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Magyari M, Koechlin A, Duclos A, Kopp TI, Allaoui EM, Polazzi S, Seeldrayers P, Autier P. Long-Term Safety of Teriflunomide in Multiple Sclerosis Patients: Results of Prospective Comparative Studies in Three European Countries. Pharmacoepidemiol Drug Saf 2024; 33:e5866. [PMID: 39013832 DOI: 10.1002/pds.5866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/02/2024] [Accepted: 06/20/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND AND OBJECTIVES Teriflunomide is a disease-modifying therapy (DMT) for multiple sclerosis (MS). This post authorisation safety study assessed risks of adverse events of special interest (AESI) associated with teriflunomide use. METHODS Secondary use of individual data from the Danish MS Registry (DMSR), the French National Health Data System (SNDS), the Belgian national database of health care claims (AIM-IMA) and the Belgian Treatments in MS Registry (Beltrims). We included patients treated with a DMT at the date of teriflunomide reimbursement or initiating another DMT. Adjusted hazard rates (aHR) and 95% confidence intervals were derived from Cox models with time-dependent exposure comparing teriflunomide treatment with another DMT. RESULTS Of 81 620 patients (72% women) included in the cohort, 22 324 (27%) were treated with teriflunomide. After a median follow-up of 4 years, teriflunomide use compared to other DMT was not associated with a risk of all-cause mortality, severe infection, pneumoniae, herpes zoster reactivation, pancreatitis, cardiovascular condition and cancers. For opportunistic infections, aHR for teriflunomide versus other DMT was 2.4 (1.2-4.8) in SNDS, which was not bound to a particular opportunistic agent. The aHR was 2.0 (1.1-3.7) for renal failures in the SNDS, but no association was found in other data sources. A total of 187 SNDS patients had a history of renal failure prior to cohort entry. None of these patients (0%) had a renal failure recurrence when treated with teriflunomide for 19 (13%) recurrences reported for patients on another DMT. DISCUSSION We found no evidence that teriflunomide use would be associated with an increased risk of AESI. Trial Registration EUPAS register: EU PAS 19610.
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Affiliation(s)
- Melinda Magyari
- Danish Multiple Sclerosis Registry, Copenhagen University Hospital Rigshospitalet Denmark, Glostrup, Denmark
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
- Institute for Clinical Medicine, University of Copenhagen, Denmark
| | - Alice Koechlin
- International Prevention Research Institute (iPRI), Lyon, France
| | - Antoine Duclos
- Health Data Department, Hospices Civils de Lyon, Lyon, France
| | - Tine Iskov Kopp
- Danish Multiple Sclerosis Registry, Copenhagen University Hospital Rigshospitalet Denmark, Glostrup, Denmark
| | - El Maâti Allaoui
- L'Agence Intermutualiste-Het InterMutualistisch Agentschap (AIM-IMA), Brussels, Belgium
| | | | | | - Philippe Autier
- International Prevention Research Institute (iPRI), Lyon, France
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Chitnis T, Banwell B, Kappos L, Arnold DL, Gücüyener K, Deiva K, Saubadu S, Hu W, Benamor M, Le-Halpere A, Truffinet P, Tardieu M. Teriflunomide in pediatric patients with relapsing multiple sclerosis: Open-label extension of TERIKIDS. Mult Scler 2024; 30:833-842. [PMID: 38619037 PMCID: PMC11134969 DOI: 10.1177/13524585241242050] [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: 09/24/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The double-blind TERIKIDS study demonstrated the efficacy and safety of teriflunomide. OBJECTIVE To evaluate the efficacy, safety, and tolerability of continuous teriflunomide treatment in the TERIKIDS open-label extension. METHODS In the double-blind period, children with relapsing MS were randomized to placebo or teriflunomide (14 mg adult-equivalent dose) for ⩽ 96 weeks. Participants received teriflunomide for ⩽ 192 weeks post-randomization in the open-label extension. RESULTS The mean age at screening was 14.6 years. For teriflunomide/teriflunomide versus placebo/teriflunomide, estimated clinical relapse risk was reduced by 38% (hazard ratio (HR) 0.62; 95% confidence interval (CI) 0.39-0.98; p = 0.11) and numbers of gadolinium-enhancing T1 and new/enlarging T2 lesions were reduced by 43% (relative risk (RR) 0.570; 95% CI 0.33-0.98; p = 0.043) and 49% (RR 0.511; 95% CI 0.34-0.76; p = 0.001), respectively, in the combined double-blind and open-label periods. There was a trend toward reduced risk of 24-week sustained disability progression for teriflunomide/teriflunomide versus placebo/teriflunomide (HR 0.47; 95% CI 0.23-0.96). During the open-label extension, incidences of safety-related discontinuations were 4.0% (teriflunomide/teriflunomide) and 13.5% (placebo/teriflunomide), including two children who developed pancreatitis in the teriflunomide/teriflunomide group. CONCLUSION Teriflunomide reduced the long-term risk of focal inflammatory activity, with generally manageable tolerability and no new safety signals. Further evidence would strengthen clinical efficacy findings.ClinicalTrials.gov: NCT02201108.
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Affiliation(s)
- Tanuja Chitnis
- Massachusetts General Hospital for Children, Boston, MA, USA
| | - Brenda Banwell
- Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University of Basel, Basel, Switzerland/MS Center and Neurologic Clinic and Policlinic, Departments of Biomedicine and Clinical Research, University Hospital of Basel, Basel, Switzerland
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada
- NeuroRx Research, Montréal, QC, Canada
| | - Kivilcim Gücüyener
- Gazi Universitesi Tip Fakultesi Pediatrik Nöroloji Bilim Dali, Ankara, Turkey
| | - Kumaran Deiva
- Department of Pediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Paris, France
| | | | | | | | | | | | - Marc Tardieu
- Department of Pediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Paris, France
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Ketabforoush AHME, Tajik A, Habibi MA, Khoshsirat NA. Acute Ischemic Stroke in a Patient with Multiple Sclerosis after Initiating Teriflunomide Treatment: A Challenging Case. CURRENT THERAPEUTIC RESEARCH 2024; 100:100732. [PMID: 38404915 PMCID: PMC10884338 DOI: 10.1016/j.curtheres.2024.100732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/23/2024] [Indexed: 02/27/2024]
Abstract
Multiple sclerosis is an autoimmune disease of the central nervous system, during which vascular events, including atherosclerosis, are more common and progress faster. Teriflunomide (TFN) is an oral drug that studies have indicated has low side effects alongside high efficiency. In this article, a middle-aged woman with multiple sclerosis was introduced, whose medication was changed to TFN. Thirty-five days later, she presented with focal neurologic symptoms, and investigations reported a lacunar infarction. Having excluded potential causes of acute ischemic stroke, such as vascular and rheumatologic factors, the only identifiable factor was the introduction of a new medication. The process of conclusively attributing TFN as the causative agent requires further clarification in future studies.
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Affiliation(s)
| | - Armin Tajik
- Research Students Committee, Alborz University of Medical Sciences, Alborz, Iran
| | - Mohammad Amin Habibi
- Clinical Research Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
| | - Nahid Abbasi Khoshsirat
- Department of Neurology, Clinical Research Development Unit of Shahid Rajaei Hospital, Alborz University of Medical Sciences, Karaj, Iran
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Bellanca CM, Augello E, Mariottini A, Bonaventura G, La Cognata V, Di Benedetto G, Cantone AF, Attaguile G, Di Mauro R, Cantarella G, Massacesi L, Bernardini R. Disease Modifying Strategies in Multiple Sclerosis: New Rays of Hope to Combat Disability? Curr Neuropharmacol 2024; 22:1286-1326. [PMID: 38275058 PMCID: PMC11092922 DOI: 10.2174/1570159x22666240124114126] [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: 05/04/2023] [Revised: 08/21/2023] [Accepted: 09/22/2023] [Indexed: 01/27/2024] Open
Abstract
Multiple sclerosis (MS) is the most prevalent chronic autoimmune inflammatory- demyelinating disorder of the central nervous system (CNS). It usually begins in young adulthood, mainly between the second and fourth decades of life. Usually, the clinical course is characterized by the involvement of multiple CNS functional systems and by different, often overlapping phenotypes. In the last decades, remarkable results have been achieved in the treatment of MS, particularly in the relapsing- remitting (RRMS) form, thus improving the long-term outcome for many patients. As deeper knowledge of MS pathogenesis and respective molecular targets keeps growing, nowadays, several lines of disease-modifying treatments (DMT) are available, an impressive change compared to the relative poverty of options available in the past. Current MS management by DMTs is aimed at reducing relapse frequency, ameliorating symptoms, and preventing clinical disability and progression. Notwithstanding the relevant increase in pharmacological options for the management of RRMS, research is now increasingly pointing to identify new molecules with high efficacy, particularly in progressive forms. Hence, future efforts should be concentrated on achieving a more extensive, if not exhaustive, understanding of the pathogenetic mechanisms underlying this phase of the disease in order to characterize novel molecules for therapeutic intervention. The purpose of this review is to provide a compact overview of the numerous currently approved treatments and future innovative approaches, including neuroprotective treatments as anti-LINGO-1 monoclonal antibody and cell therapies, for effective and safe management of MS, potentially leading to a cure for this disease.
