1
|
Ridley B, Minozzi S, Gonzalez-Lorenzo M, Del Giovane C, Piggott T, Filippini G, Peryer G, Foschi M, Tramacere I, Baldin E, Nonino F. Immunomodulators and immunosuppressants for progressive multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2024; 9:CD015443. [PMID: 39254048 DOI: 10.1002/14651858.cd015443.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND In recent years a broader range of immunomodulatory and immunosuppressive treatment options have emerged for people with progressive forms of multiple sclerosis (PMS). While consensus supports these options as reducing relapses, their relative benefit and safety profiles remain unclear due to a lack of direct comparison trials. OBJECTIVES To compare through network meta-analysis the efficacy and safety of alemtuzumab, azathioprine, cladribine, cyclophosphamide, daclizumab, dimethylfumarate, diroximel fumarate, fingolimod, fludarabine, glatiramer acetate, immunoglobulins, interferon beta 1-a and beta 1-b, interferon beta-1b (Betaferon), interferon beta-1a (Avonex, Rebif), laquinimod, leflunomide, methotrexate, minocycline, mitoxantrone, mycophenolate mofetil, natalizumab, ocrelizumab, ofatumumab, ozanimod, pegylated interferon beta-1a, ponesimod, rituximab, siponimod, corticosteroids, and teriflunomide for PMS. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase up to August 2022, as well as ClinicalTrials.gov and the WHO ICTRP. SELECTION CRITERIA Randomised controlled trials (RCTs) that studied one or more treatments as monotherapy, compared to placebo or to another active agent, for use in adults with PMS. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. We performed data synthesis by pair-wise and network meta-analysis. We assessed the certainty of the body of evidence according to GRADE. MAIN RESULTS We included 23 studies involving a total of 10,167 participants. The most frequent (39% of studies) reason for a rating of high risk of bias was sponsor role in study authorship and data management and analysis. Other concerns were performance, attrition, and selective reporting bias, with 8.7% of studies at high risk of bias for all three of these domains. The common comparator for network analysis was placebo. Relapses over 12 months: assessed in one study (318 participants). None of the treatments assessed showed moderate or high certainty evidence compared to placebo. Relapses over 24 months: assessed in six studies (1622 participants). The number of people with clinical relapses is probably trivially reduced with rituximab (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.19 to 1.95; moderate certainty evidence). None of the remaining treatments assessed showed moderate or high certainty evidence compared to placebo. Relapses over 36 months: assessed in four studies (2095 participants). The number of people with clinical relapses is probably trivially reduced with interferon beta-1b (RR 0.82, 95% CI 0.73 to 0.93; moderate certainty evidence). None of the remaining treatments assessed showed moderate or high certainty evidence compared to placebo. Disability worsening over 24 months: assessed in 11 studies (5284 participants). None of the treatments assessed showed moderate or high certainty evidence compared to placebo. Disability worsening over 36 months: assessed in five studies (2827 participants). None of the treatments assessed showed moderate or high certainty evidence compared to placebo. Serious adverse events: assessed in 15 studies (8019 participants). None of the treatments assessed showed moderate or high certainty evidence compared to placebo. Discontinuation due to adverse events: assessed in 21 studies (9981 participants). The number of people who discontinued treatment due to adverse events is trivially increased with interferon beta-1a (odds ratio (OR) 2.93, 95% CI 1.64 to 5.26; high certainty evidence). The number of people who discontinued treatment due to adverse events is probably trivially increased with rituximab (OR 4.00, 95% CI 0.84 to 19.12; moderate certainty evidence); interferon beta-1b (OR 2.98, 95% CI 1.92 to 4.61; moderate certainty evidence); immunoglobulins (OR 1.95, 95% CI 0.99 to 3.84; moderate certainty evidence); glatiramer acetate (OR 3.98, 95% CI 1.48 to 10.72; moderate certainty evidence); natalizumab (OR 1.02, 95% CI 0.55 to 1.90; moderate certainty evidence); siponimod (OR 1.53, 95% CI 0.98 to 2.38; moderate certainty evidence); fingolimod (OR 2.29, 95% CI 1.46 to 3.60; moderate certainty evidence), and ocrelizumab (OR 1.24, 95% CI 0.54 to 2.86; moderate certainty evidence). None of the remaining treatments assessed showed moderate or high certainty evidence compared to placebo. AUTHORS' CONCLUSIONS The number of people with PMS with relapses is probably slightly reduced with rituximab at two years, and interferon beta-1b at three years, compared to placebo. Both drugs are also probably associated with a slightly higher proportion of withdrawals due to adverse events, as are immunoglobulins, glatiramer acetate, natalizumab, fingolimod, siponimod, and ocrelizumab; we have high confidence that this is the case with interferon beta-1a. We found only low or very low certainty evidence relating to disability progression for the included disease-modifying treatments compared to placebo, largely due to imprecision. We are also uncertain about the effect of interventions on serious adverse events, also because of imprecision. These findings are due in part to the short follow-up of the included RCTs, which lacked detection of less common severe adverse events. Moreover, the funding source of many included studies may have introduced bias into the results. Future research on PMS should include head-to-head rather than placebo-controlled trials, with a longer follow-up of at least three years. Given the relative rarity of PMS, controlled, non-randomised studies on large samples may usefully integrate data from pivotal RCTs. Outcomes valuable and meaningful to people with PMS should be consistently adopted and measured to permit the evaluation of relative effectiveness among treatments.
Collapse
Affiliation(s)
- Ben Ridley
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Marien Gonzalez-Lorenzo
- Laboratorio di Metodologia delle revisioni sistematiche e produzione di Linee Guida, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), Bern, Switzerland
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, Queens University, Kingston, Ontario, Canada
| | - Graziella Filippini
- Scientific Director's Office, Fondazione IRCCS, Istituto Neurologico Carlo Besta, Milan, Italy
| | - Guy Peryer
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Matteo Foschi
- Department of Neuroscience, Multiple Sclerosis Center - Neurology Unit, S.Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| |
Collapse
|
2
|
Nicholas R, Scalfaro E, Dorsey R, Angehrn Z, Banhazi J, Brennan R, Adlard N. ENTIMOS: Decision Support Tool Highlights Potential Impact of Non-intravenous Therapies for Multiple Sclerosis on Patient Care via Clinical Scenario Simulation. PHARMACOECONOMICS - OPEN 2024; 8:755-764. [PMID: 38990487 PMCID: PMC11362419 DOI: 10.1007/s41669-024-00493-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Administration of intravenous (IV), high-efficacy treatments (HETs) for the treatment of multiple sclerosis (MS) poses a high resourcing and planning burden on infusion centres, resulting in treatment delays that may increase the risk of breakthrough disease activity. Simulation tools can be used to systematically analyse capacity scenarios and identify and better understand constraints, therefore enabling decision-makers to optimise patient care. We have previously applied ENTIMOS, a discrete event simulation model, to assess scenarios of patient flow and care delivery using real-life data inputs from the neurology infusion suite at Charing Cross Hospital London. The model predicted that, given current capacity and projected demand, patients would experience high-risk treatment delays within 30 months. OBJECTIVE This study aimed to address key healthcare challenges for MS patient care management as seen from a neurologist's perspective. We used ENTIMOS to predict the impact of several distinct and clinically plausible scenarios on patient waiting times at the same MS infusion suite and to quantify mitigation strategies needed to assure continuity of care. METHODS We used real-world experience of an expert neurologist to identify five clinical scenarios: (1) switching patients to a subcutaneous (SC) MS treatment of the same therapeutic agent, in the same hospital setting; (2) extending opening times to the weekend; (3) reducing the number of infusion chairs (to simulate social distancing measures applied during the coronavirus disease 2019 [COVID-19] pandemic); (4) increasing demand for infusions; and (5) increasing the scheduling approval time. Patient waiting time for next due infusion and time to high-risk treatment delays (≥ 30 days) were the main analysed model outputs. Previously published base case results were used as reference. All hypothetical scenarios were run over a 3-year horizon (with the exception of scenario 1, which was run over a 3- and 5-year horizon). Strategies to mitigate treatment delays were analysed and discussed. RESULTS Switching 50% of patients to SC treatment of the same therapeutic agent administered in hospital postponed the predicted high-risk treatment delays to shortly beyond the 3-year simulation timeframe (month 38). Weekend opening reduced waiting times from 20 days to 4 days and prevented treatment delays, however, at elevated labour costs. Reducing the infusion chairs increased waiting time to 53 days on average and 86 days at the end of the simulation, leading to high-risk treatment delays within 6 months. An increased demand for infusions increased waiting time to 26 days on average and 47 days at the end of the simulation, leading to high-risk treatment delays within 22 months. Prolonged scheduling approval time did not reduce the waiting time, nor postpone the high-risk treatment delays. CONCLUSION Decision makers need transparency on capacity constraints to better plan resourcing at infusion suites and MS treatments. Our results showed that various mitigation measures, such as increasing capacity by additional infusion chairs per year and transferring patients to other infusion suites, may help prevent treatment delays. Switching patients from IV to an SC version of the same therapeutic agent reduced the waiting time moderately and postponed high-risk treatment delays. It was insufficient to prevent high-risk treatment delays in the long term.
Collapse
|
3
|
Hartung HP, Berger T, Bermel RA, Brochet B, Carroll WM, Holmøy T, Karabudak R, Killestein J, Nos C, Patti F, Perrin Ross A, Vanopdenbosch L, Vollmer T, Buffels R, Garas M, Kadner K, Manfrini M, Wang Q, Freedman MS. ENSEMBLE PLUS: final results of shorter ocrelizumab infusion from a randomized controlled trial. J Neurol 2024; 271:4348-4360. [PMID: 38649522 PMCID: PMC11233283 DOI: 10.1007/s00415-024-12326-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/16/2024] [Accepted: 03/12/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Ocrelizumab is an approved intravenously administered anti-CD20 antibody for multiple sclerosis (MS). The safety profile and patient preference for conventional versus shorter ocrelizumab infusions were investigated in the ENSEMBLE PLUS study. METHODS ENSEMBLE PLUS was a randomized, double-blind substudy to the single-arm ENSEMBLE study (NCT03085810), comparing outcomes in patients with early-stage relapsing-remitting MS receiving ocrelizumab 600 mg over the approved 3.5-h (conventional) versus 2-h (shorter) infusion. The primary endpoint was the proportion of patients with infusion-related reactions (IRRs) following the first randomized dose (RD); the secondary endpoint included IRR frequency at subsequent RDs. RESULTS At first RD, the number of patients with an IRR in the conventional (101/373; 27.1%) versus shorter (107/372; 28.8%) infusion group was similar (difference, stratified estimates [95% CI]: 1.9% [- 4.4, 8.2]). Most IRRs (conventional: 99.4%; shorter: 97.7%) were mild/moderate. IRR frequency decreased over the course of RDs; three patients discontinued from the shorter infusion arm but continued with conventional infusion. Overall, > 98% of IRRs resolved without sequelae in both groups. Pre-randomization throat irritation was predictive of future throat irritation as an IRR symptom. Adverse events (AEs) and serious AEs were consistent with the known ocrelizumab safety profile. On completion of ENSEMBLE PLUS, most patients chose to remain on (95%) or switch to (80%) shorter infusion. CONCLUSION ENSEMBLE PLUS demonstrates the safety and tolerability of shorter ocrelizumab infusions. Most patients remained on/switched to shorter infusion after unblinding; IRRs did not strongly influence patient decisions. CLINICAL TRIALS REGISTRATION Substudy of ENSEMBLE (NCT03085810). REGISTRATION March 21, 2017.
