a possible therapeutic option in order to address this unmet clinical need. These studies demonstrated that AHSCT is a highly efficacious and relatively safe therapeutic option for the treatment of highly active MS. Particularly, over recent years, the amount of evidence has grown, with significant improvements in the development of patient selection criteria, choice of the most suitable transplant technique and clinical experience. In this paper, we present six patients who received AHSCT in our MS center and we systematically reviewed recent evidence about the long-term efficacy and safety of AHSCT and the placement of AHSCT in the rapidly evolving therapeutic armamentarium for MS.
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Affiliation(s)
- Francesco Patti
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Clara Grazia Chisari
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Simona Toscano
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Sebastiano Arena
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Chiara Finocchiaro
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Vincenzo Cimino
- IRCCS Centro Neurolesi “Bonino Pulejo”, 98124 Messina, Italy;
| | - Giuseppe Milone
- Hematology and Bone Marrow Transplant Unit, Azienda Policlinico-Vittorio Emanuele, 95124 Catania, Italy;
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6
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Ståhl D, Bjereld Y, Dunér A. Disabled in Society - A Scoping Review on Persons Living with Multiple Sclerosis and Disability. J Multidiscip Healthc 2022; 15:375-390. [PMID: 35237043 PMCID: PMC8884705 DOI: 10.2147/jmdh.s353347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/28/2022] [Indexed: 01/02/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic neurological disease with an increasing prevalence. As such, most studies are devoted to various medical aspects of the disease. The theoretical framework used in this scoping review was the social model of disability – a perspective focusing on environmental barriers and discrimination that disabled people face in society. The aim was to explore previous research on disabling barriers and discrimination against persons with MS, and to identify research gaps in connection with this population. The scoping review was performed in two steps: (1) a main search in 8 databases, followed by (2) citation and reference searches. The final sample consisted of 96 included articles. The result showed that most studies had been conducted in the US, and the dominant area of research was employment discrimination. Previous research has studied MS related to various areas, such as employment, social welfare and social services, transportation, housing and accessibility of public places, health services, and in relation to others within society. However, this scoping review showed that although several areas of disability and MS had been included in the previous research, most of the identified areas were researched in few studies without the possibility to generalize the findings to a larger population or a cross-cultural context. Few studies compared differences between persons with MS based on gender, age, and ethnicity. What impact the invisible symptoms of MS had on disability was also researched to a limited extent. The findings have implications for future research and clinical practice. To better understand living conditions for persons with MS from a global perspective, more research across countries is needed. Healthcare professionals need to assess the individual’s situation regarding both symptoms of the disease and the impact of societal barriers and discrimination to optimize care of persons with MS.
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Affiliation(s)
- Daniel Ståhl
- Department of Social Work, University of Gothenburg, Gothenburg, Sweden
- Correspondence: Daniel Ståhl, Department of Social Work, University of Gothenburg, Sprängkullsgatan 23, PO Box 720, Gothenburg, SE 405 30, Sweden, Tel +46 766 186 878, Fax +46 31 786 1888, Email
| | - Ylva Bjereld
- Department of Social Work, University of Gothenburg, Gothenburg, Sweden
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Anna Dunér
- Department of Social Work, University of Gothenburg, Gothenburg, Sweden
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7
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Baker D, Asardag AN, Quinn OA, Efimov A, Kang AS. Anti-drug antibodies to antibody-based therapeutics in multiple sclerosis. Hum Antibodies 2021; 29:255-262. [PMID: 34397407 DOI: 10.3233/hab-210453] [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: 11/15/2022]
Abstract
Multiple sclerosis is the major demyelinating autoimmune disease of the central nervous system. Relapsing MS can be treated by a number of approved monoclonal antibodies that currently target: CD20, CD25 (withdrawn), CD49d and CD52. These all target potentially pathogenic memory B cell subsets and perhaps functionally inhibit pathogenic T cell function. These consist of chimeric, humanized and fully human antibodies. However, despite humanization it is evident that all of these monoclonal antibodies can induce binding and neutralizing antibodies ranging from < 1% to over 80% within a year of treatment. Importantly, it is evident that monitoring these allow prediction of future treatment-failure in some individuals and treatment cessation and switching therefore potentially limiting disease breakthrough and disability accumulation. In response to the COVID-19 pandemic and the need to avoid hospitals, shortened infusion times and extended dose intervals have been implemented, importantly, subcutaneous delivery of alternative treatments or formulations have been developed to allow for home treatment. Therefore, hospital-based and remote monitoring of ADA could therefore be advantageous to optimize patient responses in the future.