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Affiliation(s)
- Carlo Maria Bellanca
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Egle Augello
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Alice Mariottini
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Gabriele Bonaventura
- Institute for Biomedical Research and Innovation (IRIB), Italian National Research Council, 95126 Catania, Italy
| | - Valentina La Cognata
- Institute for Biomedical Research and Innovation (IRIB), Italian National Research Council, 95126 Catania, Italy
| | - Giulia Di Benedetto
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Anna Flavia Cantone
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppe Attaguile
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Rosaria Di Mauro
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppina Cantarella
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Luca Massacesi
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Renato Bernardini
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
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Tramacere I, Virgili G, Perduca V, Lucenteforte E, Benedetti MD, Capobussi M, Castellini G, Frau S, Gonzalez-Lorenzo M, Featherstone R, Filippini G. Adverse effects of immunotherapies for multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2023; 11:CD012186. [PMID: 38032059 PMCID: PMC10687854 DOI: 10.1002/14651858.cd012186.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic disease of the central nervous system that affects mainly young adults (two to three times more frequently in women than in men) and causes significant disability after onset. Although it is accepted that immunotherapies for people with MS decrease disease activity, uncertainty regarding their relative safety remains. OBJECTIVES To compare adverse effects of immunotherapies for people with MS or clinically isolated syndrome (CIS), and to rank these treatments according to their relative risks of adverse effects through network meta-analyses (NMAs). SEARCH METHODS We searched CENTRAL, PubMed, Embase, two other databases and trials registers up to March 2022, together with reference checking and citation searching to identify additional studies. SELECTION CRITERIA We included participants 18 years of age or older with a diagnosis of MS or CIS, according to any accepted diagnostic criteria, who were included in randomized controlled trials (RCTs) that examined one or more of the agents used in MS or CIS, and compared them versus placebo or another active agent. We excluded RCTs in which a drug regimen was compared with a different regimen of the same drug without another active agent or placebo as a control arm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for data extraction and pairwise meta-analyses. For NMAs, we used the netmeta suite of commands in R to fit random-effects NMAs assuming a common between-study variance. We used the CINeMA platform to GRADE the certainty of the body of evidence in NMAs. We considered a relative risk (RR) of 1.5 as a non-inferiority safety threshold compared to placebo. We assessed the certainty of evidence for primary outcomes within the NMA according to GRADE, as very low, low, moderate or high. MAIN RESULTS This NMA included 123 trials with 57,682 participants. Serious adverse events (SAEs) Reporting of SAEs was available from 84 studies including 5696 (11%) events in 51,833 (89.9%) participants out of 57,682 participants in all studies. Based on the absolute frequency of SAEs, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 18 additional people would have a SAE compared to placebo. Low-certainty evidence suggested that three drugs may decrease SAEs compared to placebo (relative risk [RR], 95% confidence interval [CI]): interferon beta-1a (Avonex) (0.78, 0.66 to 0.94); dimethyl fumarate (0.79, 0.67 to 0.93), and glatiramer acetate (0.84, 0.72 to 0.98). Several drugs met our non-inferiority criterion versus placebo: moderate-certainty evidence for teriflunomide (1.08, 0.88 to 1.31); low-certainty evidence for ocrelizumab (0.85, 0.67 to 1.07), ozanimod (0.88, 0.59 to 1.33), interferon beta-1b (0.94, 0.78 to 1.12), interferon beta-1a (Rebif) (0.96, 0.80 to 1.15), natalizumab (0.97, 0.79 to 1.19), fingolimod (1.05, 0.92 to 1.20) and laquinimod (1.06, 0.83 to 1.34); very low-certainty evidence for daclizumab (0.83, 0.68 to 1.02). Non-inferiority with placebo was not met due to imprecision for the other drugs: low-certainty evidence for cladribine (1.10, 0.79 to 1.52), siponimod (1.20, 0.95 to 1.51), ofatumumab (1.26, 0.88 to 1.79) and rituximab (1.01, 0.67 to 1.52); very low-certainty evidence for immunoglobulins (1.05, 0.33 to 3.32), diroximel fumarate (1.05, 0.23 to 4.69), peg-interferon beta-1a (1.07, 0.66 to 1.74), alemtuzumab (1.16, 0.85 to 1.60), interferons (1.62, 0.21 to 12.72) and azathioprine (3.62, 0.76 to 17.19). Withdrawals due to adverse events Reporting of withdrawals due to AEs was available from 105 studies (85.4%) including 3537 (6.39%) events in 55,320 (95.9%) patients out of 57,682 patients in all studies. Based on the absolute frequency of withdrawals, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 31 additional people would withdraw compared to placebo. No drug reduced withdrawals due to adverse events when compared with placebo. There was very low-certainty evidence (meaning that estimates are not reliable) that two drugs met our non-inferiority criterion versus placebo, assuming an upper 95% CI RR limit of 1.5: diroximel fumarate (0.38, 0.11 to 1.27) and alemtuzumab (0.63, 0.33 to 1.19). Non-inferiority with placebo was not met due to imprecision for the following drugs: low-certainty evidence for ofatumumab (1.50, 0.87 to 2.59); very low-certainty evidence for methotrexate (0.94, 0.02 to 46.70), corticosteroids (1.05, 0.16 to 7.14), ozanimod (1.06, 0.58 to 1.93), natalizumab (1.20, 0.77 to 1.85), ocrelizumab (1.32, 0.81 to 2.14), dimethyl fumarate (1.34, 0.96 to 1.86), siponimod (1.63, 0.96 to 2.79), rituximab (1.63, 0.53 to 5.00), cladribine (1.80, 0.89 to 3.62), mitoxantrone (2.11, 0.50 to 8.87), interferons (3.47, 0.95 to 12.72), and cyclophosphamide (3.86, 0.45 to 33.50). Eleven drugs may have increased withdrawals due to adverse events compared with placebo: low-certainty evidence for teriflunomide (1.37, 1.01 to 1.85), glatiramer acetate (1.76, 1.36 to 2.26), fingolimod (1.79, 1.40 to 2.28), interferon beta-1a (Rebif) (2.15, 1.58 to 2.93), daclizumab (2.19, 1.31 to 3.65) and interferon beta-1b (2.59, 1.87 to 3.77); very low-certainty evidence for laquinimod (1.42, 1.01 to 2.00), interferon beta-1a (Avonex) (1.54, 1.13 to 2.10), immunoglobulins (1.87, 1.01 to 3.45), peg-interferon beta-1a (3.46, 1.44 to 8.33) and azathioprine (6.95, 2.57 to 18.78); however, very low-certainty evidence is unreliable. Sensitivity analyses including only studies with low attrition bias, drug dose above the group median, or only patients with relapsing remitting MS or CIS, and subgroup analyses by prior disease-modifying treatments did not change these figures. Rankings No drug yielded consistent P scores in the upper quartile of the probability of being better than others for primary and secondary outcomes. AUTHORS' CONCLUSIONS We found mostly low and very low-certainty evidence that drugs used to treat MS may not increase SAEs, but may increase withdrawals compared with placebo. The results suggest that there is no important difference in the occurrence of SAEs between first- and second-line drugs and between oral, injectable, or infused drugs, compared with placebo. Our review, along with other work in the literature, confirms poor-quality reporting of adverse events from RCTs of interventions. At the least, future studies should follow the CONSORT recommendations about reporting harm-related issues. To address adverse effects, future systematic reviews should also include non-randomized studies.
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Affiliation(s)
- Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Ophthalmology, IRCCS - Fondazione Bietti, Rome, Italy
| | - Vittorio Perduca
- Université Paris Cité, CNRS, MAP5, F-75006 Paris, France
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Ersilia Lucenteforte
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Maria Donata Benedetti
- UOC Neurologia B - Policlinico Borgo Roma, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Capobussi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Greta Castellini
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | | | - Marien Gonzalez-Lorenzo
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Department of Oncology, Laboratory of Clinical Research Methodology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
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Giovannoni G, Hawkes CH, Lechner-Scott J, Levy M, Yeh EA. Is it ethical to use teriflunomide as an active comparator in phase 3 trials? Mult Scler Relat Disord 2023; 78:104911. [PMID: 37582327 DOI: 10.1016/j.msard.2023.104911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 07/21/2023] [Indexed: 08/17/2023]
Abstract
Ethical concerns have been raised about the practice of using teriflunomide, an oral licensed disease-modifying therapy, as an active comparator in phase 3 multiple sclerosis (MS) trials. The assumption is based on the perceived low efficacy of teriflunomide as judged by its effect on relapses and focal MRI activity. However, when you look beyond focal inflammation, teriflunomide has a robust impact on disability progression and a similar effect to the anti-CD20 monoclonal antibody therapies on slowing down the accelerated brain volume loss associated with MS. Teriflunomide is also more effective when used second or third line. The other classes of disease-modifying therapies have problems with their use as active comparators in clinical trials. Using a non-inferiority or equivalence trial design has its own unique set of regulatory and ethical challenges and is not necessarily a solution. There are also economic, altruistic and pragmatic reasons for continuing to use teriflunomide as an active comparator in MS clinical trials. An online survey indicates that the majority of the MS community feels it is still ethical to randomise subjects to teriflunomide and that procedures can be put in place to protect trial subjects randomised to teriflunomide. Therefore, we still have equipoise, and teriflunomide comparator trials are ethical.
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Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | - Christopher H Hawkes
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Michael Levy
- Massachusetts General Hospital and Harvard Medical School, MA, USA
| | - E Ann Yeh
- Department of Paediatrics, Dalla Lana School of Public Health, University of Toronto, Canada
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7
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Lebrun-Frénay C, Siva A, Sormani MP, Landes-Chateau C, Mondot L, Bovis F, Vermersch P, Papeix C, Thouvenot E, Labauge P, Durand-Dubief F, Efendi H, Le Page E, Terzi M, Derache N, Bourre B, Hoepner R, Karabudak R, De Seze J, Ciron J, Clavelou P, Wiertlewski S, Turan OF, Yucear N, Cohen M, Azevedo C, Kantarci OH, Okuda DT, Pelletier D. Teriflunomide and Time to Clinical Multiple Sclerosis in Patients With Radiologically Isolated Syndrome: The TERIS Randomized Clinical Trial. JAMA Neurol 2023; 80:1080-1088. [PMID: 37603328 PMCID: PMC10442780 DOI: 10.1001/jamaneurol.2023.2815] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/13/2023] [Indexed: 08/22/2023]
Abstract
Importance Radiologically isolated syndrome (RIS) represents the earliest detectable preclinical phase of multiple sclerosis (MS) punctuated by incidental magnetic resonance imaging (MRI) white matter anomalies within the central nervous system. Objective To determine the time to onset of symptoms consistent with MS. Design, Setting, and Participants From September 2017 to October 2022, this multicenter, double-blind, phase 3, randomized clinical trial investigated the efficacy of teriflunomide in delaying MS in individuals with RIS, with a 3-year follow-up. The setting included referral centers in France, Switzerland, and Turkey. Participants older than 18 years meeting 2009 RIS criteria were randomly assigned (1:1) to oral teriflunomide, 14 mg daily, or placebo up to week 96 or, optionally, to week 144. Interventions Clinical, MRI, and patient-reported outcomes (PROs) were collected at baseline and yearly until week 96, with an optional third year in the allocated arm if no symptoms have occurred. Main outcomes Primary analysis was performed in the intention-to-treat population, and safety was assessed accordingly. Secondary end points included MRI outcomes and PROs. Results Among 124 individuals assessed for eligibility, 35 were excluded for declining to participate, not meeting inclusion criteria, or loss of follow-up. Eighty-nine participants (mean [SD] age, 37.8 [12.1] years; 63 female [70.8%]) were enrolled (placebo, 45 [50.6%]; teriflunomide, 44 [49.4%]). Eighteen participants (placebo, 9 [50.0%]; teriflunomide, 9 [50.0%]) discontinued the study, resulting in a dropout rate of 20% for adverse events (3 [16.7%]), consent withdrawal (4 [22.2%]), loss to follow-up (5 [27.8%]), voluntary withdrawal (4 [22.2%]), pregnancy (1 [5.6%]), and study termination (1 [5.6%]). The time to the first clinical event was significantly extended in the teriflunomide arm compared with placebo, in both the unadjusted (hazard ratio [HR], 0.37; 95% CI, 0.16-0.84; P = .02) and adjusted (HR, 0.28; 95% CI, 0.11-0.71; P = .007) analysis. Secondary imaging end point outcomes including the comparison of the cumulative number of new or newly enlarging T2 lesions (rate ratio [RR], 0.57; 95% CI, 0.27-1.20; P = .14), new gadolinium-enhancing lesions (RR, 0.33; 95% CI, 0.09-1.17; P = .09), and the proportion of participants with new lesions (odds ratio, 0.72; 95% CI, 0.25-2.06; P = .54) were not significant. Conclusion and Relevance Treatment with teriflunomide resulted in an unadjusted risk reduction of 63% and an adjusted risk reduction of 72%, relative to placebo, in preventing a first clinical demyelinating event. These data suggest a benefit to early treatment in the MS disease spectrum. Trial Registration ClinicalTrials.gov Identifier: NCT03122652.