Collapse
Affiliation(s)
- Hans-Peter Hartung
- Department of Neurology, UKD, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
- Brain and Mind Centre, University of Sydney, Sydney, Australia.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Robert A Bermel
- Mellen Center for MS, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bruno Brochet
- INSERM U 1215, Neurocentre Magendie, University of Bordeaux, Bordeaux, France
| | - William M Carroll
- Department of Neurology, Sir Charles Gairdner Hospital, Perron Institute for Neurological and Translational Science, The University of Western Australia, Nedlands, Australia
| | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rana Karabudak
- Department of Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Carlos Nos
- Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, UOS Sclerosi Multipla Policlinico G Rodolico, University of Catania, Catania, Italy
| | | | | | - Timothy Vollmer
- University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Regine Buffels
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
- , Basel, Switzerland
| | | | | | | | - Qing Wang
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Mark S Freedman
- Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
4
|
Scavone C, Anatriello A, Baccari I, Cantone A, Di Giulio Cesare D, Bernardi FF, Moreggia O, Liguori V, Andreone V, Maniscalco GT, Capuano A. Comparison of injective related reactions following ofatumumab and ocrelizumab in patients with multiple sclerosis: data from the European spontaneous reporting system. Front Neurol 2024; 15:1383910. [PMID: 38994488 PMCID: PMC11236557 DOI: 10.3389/fneur.2024.1383910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/18/2024] [Indexed: 07/13/2024] Open
Abstract
Introduction In 2021 ofatumumab, a recombinant human anti-CD20 monoclonal antibody (mAb) already authorized for the treatment of chronic lymphocytic leukemia, received the marketing approval for the treatment of relapsing forms of multiple sclerosis (MS). Differently from ocrelizumab, that is administered intravenously, ofatumumab if the first anti-CD20 mAb to be administered subcutaneously without a premedication. Methods and objectives In this study we aimed to describe and compare the main characteristics of Individual Case Safety Reports (ICSRs) describing the occurrence of Injective Related Reactions (IRRs) following the treatment with ocrelizumab and ofatumumab reported in the Eudravigilance (EV) database during years 2021-2023. Results A total of 860 ICSRs with either ofatumumab and ocrelizumab as suspected drug were retrieved from Eudravigilance, of which 51% associated with ofatumumab and 49% with ocrelizumab. The majority of patients who experienced IRRs following ocrelizumab belonged to the age group of 18-64 years (73%), while the age-group was mostly not specified (55%) in ICSRs reporting ofatumumab as suspected. The distribution of gender was almost similar in the two groups, with the majority of ICSRs related to female patients. "Pyrexia" was the Preferred Term (PT) most reported for ofatumumab, while "Infusion related reaction" were more frequently reported with ocrelizumab. Premedication drugs were reported in 148 ICSRs. Out of 89 ICSRs for which the Time to Event (TTE) was calculated, 74 reported IRRs that occurred the same day of the drug administration. Discussion Based on the results of this study, although a risk of ofatumumab-induced IRRs cannot be excluded, it should be considered as manageable considering that the drug seems to be mostly associated with the occurrence of fever. Thus, it is important to continue to closely monitor the use of these in clinical practice to improve the knowledge on their long-term safety.
Collapse
Affiliation(s)
- Cristina Scavone
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
| | - Antonietta Anatriello
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
| | - Isabella Baccari
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
| | - Andrea Cantone
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
| | | | | | - Ornella Moreggia
- Multiple Sclerosis Regional Center, "A. Cardarelli" Hospital, Naples, Italy
| | - Valerio Liguori
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
| | - Vincenzo Andreone
- Neurological Clinic and Stroke Unit, "A. Cardarelli" Hospital, Naples, Italy
| | - Giorgia Teresa Maniscalco
- Multiple Sclerosis Regional Center, "A. Cardarelli" Hospital, Naples, Italy
- Neurological Clinic and Stroke Unit, "A. Cardarelli" Hospital, Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
| |
Collapse
|
5
|
Teichner P, Chamay N, Elliot E, Pascual-Bernáldez M, Merrill D, Garris C, D'Amico R, Felizarta C, Torres E, Van Solingen-Ristea R, Baugh B, Patel P, Vannappagari V, Dakhia S, Polli JW, Garside L, Grove R, Thiagarajah S, Birmingham E, van Wyk J. Cabotegravir + Rilpivirine Long-Acting: Overview of Injection Guidance, Injection Site Reactions, and Best Practices for Intramuscular Injection Administration. Open Forum Infect Dis 2024; 11:ofae282. [PMID: 38882931 PMCID: PMC11179104 DOI: 10.1093/ofid/ofae282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/23/2024] [Indexed: 06/18/2024] Open
Abstract
Background Cabotegravir (CAB) + rilpivirine (RPV) dosed monthly or every 2 months is a complete long-acting (LA) regimen for the maintenance of human immunodeficiency virus type 1 virologic suppression. Across the phase 3/3b trials, the most frequently reported adverse events were injection site reactions (ISRs). Methods We present pooled ISR characteristics and outcomes for participants receiving CAB + RPV LA through week 96 of the FLAIR and ATLAS-2M studies, and survey results from healthcare providers (HCPs) giving injections (eg, injectors) in the ATLAS, FLAIR, and ATLAS-2M studies to determine optimal injection techniques. Surveys were anonymous, self-administered online questionnaires that queried provider demographics, injection experience, and techniques to minimize pre-/postinjection discomfort. Data were summarized using descriptive statistics. Results Overall, 8453 ISRs were reported by 801 participants receiving ≥1 injection of CAB LA/RPV LA. Most ISRs were mild to moderate in severity (grade 1-2, 99%), with a median duration of 3 days (interquartile range, 2-4 days), and rarely led to withdrawal (2%). Surveys were completed by 181 HCPs across 113 sites. Pushing the intramuscular injection at slow speed (66%), bringing the medication to room temperature (58%), and relaxing the gluteus muscle before injecting (53%) were ranked as effective preinjection/injection procedure practices for minimizing pain. Most injectors (60%) indicated that a prone position provided optimal patient comfort, and 41% had no preference on injection medication order. Conclusions Taken together, the data demonstrate favorable tolerability with CAB + RPV LA injections over the long term and simple techniques routinely used by injectors to help optimize the administration of CAB + RPV LA injections.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Cecy Felizarta
- Private practice of Franco Felizarta, MD, Bakersfield, California, USA
| | - Emma Torres
- Service de maladies infectieuses et tropicales, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Bryan Baugh
- Janssen Research and Development, Titusville, New Jersey, USA
| | - Parul Patel
- ViiV Healthcare, Durham, North Carolina, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Smoot K, Marginean H, Gervasi-Follmar T, Chen C. Comparing the Risk of Infusion-Related Reactions and Tolerability in Patients Given Cetirizine or Diphenhydramine Prior to Ocrelizumab Infusion (PRECEPT). MEDICINA (KAUNAS, LITHUANIA) 2024; 60:659. [PMID: 38674305 PMCID: PMC11051876 DOI: 10.3390/medicina60040659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
Background: Ocrelizumab is an effective medication for multiple sclerosis. However, infusion-related reactions (IRRs) are a concern for patients and may lead to discontinuation of ocrelizumab. To minimize IRRs, pre-medications are administered. However, from our experience, these medications, especially diphenhydramine, can cause marked drowsiness. The primary objective of this study was to evaluate whether cetirizine is non-inferior to diphenhydramine in limiting the proportion and severity of reactions from ocrelizumab infusions. Methods: Twenty participants were serially randomized in a 1:1 ratio to receive 10 mg of cetirizine or 25 mg of diphenhydramine orally prior to their first three ocrelizumab infusions. Results: The rate of IRRs in this study was similar across both treatment groups with no increase in the risk of severity, and no grade 3 IRRs. Further, patients receiving cetirizine experienced a reduction in fatigue. While there was not a significant difference in global satisfaction, this score increased over time in the cetirizine arm while it remained unchanged in the diphenhydramine arm. Conclusions: Overall, our results suggest that cetirizine does not increase the risk of infusion-related reactions compared to diphenhydramine.
Collapse
Affiliation(s)
- Kyle Smoot
- Providence Brain and Spine Institute, Portland, OR 97225, USA; (H.M.); (T.G.-F.); (C.C.)
| | | | | | | |
Collapse
|
7
|
Zanetta C, Faustino P, Guerrieri S, Nozzolillo A, Genchi A, Bucca C, Rocca MA, Moiola L, Filippi M. Fast but not furious: Rapid ocrelizumab infusion as a strategy to optimize multiple sclerosis patients' management. J Neurol Sci 2024; 457:122897. [PMID: 38278095 DOI: 10.1016/j.jns.2024.122897] [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: 11/15/2023] [Accepted: 01/18/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVES Multiple sclerosis clinicians are continuously challenged to be innovative in delivering therapies and there is ongoing pressure to maximize day-hospital vacancies. We describe our single-center experience with ocrelizumab (OCR) rapid infusion (OCR-RI) in patients with MS (pwMS). METHODS For pwMS with prior exposure to OCR standard infusion (OCR-SI) for at least one year/two cycles, infusion time was reduced from 3.5 to 2.0 h. A comparative analysis between OCR-RI vs OCR-SI patients was conducted. RESULTS 283 (76.7%) out of 369 OCR-treated pwMS performed OCR-RI; 86 subjects did not start OCR-RI due to infusion-related reactions (IRR) occurring with OCR-SI (n = 13) or OCR-treatment duration shorter than one year (n = 73). Disease duration was longer in OCR-RI (p < 0.001). Median numbers of overall-OCR and OCR-RI cycles were 7 (IQR = 5-8) and 4 (IQR = 2-5) (p < 0.001). Overall, 38 (10.3%) IRR were reported, 25 (8.8%) in OCR-RI and 13 (15.1%) in OCR-SI group. IRR frequency did not differ between the two groups (p = 0.106). IRR included throat irritation, rash, hypotension, fever and gastrointestinal symptoms. IRR severity was mild (81.6%) or moderate (18.4%), all resolved and did not differ in distribution between the two groups. When IRR occurred, infusions were temporarily stopped, hydration and/or symptomatic medications were given and infusions were subsequently resumed at standard velocity. OCR-RI was not a risk factor for IRR (OR 0.55, 95% CI: 0.27-1.13, p = 0.096). CONCLUSIONS In our cohort, IRR frequency, severity and management were comparable to literature. No severe IRR were observed. RI protocols represent a strategy to optimize patients' management in the clinic.
Collapse
Affiliation(s)
- Chiara Zanetta
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patricia Faustino
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neurology Department and Multiple Sclerosis Centre of Integrated Responsibility, Centro Hospitalar Universitário de Lisboa Central, EPE, Lisboa, Portugal
| | - Simone Guerrieri
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Agostino Nozzolillo
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angela Genchi
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Bucca
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria A Rocca
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Lucia Moiola
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| |
Collapse
|
8
|
Abbasi Kasbi N, Ghadiri F, Sahraian MA, Nahayati MA, Moghadasi AN, Langroodi HG, Poursadeghfard M, Hosseini S, Heidari H, Baghbanian SM, Kamali H, Ameli Z, Shahmohammadi S, Navardi S. Comparing infusion-related reactions of the first full dose (600 mg) biosimilar ocrelizumab administration with the standard divided protocol in multiple sclerosis patients: a randomized controlled trial study. Acta Neurol Belg 2024; 124:205-212. [PMID: 37715074 DOI: 10.1007/s13760-023-02366-z] [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: 01/31/2023] [Accepted: 08/16/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Ocrelizumab is a humanized antiCD20, thought to be a highly effective disease-modifying therapy (DMT). Its most frequent adverse effects are infusion-related reactions (IRRs). To reduce these reactions, the first dose of ocrelizumab is administered as two 300 mg infusions separated by two weeks. However, in the phase II trial of ocrelizumab, severe IRRs were not significantly different between two doses of 600 mg dose (two separate 300 mg doses) and 2000 mg dose (two separate 1000 mg doses). We compared the IRRs in undivided full (one 600 mg) and divided (two 300 mg) doses of ocrelizumab which is the standard protocol. METHODS MS patients (relapsing or primary progressive MS) who are selected to receive ocrelizumab by neurologist or MS fellowship were enrolled in an open-label randomized controlled trial. Iranian biosimilar of the drug (Xacrel® by Cinnagen, approved by the Iranian Food and Drug Administration in 2021) was used. The participants received the first dose of ocrelizumab as either one 600 mg dose in one session or two 300 mg doses in two weeks apart. IRRs during or in the first 24 h after infusion were recorded. RESULTS Of 332 participants, 150 received two 300 mg doses, and 182 received one 600 mg dose (by random selection). Life-threatening adverse effects were not observed in both groups. Overnight admission or permanent drug discontinuation was not needed. Temporary drug discontinuation was significantly higher in the one 600 mg dose group (p-value < 0.001). During the infusions, malaise (p-value: 0.003), skin reactions (p-value: 0.04), throat swelling (p-value: 0.03), and dyspnea (p-value: 0.01) were significantly increased in the intervention group. However, in the first 24 h, there was no significant difference between two different treatment protocols (one 600 mg dose or two 300 mg doses) in the onset of IRRS (p-value: 0.12). CONCLUSION These findings suggest one 600 mg dose of ocrelizumab administration for the first dose is relatively safe. With some protocol modifications, it could lead to fewer patient referrals, saving time and cost and improvement the access for patients.