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Affiliation(s)
- David Baker
- Blizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Nazli Asardag
- Blizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Olivia A Quinn
- Blizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alex Efimov
- Camstech Limited, Daresbury Laboratory Science and Technology Facilities Council Sci-Tech, Keckwick, Cheshire, UK
| | - Angray S Kang
- Blizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Centre for Oral Immunobiology and Regenerative Medicine, Dental Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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8
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Mariottini A, De Matteis E, Muraro PA. Haematopoietic Stem Cell Transplantation for Multiple Sclerosis: Current Status. BioDrugs 2021; 34:307-325. [PMID: 32166703 DOI: 10.1007/s40259-020-00414-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is a treatment option for aggressive forms of multiple sclerosis (MS) that has been derived from haematological indications and repurposed for treatment of refractory autoimmune diseases. In the present review, a search for clinical studies on AHSCT was performed on the PubMed website and ClinicalTrials.gov databases. Papers were selected according to the following criteria: text written in English language, publication date between 2014 and August 2019, and reports including more than five patients. Prospective randomised and uncontrolled trials and retrospective case series were reviewed to examine the safety and efficacy of the procedure. Treatment protocols, pathological data and economic aspects of AHSCT were also succinctly covered. Growing evidence suggests that long-term suppression of inflammatory activity with stabilization or improvement of disability can be achieved in a high proportion of properly selected patients. More sophisticated outcome measures recently adopted, including effect on brain atrophy and disease biomarkers, are giving further insight into the effectiveness of transplant. The risks of the procedure have decreased to levels that can be considered acceptable for treatment of individuals with aggressive forms of MS. Careful selection of patients with an expected good benefit/risk profile, which is maximal when AHSCT is performed in early phases of the disease, and the expertise of transplant centres are critical to the success of treatment. Higher efficacy of AHSCT than with conventional treatments has recently been demonstrated by one randomised trial and further evidence is awaited from ongoing and planned trials comparing AHSCT with the most effective disease-modifying therapeutic agents.
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Affiliation(s)
- Alice Mariottini
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | - Eleonora De Matteis
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Centre for Experimental Neurological Therapies, Sapienza University, Rome, Italy
| | - Paolo A Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.
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9
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Bose G, Freedman MS. Recent advances and remaining questions of autologous hematopoietic stem cell transplantation in multiple sclerosis. J Neurol Sci 2021; 421:117324. [PMID: 33497951 DOI: 10.1016/j.jns.2021.117324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/29/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
The judicious use of autologous hematopoietic stem cell transplantation (AHSCT) for MS requires understanding the potential benefits, identifying the most appropriate patient, and acknowledging the risks and differences between different protocols. Recently, AHSCT for MS is occurring more frequently, with a better safety profile than earlier studies. This review assesses recently published studies to determine the advances that have been made and remaining questions that future studies are poised to answer. We included studies from January 2016 to November 2020 with 20 or more patients. The benefits of AHSCT, including "no evidence of disease activity", functional and patient-reported outcomes, novel biomarkers such as brain atrophy or neurofilament light chain, and cost-effectiveness were assessed. The patient selection, treatment protocols, and safety outcomes differ between reports. The overall efficacy of AHSCT is better than standard treatments. Younger patients with highly active disease have greater chance for improvement, while patients who have comorbidities, failed more treatments, and are transitioning to a more progressive phase may not respond as well to AHSCT. The safety profiles for all AHSCT protocols is improving, however the durability of treatment response may not be the same for all protocols. The goal of AHSCT is to stop disease activity, avoid worsening disability, and obviate the need for further disease-modifying treatment, while improving patient quality of life and minimizing treatment-related risk. Results from currently enrolling randomized controlled trials, as well as ongoing registries, will provide more evidence for the safe and appropriate use of AHSCT.