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Affiliation(s)
- Christine Lebrun-Frénay
- Centre de Ressources et de Compétences Sclerose En Plaques, Neurologie Pasteur 2, CHU de Nice, Université Cote d’Azur, UMR2CA-URRIS, Nice, France
| | - Aksel Siva
- Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkiye
| | - Maria Pia Sormani
- University of Genoa, Genoa, Italy
- Ospedale Policlinico San Martino Instituti di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Cassandre Landes-Chateau
- Centre de Ressources et de Compétences Sclerose En Plaques, Neurologie Pasteur 2, CHU de Nice, Université Cote d’Azur, UMR2CA-URRIS, Nice, France
| | - Lydiane Mondot
- Centre de Ressources et de Compétences Sclerose En Plaques, Neurologie Pasteur 2, CHU de Nice, Université Cote d’Azur, UMR2CA-URRIS, Nice, France
| | | | - Patrick Vermersch
- Université de Lille, Inserm, Unit 1172, LilNCog, Centre Hospitalier Universitaire de Lille, Fédération Hospitalo-Universitaire Precise, Lille, France
| | - Caroline Papeix
- Assistance Publique des Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Thouvenot
- Multiple Sclerosis Clinic, Nîmes University Hospital, Nîmes, France
| | - Pierre Labauge
- Multiple Sclerosis Clinic, Montpellier University Hospital, Montpellier, France
| | | | - Husnu Efendi
- Neurology, Kocaeli University Faculty of Medicine, Kocaeli, Turkiye
| | - Emmanuelle Le Page
- Multiple Sclerosis Clinic, Rennes University Hospital, Inserm, CIC1414, Rennes, France
| | - Murat Terzi
- School of Medicine, Neurology, Ondokuz Mayis University, Samsun, Turkiye
| | - Nathalie Derache
- Multiple Sclerosis Clinic, Caen University Hospital, Caen, France
| | - Bertrand Bourre
- Multiple Sclerosis Clinic, Rouen University Hospital, Rouen, France
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Rana Karabudak
- Hacettepe University Medical Faculty, School of Medicine, Ankara, Turkiye
| | - Jérôme De Seze
- Strasbourg University Hospital, Clinical Investigation Center, INBSRM 1434, Strasbourg, France
| | - Jonathan Ciron
- Toulouse University Hospital, Centre de Ressources et de Compétences Sclérose en Plaques, Department of Neurology, Université Toulouse III, Infinity, Inserm UMR1291, CNRS UMR5051, Toulouse, France
| | - Pierre Clavelou
- Multiple Sclerosis Clinic, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Sandrine Wiertlewski
- Centre de Ressources et de Compétences Sclérose en Plaques and Clinical Investigation Center, Inserm, Nantes University Hospital, France
- Transplantation and Immunology Transplantation Center, Inserm, Nantes, France
| | | | - Nur Yucear
- Ege University Medical Faculty, Bornova, Izmir, Turkiye
| | - Mikael Cohen
- Centre de Ressources et de Compétences Sclerose En Plaques, Neurologie Pasteur 2, CHU de Nice, Université Cote d’Azur, UMR2CA-URRIS, Nice, France
| | | | | | - Darin T. Okuda
- The University of Texas Southwestern Medical Center, Dallas
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Elrefaey A, Memon AB. Painful Small Fiber Neuropathy Associated With Teriflunomide: A Case Series and Literature Review Related to Teriflunomide and Leflunomide. Cureus 2023; 15:e45079. [PMID: 37705563 PMCID: PMC10496022 DOI: 10.7759/cureus.45079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 09/15/2023] Open
Abstract
Teriflunomide and its prodrug, leflunomide, are disease-modifying medications used to treat relapsing-remitting multiple sclerosis (RRMS) and rheumatoid arthritis (RA), respectively. Peripheral neuropathy is a rare side effect associated with both medications, although the incidence rate and exact pathological mechanism remain unknown. We present a retrospective case series of three patients with RRMS, who developed painful small fiber neuropathy at various timeframes (<6 months, one year, and four years, respectively) while on teriflunomide treatment (14 mg/day); we also engage in a literature review of small and large fiber neuropathy associated with teriflunomide and leflunomide use. All three patients developed small fiber neuropathy following teriflunomide exposure. Laboratory workup was negative for metabolic, infectious, vitamin deficiency-related, and autoimmune etiologies, except for one patient who had chronic metabolic syndromes (impaired glucose, hyperlipidemia) before medication intake. However, the patient developed neuropathy following teriflunomide treatment. Electrophysiological findings were negative for large fiber neuropathy in all three patients with positive skin biopsy, with reduced epidermal nerve fiber density (ENFD) in two of the three patients. Teriflunomide was discontinued in all cases, after which symptoms stabilized. Current literature on leflunomide supports a direct neurotoxic effect or buildup of toxic intermediates from uridine synthesis inhibition. Cessation of teriflunomide use in the described cases resulted in symptom stabilization. Early recognition and treatment may lead to good clinical outcomes in these patients.
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Affiliation(s)
- Ahmed Elrefaey
- Neurology, Faculty of Medicine, Ain Shams University, Cairo, EGY
| | - Anza B Memon
- Neurology, John D. Dingell VA Medical Center, Detroit, USA
- Neurology, Wayne State University School of Medicine, Detroit, USA
- Neurology, Henry Ford Health, Detroit, USA
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9
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Bridge F, Brotherton JML, Foong Y, Butzkueven H, Jokubaitis VG, Van der Walt A. Risk of cervical pre-cancer and cancer in women with multiple sclerosis exposed to high efficacy disease modifying therapies. Front Neurol 2023; 14:1119660. [PMID: 36846149 PMCID: PMC9950275 DOI: 10.3389/fneur.2023.1119660] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/24/2023] [Indexed: 02/12/2023] Open
Abstract
There is a growing need to better understand the risk of malignancy in the multiple sclerosis (MS) population, particularly given the relatively recent and widespread introduction of immunomodulating disease modifying therapies (DMTs). Multiple sclerosis disproportionately affects women, and the risk of gynecological malignancies, specifically cervical pre-cancer and cancer, are of particular concern. The causal relationship between persistent human papillomavirus (HPV) infection and cervical cancer has been definitively established. To date, there is limited data on the effect of MS DMTs on the risk of persistent HPV infection and subsequent progression to cervical pre-cancer and cancer. This review evaluates the risk of cervical pre-cancer and cancer in women with MS, including the risk conferred by DMTs. We examine additional factors, specific to the MS population, that alter the risk of developing cervical cancer including participation in HPV vaccination and cervical screening programs.
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Affiliation(s)
- Francesca Bridge
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia,*Correspondence: Francesca Bridge ✉
| | - Julia M. L. Brotherton
- Australian Centre for the Prevention of Cervical Cancer (Formerly Victorian Cytology Service), Carlton South, VIC, Australia,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Yi Foong
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia,Department of Neurosciences, Eastern Health, Melbourne, VIC, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Vilija G. Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Anneke Van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
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10
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Teriflunomide Concentrations in Cerebrospinal Fluid and Plasma in Patients with Multiple Sclerosis: A Pharmacokinetic Study. CNS Drugs 2023; 37:181-188. [PMID: 36729276 PMCID: PMC9911485 DOI: 10.1007/s40263-023-00985-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Teriflunomide is a disease modifying treatment (DMT) approved for relapsing-remitting multiple sclerosis (RRMS) in adults and children. It reduces lymphocyte proliferation by inhibiting the mitochondrial enzyme dihydroorotate dehydrogenase (DHODH) and thereby the pyrimidine synthesis. Although most DMTs in multiple sclerosis (MS) modulate or inhibit the immune system in the periphery, the efficacy may improve if the agent also targets immune activity within the central nervous system (CNS), acts as a neuro-protective and enhances neuro-regeneration. The objective of this study was to determine the passage of teriflunomide over the blood-cerebrospinal fluid barrier (BCSFB). METHODS Plasma and cerebrospinal fluid (CSF) teriflunomide concentrations were determined at steady state in 12 patients with RRMS, treated with oral teriflunomide 14 mg once daily. Included patients were all clinically stable without relapse or disability worsening within 6 months prior from baseline and were on no other immune modulating or immunosuppressive drugs. RESULTS The mean teriflunomide concentrations in plasma and CSF were 38775 (SEM ± 7256) ng/mL and 68 (SEM ± 15) ng/mL, respectively. The passage over the BCSFB was 0.17 % (SEM ± 0.01). While no correlation was found between the function of the BCSFB assessed with the albumin ratio and the CSF teriflunomide concentration, the CSF and plasma teriflunomide concentrations were highly correlated (rs = 0.90, < 0.0001). CONCLUSIONS Further studies are warranted to determine if the obtained CSF teriflunomide concentration reflects that in the CNS and is able to influence inflammatory and degenerative processes within the CNS.
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Morton RL, Tuffaha H, Blaya-Novakova V, Spencer J, Hawley CM, Peyton P, Higgins A, Marsh J, Taylor WJ, Huckson S, Sillett A, Schneemann K, Balagurunanthan A, Cumpston M, Scuffham PA, Glasziou P, Simes RJ. Approaches to prioritising research for clinical trial networks: a scoping review. Trials 2022; 23:1000. [PMID: 36510214 PMCID: PMC9743749 DOI: 10.1186/s13063-022-06928-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Prioritisation of clinical trials ensures that the research conducted meets the needs of stakeholders, makes the best use of resources and avoids duplication. The aim of this review was to identify and critically appraise approaches to research prioritisation applicable to clinical trials, to inform best practice guidelines for clinical trial networks and funders. METHODS A scoping review of English-language published literature and research organisation websites (January 2000 to January 2020) was undertaken to identify primary studies, approaches and criteria for research prioritisation. Data were extracted and tabulated, and a narrative synthesis was employed. RESULTS Seventy-eight primary studies and 18 websites were included. The majority of research prioritisation occurred in oncology and neurology disciplines. The main reasons for prioritisation were to address a knowledge gap (51 of 78 studies [65%]) and to define patient-important topics (28 studies, [35%]). In addition, research organisations prioritised in order to support their institution's mission, invest strategically, and identify best return on investment. Fifty-seven of 78 (73%) studies used interpretative prioritisation approaches (including Delphi surveys, James Lind Alliance and consensus workshops); six studies used quantitative approaches (8%) such as prospective payback or value of information (VOI) analyses; and 14 studies used blended approaches (18%) such as nominal group technique and Child Health Nutritional Research Initiative. Main criteria for prioritisation included relevance, appropriateness, significance, feasibility and cost-effectiveness. CONCLUSION Current research prioritisation approaches for groups conducting and funding clinical trials are largely interpretative. There is an opportunity to improve the transparency of prioritisation through the inclusion of quantitative approaches.
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Affiliation(s)
- Rachael L. Morton
- grid.1013.30000 0004 1936 834XNational Health and Medical Research Council Clinical Trials Centre (NHMRC CTC), University of Sydney, Sydney, Australia
| | - Haitham Tuffaha
- grid.1003.20000 0000 9320 7537Centre for the Business and Economics of Health, University of Queensland, Brisbane, Australia
| | - Vendula Blaya-Novakova
- grid.1013.30000 0004 1936 834XNational Health and Medical Research Council Clinical Trials Centre (NHMRC CTC), University of Sydney, Sydney, Australia
| | - Jenean Spencer
- Australian Clinical Trials Alliance (ACTA), Melbourne, Victoria Australia
| | - Carmel M. Hawley
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network (AKTN), Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Phil Peyton
- grid.418175.e0000 0001 2225 7841Australian and New Zealand College of Anaesthetists (ANZCA), Melbourne, Australia
| | - Alisa Higgins
- grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria Australia
| | - Julie Marsh
- grid.414659.b0000 0000 8828 1230Telethon Kids Institute, West Perth, Australia
| | - William J. Taylor
- grid.29980.3a0000 0004 1936 7830University of Otago, Rehabilitation Teaching and Research Unit, Dunedin, New Zealand
| | - Sue Huckson
- grid.489411.10000 0004 5905 1670Australian and New Zealand Intensive Care Society (ANZICS), Camberwell, Victoria Australia
| | - Amy Sillett
- grid.467202.50000 0004 0445 3920AstraZeneca Australia, Macquarie Park, New South Wales Australia
| | - Kieran Schneemann
- Australian Clinical Trials Alliance (ACTA), Melbourne, Victoria Australia ,grid.467202.50000 0004 0445 3920AstraZeneca Australia, Macquarie Park, New South Wales Australia
| | | | - Miranda Cumpston
- Australian Clinical Trials Alliance (ACTA), Melbourne, Victoria Australia ,grid.266842.c0000 0000 8831 109XSchool of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
| | - Paul A. Scuffham
- grid.1003.20000 0000 9320 7537Centre for the Business and Economics of Health, University of Queensland, Brisbane, Australia
| | - Paul Glasziou
- grid.1033.10000 0004 0405 3820Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia
| | - Robert J. Simes
- grid.1013.30000 0004 1936 834XNational Health and Medical Research Council Clinical Trials Centre (NHMRC CTC), University of Sydney, Sydney, Australia
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12
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Liu R, Du S, Zhao L, Jain S, Sahay K, Rizvanov A, Lezhnyova V, Khaibullin T, Martynova E, Khaiboullina S, Baranwal M. Autoreactive lymphocytes in multiple sclerosis: Pathogenesis and treatment target. Front Immunol 2022; 13:996469. [PMID: 36211343 PMCID: PMC9539795 DOI: 10.3389/fimmu.2022.996469] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) characterized by destruction of the myelin sheath structure. The loss of myelin leads to damage of a neuron’s axon and cell body, which is identified as brain lesions on magnetic resonance image (MRI). The pathogenesis of MS remains largely unknown. However, immune mechanisms, especially those linked to the aberrant lymphocyte activity, are mainly responsible for neuronal damage. Th1 and Th17 populations of lymphocytes were primarily associated with MS pathogenesis. These lymphocytes are essential for differentiation of encephalitogenic CD8+ T cell and Th17 lymphocyte crossing the blood brain barrier and targeting myelin sheath in the CNS. B-lymphocytes could also contribute to MS pathogenesis by producing anti-myelin basic protein antibodies. In later studies, aberrant function of Treg and Th9 cells was identified as contributing to MS. This review summarizes the aberrant function and count of lymphocyte, and the contributions of these cell to the mechanisms of MS. Additionally, we have outlined the novel MS therapeutics aimed to amend the aberrant function or counts of these lymphocytes.