Collapse
Affiliation(s)
- Naghmeh Abbasi Kasbi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - F Ghadiri
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - M A Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - M A Nahayati
- Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - A Naser Moghadasi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - M Poursadeghfard
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - S Hosseini
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - H Heidari
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - S M Baghbanian
- Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - H Kamali
- Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Z Ameli
- Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - S Shahmohammadi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - S Navardi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
9
|
Kappos L, Traboulsee A, Li DKB, Bar-Or A, Barkhof F, Montalban X, Leppert D, Baldinotti A, Schneble HM, Koendgen H, Sauter A, Wang Q, Hauser SL. Ocrelizumab exposure in relapsing-remitting multiple sclerosis: 10-year analysis of the phase 2 randomized clinical trial and its extension. J Neurol 2024; 271:642-657. [PMID: 37906326 PMCID: PMC10827899 DOI: 10.1007/s00415-023-11943-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 11/02/2023]
Abstract
Open-label extension (OLE) studies help inform long-term safety and efficacy of disease-modifying therapies in multiple sclerosis (MS). We report exploratory analyses from a phase 2 trial on the longest follow-up to date of ocrelizumab-treated patients with relapsing-remitting MS (RRMS). The primary treatment period (PTP) comprised four 24-week treatment cycles; participants were randomized to double-blind ocrelizumab (2000 mg or 600 mg), placebo, or interferon β-1a (open label) for one cycle, then dose-blinded ocrelizumab 1000 mg or 600 mg for the remaining cycles. The PTP was followed by consecutive assessed and unassessed treatment-free periods (TFPs) and then the OLE (ocrelizumab 600 mg every 24 weeks). Safety and efficacy were prospectively assessed. Of 220 participants randomized, 183 (84%) completed the PTP. After the TFP, 103 entered OLE (median OLE ocrelizumab exposure 6.5 years). Most common adverse events across all periods were infusion-related reactions. MRI activity, annualized relapse rate, and confirmed disability progression (CDP) rates remained low throughout. During the assessed TFP, there was a trend toward less and later B-cell repletion, and later CDP, for patients randomized to ocrelizumab; MRI activity was observed in 16.3% of patients, the earliest 24 weeks after the last ocrelizumab dose. This is the longest follow-up of ocrelizumab-treated patients with RRMS, with no new safety signals emerging during an observation period from 2008 to 2020. Results reinforce the sustained efficacy of long-term ocrelizumab. Reduced disease activity was maintained following interruption of 6-month dosing cycles, with no evidence of rebound.
Collapse
Affiliation(s)
- Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital and University of Basel, Basel, Switzerland.
| | - Anthony Traboulsee
- Department of Medicine (Neurology), University of British Columbia, Vancouver, BC, Canada
| | - David K B Li
- Department of Radiology and Medicine (Neurology), University of British Columbia, Vancouver, BC, Canada
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frederik Barkhof
- VU University Medical Centre, Amsterdam, The Netherlands
- UCL Institutes of Biomedical Engineering and Neurology, London, UK
| | - Xavier Montalban
- Department of Neurology-Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - David Leppert
- Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | | | - Harold Koendgen
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
- UCB Farchim SA, Bulle, Switzerland
| | - Annette Sauter
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
- Janssen Pharmaceuticals, Allschwil, Basel-Landschaft, Switzerland
| | - Qing Wang
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Stephen L Hauser
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
10
|
Gonzalez-Lorenzo M, Ridley B, Minozzi S, Del Giovane C, Peryer G, Piggott T, Foschi M, Filippini G, Tramacere I, Baldin E, Nonino F. Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD011381. [PMID: 38174776 PMCID: PMC10765473 DOI: 10.1002/14651858.cd011381.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Different therapeutic strategies are available for the treatment of people with relapsing-remitting multiple sclerosis (RRMS), including immunomodulators, immunosuppressants and biological agents. Although each one of these therapies reduces relapse frequency and slows disability accumulation compared to no treatment, their relative benefit remains unclear. This is an update of a Cochrane review published in 2015. OBJECTIVES To compare the efficacy and safety, through network meta-analysis, of interferon beta-1b, interferon beta-1a, glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab, pegylated interferon beta-1a, daclizumab, laquinimod, azathioprine, immunoglobulins, cladribine, cyclophosphamide, diroximel fumarate, fludarabine, interferon beta 1-a and beta 1-b, leflunomide, methotrexate, minocycline, mycophenolate mofetil, ofatumumab, ozanimod, ponesimod, rituximab, siponimod and steroids for the treatment of people with RRMS. SEARCH METHODS CENTRAL, MEDLINE, Embase, and two trials registers were searched on 21 September 2021 together with reference checking, citation searching and contact with study authors to identify additional studies. A top-up search was conducted on 8 August 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) that studied one or more of the available immunomodulators and immunosuppressants as monotherapy in comparison to placebo or to another active agent, in adults with RRMS. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data. We considered both direct and indirect evidence and performed data synthesis by pairwise and network meta-analysis. Certainty of the evidence was assessed by the GRADE approach. MAIN RESULTS We included 50 studies involving 36,541 participants (68.6% female and 31.4% male). Median treatment duration was 24 months, and 25 (50%) studies were placebo-controlled. Considering the risk of bias, the most frequent concern was related to the role of the sponsor in the authorship of the study report or in data management and analysis, for which we judged 68% of the studies were at high risk of other bias. The other frequent concerns were performance bias (34% judged as having high risk) and attrition bias (32% judged as having high risk). Placebo was used as the common comparator for network analysis. Relapses over 12 months: data were provided in 18 studies (9310 participants). Natalizumab results in a large reduction of people with relapses at 12 months (RR 0.52, 95% CI 0.43 to 0.63; high-certainty evidence). Fingolimod (RR 0.48, 95% CI 0.39 to 0.57; moderate-certainty evidence), daclizumab (RR 0.55, 95% CI 0.42 to 0.73; moderate-certainty evidence), and immunoglobulins (RR 0.60, 95% CI 0.47 to 0.79; moderate-certainty evidence) probably result in a large reduction of people with relapses at 12 months. Relapses over 24 months: data were reported in 28 studies (19,869 participants). Cladribine (RR 0.53, 95% CI 0.44 to 0.64; high-certainty evidence), alemtuzumab (RR 0.57, 95% CI 0.47 to 0.68; high-certainty evidence) and natalizumab (RR 0.56, 95% CI 0.48 to 0.65; high-certainty evidence) result in a large decrease of people with relapses at 24 months. Fingolimod (RR 0.54, 95% CI 0.48 to 0.60; moderate-certainty evidence), dimethyl fumarate (RR 0.62, 95% CI 0.55 to 0.70; moderate-certainty evidence), and ponesimod (RR 0.58, 95% CI 0.48 to 0.70; moderate-certainty evidence) probably result in a large decrease of people with relapses at 24 months. Glatiramer acetate (RR 0.84, 95%, CI 0.76 to 0.93; moderate-certainty evidence) and interferon beta-1a (Avonex, Rebif) (RR 0.84, 95% CI 0.78 to 0.91; moderate-certainty evidence) probably moderately decrease people with relapses at 24 months. Relapses over 36 months findings were available from five studies (3087 participants). None of the treatments assessed showed moderate- or high-certainty evidence compared to placebo. Disability worsening over 24 months was assessed in 31 studies (24,303 participants). Natalizumab probably results in a large reduction of disability worsening (RR 0.59, 95% CI 0.46 to 0.75; moderate-certainty evidence) at 24 months. Disability worsening over 36 months was assessed in three studies (2684 participants) but none of the studies used placebo as the comparator. Treatment discontinuation due to adverse events data were available from 43 studies (35,410 participants). Alemtuzumab probably results in a slight reduction of treatment discontinuation due to adverse events (OR 0.39, 95% CI 0.19 to 0.79; moderate-certainty evidence). Daclizumab (OR 2.55, 95% CI 1.40 to 4.63; moderate-certainty evidence), fingolimod (OR 1.84, 95% CI 1.31 to 2.57; moderate-certainty evidence), teriflunomide (OR 1.82, 95% CI 1.19 to 2.79; moderate-certainty evidence), interferon beta-1a (OR 1.48, 95% CI 0.99 to 2.20; moderate-certainty evidence), laquinimod (OR 1.49, 95 % CI 1.00 to 2.15; moderate-certainty evidence), natalizumab (OR 1.57, 95% CI 0.81 to 3.05), and glatiramer acetate (OR 1.48, 95% CI 1.01 to 2.14; moderate-certainty evidence) probably result in a slight increase in the number of people who discontinue treatment due to adverse events. Serious adverse events (SAEs) were reported in 35 studies (33,998 participants). There was probably a trivial reduction in SAEs amongst people with RRMS treated with interferon beta-1b as compared to placebo (OR 0.92, 95% CI 0.55 to 1.54; moderate-certainty evidence). AUTHORS' CONCLUSIONS We are highly confident that, compared to placebo, two-year treatment with natalizumab, cladribine, or alemtuzumab decreases relapses more than with other DMTs. We are moderately confident that a two-year treatment with natalizumab may slow disability progression. Compared to those on placebo, people with RRMS treated with most of the assessed DMTs showed a higher frequency of treatment discontinuation due to AEs: we are moderately confident that this could happen with fingolimod, teriflunomide, interferon beta-1a, laquinimod, natalizumab and daclizumab, while our certainty with other DMTs is lower. We are also moderately certain that treatment with alemtuzumab is associated with fewer discontinuations due to adverse events than placebo, and moderately certain that interferon beta-1b probably results in a slight reduction in people who experience serious adverse events, but our certainty with regard to other DMTs is lower. Insufficient evidence is available to evaluate the efficacy and safety of DMTs in a longer term than two years, and this is a relevant issue for a chronic condition like MS that develops over decades. More than half of the included studies were sponsored by pharmaceutical companies and this may have influenced their results. Further studies should focus on direct comparison between active agents, with follow-up of at least three years, and assess other patient-relevant outcomes, such as quality of life and cognitive status, with particular focus on the impact of sex/gender on treatment effects.
Collapse
Affiliation(s)
- Marien Gonzalez-Lorenzo
- Laboratorio di Metodologia delle revisioni sistematiche e produzione di Linee Guida, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ben Ridley
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Cochrane Italy, Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Guy Peryer
- School of Health Sciences, University of East Anglia (UEA), Norwich, UK
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, Queens University, Kingston, Ontario, Canada
| | - Matteo Foschi
- Department of Neuroscience, Multiple Sclerosis Center - Neurology Unit, S.Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| |
Collapse
|
11
|
Yepanchintseva O, Babenko V, Yarosh V, Golubovska O. The course of COVID-19 in a multiple sclerosis: a case report. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:166-170. [PMID: 38431822 DOI: 10.36740/wlek202401121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
The authors present the case of a prolonged course of COVID 19 disease in a 37-year-old patient with multiple sclerosis on anti-CD20 monoclonal antibodies immunotherapy. This publication presents a clinical case of the course of COVID-19 disease in a multiple sclerosis patient receiving ublituximab therapy. The use of disease-modifying anti-CD20 monoclonal antibody therapy was associated with a protracted wave-like course of COVID-19 with the addition of a bacterial infection. This publication illustrates the key mechanisms and approaches to the treatment of such a cohort of patients. The use of highly effective multiple sclerosis treatment methods may be associated with an increase in the incidence of COVID-19 and worsening of its course. Multiple sclerosis patients receiving anti-CD20 therapy are at particular risk of a wave-like course of COVID-19, caused by immunosuppression, creates a basis for bacterial and fungal coinfection.
Collapse
Affiliation(s)
- Olga Yepanchintseva
- HEART INSTITUTE OF THE MINISTRY OF HEALTH OF UKRAINE, KYIV, UKRAINE; SHUPYK NATIONAL HEALTHCARE UNIVERSITY OF UKRAINE, KYIV, UKRAINE
| | - Vasyl Babenko
- HEART INSTITUTE OF THE MINISTRY OF HEALTH OF UKRAINE, KYIV, UKRAINE
| | - Vitalina Yarosh
- HEART INSTITUTE OF THE MINISTRY OF HEALTH OF UKRAINE, KYIV, UKRAINE
| | | |
Collapse
|
12
|
Pang V, Seery N, Wesselingh R, Yeh W, Zhong M, Tan T, Dwyer C, Nesbitt C, Rath L, Perera D, Bridge F, Skibina O, Bosco JJ, Jokubaitis V, Marriott M, Butkueven H, Van Der Walt A, Massey J, Sutton I, Monif M. Neutropaenia complications from Ocrelizumab and Rituximab treatment. Mult Scler Relat Disord 2024; 81:105147. [PMID: 38043368 DOI: 10.1016/j.msard.2023.105147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 11/11/2023] [Accepted: 11/19/2023] [Indexed: 12/05/2023]
Abstract
Ocrelizumab is an anti-CD20 monoclonal antibody (mAb) that has been shown in phase 3 clinical trials to reduce relapses and disease progression in multiple sclerosis (MS) patients. Prior to the approval of ocrelizumab, rituximab, a chimeric anti-CD20 mAb was used to treat MS. Rituximab is still used to treat MS in many countries outside of Australia and remains mainstay of treatment of many non-MS neuroimmunological and systemic inflammatory diseases. Rituximab is currently used in neuromyelitis optica spectrum disorder (NMOSD) and autoimmune encephalitis, in addition to its widespread usage in hematological malignancies and systemic inflammatory diseases. Ocrelizumab is currently approved in Australia for treatment of relapsing-remitting MS (RRMS). Neutropaenia is a rare complication of both ocrelizumab and rituximab treatment. This case series reports 12 patients who have experienced neutropaenia following ocrelizumab or rituximab treatment and aims to characterize the clinical parameters of neutropaenia experienced by these patients, including the severity and duration of neutropaenia, length of hospital admission, the types of subsequent infections experienced and types of treatment necessary before patients reached count recovery. The unpredictability of neutropaenia and potential for serious infections highlight the need for continued hematological monitoring for patients on B-cell depleting therapies and calls for careful patient counselling to provide guidance on whether to continue such therapies in patients who have experienced related neutropaenia.