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Affiliation(s)
- Gauruv Bose
- University of Ottawa, The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada.
| | - Mark S Freedman
- University of Ottawa, The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital General Campus, 501 Smyth Road, Box 606, Ottawa, ON K1H 8L6, Canada.
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10
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Bertolotto A, Martire S, Mirabile L, Capobianco M, De Gobbi M, Cilloni D. Autologous Hematopoietic Stem Cell Transplantation (AHSCT): Standard of Care for Relapsing-Remitting Multiple Sclerosis Patients. Neurol Ther 2020; 9:197-203. [PMID: 32548740 PMCID: PMC7606396 DOI: 10.1007/s40120-020-00200-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Indexed: 12/24/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) has been used in the treatment of highly active multiple sclerosis (MS) for over two decades. It has been demonstrated to be highly efficacious in relapsing-remitting (RR) MS patients failing to respond to disease-modifying drugs (DMDs). AHSCT guarantees higher rates of no evidence of disease activity (NEDA) than those achieved with any other DMDs, but it is also associated with greater short-term risks which have limited its use. In the 2019 updated EBMT and ASBMT guidelines, which review the clinical evidence of AHSCT in MS, AHSCT indication for highly active RRMS has changed from "clinical option" to "standard of care". On this basis, AHSCT must be proposed on equal footing with second-line DMDs to patients with highly active RRMS, instead of being considered as a last resort after failure of all available treatments. The decision-making process requires a close collaboration between transplant hematologists and neurologists and a full discussion of risk-benefit of AHSCT and alternative treatments. In this context, we propose a standardized protocol for decision-making and informed consent process.
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Affiliation(s)
- Antonio Bertolotto
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy.
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy.
| | - Serena Martire
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy
| | - Luca Mirabile
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy
| | - Marco Capobianco
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy
| | - Marco De Gobbi
- SSD Terapia oncoematologica intensiva e trapianto CSE, AOU San Luigi Gonzaga, Dipartimento di Scienze Cliniche e Biologiche, University of Turin, Turin, Italy
| | - Daniela Cilloni
- SSD Terapia oncoematologica intensiva e trapianto CSE, AOU San Luigi Gonzaga, Dipartimento di Scienze Cliniche e Biologiche, University of Turin, Turin, Italy
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11
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Das J, Sharrack B, Snowden JA. Autologous hematopoietic stem-cell transplantation in neurological disorders: current approach and future directions. Expert Rev Neurother 2020; 20:1299-1313. [PMID: 32893698 DOI: 10.1080/14737175.2020.1820325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Autologous hematopoietic stem-cell transplantation (AHSCT) has become increasingly popular in recent years as an effective treatment of immune-mediated neurological diseases. Treatment-related mortality has significantly reduced primarily through better patient selection, optimization of transplant technique, and increased center experience. AREA COVERED Multiple sclerosis is the main indication, but people with neuromyelitis optica spectrum disorder, stiff-person spectrum disorder, chronic inflammatory demyelinating polyneuropathy, myasthenia gravis, and other immune-mediated neurological disorders also have been treated. The review herein discusses the use of AHSCT in these neurological disorders, the importance of patient selection and transplant technique optimization and future directions. EXPERT OPINION Phase II and III clinical trials have confirmed the safety and efficacy of AHSCT in multiple sclerosis and recent phase II clinical trials have also suggested its safety and efficacy in chronic inflammatory demyelinating polyneuropathy and neuromyelitis optica spectrum disorder, with the evidence in other neurological disorders limited to individual case reports, small case series, and registry data. Therefore, further randomized controlled clinical trials are required to assess its safety and efficacy in other neurological conditions. However, in rare neurological conditions, pragmatic treatment trials or registry-based studies may be more realistic options for gathering efficacy and safety data.
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Affiliation(s)
- Joyutpal Das
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust , Salford, UK.,Cardiovascular medicine, University of Manchester , Manchester, UK.,Department of Neuroscience, NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield , Sheffield, UK
| | - Basil Sharrack
- Department of Neuroscience, NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield , Sheffield, UK
| | - John A Snowden
- Department of Hematology, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
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