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Affiliation(s)
- Rongzeng Liu
- Department of Immunology, School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Shushu Du
- Department of Immunology, School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Lili Zhao
- Department of Immunology, School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Sahil Jain
- Department of Biochemistry and Molecular Biology, Faculty of Life Sciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Kritika Sahay
- Department of Biotechnology, Thapar Institute of Engineering and Technology, Patiala, India
| | - Albert Rizvanov
- Gene and cell Department, Kazan Federal University, Kazan, Russia
| | - Vera Lezhnyova
- Gene and cell Department, Kazan Federal University, Kazan, Russia
| | - Timur Khaibullin
- Neurological Department, Republican Clinical Neurological Center, Kazan, Russia
| | | | - Svetlana Khaiboullina
- Gene and cell Department, Kazan Federal University, Kazan, Russia
- *Correspondence: Svetlana Khaiboullina, ; Manoj Baranwal, ;
| | - Manoj Baranwal
- Department of Biotechnology, Thapar Institute of Engineering and Technology, Patiala, India
- *Correspondence: Svetlana Khaiboullina, ; Manoj Baranwal, ;
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13
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Apóstolos SLP, Boaventura M, Mendes NT, Teixeira LS, Campana IG. How to choose initial treatment in multiple sclerosis patients: a case-based approach. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:159-172. [PMID: 35976318 PMCID: PMC9491420 DOI: 10.1590/0004-282x-anp-2022-s128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Immunotherapy dramatically changed the natural history of multiple sclerosis (MS), which was classically associated with severe disability. Treatment strategies advocate that early control of disease activity is crucial to avoid progressive disability, and the use of high efficacy drugs may be beneficial, but safety is a concern. Choosing the disease-modifying therapy is challenging in clinical practice and should be further discussed. OBJECTIVE To discuss the state of art of selecting the initial therapy for relapsing MS patients. METHODS We used a case-based approach followed by clinical discussion, exploring therapeutic options in different MS settings. RESULTS We presented clinical cases profile compatible with the use of MS therapies, classified into moderate and high efficacy. In the moderate efficacy group, we discussed interferons, glatiramer acetate, teriflunomide and dimethyl fumarate, while in the high efficacy group we discussed fingolimod, cladribine, natalizumab, ocrelizumab, alemtuzumab and ofatumumab. CONCLUSION Advances in MS treatment are remarkable. Strong evidence supports the use of early high efficacy therapy. However, biomarkers, clinical and radiologic prognostic factors, as well as patients' individual issues, should be valued and considered for a personalized treatment decision.
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Affiliation(s)
- Samira Luisa Pereira Apóstolos
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Mateus Boaventura
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Natalia Trombini Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Larissa Silva Teixeira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Igor Gusmão Campana
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
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14
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Real-world outcomes of teriflunomide in relapsing–remitting multiple sclerosis: a prospective cohort study. J Neurol 2022; 269:4808-4816. [PMID: 35403875 PMCID: PMC8995164 DOI: 10.1007/s00415-022-11118-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/28/2022]
Abstract
Objectives To explore efficacy, risk factors, safety, and persistence of teriflunomide in relapsing–remitting multiple sclerosis (RRMS) cohort. Methods This prospective, observational cohort study included 217 consecutive teriflunomide treated RRMS patients, 192 of which with at least 3-month persistence on teriflunomide were included in effectiveness and risk factor analyses. Multivariate Cox proportional regression analysis was performed to identify factors associated with failure of no evidence of disease activity (NEDA) 3. Results At baseline 82% patients were treatment naïve while 18.0% interferon-β1b treated patients had stopped treatments for more than 1 year. After treatment, 79.0% patients achieved NEDA 3 at 12-month, mean annualized relapse rate (ARR) reduced significantly (0.79 ± 0.80 vs 0.16 ± 0.70; P < 0.001), and mean expanded disability status score (EDSS) remained stable (1.40 ± 1.67 vs 1.56 ± 1.88; P > 0.05). Male sex (hazard ratio [HR] 1.856; 95% confidence interval [CI] 1.118–3.082, P < 0.05), baseline EDSS score ≥ 4 (HR 2.682; 95% CI 1.375–5.231, P < 0.01), and frequent relapses before treatment (HR 3.056; 95% CI 1.737–5.377, P < 0.01) were independent factors significantly associated with failure of NEDA 3. The most frequent adverse events (AEs) were hair thinning, alanine aminotransferase (ALT) elevation, and leukopenia, the latter two most commonly lead to teriflunomide discontinuation during the first 3 months. Persistence rates at 6, 12, and 24 months after teriflunomide initiation were 86.9%, 72.4%, and 52.8%, respectively. Conclusions Our results support efficacy and tolerability of teriflunomide for treatment-naïve RRMS patients in real-world practice. Female patients, patients with less relapses and less disability before treatment are most likely to benefit from teriflunomide treatment.
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15
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A case of multiple sclerosis diagnosed with tuberculosis during teriflunomide therapy. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.875764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Racke MK, Frohman EM, Frohman T. Pain in Multiple Sclerosis: Understanding Pathophysiology, Diagnosis, and Management Through Clinical Vignettes. Front Neurol 2022; 12:799698. [PMID: 35095742 PMCID: PMC8794582 DOI: 10.3389/fneur.2021.799698] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
Neuropathic pain and other pain syndromes occur in the vast majority of patients with multiple sclerosis at some time during their disease course. Pain can become chronic and paroxysmal. In this review, we will utilize clinical vignettes to describe various pain syndromes associated with multiple sclerosis and their pathophysiology. These syndromes vary from central neuropathic pain or Lhermitte's phenomenon associated with central nervous system lesions to trigeminal neuralgia and optic neuritis pain associated with nerve lesions. Muscular pain can also arise due to spasticity. In addition, we will discuss strategies utilized to help patients manage these symptoms.
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Affiliation(s)
- Michael K Racke
- Department of Medical Affairs, Quest Diagnostics, Secaucus, NJ, United States
| | - Elliot M Frohman
- Neuroimmunology Laboratory of Lawrence Steinman, Stanford University School of Medicine, Stanford, CA, United States
| | - Teresa Frohman
- Neuroimmunology Laboratory of Lawrence Steinman, Stanford University School of Medicine, Stanford, CA, United States
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17
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Thrombotic Thrombocytopenic Purpura in Interferon Beta-1a-Treated Patient Diagnosed with Relapsing-Remitting Multiple Sclerosis: A Case Report. LIFE (BASEL, SWITZERLAND) 2022; 12:life12010080. [PMID: 35054473 PMCID: PMC8778067 DOI: 10.3390/life12010080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 12/04/2022]
Abstract
Background: Secondary thrombotic thrombocytopenic purpura (TTP) due to interferon beta-1a intramuscular (im) treatment is an uncommon adverse effect with only a few cases in multiple sclerosis patients reported worldwide. TTP together with haemolytic uremic syndrome (HUS) are classic forms of thrombotic microangiopathy, characterized by small-vessel platelet micro-thrombi that manifest clinically in a similar manner. Most common signs and symptoms include bruises and ecchymosis, neurologic symptoms and renal impairment. Interferon beta-1a represents one of the first-line therapies for relapsing-remitting multiple sclerosis due to its accessibility and efficacy. Case presentation: A 36-year-old woman who was previously diagnosed with relapsing-remitting multiple sclerosis had received weekly intramuscular injections with beta-interferon-1a (Avonex 30 mcg). After 9 months of treatment, she presented bruises and ecchymosis on her limbs and torso, epistaxis, gingival bleeding aggravated within 48 h and a persistent headache that was non-responsive to common analgesics. Haematology tests revealed typical results for thrombotic microangiopathy, including severe thrombocytopenia (4000/mm3) and microangiopathic haemolytic anaemia with frequent schistocytes on the peripheral blood smear. Once the beta-interferon administration was ceased and upon the initiation of methylprednisolone, the symptoms remitted. Conclusions: In this case study, we portrayed the particular association between the remission phase of multiple sclerosis and the violent onset of interferon-induced thrombotic thrombocytopenic purpura.
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Abrams AW, March A, Porat D, Bhayana K, Rensel M. Treatment Updates in Paediatric-onset Multiple Sclerosis. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A number of new disease-modifying therapies have recently been developed and approved for use in adult-onset multiple sclerosis. However, few treatment options are approved for patients with paediatric-onset multiple sclerosis. There are an increasing number of clinical trials evaluating the efficacy and safety of disease-modifying therapies in children and teens living with multiple sclerosis. Clinical trials are difficult to complete in rare diseases like paediatric-onset multiple sclerosis; however, it is critical to assess safety and monitoring in this vulnerable population by applying robust research methodology to randomized controlled clinical trials. Longer-term extension analyses are also needed to better evaluate the efficacy, dosing and long-term safety of adult disease-modifying therapy for use in paediatric-onset multiple sclerosis. Future research should focus on defining optimal first-line disease-modifying therapy in paediatric-onset multiple sclerosis as related to both efficacy and safety, improving recruitment and completion rates of clinical trials, identifying relevant biomarkers of disease activity, analysing outcome measures related to treatment response and assessing long-term safety for this unique population living with a chronic disease.
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19
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Ferreira CM, de Vasconcelos-Pereira EF, de Oliveira VM, Salgado PR, Domingos JA, Monreal MTFD, Guerra-Shinohara EM, Gubert VT. Hepatotoxicity associated with the use of teriflunomide in a patient with multiple sclerosis: A case report. Medicine (Baltimore) 2021; 100:e28246. [PMID: 34941096 PMCID: PMC8701948 DOI: 10.1097/md.0000000000028246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/25/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Teriflunomide is an inhibitor of pyrimidine synthesis available as a first-line treatment for relapsing-remitting multiple sclerosis. Drug-induced liver damage is a relevant problem in clinical practice, representing a frequent cause of treatment discontinuation. This case report describes the occurrence of liver injury, with a 33.7-fold increase in the upper limit of normality of the liver enzyme alanine aminotransferase during treatment with teriflunomide 14 mg. PATIENT CONCERN A 44-year-old woman receiving teriflunomide 14 mg for the treatment of multiple sclerosis presented symptoms suggestive of liver dysfunction 54 days after starting treatment. The patient had no history of using disease-modifying therapy, neither previous liver disease nor other comorbidities. DIAGNOSTICS The suggested diagnosis was drug-induced liver injury, classified as hepatocellular. Other possible hepatic and autoimmune etiologies were ruled out. INTERVENTIONS Replacement of teriflunomide treatment with glatiramer acetate and follow-up of the disease. OUTCOMES Signs and symptoms regressed after treatment with teriflunomide 14 mg was discontinued, with normalization of liver enzyme activity in ∼5 months. The causality assessment of the adverse drug reaction was determined by the Naranjo scaling system, resulting in probable, with a final score of 7. CONCLUSIONS Teriflunomide-induced liver injury in patients with multiple sclerosis is a serious adverse reaction. The report of this case contributes to updating knowledge about the safety aspects of treatment with teriflunomide and planning of monitoring strategies and patient risk management.