Collapse
Affiliation(s)
- Venus Pang
- Department of Neuroscience Monash University, Melbourne, Australia
| | - Nabil Seery
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Robb Wesselingh
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Wei Yeh
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Michael Zhong
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Tracie Tan
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Chris Dwyer
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Cassie Nesbitt
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Louise Rath
- Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Deborah Perera
- Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Francesca Bridge
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Olga Skibina
- Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Julian J Bosco
- Department of Allergy, asthma, Immunology, Alfred Hospital, Melbourne, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Mark Marriott
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Helmut Butkueven
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Anneke Van Der Walt
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Jennifer Massey
- Department of Neurology, St Vincent's Hospital, Sydney, Australia
| | - Ian Sutton
- Department of Neurology, St Vincent's Hospital, Sydney, Australia
| | - Mastura Monif
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia; Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia.
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Sabahi Z, Daei Sorkhabi A, Sarkesh A, Naseri A, Asghar-Rezaei N, Talebi M. A systematic review of the safety and efficacy of monoclonal antibodies for progressive multiple sclerosis. Int Immunopharmacol 2023; 120:110266. [PMID: 37209514 DOI: 10.1016/j.intimp.2023.110266] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/17/2023] [Accepted: 04/28/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Progressive multiple sclerosis (PMS) is a debilitating condition characterized by progressively worsening symptoms. Monoclonal antibodies are novel therapies for MS, but their safety and efficacy in the progressive form have not been comprehensively studied. In this systematic review, we aimed to evaluate the available evidence regarding monoclonal antibody treatment for PMS. METHODS After registration of the study protocol in PROSPERO, we systematically searched three major databases for clinical trials involving monoclonal antibodies administration for PMS treatment. All the retrieved results were imported into the EndNote reference manager. After removing the duplicates, two independent researchers did the study selection and data extraction. The risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist. RESULTS Of the 1846 studies in the preliminary search, 13 clinical trials investigating monoclonal antibodies (Ocrelizumab, Natalizumab, Rituximab, and Alemtuzumab) in PMS patients were included. Ocrelizumab was significantly effective in reducing clinical disease progression measures in primary PMS patients. The results for Rituximab were not completely reassuring and only showed significant changes for some endpoints on MRI and clinical measures. Natalizumab decreased the relapse rate and improved MRI features for secondary PMS patients, but not clinical endpoints. The studies on Alemtuzumab treatment revealed conflicting outcomes, with improvements observed in MRI endpoints but clinical worsening in patients. Additionally, among the studied adverse events, upper respiratory infections, urinary tract infections, and nasopharyngitis were frequently reported. CONCLUSION Based on our findings, Ocrelizumab is the most efficient monoclonal antibody for primary PMS, although it is associated with a higher risk of infection. While other monoclonal antibodies did not show significant promise in treating PMS, more research is necessary.
Collapse
Affiliation(s)
- Zahra Sabahi
- Research Center for Evidence-Based Medicine, Iranian EBM Centre: A Joanna Briggs Institute (JBI) Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Daei Sorkhabi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aila Sarkesh
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amirreza Naseri
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nazli Asghar-Rezaei
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahnaz Talebi
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| |
Collapse
|
15
|
Barrera B, Simpson H, Engebretson E, Sillau S, Valdez B, Parra‐González J, Winger RC, Epperson LA, Banks A, Pierce K, Spotts M, O'Gean K, Alvarez E, Gross R, Piquet AL, Schreiner T, Corboy JR, Pei J, Vollmer TL, Nair KV. Safety and patient experience with at-home infusion of ocrelizumab for multiple sclerosis. Ann Clin Transl Neurol 2023; 10:579-588. [PMID: 36811392 PMCID: PMC10109340 DOI: 10.1002/acn3.51745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE This study aimed to evaluate safety (infusion-related reactions [IRRs]) and patient satisfaction (patient-reported outcomes [PROs]) for at-home ocrelizumab administration for patients with multiple sclerosis (MS). METHODS This open-label study included adult patients with an MS diagnosis who had completed a ≥ 600-mg ocrelizumab dose, had a patient-determined disease steps score of 0 to 6 and had completed PROs. Eligible patients received a 600-mg ocrelizumab home-based infusion over 2 h, followed by 24-h and 2-week post-infusion follow-up calls. IRRs and adverse events (AEs) were documented during infusions and follow-up calls. PROs were completed before and 2 weeks post infusion. RESULTS Overall, 99 of 100 expected patients were included (mean [SD] age, 42.3 [7.7] years; 72.7% female; 91.9% White). The mean (SD) infusion time was 2.5 (0.6) hours, and 75.8% of patients completed their ocrelizumab infusion between 2 to 2.5 h. The IRR incidence rate was 25.3% (95% CI: 16.7%, 33.8%)-similar to other shorter ocrelizumab infusion studies-and all AEs were mild/moderate. In total, 66.7% of patients experienced AEs, including itch, fatigue, and grogginess. Patients reported significantly increased satisfaction with the at-home infusion process and confidence in the care provided. Patients also reported a significant preference for at-home infusion compared with prior infusion center experiences. INTERPRETATION IRRs and AEs occurred at acceptable rates during in-home infusions of ocrelizumab over a shorter infusion time. Patients reported increased confidence and comfort with the home infusion process. Findings from this study provide evidence of the safety and feasibility of home-based ocrelizumab infusion over a shorter infusion period.
Collapse
Affiliation(s)
- Britney Barrera
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Haley Simpson
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Eric Engebretson
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Stefan Sillau
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Brooke Valdez
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - José Parra‐González
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | | | | | - Ashley Banks
- Amerita Specialty Infusion ServicesDenverColoradoUSA
| | | | | | - Katie O'Gean
- University of Colorado HospitalAuroraColoradoUSA
| | - Enrique Alvarez
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Robert Gross
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Amanda L. Piquet
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Teri Schreiner
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - John R. Corboy
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Jinglan Pei
- Genentech, IncSouth San FranciscoCaliforniaUSA
| | - Timothy L. Vollmer
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Kavita V. Nair
- Department of Neurology, Rocky Mountain MS CenterUniversity of Colorado School of MedicineAuroraColoradoUSA
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| |
Collapse
|
16
|
Greve AS, Prakash S, Krag S, Randers E. Focal segmental glomerulosclerosis in a patient with multiple sclerosis treated with Teriflunomide and Ocrelizumab. J Nephrol 2023; 36:659-661. [PMID: 36414886 DOI: 10.1007/s40620-022-01504-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/12/2022] [Indexed: 11/24/2022]
Abstract
We describe the case of a 24-year-old male patient with multiple sclerosis (MS) who was treated with Teriflunomide for eight months. However, due to MS progression, treatment was switched to Ocrelizumab. After 15 months of therapy with Ocrelizumab the patient developed edema and nephrotic-range albuminuria. Kidney biopsy showed focal segmental glomerulosclerosis (FSGS) and Ocrelizumab treatment was stopped. Teriflunomide is less likely to have caused FSGS due to a three week wash-out period and a timespan of 15 months between the last Teriflunomide dose and development of albuminuria. Treatment with Ocrelizumab has been associated with organ-specific inflammation in MS-patients, thus an association between the development of FSGS and Ocrelizumab therapy is possible, and this case suggests considering this potential association.
Collapse
Affiliation(s)
- Anne-Sofie Greve
- Department of Medicine, Viborg Regional Hospital, Viborg, Denmark.
| | - Sivagini Prakash
- Department of Neurology, Viborg Regional Hospital, Viborg, Denmark
| | - Søren Krag
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Else Randers
- Department of Medicine, Viborg Regional Hospital, Viborg, Denmark
- Research Unit of Multimorbidity, Viborg Regional Hospital, Viborg, Denmark
| |
Collapse
|
17
|
Kwiatkowski AJ, Helm EY, Stewart J, Leon J, Drashansky T, Avram D, Keselowsky B. Design principles of microparticle size and immunomodulatory factor formulation dictate antigen-specific amelioration of multiple sclerosis in a mouse model. Biomaterials 2023; 294:122001. [PMID: 36716589 DOI: 10.1016/j.biomaterials.2023.122001] [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: 09/07/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/21/2023]
Abstract
Antigen-specific therapies allow for modulation of the immune system in a disease relevant context without systemic immune suppression. These therapies are especially valuable in autoimmune diseases such as multiple sclerosis (MS), where autoreactive T cells destroy myelin sheath. This work shows that an antigen-specific dual-sized microparticle (dMP) system can effectively halt and reverse disease progression in a mouse model of MS. Current MS treatments leave patients immunocompromised, but the dMP formulation spares the immune system as mice can successfully clear a Listeria Monocytogenes infection. Furthermore, we highlight design principles for particle based immunotherapies including the importance of delivering factors specific for immune cell recruitment (GM-CSF or SDF-1), differentiation (GM-CSF or FLT3L) and suppression (TGF-β or VD3) in conjunction with disease relevant antigen, as the entire formulation is required for maximum efficacy. Lastly, the dMP scheme relies on formulating phagocytosable and non-phagocytosable MP sizes to direct payload to target either cell surface receptors or intracellular targets, as the reverse sized dMP formulation failed to reverse paralysis. We also challenge the design principles of the dMP system showing that the size of the MPs impact efficacy and that GM-CSF plays two distinct roles and that both of these must be replaced to match the primary effect of the dMP system. Overall, this work shows the versatile nature of the dMP system and expands the knowledge in particle science by emphasizing design tenets to guide the next generation of particle based immunotherapies.
Collapse
Affiliation(s)
- Alexander J Kwiatkowski
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Eric Y Helm
- Department of Anatomy and Cell Biology, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Joshua Stewart
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Juan Leon
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Theodore Drashansky
- Department of Anatomy and Cell Biology, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Dorina Avram
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, 33612, USA.
| | - Benjamin Keselowsky
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA; Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville FL, 32610, USA.
| |
Collapse
|
18
|
Brandt C. Effects of an Ocrevus Rapid Infusion Protocol: A Literature Review and Quality Improvement Project. JOURNAL OF INFUSION NURSING 2023; 46:78-86. [PMID: 36853870 DOI: 10.1097/nan.0000000000000498] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
The administration of Ocrevus, an infusion therapy for the treatment of multiple sclerosis, is time and labor intensive, leading to poor patient adherence, treatment delays due to scheduling issues, and significant staff workload. This problem worsened during the COVID-19 pandemic, which created scheduling difficulties due to space restrictions. A US Food and Drug Administration-approved rapid infusion protocol for Ocrevus decreases the infusion time by 1.5 hours per patient. The purpose of this project was to complete a literature review on rapid infusion protocols and analyze the effects of the Ocrevus rapid infusion protocol on 2 outcomes of interest: total visit time and infusion reaction rates. Data were collected using retrospective chart review and analyzed by comparing the results of each outcome to the same data points prior to the implementation of the project. Results found a statistically significant decrease in visit time, with no increase in infusion reaction rates. These findings support the implementation of this rapid Ocrevus infusion protocol in the outpatient setting with the potential to improve patient scheduling, patient satisfaction, and nursing workload, while maintaining patient safety.
Collapse
Affiliation(s)
- Courtney Brandt
- Baylor University LHSON, Dallas, TX, and Paragon Healthcare, Dallas, TX
- Courtney Brandt, DNP, APRN, FNP-C, is a family nurse practitioner and clinical assistant professor of nursing at Baylor University. She has been practicing in outpatient infusion centers for 4 years and currently works for Paragon Healthcare in Dallas, Texas. She earned her DNP from University of Texas at Arlington in 2021 and her MSN from Texas Tech Health Sciences Center in 2017. She also has previous experience as a family nurse practitioner in asthma/allergy medicine, as well as a nursing background in the pediatric intensive care unit and adult medical/surgical nursing. Her areas of research interest include infusion medicine and nursing education. She lives in Arlington, Texas, with her husband and 4 young children
| |
Collapse
|
19
|
Zhang Z, Xu Q, Huang L. B cell depletion therapies in autoimmune diseases: Monoclonal antibodies or chimeric antigen receptor-based therapy? Front Immunol 2023; 14:1126421. [PMID: 36855629 PMCID: PMC9968396 DOI: 10.3389/fimmu.2023.1126421] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 01/26/2023] [Indexed: 03/02/2023] Open
Abstract
Immune system detects foreign pathogens, distinguishes them from self-antigens and responds to defend human body. When this self-tolerance is disrupted, the overactive immune system attacks healthy tissues or organs and the autoimmune diseases develop. B cells and plasma cells contribute a lot to pathogenesis and persistence of autoimmune diseases in both autoantibody-dependent and autoantibody-independent ways. Accumulating data indicates that treatments aiming to eliminate antibody-secreting cells (B cells or plasma cells) are effective in a wide spectrum of autoimmune diseases. Monoclonal antibodies (mAbs) deplete B cell lineage or plasma cells by signaling disruption, complement-dependent cytotoxicity (CDC) and antibody-dependent cellular cytotoxicity (ADCC). Engineered-T cells armed with chimeric antigen receptors (CARs) have been adopted from field of hematological malignancies as a method to eliminate B cells or plasma cells. In this review, we update our understanding of B cell depletion therapies in autoimmune diseases, review the mechanism, efficacy, safety and application of monoclonal antibodies and CAR-based immunotherapies, and discuss the strengths and weaknesses of these treatment options for patients.