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Affiliation(s)
- Cristiane Munaretto Ferreira
- Pharmacy Post-Graduation Program, Faculty Pharmaceutical Sciences, Food and Nutrition, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
- Pharmacy School Profª Ana Maria Cervantes Baraza, Faculty Pharmaceutical Sciences, Food and Nutrition, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
| | - Erica Freire de Vasconcelos-Pereira
- Pharmacy School Profª Ana Maria Cervantes Baraza, Faculty Pharmaceutical Sciences, Food and Nutrition, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
| | - Vanessa Marcon de Oliveira
- Pharmacy School Profª Ana Maria Cervantes Baraza, Faculty Pharmaceutical Sciences, Food and Nutrition, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
| | - Pedro Rippel Salgado
- Faculty of Medicine, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
| | - João Américo Domingos
- Faculty of Medicine, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
| | - Maria Tereza Ferreira Duenhas Monreal
- Pharmacy School Profª Ana Maria Cervantes Baraza, Faculty Pharmaceutical Sciences, Food and Nutrition, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
| | - Elvira Maria Guerra-Shinohara
- Pharmacy Post-Graduation Program, Faculty Pharmaceutical Sciences, Food and Nutrition, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
| | - Vanessa Terezinha Gubert
- Pharmacy Post-Graduation Program, Faculty Pharmaceutical Sciences, Food and Nutrition, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
- Pharmacy School Profª Ana Maria Cervantes Baraza, Faculty Pharmaceutical Sciences, Food and Nutrition, Federal University of Mato Grosso do Sul, Campo Grande – MS, Brazil
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20
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Zhou R, Li H, Yang H, Jiang F, Cai H, Li J, Chen S, Fang L, Yin J, Zeng Q. Serological markers exploration and real-world effectiveness and safety of teriflunomide in south Chinese patients with multiple sclerosis. Mult Scler Relat Disord 2021; 58:103446. [PMID: 34929454 DOI: 10.1016/j.msard.2021.103446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Since September 2012, when teriflunomide was approved as a disease-modifying treatment for relapsing multiple sclerosis, real-world observational studies on teriflunomide in Chinese patients are limited. METHODS We collected demographic characteristics and peripheral blood samples at different time points. Clinical symptoms, magnetic resonance imaging data, and concentrations of neurofilament light chains and multiple cytokines at different time points were compared to assess the efficacy. Moreover, the safety was assessed by blood routine, liver and kidney function, and a questionnaire to report adverse reactions. RESULTS Teriflunomide significantly reduced serum levels of neurofilament light chains and several inflammatory cytokines. After accepting teriflunomide treatment, many clinical symptoms improved, scores of the expanded disability status scale decreased from 2.0 to 1.75, and annualized relapse rates decreased from 1.45 to 0.31. 29 (80.56%) and 15 (78.95%) patients achieved the no evidence of disease activity-3 status after 6 months and 12 months treatment, respectively. Teriflunomide was associated with mild or moderate discomfort, and discontinuation rates due to adverse events were low. CONCLUSION Serum neurofilament light chain protein is sensitive to teriflunomide treatment, suggesting that it has the potential to be used as an indicator to assess the efficacy of teriflunomide. Teriflunomide can significantly reduce the concentrations of inflammatory cytokines, indicating that teriflunomide may regulate neuroinflammation through the inhibitory effect on a variety of immune cells and their cytokines. Teriflunomide can improve clinical symptoms and disease severity in MS patients in southern China, and patients have good compliance.
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Affiliation(s)
- Ran Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Hongliang Li
- The First Affiliated Hospital, Hunan University of Chinese Medicine, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Fei Jiang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Haobing Cai
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Jing Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Si Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Liangjuan Fang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Jun Yin
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qiuming Zeng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
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21
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Miller AE. An updated review of teriflunomide's use in multiple sclerosis. Neurodegener Dis Manag 2021; 11:387-409. [PMID: 34486382 DOI: 10.2217/nmt-2021-0014] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Teriflunomide, a once daily, oral disease-modifying therapy, has demonstrated consistent efficacy, safety and tolerability in patients with relapsing forms of multiple sclerosis (MS) and with a first clinical episode suggestive of MS treated up to 12 years. This review is an update to a previous version that examined data from the teriflunomide core clinical development program and extension studies. Data have since become available from active comparator trials with other disease-modifying therapies, treatment-related changes in brain volume (analyzed using structural image evaluation using normalization of atrophy) and real-world evidence including patient-reported outcomes. Initial data on the potential antiviral effects of teriflunomide in patients with MS, including case reports of patients infected with the 2019 novel coronavirus (SARS-CoV-2), are also presented.
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA
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22
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Papeix C, Donze C, Lebrun-Frénay C. Infections and multiple sclerosis: Recommendations from the French Multiple Sclerosis Society. Rev Neurol (Paris) 2021; 177:980-994. [PMID: 34303537 DOI: 10.1016/j.neurol.2021.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/29/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Viral, bacterial, or fungal infections are suspected of triggering multiple sclerosis (MS) and promoting relapses of the disease and are likely to be promoted by immune-active treatments. This raises questions about the infectious workup and preventive treatment of these infections prior to their initiation. OBJECTIVES To establish recommendations on infections and MS. Provide information to patients and healthcare professionals on the minimal infectious workup to be performed in an MS patient at diagnosis and prior to initiation of immuno-active therapy in MS. METHODS The recommendation attempts to answer four main questions about infections and MS. The French Group for Recommendations in Multiple Sclerosis (France4MS) did a systematic review of articles from PubMed and universities databases (from January 1975 to June 2020), using the RAND/UCLA formalized consensus method. The RAND/UCLA method has been developed to synthesize the scientific literature and expert opinions on health care topics and was used for reaching a formal agreement. Twenty-three experts contributed to the detailed review and a group of 63 multidisciplinary health professionals validated the final version of 36 recommendations. RESULTS It is recommended that MS patients undergo a minimal infectious workup, check their vaccination status at diagnosis, and repeat it during follow-up and before starting immunotherapy. Screening and preventive treatment of viral (group Herpes virus, HPV, JCV, HCV, HBV), bacterial (mycobacteria) and fungal (Cryptococcus) infections is recommended prior to the initiation of certain immuno-active MS therapies. DISCUSSION AND CONCLUSIONS At diagnosis of MS and prior to the choice of therapeutic strategy, it is recommended to update the vaccination schedule of MS patients in reference to the HCSP vaccination schedule and the SFSEP recommendations. Before starting immunosuppressive treatment, it is recommended to inform patients of the risks of infections and to look for a constitutive or acquired immune deficiency. Health professionals and patients should be informed of the updated recommendations on infections and MS.
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Affiliation(s)
- C Papeix
- Département de neurologie, CRCSEP-Paris, Sorbonne Université, Hôpital de la Pitié salpêtrière, AP-HP 6, Paris 75013, France.
| | - C Donze
- Faculté de médecine et de maïeutique de Lille, hôpital Saint-Philibert, groupement des hôpitaux de l'institut catholique de Lille, Lomme, France
| | - C Lebrun-Frénay
- URC2A, Cote d'Azur University, CRCSEP-Côte d'Azur, neurologie, Hôpital Pasteur2, CHU Nice, France
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23
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Pavelek Z, Sobíšek L, Šarláková J, Potužník P, Peterka M, Štětkárová I, Štourač P, Mareš J, Hradílek P, Ampapa R, Grünermelová M, Vachová M, Recmanová E, Angelucci F, Halúsková S, Vališ M. Comparison of Therapies in MS Patients After the First Demyelinating Event in Real Clinical Practice in the Czech Republic: Data From the National Registry ReMuS. Front Neurol 2021; 11:593527. [PMID: 33510704 PMCID: PMC7835499 DOI: 10.3389/fneur.2020.593527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/08/2020] [Indexed: 01/25/2023] Open
Abstract
Background: Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system. Well-established drugs used for MS patients after the first demyelinating event in the Czech Republic include glatiramer acetate (GA), interferon beta-1a (IFNβ-1a), IFN beta-1b (IFNβ-1b), peginterferon beta-1a (peg-IFNβ-1a), and teriflunomide. Objective: The objective of this observational study was to compare the effectiveness of the abovementioned drugs in patients with MS who initiated their therapy after the first demyelinating event. Patients were followed for up to 2 years in real clinical practice in the Czech Republic. Methods: A total of 1,654 MS patients treated after the first demyelinating event and followed up for 2 years were enrolled. Evaluation parameters (endpoints) included the annualized relapse rate (ARR), time to next relapse, change in the Expanded Disability Status Scale (EDSS) score, and time of confirmed disease progression (CDP). When patients ended the therapy before the observational period, the reason for ending the therapy among different treatments was compared. Results: No significant difference was found among the groups of patients treated with IFNβ-1a/1b, GA, or teriflunomide for the following parameters: time to the first relapse, change in the EDSS score, and the proportion of patients with CDP. Compared to IFNβ-1a (44 mcg), a significant increase in the percentage of relapse-free patients was found for GA, but this treatment effect was not confirmed by the validation analysis. Compared to the other drugs, there was a significant difference in the reasons for terminating GA therapy. Conclusion: Small differences were found among GA, IFNβ and teriflunomide therapies, with no significant impact on the final outcome after 2 years. Therefore, in clinical practice, we recommend choosing the drug based on individual potential risk from long-term therapy and on patient preferences and clinical characteristics.
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Affiliation(s)
- Zbyšek Pavelek
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Lukáš Sobíšek
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Jana Šarláková
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Pavel Potužník
- Department of Neurology, Faculty of Medicine and University Hospital Plzen, Charles University in Prague, Plzeň, Czechia
| | - Marek Peterka
- Department of Neurology, Faculty of Medicine and University Hospital Plzen, Charles University in Prague, Plzeň, Czechia
| | - Ivana Štětkárová
- Third Faculty of Medicine, Charles University and Hospital Kralovské Vinohrady, Charles University in Prague, Prague, Czechia
| | - Pavel Štourač
- Department of Neurology, University Hospital and Masaryk University, Brno, Czechia
| | - Jan Mareš
- Department of Neurology, Faculty of Medicine, Palacky University and University Hospital Olomouc, Olomouc, Czechia
| | - Pavel Hradílek
- Clinic of Neurology, University Hospital Ostrava, Ostrava, Czechia
| | - Radek Ampapa
- Department of Neurology, Hospital of Jihlava, Jihlava, Czechia
| | | | - Marta Vachová
- Department of Neurology, KZ a.s., Hospital Teplice, Teplice, Czechia
| | - Eva Recmanová
- Department of Neurology, Tomas Bata Regional Hospital, Zlín, Czechia
| | - Francesco Angelucci
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia.,Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
| | - Simona Halúsková
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Martin Vališ
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
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24
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de Sèze J, Devy R, Planque E, Delabrousse-Mayoux JP, Vandhuick O, Kabir M, Gherib A. Fatigue in teriflunomide-treated patients with relapsing remitting multiple sclerosis in the real-world Teri-FAST study. Mult Scler Relat Disord 2020; 47:102659. [PMID: 33291032 DOI: 10.1016/j.msard.2020.102659] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/04/2020] [Accepted: 11/25/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fatigue is a frequent and disabling symptom of multiple sclerosis (MS) often associated with impaired quality of life (QoL) in patients. Teriflunomide is a once-daily oral immunomodulator used for the treatment of relapsing remitting forms of MS. However, its effect on fatigue is not well known in real life practice. We evaluated the impact of teriflunomide on fatigue in patients with relapsing remitting MS (RRMS) after 2 years of treatment in the real-world Teri-FAST study. METHODS Teri-FAST was a 2-year, prospective, observational study conducted in France in RRMS patients treated with teriflunomide 14 mg. Fatigue was assessed using the French version of the modified fatigue impact scale (EMIF-SEP). The primary endpoint was the change from baseline in EMIF-SEP score after 2 years of treatment. Secondary endpoints included evaluation of depression (Beck Depression Inventory [BDI]), health-related QoL (Two-Life Scale TLS-QoL 10), self-reported physical activity, and adverse events. RESULTS 210 eligible patients were included in the study with a mean age of 45.4 years and a mean ± SD Expanded Disability Status Scale score of 1.76 ± 1.43 at baseline. About half (52.4%) of patients had no previous treatment for MS. In the 163 patients who completed at least 1 follow-up visit, the mean change in EMIF-SEP score at Year 2 was -1.54 (95% CI: -4.02, 0.94) indicating that fatigue remained stable. Similarly, there were no changes in depression level and QoL after 2 years of treatment. Physical activity slightly improved with 57% of patients reporting being physically active after 2 years as compared to 46% at baseline. The safety profile of teriflunomide was consistent with that seen during clinical development, and compliance with treatment was high. CONCLUSION Fatigue scores remained stable in RRMS patients treated with teriflunomide 14 mg over 2 years in real-life setting. Teriflunomide did not negatively impact depression or QoL.
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Affiliation(s)
- Jérôme de Sèze
- Strasbourg University, Hôpital Civil, Strasbourg, France.
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25
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Miller AE, Olsson TP, Wolinsky JS, Comi G, Kappos L, Hu X, Xu X, Lublin AL, Truffinet P, Chavin J, Delhay JL, Benamor M, Purvis A, Freedman MS. Long-term safety and efficacy of teriflunomide in patients with relapsing multiple sclerosis: Results from the TOWER extension study. Mult Scler Relat Disord 2020; 46:102438. [DOI: 10.1016/j.msard.2020.102438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 10/23/2022]
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26
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LeSaint KT, Waksman J, Smollin CG. A case of teriflunomide-induced hepatic injury: assessing causality using available rules. TOXICOLOGY COMMUNICATIONS 2020. [DOI: 10.1080/24734306.2020.1835413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Kathy T. LeSaint
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Division, California Poison Control System, San Francisco, CA, USA
| | - Javier Waksman
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Craig G. Smollin
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Division, California Poison Control System, San Francisco, CA, USA
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27
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Peyro-Saint-Paul L, Derache N, Ficheux M, Allouche S, Parienti JJ, Calocer F, Le Caignec F, Fedrizzi S, Defer G. Severe bone pain with teriflunomide: Five case reports and review of the French pharmacovigilance database. Therapie 2020; 75:503-506. [DOI: 10.1016/j.therap.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/06/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
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28
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Jakimovski D, Vaughn CB, Eckert S, Zivadinov R, Weinstock-Guttman B. Long-term drug treatment in multiple sclerosis: safety success and concerns. Expert Opin Drug Saf 2020; 19:1121-1142. [PMID: 32744073 DOI: 10.1080/14740338.2020.1805430] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The portfolio of multiple sclerosis (MS) disease modifying treatments (DMTs) has significantly expanded over the past two decades. Given the lifelong use of MS pharmacotherapy, understanding their long-term safety profiles is essential in determining suitable and personalized treatment. AREAS COVERED In this narrative review, we summarize the short-, mid-, and long-term safety profile of currently available MS DMTs categories. In addition to the initial trial findings, safety outcomes derived from long-term extension studies (≥5-20 years) and safety-based prescription programs have been reviewed. In order to better understand the risk-benefit ratio for each particular DMT group, a short description of the DMT-based efficacy outcomes has been included. EXPERT OPINION Long-term extension trials, large observational studies and real-world databases allow detection of rare and potentially serious adverse events. Two-year-long trials are unable to fully capture the positive and negative effects of immune system modulation and reconstitution. DMT-based monitoring programs can provide greater insights regarding safe use of MS medications in different patient populations and clinical settings. During the process of shared DMT decision, both MS care providers and their patients should be aware of an ever-expanding number of drug-based adverse events and their influence on the risk-benefit analysis.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo, NY, USA
| | - Caila B Vaughn
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
| | - Svetlana Eckert
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo, NY, USA.,Translational Imaging Center at Clinical Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Stat37$e University of New York , Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
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29
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What are the infectious risks with disease-modifying drugs for multiple sclerosis and how to reduce them? A review of literature. Rev Neurol (Paris) 2020; 176:235-243. [DOI: 10.1016/j.neurol.2019.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 08/05/2019] [Accepted: 08/28/2019] [Indexed: 11/21/2022]
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30
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Förster M, Küry P, Aktas O, Warnke C, Havla J, Hohlfeld R, Mares J, Hartung HP, Kremer D. Managing Risks with Immune Therapies in Multiple Sclerosis. Drug Saf 2020; 42:633-647. [PMID: 30607830 DOI: 10.1007/s40264-018-0782-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Since the introduction of the interferons in the 1990s, a multitude of different immunomodulatory and immunosuppressant disease-modifying therapies for multiple sclerosis (MS) have been developed. They have all shown positive effects on clinical endpoints such as relapse rate and disease progression and are a heterogeneous group of therapeutics comprising recombinant pegylated and non-pegylated interferon-β variants, peptide combinations, monoclonal antibodies, and small molecules. However, they have relevant side effect profiles, which necessitate thorough monitoring and straightforward patient education. In individual cases, side effects can be severe and potentially life-threatening, which is why knowledge about (neurological and non-neurological) adverse drug reactions is essential for prescribing neurologists as well as general practitioners. This paper aims to provide an overview of currently available MS therapies, their modes of action and safety profiles, and the necessary therapy monitoring.
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Affiliation(s)
- Moritz Förster
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Patrick Küry
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Clemens Warnke
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilian-Universität München, Munich, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilian-Universität München, Munich, Germany.,The Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Jan Mares
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - David Kremer
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
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31
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Chisari CG, Toscano S, D’Amico E, Lo Fermo S, Zanghì A, Arena S, Zappia M, Patti F. An update on the safety of treating relapsing-remitting multiple sclerosis. Expert Opin Drug Saf 2019; 18:925-948. [DOI: 10.1080/14740338.2019.1658741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Clara G. Chisari
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Simona Toscano
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Emanuele D’Amico
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Salvatore Lo Fermo
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Aurora Zanghì
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Sebastiano Arena
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Mario Zappia
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Francesco Patti
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
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32
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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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Teriflunomide real-world evidence: Global differences in the phase 4 Teri-PRO study. Mult Scler Relat Disord 2019; 31:157-164. [DOI: 10.1016/j.msard.2019.03.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/21/2019] [Accepted: 03/28/2019] [Indexed: 11/23/2022]
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Long-term outcomes with teriflunomide in patients with clinically isolated syndrome: Results of the TOPIC extension study ★★. Mult Scler Relat Disord 2019; 33:131-138. [PMID: 31195337 DOI: 10.1016/j.msard.2019.05.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/20/2019] [Accepted: 05/22/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND In the phase 3 TOPIC study, teriflunomide significantly reduced the risk of relapse determining conversion to clinically definite multiple sclerosis (CDMS) in patients with clinically isolated syndrome, versus placebo. We assessed clinical and safety outcomes associated with extended teriflunomide treatment in the TOPIC extension study. METHODS Patients who completed the TOPIC core study (including those still on study at early termination) or converted to CDMS after at least 24 weeks in the core study were eligible to participate in the extension. The primary efficacy endpoint in the extension was time to conversion to CDMS. RESULTS Risk of relapse determining conversion to CDMS was 47.1% lower in patients treated with teriflunomide 14 mg during the core and extension studies compared with patients treated with placebo during the core study and teriflunomide 14 mg during the extension. The incidence of adverse events was 75.8% and 81.9% for 7 and 14 mg teriflunomide, respectively. CONCLUSIONS Reduced risk of relapse determining conversion to CDMS in patients with early MS receiving teriflunomide 14 mg in the core study remained throughout the extension supporting the benefits of early treatment. No new safety signals were observed for teriflunomide 7 or 14 mg.
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Reis J, Duarte S, Sardoeira A, Santos E, Sanches M, Lobo I, Selores M. Case report of recalcitrant allergic contact eczema successfully treated with teriflunomide. Dermatol Ther 2019; 32:e12947. [PMID: 31025527 DOI: 10.1111/dth.12947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/25/2019] [Accepted: 04/05/2019] [Indexed: 11/27/2022]
Abstract
Allergic contact dermatitis (ACD) is a type IV, delayed-type reaction caused by skin contact with low-molecular-weight organic chemicals and metal ions that activate antigen-specific T cells, primarily T-helper 1 (Th1), in a sensitized individual, leading to skin eczema.First-line treatments are based on avoidance of causal agents and topical corticosteroids/immunomodulators. In recalcitrant cases, chronic oral immunosuppressive agents may be used, but they may have serious adverse effects and do not address the immunological disfunction. We report a case of severe ACD, unresponsive to topical or oral immunosuppressive therapy, which resolved itself after treatment with teriflunomide (TF) 14 mg/daily used for multiple sclerosis. TF is a once-daily, oral selective and reversible dihydroorotate dehydrogenase inhibitor, revealing a new treatment option for ACD.
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Affiliation(s)
- Joel Reis
- Department of Dermatology, Centro Hospitalar Universitário do Porto, Portugal
| | - Sara Duarte
- Department of Neurology, Centro Hospitalar Universitário do Porto, Portugal
| | - Ana Sardoeira
- Department of Neurology, Centro Hospitalar Universitário do Porto, Portugal
| | - Ernestina Santos
- Department of Neurology, Centro Hospitalar Universitário do Porto, Portugal
| | - Madalena Sanches
- Department of Dermatology, Centro Hospitalar Universitário do Porto, Portugal
| | - Inês Lobo
- Department of Dermatology, Centro Hospitalar Universitário do Porto, Portugal
| | - Manuela Selores
- Department of Dermatology, Centro Hospitalar Universitário do Porto, Portugal
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Xu Y, Mao N, Chirikov V, Du F, Yeh YC, Liu L, Liu R, Gao X. Cost-effectiveness of Teriflunomide Compared to Interferon Beta-1b for Relapsing Multiple Sclerosis Patients in China. Clin Drug Investig 2019; 39:331-340. [PMID: 30684251 PMCID: PMC6400872 DOI: 10.1007/s40261-019-00750-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background and Objective Teriflunomide is a once-daily oral immunomodulatory agent approved in 80 countries for the treatment of patients with relapsing multiple sclerosis (RMS). The study objective was to estimate the cost effectiveness of teriflunomide (14 mg tablet, daily) versus interferon beta-1b (250 mcg subcutaneous injection, every other day) among RMS patients from the Chinese healthcare system perspective. Methods A Markov model with annual cycles and a lifetime horizon was utilized to assess cost-effectiveness of teriflunomide in comparison with interferon beta-1b in RMS patients. Treatment effects, including 3-month confirmed disability worsening and annualized relapse rate, were derived from a network meta-analysis. Cost inputs included costs related to treatment acquisition, administration, monitoring, natural disease management through Expanded Disability Status Scale states, relapse treatment, and adverse event management. These costs were calculated as the product between unit costs from published sources and healthcare resource utilization patterns identified in a survey conducted among 11 neurologists across different areas in China. Health effects were expressed as quality-adjusted life years (QALYs) with costs in local currency (¥) and US dollars (US$), 2018. Results Teriflunomide dominated interferon beta-1b and was associated with lower total costs (teriflunomide ¥1,887,144 vs interferon beta-1b ¥2,061,393) and higher QALYs (teriflunomide 9.60 QALYs vs interferon beta-1b 8.88 QALYs). In probabilistic sensitivity analysis, teriflunomide was dominant in 62.2% of model runs. Conclusion Teriflunomide is a cost-effective therapy over a lifetime time horizon compared to interferon beta-1b in the treatment of RMS patients in China. Results should be interpreted with caution as head-to-head comparisons are not available. Electronic supplementary material The online version of this article (10.1007/s40261-019-00750-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yan Xu
- Peking Union Medical College Hospital, Beijing, China
| | | | - Viktor Chirikov
- Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD, 20814, USA.