Collapse
Affiliation(s)
- Zheng Zhang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qian Xu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, China
| | - Liang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, China,*Correspondence: Liang Huang,
| |
Collapse
|
20
|
Saidha S, Bell J, Harold S, Belisario JM, Hawe E, Shao Q, Wyse K, Maiese EM. Systematic literature review of immunoglobulin trends for anti-CD20 monoclonal antibodies in multiple sclerosis. Neurol Sci 2023; 44:1515-1532. [PMID: 36648561 PMCID: PMC9843103 DOI: 10.1007/s10072-022-06582-y] [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: 09/01/2022] [Accepted: 12/21/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To exp lore changes in immunoglobulin (Ig) levels for people with relapsing-multiple sclerosis (RMS) treated with ocrelizumab or ofatumumab and the relationship between Ig levels and infections. METHODS A systematic literature review (SLR) was conducted to identify clinical trials and real-world evidence (RWE) studies on Ig levels over time and studies on associations with infections for ocrelizumab and ofatumumab for people with RMS through 10 September 2021. Searches were conducted in Embase, MEDLINE, Cochrane Library, trial registries, and recent conference abstracts. RESULTS Of 1,580 articles identified, 30 reporting on 11 trials and 5 RWE studies were included. Ocrelizumab trials (n = 4) had 24-336 weeks of follow-up and reported decreasing Ig G (IgG) levels, while RWE (n = 5) had 52-78 weeks of follow-up and reported IgG to be stable or decrease only slightly. IgG levels were stable in ofatumumab trials (n = 5; 104-168 weeks of follow-up), but no RWE or longer-term studies were identified. No apparent association between decreased Ig levels and infections was observed during ofatumumab treatment (ASCLEPIOS I/II), while for ocrelizumab, the only data on apparent associations between decreased IgG levels and serious infection rates were for a pooled population of people with RMS or primary progressive MS. CONCLUSION Decreasing IgG levels have been correlated with increased infection risk over time. IgG levels appeared to decrease over time in ocrelizumab trials but remained relatively stable over time in ofatumumab trials. Additional research is needed to understand differences between ocrelizumab and ofatumumab and identify people at risk of decreasing IgG levels and infection.
Collapse
Affiliation(s)
- Shiv Saidha
- Division of Neuroimmunology and Neurological Infections, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | | | | | | | - Emma Hawe
- RTI Health Solutions, Manchester, UK
| | - Qiujun Shao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ USA
| | - Kerri Wyse
- Novartis Pharmaceuticals Corporation, East Hanover, NJ USA
| | - Eric M. Maiese
- Novartis Pharmaceuticals Corporation, East Hanover, NJ USA
| |
Collapse
|
21
|
Relapsing-remitting and primary progressive multiple sclerosis treated with ocrelizumab: A comparative study. Mult Scler Relat Disord 2023; 69:104441. [PMID: 36493559 DOI: 10.1016/j.msard.2022.104441] [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: 09/29/2022] [Revised: 11/11/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To compare the clinical and radiological effectiveness of ocrelizumab in primary progressive multiple sclerosis (PPMS) and relapsing-remitting multiple sclerosis (RRMS) in a clinical practice setting and describe its tolerability and adverse events. METHODS A retrospective observational cohort study was conducted comparing clinical and magnetic resonance imaging (MRI) data of all patients with (pw)PPMS and RRMS who had received treatment with ocrelizumab at least one cycle and have been followed up for one year at minimum. RESULTS 42 patients (27 women) treated with ocrelizumab: 29 had RRMS and 13 PPMS. The follow-up period was 26.4 ± 8.4 months. The proportion of pwRRMS with no evidence of disease activity (NEDA) in the first year was 69.2% and in the second was 80%. In the first year, radiological activity was reduced by 80.0% in pwRRMS and 91.7% in pwPPMS. In the second year, radiological activity was completely reduced in both groups. A statistically significant difference (p<0.05) was observed between the pre-ocrelizumab rate of disability progression vs. the first year rate of progression for pwRRMS and pwPPMS. However, an increase in the disability progression rate in the second year of treatment was found in pwPPMS. Ocrelizumab was mostly well tolerated and some adverse effects were reported: infusion-related reactions (IRRs) were the most frequent adverse event, followed by infections and hematological side effects. Discontinuations were due to infections, hematological complications, and perception of ineffectiveness. CONCLUSIONS Ocrelizumab was very effective in reducing relapses and MRI activity. The rate of progression was slowed down; however, the effect was more evident for pwRRMS than for pwPPMS over time.
Collapse
|
22
|
Gu SC, Yuan CX, Gu C. Identification of ferroptosis-related gene signatures associated with multiple sclerosis using weighted gene co-expression network analysis. Medicine (Baltimore) 2022; 101:e31802. [PMID: 36595760 PMCID: PMC9794287 DOI: 10.1097/md.0000000000031802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of central nervous system leading to demyelination followed by neurological symptoms. Ferroptosis is a newly discovered pathogenic hallmark important for the progression of MS. However, the gene markers of ferroptosis in MS are still uncertain. In this study, mRNA expression profiles and clinical data of MS samples were retrieved from Gene Expression Omnibus database. Weighted gene co-expression network analysis and receiver operating characteristic curve analysis were utilized to identify ferroptosis-related gene (FRG) signatures of MS. Gene set enrichment analysis and gene set variation analysis were performed to explore the biological functions of single FRG signature. HMOX1, LPCAT3 and RPL8 were firstly identified as FRG signatures of MS with the predictive capacity confirmed. Gene set enrichment analysis and gene set variation analyses revealed that metabolism-related, immune and inflammation-related, microglia-related, oxidation-related, and mitochondria-related biological functions were enriched, providing implications of the mechanisms underlying ferroptosis in MS. This study presented a systematic analysis of FRG in MS and explored the potential ferroptosis targets for new interventional strategies in MS.
Collapse
Affiliation(s)
- Si-Chun Gu
- Department of Neurology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Can-Xing Yuan
- Department of Neurology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chao Gu
- Department of Neurology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- * Correspondence: Chao Gu, Department of Neurology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 South Wanping Road, Shanghai, 200032, China (e-mail: )
| |
Collapse
|
23
|
Manchon E, Laplaud D, Vukusic S, Labauge P, Moreau T, Kobelt G, Grouin JM, Lotz M, Pau D, Christine LF. Efficacy, safety and patient reported outcomes in patients with active relapsing multiple sclerosis treated with ocrelizumab: Final results from the PRO-MSACTIVE study. Mult Scler Relat Disord 2022; 68:104109. [PMID: 36007299 DOI: 10.1016/j.msard.2022.104109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/03/2022] [Accepted: 08/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ocrelizumab, a humanized anti-CD20 monoclonal antibody, has been approved in Europe for the treatment of adult patients with active relapsing multiple sclerosis (RMS) and primary progressive multiple sclerosis (PPMS), on the basis of previous phase III studies. However, limited data were available on ocrelizumab efficacy in RMS according to the Lublin definition of activity (clinical and/or imaging features) used in the current drug label. The PRO-MSACTIVE study was thus designed to provide additional data on ocrelizumab efficacy according to this definition, and also on safety and patient reported outcomes (PROs). METHODS PRO-MSACTIVE is a national, multicenter, open-label, single-arm phase IV French study, conducted in patients with active RMS (relapsing-remitting multiple sclerosis, RRMS, or secondary progressive multiple sclerosis, SPMS). The primary endpoint, which was assessed at week (W) 48, was defined as the proportion of patients free of disease activity (defined by no relapses and no T1 gadolinium-enhancing nor new and/or enlarging T2 lesions using brain MRI). Disease activity, disability and PROs using 6 questionnaires for disease severity, quality of life, impact on work productivity, and treatment satisfaction were described at W24 and W48. Adverse events were described until W72. RESULTS Among the 422 analyzed patients (RRMS: 376, SPMS: 46), 63.3% (95% CI [58.5%; 67.9%]) were free of disease activity at W48 (RRMS: 62.2% [57.1%; 67.2%], SPMS: 71.7% [56.5%; 84.0%]). A total of 358 patients (84.8%; RRMS: 84.6%, SPMS: 87.0%) were relapse-free up to W48, and the overall adjusted annualized relapse rate was 0.14 (RRMS: 0.15, SPMS: 0.09). Overall, 67.8% of patients (RRMS: 66.8%, SPMS: 76.1%) had no evidence of MRI activity (no T1 gadolinium-enhancing lesions [83.4%] and no new/enlarging T2 lesions [75.1%]); 58.5% of patients (RRMS: 57.7%, SPMS: 65.2%) achieved No Evidence of Disease Activity (NEDA: no relapses, no confirmed disability progression, and no MRI activity) at W48. All PRO scores were stable between the first dose of ocrelizumab and W48 and better outcomes were seen for patients having an EDSS score ≥4. Overall, 89.3% of patients reported adverse events, 62.3% adverse events assessed as related to ocrelizumab, and 8.5% serious adverse events. No serious infusion-related reactions, opportunistic infections, progressive multifocal leukoencephalopathy, nor deaths were reported. No new safety signal was identified. CONCLUSION These data confirm the efficacy of ocrelizumab in a pragmatic setting and its favorable benefit-risk profile in patients with RMS. (ClinicalTrials.gov identifier: NCT03589105; EudraCT identifier: 2018-000780-91).
Collapse
Affiliation(s)
- Eric Manchon
- Centre Hospitalier de Gonesse, Service de Neurologie, Gonesse, France.
| | - David Laplaud
- Nantes Université, Service de Neurologie, Centre Hospitalier Universitaire de Nantes, CIC INSERM 1413, Center for Research in Transplantation and Translational Immunology, INSERM UMR 1064, Nantes, France
| | - Sandra Vukusic
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Service de Neurologie, Centre de Recherche en Neurosciences de Lyon, OFSEP, INSERM 1028 et CNRS UMR 5292, Université Claude Bernard de Lyon, Eugène Devic EDMUS Foundation, Bron, France
| | - Pierre Labauge
- Centre Hospitalier Universitaire de Montpellier, Hôpital Gui de Chauliac, Service de Neurologie, Montpellier, France
| | - Thibault Moreau
- Centre Hospitalier Universitaire de Dijon Bourgogne, Hôpital François Mitterrand, Maladies Inflammatoires du Système Nerveux et Neurologie Générale, Service de Neurologie, Dijon, France
| | | | | | | | - David Pau
- Roche SAS, Boulogne-Billancourt, France
| | - Lebrun Frenay Christine
- Centre Hospitalier Universitaire Pasteur 2, Service de Neurologie, CRCSEP, Unitéde Recherche Clinique Côte d'Azur (UR2CA-URRIS), Nice, France
| |
Collapse
|
24
|
Mekky RY, Elemam NM, Eltahtawy O, Zeinelabdeen Y, Youness RA. Evaluating Risk: Benefit Ratio of Fat-Soluble Vitamin Supplementation to SARS-CoV-2-Infected Autoimmune and Cancer Patients: Do Vitamin-Drug Interactions Exist? Life (Basel) 2022; 12:1654. [PMID: 36295089 PMCID: PMC9604733 DOI: 10.3390/life12101654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
COVID-19 is a recent pandemic that mandated the scientific society to provide effective evidence-based therapeutic approaches for the prevention and treatment for such a global threat, especially to those patients who hold a higher risk of infection and complications, such as patients with autoimmune diseases and cancer. Recent research has examined the role of various fat-soluble vitamins (vitamins A, D, E, and K) in reducing the severity of COVID-19 infection. Studies showed that deficiency in fat-soluble vitamins abrogates the immune system, thus rendering individuals more susceptible to COVID-19 infection. Moreover, another line of evidence showed that supplementation of fat-soluble vitamins during the course of infection enhances the viral clearance episode by promoting an adequate immune response. However, more thorough research is needed to define the adequate use of vitamin supplements in cancer and autoimmune patients infected with COVID-19. Moreover, it is crucial to highlight the vitamin-drug interactions of the COVID-19 therapeutic modalities and fat-soluble vitamins. With an emphasis on cancer and autoimmune patients, the current review aims to clarify the role of fat-soluble vitamins in SARS-CoV-2 infection and to estimate the risk-to-benefit ratio of a fat-soluble supplement administered to patients taking FDA-approved COVID-19 medications such as antivirals, anti-inflammatory, receptor blockers, and monoclonal antibodies.