| | - Fen Du
- Pharmerit (Shanghai) Company Limited, Shanghai, China
| | | | | | | | - Xin Gao
- Pharmerit (Shanghai) Company Limited, Shanghai, China
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Deleu D, Mesraoua B, Canibaño B, Melikyan G, Al Hail H, El-Sheikh L, Ali M, Al Hussein H, Ibrahim F, Hanssens Y. Oral disease-modifying therapies for multiple sclerosis in the Middle Eastern and North African (MENA) region: an overview. Curr Med Res Opin 2019; 35:249-260. [PMID: 29764226 DOI: 10.1080/03007995.2018.1476334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND The introduction of new disease-modifying therapies (DMTs) for remitting-relapsing multiple sclerosis (RRMS) has considerably transformed the landscape of therapeutic opportunities for this chronic disabling disease. Unlike injectable drugs, oral DMTs promote patient satisfaction and increase therapeutic adherence. REVIEW This article reviews the salient features about the mode of action, efficacy, safety, and tolerability profile of approved oral DMTs in RRMS, and reviews their place in clinical algorithms in the Middle East and North Africa (MENA) region. A systematic review was conducted using a comprehensive search of MEDLINE, PubMed, Cochrane Database of Systematic Reviews (period January 1, 1995-January 31, 2018). Additional searches of the American Academy of Neurology and European Committee for Treatment and Research in Multiple Sclerosis abstracts from 2012-2017 were performed, in addition to searches of the Food and Drug Administration and European Medicines Agency websites, to obtain relevant safety information on these DMTs. CONCLUSIONS Four oral DMTs: fingolimod, teriflunomide, dimethyl fumarate, and cladribine have been approved by the regulatory agencies. Based on the number needed to treat (NNT), the potential role of these DMTs in the management of active and highly active or rapidly evolving RRMS is assessed. Finally, the place of the oral DMTs in clinical algorithms in the MENA region is reviewed.
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Affiliation(s)
- Dirk Deleu
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Boulenouar Mesraoua
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Beatriz Canibaño
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Gayane Melikyan
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Hassan Al Hail
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Lubna El-Sheikh
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Musab Ali
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Hassan Al Hussein
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Faiza Ibrahim
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Yolande Hanssens
- b Department of Clinical Services Unit , Corporate Pharmacy, Hamad Medical Corporation , Doha , State of Qatar
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Negrotto L, Correale J. Palmar pustular psoriasis associated with teriflunomide treatment. Mult Scler Relat Disord 2019; 27:400-402. [DOI: 10.1016/j.msard.2018.11.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 11/04/2018] [Accepted: 11/18/2018] [Indexed: 01/18/2023]
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Qiu W, Huang DH, Hou SF, Zhang MN, Jin T, Dong HQ, Peng H, Zhang CD, Zhao G, Huang YN, Zhou D, Wu WP, Wang BJ, Li JM, Zhang XH, Cheng Y, Li HF, Li L, Lu CZ, Zhang X, Bu BT, Dong WL, Fan DS, Hu XQ, Xu XH. Efficacy and Safety of Teriflunomide in Chinese Patients with Relapsing Forms of Multiple Sclerosis: A Subgroup Analysis of the Phase 3 TOWER Study. Chin Med J (Engl) 2018; 131:2776-2784. [PMID: 30511679 PMCID: PMC6278187 DOI: 10.4103/0366-6999.246067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Disease-modifying therapy is the standard treatment for patients with multiple sclerosis (MS) in remission. The primary objective of the current analysis was to assess the efficacy and safety of two teriflunomide doses (7 mg and 14 mg) in the subgroup of Chinese patients with relapsing MS included in the TOWER study. Methods TOWER was a multicenter, multinational, randomized, double-blind, parallel-group (three groups), placebo-controlled study. This subgroup analysis includes 148 Chinese patients randomized to receive either teriflunomide 7 mg (n = 51), teriflunomide 14 mg (n = 43), or placebo (n = 54). Results Of the 148 patients in the intent-to-treat population, adjusted annualized relapse rates were 0.63 (95% confidence interval [CI]: 0.44, 0.92) in the placebo group, 0.48 (95% CI: 0.33, 0.70) in the teriflunomide 7 mg group, and 0.18 (95% CI: 0.09, 0.36) in the teriflunomide 14 mg group; this corresponded to a significant relative risk reduction in the teriflunomide 14 mg group versus placebo (-71.2%, P = 0.0012). Teriflunomide 14 mg also tended to reduce 12-week confirmed disability worsening by 68.1% compared with placebo (hazard ratio: 0.319, P = 0.1194). There were no differences across all treatment groups in the proportion of patients with treatment-emergent adverse events (TEAEs; 72.2% in the placebo group, 74.5% in the teriflunomide 7 mg group, and 69.8% in the teriflunomide 14 mg group); corresponding proportions for serious adverse events were 11.1%, 3.9%, and 11.6%, respectively. The most frequently reported TEAEs with teriflunomide versus placebo were neutropenia, increased alanine aminotransferase, and hair thinning. Conclusions Teriflunomide was as effective and safe in the Chinese subpopulation as it was in the overall population of patients in the TOWER trial. Teriflunomide has the potential to meet unmet medical needs for MS patients in China. Trial Registration ClinicalTrials.gov, NCT00751881; https://clinicaltrials.gov/ct2/show/NCT00751881?term=NCT00751881&rank=1.
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Affiliation(s)
- Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510000, China
| | - De-Hui Huang
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Shi-Fang Hou
- Department of Neurology, Beijing Hospital, Beijing 100730, China
| | - Mei-Ni Zhang
- Department of Neurology, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi 030001, China
| | - Tao Jin
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130012, China
| | - Hui-Qing Dong
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Hua Peng
- Department of Neurology, Shanghai Chang Zheng Hospital, Shanghai 200003, China
| | - Chao-Dong Zhang
- Department of Neurology, The First Hospital of China Medical University, Shenyang, Liaoning 110000, China
| | - Gang Zhao
- Department of Neurology, Fourth Military Medical University, Xi'an, Shaanxi 710001, China
| | - Yi-Ning Huang
- Department of Neurology, Peking University First Hospital, Beijing 100034, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Wei-Ping Wu
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Bao-Jun Wang
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia 014040, China
| | - Ji-Mei Li
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing 100000, China
| | - Xing-Hu Zhang
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
| | - Yan Cheng
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Hai-Feng Li
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Ling Li
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei 050051, China
| | - Chuan-Zhen Lu
- Department of Neurology, Hua Shan Hospital of the Shanghai Fudan University Medical College, Shanghai 200040, China
| | - Xu Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Bi-Tao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Wan-Li Dong
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, China
| | - Dong-Sheng Fan
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Beijing 100083, China
| | - Xue-Qiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510000, China
| | - Xian-Hao Xu
- Department of Neurology, Beijing Hospital, Beijing 100730, China
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Lebrun C, Bertagna M, Bresch S, Cohen M. Digestive side-effects with teriflunomide: Thoughts on lactose. Rev Neurol (Paris) 2018; 174:722-725. [DOI: 10.1016/j.neurol.2017.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/25/2017] [Accepted: 11/20/2017] [Indexed: 12/21/2022]
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Hendin Travis L, Okai A, Cavalier S, Stam D, Farnett L, Edwards KR. Real-World Observational Evaluation of Hair Thinning in Patients with Multiple Sclerosis Receiving Teriflunomide: Is It an Issue in Clinical Practice? Neurol Ther 2018; 7:341-347. [PMID: 30084001 PMCID: PMC6283787 DOI: 10.1007/s40120-018-0107-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Hair thinning occurred in 10-14% of teriflunomide-treated patients in the teriflunomide multiple sclerosis clinical development program, compared with 5% of placebo-treated patients. Our objective was to examine the clinical course of hair thinning in patients in an observational real-world project. METHODS Patients with relapsing-remitting multiple sclerosis who reported hair thinning to healthcare professionals (HCPs) during treatment with teriflunomide were eligible for inclusion. During two office visits, one at onset of hair thinning and another at follow-up, HCPs and patients completed questionnaires that categorized hair thinning as mild, moderate, or severe, or from 0 (no hair thinning) to 10 (very severe hair thinning), respectively. At the follow-up visit, patients also rated the degree of recovery. Patients were photographed at both visits with a standardized protocol and camera. RESULTS Of the 38 patients who completed follow-up, most were women (97%) without prior history of hair thinning (87%), with the majority (68%) receiving concomitant medications potentially associated with hair thinning. The mean time to onset of hair thinning was 77 days after the first teriflunomide dose. HCPs classified the majority of hair thinning events as mild (63%) or moderate (34%), with one event classified as severe (3%). The mean patient severity perception was 5/10, and complete/near-complete resolution or marked improvement was reported by 79% of patients. CONCLUSION Consistent with observations from the teriflunomide clinical program, hair thinning was usually mild and occurred within the first 3 months of treatment, with most patients fully recovering while remaining on teriflunomide treatment. As with any potential adverse event, it is important to ensure appropriate expectations through patient education before treatment. FUNDING Sanofi.
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Affiliation(s)
| | - Annette Okai
- Multiple Sclerosis Treatment Center of Dallas, Dallas, TX, USA
| | | | | | | | - Keith R Edwards
- Multiple Sclerosis Center of Northeastern New York, Latham, NY, USA
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Janakiraman K, Krishnaswami V, Rajendran V, Natesan S, Kandasamy R. Novel nano therapeutic materials for the effective treatment of rheumatoid arthritis-recent insights. MATERIALS TODAY. COMMUNICATIONS 2018; 17:200-213. [PMID: 32289062 PMCID: PMC7104012 DOI: 10.1016/j.mtcomm.2018.09.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 05/02/2023]
Abstract
Rheumatoid arthritis (RA) is the most common complex multifactorial joint related autoimmune inflammatory disease with unknown etiology accomplished with increased cardiovascular risks. RA is characterized by the clinical findings of synovial inflammation, autoantibody production, and cartilage/bone destruction, cardiovascular, pulmonary and skeletal disorders. Pro-inflammatory cytokines such as IL-1, IL-6, IL-8, and IL-10 were responsible for the induction of inflammation in RA patients. Drawbacks such as poor efficacy, higher doses, frequent administration, low responsiveness, and higher cost and serious side effects were associated with the conventional dosage forms for RA treatment. Nanomedicines were recently gaining more interest towards the treatment of RA, and researchers were also focusing towards the development of various anti-inflammatory drug loaded nanoformulations with an aid to both actively/passively targeting the inflamed site to afford an effective treatment regimen for RA. Alterations in the surface area and nanoscale size of the nanoformulations elicit beneficial physical and chemical properties for better pharmacological activities. These drug loaded nanoformulations may enhances the solubility of poorly water soluble drugs, improves the bioavailability, affords targetability and may improve the therapeutic activity. In this regimen, the present review focus towards the novel nanoparticulate formulations (nanoparticles, nanoemulsions, solid lipid nanoparticles, nanomicelles, and nanocapsules) utilized for the treatment of RA. The recent advancements such as siRNA, peptide and targeted based nanoparticulate systems for RA treatment were also discussed. Special emphasis was provided regarding the pathophysiology, prevalence and symptoms towards the development of RA.
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Key Words
- A-SLN, actarit loaded solid lipid nanoparticles
- ACF-SLN, aceclofenac loaded solid lipid nanoparticles
- AIA, antigen-induced arthritis
- ALP, alkaline phosphate
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- C-SLN, curcumin loaded solid lipid nanoparticles
- CEL-TS-LN, celecoxib loaded tristearin based lipidic nanoparticles
- CFA, complete freund’s adjuvant
- CHNP, chitosan nanoparticle
- CLSM, confocal laser scanning microscopy
- COX- 1, cyclooxygenase - 1
- COX- 2, cyclooxygenase - 2
- DEX, dexamethasone
- DEX-PMs, dexamethasone-loaded polymeric micelles
- DMARD, disease modifying antirheumatic drugs
- FA, folic acid
- FR-β, folate receptor-beta
- GC, glucocorticoid
- HA- AuNP/TCZ, hyaluronate gold nanoparticle/Tocilizumab
- HEKcells, human embryonic kidney cells
- HSA-NCs, human serum albumin nanocapsules
- HUVEC, human umbilical vein cells
- IL, interleukin
- IND-NMs, indomethacin loaded polymeric micelles
- Ig, immunoglobulin
- Ind-NCs, indomethacin-loaded nanocapsules
- Inflammation
- LDE, lipidic nanoemulsion
- LX-NMs, larnoxicam loaded nanomicelles
- MTX-LCNCs, methotrexate-loaded lipidic core nanocapsules
- NSAIDs, non steroidal anti-inflammatory drugs
- Nanoformulation
- Nanoparticles
- P-SLN, piperine loaded solid lipid nanoparticle
- PCL, polycaprolactone
- PCL-PEG, poly (ethylene glycol)-block-poly (ε-caprolactone)
- PSA, polysialic acid
- PSA-PCL-CyA-NMs, polysialic acid- polycaprolactone cyclosporine A nanomicelles
- Pir-SLN, piroxicam solid lipid nanoparticles
- RA, rheumatoid arthritis
- RGD, arginine-glycine aspartic acid
- RNAi, RNA interference
- Rheumatoid arthritis
- SLN, solid lipid nanoparticles
- TAC-HSA-NPs, tacrolimus human serum albumin nanoparticle
- TAC-LCNCs, tacrolimus loaded lipidic core nanocapsules
- TNF-α, tumour necrosis factor
- VCAM-1, vascular cell adhesion molecule-1
- VEGF, vascular endothelial growth factor
- VIP, vasoactive intestinal peptide
- mRNA, messenger RNA
- shRNA, short hairpin RNA
- siRNA, small interfering RNA
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Affiliation(s)
- Kumar Janakiraman
- National Facility for Drug Development for Academia, Pharmaceutical and Allied Industries (NFDD), Centre for Excellence in Nanobio Translational REsearch (CENTRE), Department of Pharmaceutical Technology, University College of Engineering, Anna University, BIT Campus, Tiruchirappalli 620 024, Tamil Nadu, India
| | - Venkateshwaran Krishnaswami
- National Facility for Drug Development for Academia, Pharmaceutical and Allied Industries (NFDD), Centre for Excellence in Nanobio Translational REsearch (CENTRE), Department of Pharmaceutical Technology, University College of Engineering, Anna University, BIT Campus, Tiruchirappalli 620 024, Tamil Nadu, India
| | - Vijaya Rajendran
- National Facility for Drug Development for Academia, Pharmaceutical and Allied Industries (NFDD), Centre for Excellence in Nanobio Translational REsearch (CENTRE), Department of Pharmaceutical Technology, University College of Engineering, Anna University, BIT Campus, Tiruchirappalli 620 024, Tamil Nadu, India
| | - Subramanian Natesan
- National Facility for Drug Development for Academia, Pharmaceutical and Allied Industries (NFDD), Centre for Excellence in Nanobio Translational REsearch (CENTRE), Department of Pharmaceutical Technology, University College of Engineering, Anna University, BIT Campus, Tiruchirappalli 620 024, Tamil Nadu, India
| | - Ruckmani Kandasamy
- National Facility for Drug Development for Academia, Pharmaceutical and Allied Industries (NFDD), Centre for Excellence in Nanobio Translational REsearch (CENTRE), Department of Pharmaceutical Technology, University College of Engineering, Anna University, BIT Campus, Tiruchirappalli 620 024, Tamil Nadu, India
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Patient-reported outcomes in patients with relapsing forms of MS switching to teriflunomide from other disease-modifying therapies: Results from the global Phase 4 Teri-PRO study in routine clinical practice. Mult Scler Relat Disord 2018; 26:211-218. [DOI: 10.1016/j.msard.2018.09.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/31/2018] [Accepted: 09/14/2018] [Indexed: 01/12/2023]
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Gholamzad M, Ebtekar M, Ardestani MS, Azimi M, Mahmodi Z, Mousavi MJ, Aslani S. A comprehensive review on the treatment approaches of multiple sclerosis: currently and in the future. Inflamm Res 2018; 68:25-38. [DOI: 10.1007/s00011-018-1185-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/13/2018] [Accepted: 08/23/2018] [Indexed: 12/13/2022] Open
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Teeth loss after teriflunomide treatment: Casual or causal? A short case series. Mult Scler Relat Disord 2018; 24:120-122. [PMID: 29982109 DOI: 10.1016/j.msard.2018.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 06/18/2018] [Accepted: 06/28/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Teriflunomide is a once-daily oral immunomodulator approved for the treatment of relapsing-remitting multiple sclerosis (RRMS) with a consistent safety profile in clinical trials. We report three cases of multiple teeth loss during teriflunomide treatment. CASE REPORTS Case 1: a 39 year-old woman started teriflunomide for RRMS, switching from interferon beta. Four months later she complained about mandibular pain followed by the sudden loss of 4 teeth, in the absence of bleeding or trauma. Suspecting a causal role, we discontinued teriflunomide and started the accelerated elimination procedure with cholestyramine. Orthopantomography and a subsequent dental CT scan showed diffuse alveolar atrophy and periapical bone loss in several residual roots. Investigating retrospectively the patient's dental history, and revising previous orthopantomographies dating from 2009, we highlighted a chronic and progressive dental pathology with several cavities and teeth loss. Case 2: A 52-year-old woman affected by multiple sclerosis (MS) since 1988, switched from interferon beta to teriflunomide treatment due to poor tolerability. One year later she experienced the sudden loss of five teeth in the absence of traumatic events. Dental assessment and orthopantomography confirmed moderate chronic periodontitis. Teriflunomide was discontinued and the accelerated elimination procedure with cholestyramine was performed. Case 3: A 56-year-old woman affected by MS for thirty years. She switched from interferon beta to teriflunomide due to injection site reactions. After eighteen months she experienced hypermobility of several teeth without gum inflammation or pain, followed by sudden loss of twelve teeth. No dental examination is available. Teriflunomide was discontinued without accelerated elimination procedure. DISCUSSION Odontogenic infections (periodontal disease and dental caries) are common and can cause teeth loss if left untreated as in case 1. It is conceivable that local infections favoured by teriflunomide accelerated pulpitis, endodontic infections and periapical reactions followed by teeth loss in predisposed subjects. Poor oral hygiene is common in MS patients and might favour dental infections. CONCLUSIONS We underline the importance to assess concomitant teeth morbidity and to recommend accurate oral hygiene before and during teriflunomide treatment.
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First-line therapy in relapsing remitting multiple sclerosis. Rev Neurol (Paris) 2018; 174:419-428. [DOI: 10.1016/j.neurol.2018.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/11/2018] [Accepted: 03/12/2018] [Indexed: 11/21/2022]
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Freedman MS, Morawski J, Thangavelu K. Clinical efficacy of teriflunomide over a fixed 2-year duration in the TOWER study. Mult Scler J Exp Transl Clin 2018; 4:2055217318775236. [PMID: 29796289 PMCID: PMC5960864 DOI: 10.1177/2055217318775236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/21/2018] [Accepted: 04/12/2018] [Indexed: 02/05/2023] Open
Abstract
Patients enrolled in the phase 3 TOWER study (NCT00751881) of teriflunomide had variable treatment durations (48–173 weeks). This has led to challenges when interpreting results in the context of other phase 3 trials of disease-modifying therapies for multiple sclerosis, which typically have a fixed 2-year duration. This communication reports clinical outcomes in TOWER over a fixed 2-year period. Reductions in annualised relapse rates and 12-week confirmed disability worsening associated with teriflunomide were comparable between overall intent-to-treat and fixed 2-year study populations in TOWER. Consistency in outcomes supports the inclusion of TOWER data in comparative analyses with other disease-modifying therapies. ClinicalTrials.gov: NCT00751881.
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Affiliation(s)
- Mark S Freedman
- Multiple Sclerosis Research Clinic, University of Ottawa and the Ottawa Hospital Research Institute, Canada
| | - Julia Morawski
- MS Global Health Economics and Value Assessment, Sanofi, USA
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Abstract
Multiple sclerosis treatment faces tremendous changes as a result of the approval of new medications. The new medications have differing safety considerations and risks after long-term treatment, which are important for treating physicians to optimize and individualize multiple sclerosis care. Since the approval of the first multiple sclerosis capsule, fingolimod, the armamentarium of multiple sclerosis therapy has grown with the orally available medications dimethyl fumarate and teriflunomide. Fingolimod is mainly associated with cardiac side effects, dimethyl fumarate with bowel symptoms. Several reports about progressive multifocal leukoencephalopathy as a result of dimethyl fumarate or fingolimod therapy raised the awareness of fatal opportunistic infections. Alemtuzumab, a CD52-depleting antibody, is highly effective in reducing relapses but leads to secondary immunity with mainly thyroid disorders in about 30% of patients. Development of secondary B-cell-mediated disease might also be a risk of this antibody. The follow-up drug of the B-cell-depleting antibody rituximab, ocrelizumab, is mainly associated with infusion-related reactions; long-term data are scarce. The medication daclizumab high yield process, acting via the activation of CD56bright natural killer cells, can induce the elevation of liver function enzymes, but also fulminant liver failure has been reported. Therefore, daclizumab has been retracted from the market. Long-term data on the purine nucleoside cladribine in MS therapy, recently authorized in the European Union, have been acquired during the long-term follow-up of the cladribine studies. The small molecule laquinimod is currently under development. We review data of clinical trials and their extensions regarding long-term efficacy and side effects, which might be associated with long-term treatment.
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Affiliation(s)
- Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, Bochum, 44791, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, Bochum, 44791, Germany.
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Abstract
PURPOSE OF REVIEW This review evaluates current and late-phase developing therapies for multiple sclerosis in regard to therapeutic efficacy and patient safety in light of recent published and presented observations from 2015. RECENT FINDINGS We describe data that provide supportive evidence for comparisons of therapeutic efficacy of multiple sclerosis therapies and review available data on rare but serious adverse events associated with these therapies. SUMMARY Serious adverse events that are sometimes rare and unpredictable may substantially alter current approaches to multiple sclerosis treatments. New therapies that have proved superior effects compared with older therapies will also impact multiple sclerosis treatment practice in the near future.
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