Collapse
Affiliation(s)
- Radwa Y. Mekky
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, October University for Modern Sciences and Arts (MSA University), Cairo 12622, Egypt
| | - Noha M. Elemam
- Sharjah Institute for Medical Research (SIMR), College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Omar Eltahtawy
- Molecular Genetics Research Team (MGRT), Pharmaceutical Biology Department, Faculty of Pharmacy and Biotechnology, German University in Cairo, Cairo 12622, Egypt
| | - Yousra Zeinelabdeen
- Molecular Genetics Research Team (MGRT), Pharmaceutical Biology Department, Faculty of Pharmacy and Biotechnology, German University in Cairo, Cairo 12622, Egypt
- Faculty of Medical Sciences, University Medical Center Groningen (UMCG), University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Rana A. Youness
- Molecular Genetics Research Team (MGRT), Pharmaceutical Biology Department, Faculty of Pharmacy and Biotechnology, German University in Cairo, Cairo 12622, Egypt
- Biology and Biochemistry Department, School of Life and Medical Sciences, University of Hertfordshire Hosted by Global Academic Foundation, Cairo 12622, Egypt
| |
Collapse
|
25
|
Chen TX, Fan YT, Peng BW. Distinct mechanisms underlying therapeutic potentials of CD20 in neurological and neuromuscular disease. Pharmacol Ther 2022; 238:108180. [DOI: 10.1016/j.pharmthera.2022.108180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/16/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
|
26
|
Ovchinnikov A, Findling O. An overview of pivotal trials and real-world evidence for CD20-depleting therapy in multiple sclerosis : Immunotherapy with rituximab, ocrelizumab, and ofatumumab. Wien Med Wochenschr 2022; 172:359-364. [PMID: 35723820 PMCID: PMC9208251 DOI: 10.1007/s10354-022-00939-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 05/04/2022] [Indexed: 11/28/2022]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system leading to demyelination and neurodegeneration of brain tissue. For a long time, research focused on T cells as the primary mechanism of disease. Driven by reports on the clinical results of B cell-depleting therapies, this therapeutic approach has come into focus in the last decade, and new highly effective treatments have been developed and are now complementing the therapeutic landscape. This review provides an overview of the development of B cell-depleting therapies and shows the advantages and disadvantages of current developments. In addition, we discuss basic considerations for CD20-depleted MS patients in the face of the COVID-19 pandemic.
Collapse
Affiliation(s)
- Arkady Ovchinnikov
- Department of Neurology, Kantonsspital Aarau, Tellstr. 25, 5001, Aarau, Switzerland
| | - Oliver Findling
- Department of Neurology, Kantonsspital Aarau, Tellstr. 25, 5001, Aarau, Switzerland.
| |
Collapse
|
27
|
Abstract
BACKGROUND Ocrelizumab is a humanised anti-CD20 monoclonal antibody developed for the treatment of multiple sclerosis (MS). It was approved by the Food and Drug Administration (FDA) in March 2017 for using in adults with relapsing-remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS). Ocrelizumab is the only disease-modifying therapy (DMT) approved for PPMS. In November 2017, the European Medicines Agency (EMA) also approved ocrelizumab as the first drug for people with early PPMS. Therefore, it is important to evaluate the benefits, harms, and tolerability of ocrelizumab in people with MS. OBJECTIVES To assess the benefits, harms, and tolerability of ocrelizumab in people with RRMS and PPMS. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, and two trials registers on 8 October 2021. We screened reference lists, contacted experts, and contacted the main authors of studies. SELECTION CRITERIA All randomised controlled trials (RCTs) involving adults diagnosed with RRMS or PPMS according to the McDonald criteria, comparing ocrelizumab alone or associated with other medications, at the approved dose of 600 mg every 24 weeks for any duration, versus placebo or any other active drug therapy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS Four RCTs met our selection criteria. The overall population included 2551 participants; 1370 treated with ocrelizumab 600 mg and 1181 controls. Among the controls, 298 participants received placebo and 883 received interferon beta-1a. The treatment duration was 24 weeks in one study, 96 weeks in two studies, and at least 120 weeks in one study. One study was at high risk of allocation concealment and blinding of participants and personnel; all four studies were at high risk of bias for incomplete outcome data. For RRMS, compared with interferon beta-1a, ocrelizumab was associated with: 1. lower relapse rate (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.52 to 0.73; 2 studies, 1656 participants; moderate-certainty evidence); 2. a lower number of participants with disability progression (hazard ratio (HR) 0.60, 95% CI 0.43 to 0.84; 2 studies, 1656 participants; low-certainty evidence); 3. little to no difference in the number of participants with any adverse event (RR 1.00, 95% CI 0.96 to 1.04; 2 studies, 1651 participants; moderate-certainty evidence); 4. little to no difference in the number of participants with any serious adverse event (RR 0.79, 95% CI 0.57 to 1.11; 2 studies, 1651 participants; low-certainty evidence); 5. a lower number of participants experiencing treatment discontinuation caused by adverse events (RR 0.58, 95% CI 0.37 to 0.91; 2 studies, 1651 participants; low-certainty evidence); 6. a lower number of participants with gadolinium-enhancing T1 lesions on magnetic resonance imaging (MRI) (RR 0.27, 95% CI 0.22 to 0.35; 2 studies, 1656 participants; low-certainty evidence); 7. a lower number of participants with new or enlarging T2-hyperintense lesions on MRI (RR 0.63, 95% CI 0.57 to 0.69; 2 studies, 1656 participants; low-certainty evidence) at 96 weeks. For PPMS, compared with placebo, ocrelizumab was associated with: 1. a lower number of participants with disability progression (HR 0.75, 95% CI 0.58 to 0.98; 1 study, 731 participants; low-certainty evidence); 2. a higher number of participants with any adverse events (RR 1.06, 95% CI 1.01 to 1.11; 1 study, 725 participants; moderate-certainty evidence); 3. little to no difference in the number of participants with any serious adverse event (RR 0.92, 95% CI 0.68 to 1.23; 1 study, 725 participants; low-certainty evidence); 4. little to no difference in the number of participants experiencing treatment discontinuation caused by adverse events (RR 1.23, 95% CI 0.55 to 2.75; 1 study, 725 participants; low-certainty evidence) for at least 120 weeks. There were no data for number of participants with gadolinium-enhancing T1 lesions on MRI and number of participants with new or enlarging T2-hyperintense lesions on MRI. AUTHORS' CONCLUSIONS For people with RRMS, ocrelizumab probably results in a large reduction in relapse rate and little to no difference in adverse events when compared with interferon beta-1a at 96 weeks (moderate-certainty evidence). Ocrelizumab may result in a large reduction in disability progression, treatment discontinuation caused by adverse events, number of participants with gadolinium-enhancing T1 lesions on MRI, and number of participants with new or enlarging T2-hyperintense lesions on MRI, and may result in little to no difference in serious adverse events (low-certainty evidence). For people with PPMS, ocrelizumab probably results in a higher rate of adverse events when compared with placebo for at least 120 weeks (moderate-certainty evidence). Ocrelizumab may result in a reduction in disability progression and little to no difference in serious adverse events and treatment discontinuation caused by adverse events (low-certainty evidence). Ocrelizumab was well tolerated clinically; the most common adverse events were infusion-related reactions and nasopharyngitis, and urinary tract and upper respiratory tract infections.
Collapse
Affiliation(s)
- Mengbing Lin
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jian Zhang
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yueling Zhang
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jiefeng Luo
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shengliang Shi
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| |
Collapse
|
28
|
Aun MV, Freua F, Marussi VHR, Giavina-Bianchi P. Case Report: Rapid Desensitization to Ocrelizumab for Multiple Sclerosis Is Effective and Safe. Front Immunol 2022; 13:840238. [PMID: 35222433 PMCID: PMC8865367 DOI: 10.3389/fimmu.2022.840238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Monoclonal antibodies have become a mainstay of treatment for many inflammatory diseases and malignancies. Multiple sclerosis is a chronic inflammatory, demyelinating, and neurodegenerative disease of the central nervous system and a common cause of disability in young adults. Ocrelizumab is a recombinant humanized monoclonal antibody that targets CD20-positive B cells and has been approved in the treatment of multiple sclerosis. Although considered safe, more than 30% of patients treated with Ocrelizumab developed infusion-related reactions, mostly regarded as mild. When severe, they can lead to a definite suspension of that drug. We present a case report of Ocrelizumab desensitization in a female patient who presented an immediate hypersensitivity reaction (urticaria and angioedema) during the first Ocrelizumab infusion. Although mechanisms involved in the response were not elucidated, the procedure occurred uneventfully and permitted first-line multiple sclerosis treatment maintenances. Desensitization should be considered a safe therapeutic option in patients with immediate hypersensitivity reactions to Ocrelizumab.
Collapse
Affiliation(s)
- Marcelo Vivolo Aun
- Faculdade Israelita de Ciências da Saúde Albert Einstein School of Medicine, São Paulo, Brazil.,Clinical Immunology and Allergy Division, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Fernando Freua
- Department of Neurology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil.,Neurology Division, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Pedro Giavina-Bianchi
- Clinical Immunology and Allergy Division, University of Sao Paulo School of Medicine, São Paulo, Brazil
| |
Collapse
|
29
|
Raina P, Basu S, Goyal RK, Sahoo PK, Mathur R. Systematic Review and Meta-Analysis Comparing the Safety of Natalizumab, Ocrelizumab, and Alemtuzumab in Treating Relapsing–Remitting, Primary Progressive, and Secondary Progressive Multiple Sclerosis. J Pharmacol Pharmacother 2022. [DOI: 10.1177/0976500x221080225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Three monoclonal antibodies—natalizumab (NTZ), ocrelizumab (OCR), and alemtuzumab (ALM)—are the mainstays for the treatment of both relapsing and progressive forms of multiple sclerosis (MS). Here, their safety in patients with MS is analyzed and compared for rational use, especially during the COVID-19 pandemic. All clinical studies published between 2016 and 2020 with the primary outcome of the occurrence of adverse events (AEs) with the use of NTZ, OCR, and ALM in the treatment of MS were systematically searched in the PubMed database. In this review, the percentage of patients reporting AEs was calculated and compared. The most common AEs associated with the use of NTZ, OCR, and ALM were infection and infestation. The percentage of patients reporting urinary tract infection, upper respiratory tract infection, and herpes was 16% using natalizumab, 7% using natalizumab and ocrelizumab, and 2% with ocrelizumab, respectively. The most common AEs, such as rashes, pyrexia, and influenza, were reported with ocrelizumab and alemtuzumab. Additionally, alemtuzumab was associated with immune thrombocytopenia (2%), respiratory infections (7%), and thyroid dysfunction (43%). All these data outcomes show that of the three monoclonal antibodies, natalizumab and ocrelizumab were associated with a reduced incidence of adverse events, making them a safer choice for MS.
Collapse
Affiliation(s)
- Pooja Raina
- Delhi Institute of Pharmaceutical Sciences and Research, DPSRU, Pushp Vihar, New Delhi, India
| | - Somnath Basu
- Assistant Drug Controller (India), Central Drug Standard Control Organisation, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Ramesh K Goyal
- Delhi Institute of Pharmaceutical Sciences and Research, DPSRU, Pushp Vihar, New Delhi, India
| | - Pravat K Sahoo
- Delhi Institute of Pharmaceutical Sciences and Research, DPSRU, Pushp Vihar, New Delhi, India
| | - Rajani Mathur
- Delhi Institute of Pharmaceutical Sciences and Research, DPSRU, Pushp Vihar, New Delhi, India
| |
Collapse
|
30
|
Hauser SL, Cross AH, Winthrop K, Wiendl H, Nicholas J, Meuth SG, Giacomini PS, Saccà F, Mancione L, Zielman R, Bagger M, Das Gupta A, Häring DA, Jehl V, Kieseier BC, Pingili R, Stoneman D, Su W, Willi R, Kappos L. Safety experience with continued exposure to ofatumumab in patients with relapsing forms of multiple sclerosis for up to 3.5 years. Mult Scler 2022; 28:1576-1590. [PMID: 35229668 PMCID: PMC9330270 DOI: 10.1177/13524585221079731] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Ofatumumab is approved for the treatment of relapsing multiple sclerosis
(RMS). Ongoing safety reporting is crucial to understand its long-term
benefit–risk profile. Objective: Report the safety and tolerability of ofatumumab in RMS after extended
treatment up to 3.5 years. Methods: Patients completing ASCLEPIOS I/II (phase 3), APLIOS, or APOLITOS (phase 2)
trials could enter ALITHIOS, a phase 3b, open-label, long-term safety study.
We analyzed cumulative data of continuous ofatumumab treatment and of
patients newly switched from teriflunomide. Results: The safety population had 1969 patients: 1292 continuously treated with
ofatumumab (median time-at-risk 35.5 months, 3253 patient-years) and 677
newly switched (median time-at-risk 18.3 months, 986 patient-years). A total
of 1650 patients (83.8%) had ⩾1 adverse events and 191 (9.7%) had ⩾1 serious
adverse events. No opportunistic infections or progressive multifocal
leukoencephalopathy events were identified; the risk of malignancies was
low. Mean serum immunoglobulin (Ig) G levels remained stable. Mean IgM
levels decreased but remained above the lower limit of normal in most.
Serious infection incidence was low; decreased Ig levels were not associated
with serious infections. Conclusion: In patients with up to 3.5 years’ exposure, ofatumumab was well tolerated,
with no new safety risks identified. These findings, with its established
effectiveness, support a favorable benefit–risk profile of ofatumumab in
RMS.
Collapse
Affiliation(s)
- Stephen L Hauser
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Anne H Cross
- Washington University School of Medicine, St Louis, MO, USA
| | | | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Jacqueline Nicholas
- OhioHealth Multiple Sclerosis Center, Riverside Methodist Hospital, Columbus, OH, USA
| | - Sven G Meuth
- Department of Neurology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Paul S Giacomini
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Francesco Saccà
- Department of Neurosciences, Odontostomatological and Reproductive Sciences, University Federico II, Naples, Italy
| | - Linda Mancione
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Ayan Das Gupta
- Novartis Healthcare Pvt. Ltd, Hyderabad, Telangana, India
| | | | | | - Bernd C Kieseier
- Novartis Pharma AG, Basel, Switzerland and Department of Neurology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | | | | | - Wendy Su
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB) and MS Center, Departments of Head, Spine and Neuromedicine, Clinical Research, Biomedicine, Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| |
Collapse
|
31
|
Abstract
Ocrelizumab (Ocrevus®) is an intravenously administered, humanized anti-CD20 monoclonal antibody approved for the treatment of adults with relapsing forms of multiple sclerosis (RMS) or primary progressive multiple sclerosis (PPMS). The efficacy of ocrelizumab in reducing relapse rates and disease activity in patients with RMS was demonstrated in pivotal trials (versus interferon β-1a) and supporting single-arm studies in specific subpopulations. In patients with PPMS, ocrelizumab reduced measures of clinical and MRI progression relative to placebo. Clinical benefits were maintained over ≥ 7.5 study years of treatment. Ocrelizumab was generally well tolerated and no new safety signals have emerged with long-term use. Extensive (albeit short-term) real-world data pertaining to ocrelizumab is consistent with that from clinical trials. Ocrelizumab provides the convenience of short, half-yearly infusions. Ocrelizumab continues to represent a generally well-tolerated, high-efficacy disease-modifying therapy (DMT) for RMS and is a valuable treatment for delaying disease progression in patients with PPMS (for whom there are currently no other approved DMTs).
Collapse
Affiliation(s)
- Yvette N Lamb
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
| |
Collapse
|
32
|
Alvarez E, Nair KV, Sillau S, Shelton I, Seale R, Selva S, Corboy J, Vollmer TL. Tolerability and Safety of Switching from Rituximab to Ocrelizumab: Evaluating Factors Associated with Infusion Related Reactions. Mult Scler J Exp Transl Clin 2022; 8:20552173211069359. [PMID: 35024160 PMCID: PMC8743958 DOI: 10.1177/20552173211069359] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/06/2021] [Indexed: 11/15/2022] Open
Abstract
Background Ocrelizumab and rituximab are frequently used treatments for multiple sclerosis (MS). Data on switching from rituximab to ocrelizumab is limited. Objectives To assess the frequency, severity, and factors of infusion related reactions (IRRs) in patients with MS who switch from rituximab to ocrelizumab, compared to those who stay on rituximab. Methods Prospective study on MS patients aged 18–65, on rituximab for at least 2 cycles, who either switched to ocrelizumab (switch group) or stayed on rituximab (comparator group) (n = 100 each). Participants were followed for IRRs, safety, and tolerability over 12 months. Results The proportion of IRRs in patients who continue on rituximab (14%) were similar to those who switched to ocrelizumab on Day 1 (14%; p = 1.000) and Week 24 (12%; p = 0.647) but higher than at Day 15 (4%; 0.005). The risk of IRRs for the switch group was associated with the presence of B cells (CD19 and/or CD20 counts ≥1%) increasing by 5.01 (1.49, 16.82) times on Day 1 (p = 0.007). Antidrug antibodies to ocrelizumab were not associated with IRRs. No other safety concerns were identified in switching to ocrelizumab. Conclusion IRRs are similar between both groups, which suggests that it is safe to switch from rituximab to ocrelizumab.
Collapse
Affiliation(s)
- Enrique Alvarez
- Department of Neurology, University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, USA
| | - Kavita V Nair
- Department of Neurology, University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, USA
| | - Stefan Sillau
- Department of Neurology, University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, USA
| | - Ian Shelton
- Department of Neurology, University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, USA
| | - Rebecca Seale
- Department of Neurology, University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, USA
| | - Sean Selva
- Department of Neurology, University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, USA
| | - John Corboy
- Department of Neurology, University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, USA
| | - Timothy L Vollmer
- Department of Neurology, University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, USA
| |
Collapse
|
33
|
Ghajarzadeh M, Mirmosayyeb O, Molazadeh N, Sahraian M, Bonavita S, Shaygannejad V. Predictors of Catching COVID-19 Infection during Pandemic Stage in Patients with Multiple Sclerosis (MS). Int J Prev Med 2022; 13:102. [PMID: 36119957 PMCID: PMC9470912 DOI: 10.4103/ijpvm.ijpvm_480_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 09/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Patients with multiple sclerosis (MS) are considered at higher risk of COVID-19 infection due to treatment with immune modulators and immune-suppressive agents. The exact risk factors are not clear. So, we aimed to conduct a study to determine the predictors of catching COVID-19 infection during the pandemic stage in patients with multiple sclerosis (MS). Methods: We conducted a multicenter screening study and developed an online questionnaire to collect patients’ self-reported demographic features along with MS-related and COVID-19–related information. The online questionnaire link was released by the Iran Multiple Sclerosis Society (IMSS) social media channel, accessible for 4160 MS patients totally and also was sent by WhatsApp for nonmember cases. Results: Totally, 1448 MS patients participated in our study. Twenty-five (1.7%) patients were diagnosed with COVID-19, from which 4 were hospitalized, 4 were treated with medical therapy, and 17 patients had home-quarantine. The patients with COVID-19 diagnosis were more frequently treated with rituximab (28% vs 24%, P = 0.001) than others, and cardiovascular comorbidity was more frequent in this group (8% vs 1.6%, P = 0.01). Regression analysis showed that cardiovascular disease was a significant positive predictor of COVID-19 infection (OR = 5.2, 95% CI: 1.1–23.7). Conclusions: Patients with MS who have cardiovascular disease should be more monitored for COVID-19 infection as they are at higher risk of infection.
Collapse
|
34
|
Smets I, Giovannoni G. Derisking CD20-therapies for long-term use. Mult Scler Relat Disord 2021; 57:103418. [PMID: 34902761 DOI: 10.1016/j.msard.2021.103418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/15/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022]
Abstract
Anti-CD20 have quickly become the mainstay in the treatment of multiple sclerosis (MS) and other neuroinflammatory conditions. However, when they are used as a maintenance therapy the balance between risks and benefits changes. In this review, we suggested six steps to derisk anti-CD20. Firstly and secondly, adequate infectious screening followed by vaccinations before starting anti-CD20 are paramount. Third, family planning needs to be discussed upfront with every woman of childbearing age. Fourth, infusion reactions should be adequately managed to avoid treatment interruption. After repeated infusions, it becomes important to detect and prevent anti-CD20-related adverse events. Fifth, we recommended measuring immunoglobulin levels and reviewing vaccinations annually as well as counselling adequate fever management. For female patients, we emphasised the importance to engage with the local breast cancer screening programs. Sixth, to fundamentally derisk anti-CD20 therapies, we need evidence-based approaches to reduce dosing intervals and guide retreatment.
Collapse
Affiliation(s)
- Ide Smets
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Gavin Giovannoni
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom.
| |
Collapse
|
35
|
Lymphocyte Counts and Multiple Sclerosis Therapeutics: Between Mechanisms of Action and Treatment-Limiting Side Effects. Cells 2021; 10:cells10113177. [PMID: 34831400 PMCID: PMC8625745 DOI: 10.3390/cells10113177] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 01/18/2023] Open
Abstract
Although the detailed pathogenesis of multiple sclerosis (MS) is not completely understood, a broad range of disease-modifying therapies (DMTs) are available. A common side effect of nearly every MS therapeutic agent is lymphopenia, which can be both beneficial and, in some cases, treatment-limiting. A sound knowledge of the underlying mechanism of action of the selected agent is required in order to understand treatment-associated changes in white blood cell counts, as well as monitoring consequences. This review is a comprehensive summary of the currently available DMTs with regard to their effects on lymphocyte count. In the first part, we describe important general information about the role of lymphocytes in the course of MS and the essentials of lymphopenic states. In the second part, we introduce the different DMTs according to their underlying mechanism of action, summarizing recommendations for lymphocyte monitoring and definitions of lymphocyte thresholds for different therapeutic regimens.
Collapse
|
36
|
Remyelination in PNS and CNS: current and upcoming cellular and molecular strategies to treat disabling neuropathies. Mol Biol Rep 2021; 48:8097-8110. [PMID: 34731366 DOI: 10.1007/s11033-021-06755-6] [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: 03/21/2021] [Accepted: 09/15/2021] [Indexed: 10/19/2022]
Abstract
Myelin is a lipid-rich nerve cover that consists of glial cell's plasmalemma layers and accelerates signal conduction. Axon-myelin contact is a source for many developmental and regenerative signals of myelination. Intra- or extracellular factors including both enhancers and inhibitors are other factors affecting the myelination process. Myelin damages are observed in several congenital and hereditary diseases, physicochemical conditions, infections, or traumatic insults, and remyelination is known as an intrinsic response to injuries. Here we discuss some molecular events and conditions involved in de- and remyelination and compare the phenomena of remyelination in CNS and PNS. We have explained applying some of these molecular events in myelin restoration. Finally, the current and upcoming treatment strategies for myelin restoration are explained in three groups of immunotherapy, endogenous regeneration enhancement, and cell therapy to give a better insight for finding the more effective rehabilitation strategies considering the underlying molecular events of a lesion formation and its current condition.
Collapse
|
37
|
De Mercanti SF, Vercellino M, Bosa C, Alteno A, Schillaci V, Clerico M, Cavalla P. Case Report: Covid-19 in Multiple Sclerosis Patients Treated With Ocrelizumab: A Case Series. Front Neurol 2021; 12:691616. [PMID: 34744958 PMCID: PMC8563620 DOI: 10.3389/fneur.2021.691616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Limited data are available on the course of Coronavirus disease 2019 (COVID-19) in people with Multiple Sclerosis (MS). More real-world data are needed to help the MS community to manage MS treatment properly. In particular, it is important to understand the impact of immunosuppressive therapies used to treat MS on the outcome of COVID-19. Methods: We retrospectively collected data on all confirmed cases of COVID-19 in MS patients treated with ocrelizumab, followed in two MS Centers based in University Hospitals in Northern Italy from February 2020 to June 2021. Results: We identified 15 MS patients treated with ocrelizumab with confirmed COVID-19 (mean age, 50.47 ± 9.1 years; median EDSS, 3.0; range 1.0-7.0). Of these, 14 were confirmed by nasal swab and 1 was confirmed by a serological test. COVID-19 severity was mild to moderate in the majority of patients (n = 11, 73.3%; mean age, 49.73; median EDSS 3.0). Four patients (26.7%; mean age, 52.5 years; median EDSS, 6) had severe disease and were hospitalized; one of them died (age 50, EDSS 6.0, no other comorbidities). None of them had underlying respiratory comorbidities. Conclusion: This case series highlights the large variability of the course of COVID-19 in ocrelizumab-treated MS patients. The challenges encountered by the healthcare system in the early phase of the COVID-19 pandemic might have contributed to the case fatality ratio observed in this series. Higher MS-related disability was associated with a more severe COVID-19 course.
Collapse
Affiliation(s)
| | - Marco Vercellino
- Department of Neurosciences and Mental Health, Multiple Sclerosis Center, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chiara Bosa
- Department of Neurosciences and Mental Health, Multiple Sclerosis Center, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Anastasia Alteno
- Department of Neurosciences and Mental Health, Multiple Sclerosis Center, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Valentina Schillaci
- Department of Neurosciences and Mental Health, Multiple Sclerosis Center, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marinella Clerico
- S.S.D. Patologie Neurologiche Specialistiche, AOU San Luigi Gonzaga, Orbassano, Italy
| | - Paola Cavalla
- Department of Neurosciences and Mental Health, Multiple Sclerosis Center, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| |
Collapse
|
38
|
Hauser SL, Kappos L, Montalban X, Craveiro L, Chognot C, Hughes R, Koendgen H, Pasquarelli N, Pradhan A, Prajapati K, Wolinsky JS. Safety of Ocrelizumab in Patients With Relapsing and Primary Progressive Multiple Sclerosis. Neurology 2021; 97:e1546-e1559. [PMID: 34475123 PMCID: PMC8548959 DOI: 10.1212/wnl.0000000000012700] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 07/29/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To report safety of ocrelizumab (OCR) up to 7 years in patients with relapsing multiple sclerosis (RMS) and primary progressive multiple sclerosis (PPMS) enrolled in clinical trials or treated in real-world postmarketing settings. METHODS Safety analyses are based on integrated clinical and laboratory data for all patients who received OCR in 11 clinical trials, including the controlled treatment and open-label extension (OLE) periods of the phase 2 and 3 trials, plus the phase 3b trials VELOCE, CHORDS, CASTING, OBOE, ENSEMBLE, CONSONANCE, and LIBERTO. For selected adverse events (AEs), additional postmarketing data were used. Incidence rates of serious infections (SIs) and malignancies were contextualized using multiple epidemiologic sources. RESULTS At data cutoff (January 2020), 5,680 patients with multiple sclerosis (MS) received OCR (18,218 patient-years [PY] of exposure) in clinical trials. Rates per 100 PY (95% confidence interval) of AEs (248; 246-251), serious AEs (7.3; 7.0-7.7), infusion-related reactions (25.9; 25.1-26.6), and infections (76.2; 74.9-77.4) were similar to those within the controlled treatment period of the phase 3 trials. Rates of the most common serious AEs, including SIs (2.01; 1.81-2.23) and malignancies (0.46; 0.37-0.57), were consistent with the ranges reported in epidemiologic data. DISCUSSION Continuous administration of OCR for up to 7 years in clinical trials, as well as its broader use for more than 3 years in the real-world setting, are associated with a favorable and manageable safety profile, without emerging safety concerns, in a heterogeneous MS population. CLASSIFICATION OF EVIDENCE This analysis provides Class III evidence that long-term, continuous treatment with OCR has a consistent and favorable safety profile in patients with RMS and PPMS. This study is rated Class III because of the use of OLE data and historical controls.
Collapse
Affiliation(s)
- Stephen L Hauser
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth).
| | - Ludwig Kappos
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| | - Xavier Montalban
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| | - Licinio Craveiro
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| | - Cathy Chognot
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| | - Richard Hughes
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| | - Harold Koendgen
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| | - Noemi Pasquarelli
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| | - Ashish Pradhan
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| | - Kalpesh Prajapati
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| | - Jerry S Wolinsky
- From the Department of Neurology (S.L.H.), University of California, San Francisco; Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering (L.K.), Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Switzerland; Department of Neurology-Neuroimmunology (X.M.), Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain; F. Hoffmann-La Roche Ltd. (L.C., C.C., R.H., H.K., N.P.), Basel, Switzerland; Genentech, Inc. (A.P.), South San Francisco, CA; IQVIA Solutions Inc. (K.P.), Amsterdam, The Netherlands; and Department of Neurology (J.S.W.), McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)
| |
Collapse
|
39
|
Bar-Or A, Wiendl H, Montalban X, Alvarez E, Davydovskaya M, Delgado SR, Evdoshenko EP, Giedraitiene N, Gross-Paju K, Haldre S, Herrman CE, Izquierdo G, Karelis G, Leutmezer F, Mares M, Meca-Lallana JE, Mickeviciene D, Nicholas J, Robertson DS, Sazonov DV, Sharlin K, Sundaram B, Totolyan N, Vachova M, Valis M, Bagger M, Häring DA, Ludwig I, Willi R, Zalesak M, Su W, Merschhemke M, Fox EJ. Rapid and sustained B-cell depletion with subcutaneous ofatumumab in relapsing multiple sclerosis: APLIOS, a randomized phase-2 study. Mult Scler 2021; 28:910-924. [PMID: 34605319 PMCID: PMC9024029 DOI: 10.1177/13524585211044479] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Ofatumumab, the first fully human anti-CD20 monoclonal antibody, is approved in several countries for relapsing multiple sclerosis (RMS). Objective: To demonstrate the bioequivalence of ofatumumab administered by an autoinjector versus a pre-filled syringe (PFS) and to explore the effect of ofatumumab on B-cell depletion. Methods: APLIOS (NCT03560739) is a 12-week, open-label, parallel-group, phase-2 study in patients with RMS receiving subcutaneous ofatumumab 20 mg every 4 weeks (q4w) (from Week 4, after initial doses on Days 1, 7, and 14). Patients were randomized 10:10:1:1 to autoinjector or PFS in the abdomen, or autoinjector or PFS in the thigh, respectively. Bioequivalence was determined by area under the curve (AUCτ) and maximum plasma concentration (Cmax) for Weeks 8–12. B-cell depletion and safety/tolerability were assessed. Results: A total of 256 patients contributed to the bioequivalence analyses (autoinjector-abdomen, n = 128; PFS-abdomen, n = 128). Abdominal ofatumumab pharmacokinetic exposure was bioequivalent for autoinjector and PFS (geometric mean AUCτ, 487.7 vs 474.1 h × µg/mL (ratio 1.03); Cmax, 1.409 vs 1.409 µg/mL (ratio 1.00)). B-cell counts (median cells/µL) depleted rapidly in all groups from 214.0 (baseline) to 2.0 (Day 14). Ofatumumab was well tolerated. Conclusion: Ofatumumab 20 mg q4w self-administered subcutaneously via autoinjector is bioequivalent to PFS administration and provides rapid B-cell depletion.
Collapse
Affiliation(s)
- Amit Bar-Or
- A Bar-Or Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street - 3 Gates Building, Philadelphia, PA 19104, USA.,Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Xavier Montalban
- Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Enrique Alvarez
- Department of Neurology, Rocky Mountain MS Center, University of Colorado, Aurora, CO, USA
| | - Maria Davydovskaya
- Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Silvia R Delgado
- MS Center and Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Evgeniy P Evdoshenko
- St Petersburg Center for Multiple Sclerosis and Other Autoimmune Diseases, St Petersburg, Russian Federation
| | - Natasa Giedraitiene
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Katrin Gross-Paju
- West-Tallinn Central Hospital, Tallinn, Estonia/Institute of Health Care Technology, TalTech, Tallinn, Estonia
| | - Sulev Haldre
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia/Neurology Clinic, Tartu University Hospital, Tartu, Estonia
| | | | | | - Guntis Karelis
- Neurology and Neurosurgery Department, Riga East University Hospital and Riga Stradins University, Riga, Latvia
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Miroslav Mares
- Department of Neurology, Pardubice Regional Hospital, Pardubice, Czech Republic
| | - Jose E Meca-Lallana
- Multiple Sclerosis CSUR, Department of Neurology, Virgen de la Arrixaca Clinical University Hospital-IMIB-Arrixaca, Murcia, Spain/Clinical Neuroimmunology and Multiple Sclerosis Cathedra, Universidad Católica San Antonio (UCAM), Murcia, Spain
| | | | | | - Derrick S Robertson
- Multiple Sclerosis Division, Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Denis V Sazonov
- Department of Clinical Trials FSBIH SDMC of FMBA of Russia, Novosibirsk, Russian Federation
| | | | | | - Natalia Totolyan
- Department of Neurology, First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
| | - Marta Vachova
- Department of Neurology, Teplice Hospital, Teplice, Czech Republic
| | - Martin Valis
- Department of Neurology, Faculty of Medicine in Hradec Králové, Charles University in Prague and University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | | | | | | | | | | | - Wendy Su
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | | | - Edward J Fox
- Central Texas Neurology Consultants PA, Round Rock, TX, USA
| |
Collapse
|
40
|
Mancinelli CR, Rossi ND, Capra R. Ocrelizumab for the Treatment of Multiple Sclerosis: Safety, Efficacy, and Pharmacology. Ther Clin Risk Manag 2021; 17:765-776. [PMID: 34354358 PMCID: PMC8331077 DOI: 10.2147/tcrm.s282390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/18/2021] [Indexed: 11/23/2022] Open
Abstract
The success of selective B-cells depleting therapies, as the anti-CD20 antibodies, in patients with multiple sclerosis (MS) has confirmed that B-cells are critical in the immune pathogenesis of the disease. Ocrelizumab, a humanized monoclonal antibody that selectively targets CD20+ B-cells, profoundly suppresses acute inflammatory disease activity, representing a highly effective therapy for relapsing-remitting multiple sclerosis (RRMS). It is also the first proven therapy able to slow disability progression in primary progressive multiple sclerosis (PPMS), particularly in patients with signs of acute radiological activity before being enrolled. Effectiveness has widely been demonstrated in randomized clinical trials (RCTs), and recently confirmed in open-label extension trials. Here, we review the role of B-cells in MS, the mechanism of action of ocrelizumab, its pharmacokinetics and pharmacodynamics, and the clinical data supporting its use, as well as safety data. We focus on issues related to the maintenance of immunocompetence, essential to ensure an immune response to either a primary infection or a vaccination. Lastly, we discuss about the possible role of ocrelizumab as an exit strategy from natalizumab-treated patients at risk of developing multifocal progressive leukoencephalopathy. In view of using ocrelizumab chronically, collecting long-term safety data and finding strategies to minimize adverse events will be extremely relevant.
Collapse
Affiliation(s)
| | - Nicola De Rossi
- Multiple Sclerosis Centre, Spedali Civili di Brescia, Brescia, Italy
| | - Ruggero Capra
- Multiple Sclerosis Centre, Spedali Civili di Brescia, Brescia, Italy
| |
Collapse
|
41
|
Abstract
PURPOSE OF REVIEW Treatments targeting B cells are increasingly used for patients with multiple sclerosis (MS). We review the mechanisms of action, clinical effectiveness and safety of treatment, with emphasis on recently published studies. RECENT FINDINGS Several monoclonal antibodies targeting the surface molecule CD20 on B cells are approved or being developed for treatment of MS. Overall, they seem comparable in terms of strongly suppressing radiological disease activity and relapse biology. Novel approaches include anti-CD19 antibody therapy and treatment with oral drugs targeting Bruton's tyrosine kinase (BTK). The main safety issue with persistent B cell depletion is an increased risk of infections - possibly including an increased risk of severe COVID-19. Vaccine responses are also blunted in patients treated with anti-CD20 antibodies. Lower doses or longer infusion intervals may be sufficient for control of disease activity. Whether this might also improve the safety of treatment and increase vaccination responses remains to be determined. SUMMARY Available data support the widespread use of therapies targeting B cells in MS. Whether novel approaches targeting CD19 or BTK will have advantages compared to anti-CD20 antibody therapy remains to be established. Furthermore, trials investigating alternative dosing regimens for anti-CD20 antibody treatment are warranted.
Collapse
|
42
|
Simpson A, Mowry EM, Newsome SD. Early Aggressive Treatment Approaches for Multiple Sclerosis. Curr Treat Options Neurol 2021; 23:19. [PMID: 34025110 PMCID: PMC8121641 DOI: 10.1007/s11940-021-00677-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review presents a comprehensive analysis of the current high-efficacy disease-modifying therapies (DMTs) available for treatment of multiple sclerosis (MS). We discuss the existing approved and emerging therapeutics in patients with relapsing and progressive forms of MS using data from clinical trials and observational studies. Treatment considerations in pediatric and pregnant populations are also reviewed. Finally, we discuss the treatment paradigms of the escalation and early aggressive approaches to treatment of MS, with review of ongoing clinical trials to compare these approaches. RECENT FINDINGS Natalizumab has shown promising data on efficacy in not only randomized trials but also observational studies when compared with placebo, the injectable DMTs, and fingolimod. The anti-CD20 B cell depleting therapies (rituximab, ocrelizumab, and ofatumumab) have also demonstrated superiority in randomized clinical trials compared to their comparator group (placebo, interferon, and teriflunomide, respectively) and rituximab has shown in observational studies to be more effective than older injectable therapies and some of the oral therapies. Alemtuzumab has shown good efficacy in randomized controlled trials and observational studies yet has several potentially severe side effects limiting its use. Mitoxantrone has similarly demonstrated significant reduction in new disease activity compared to placebo but is rarely used due to its severe side effects. Cladribine is an oral DMT often grouped in discussion with other higher efficacy DMTs but may be slightly less effective than the other therapies described in this review. Many emerging targets for therapeutic intervention are currently under investigation that may prove to be beneficial in early aggressive MS, including autologous hematopoietic stem cell transplantation. SUMMARY Traditionally, MS has been treated with an escalation approach, starting patients on a modestly effective DMT and subsequently escalating to a higher efficacy DMT when there is evidence of clinical and/or radiologic breakthrough activity. With the development of higher efficacy therapies and emerging data showing the potential positive long-term impact of these therapies when started earlier in the disease course, many clinicians have shifted to an early aggressive treatment approach in which patients are initially started on a higher efficacy DMT. Two clinical trials, the TRaditional versus Early Aggressive Therapy for MS (TREAT-MS) trial and the Determining the Effectiveness of earLy Intensive Versus Escalation approaches for the treatment of Relapsing-remitting MS (DELIVER-MS) trial, aim to directly compare these treatment strategies and their impact on clinical and radiologic outcomes.
Collapse
Affiliation(s)
- Alexandra Simpson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Ellen M. Mowry
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Scott D. Newsome
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
- Division of Neuroimmunology and Neurological Infections, Johns Hopkins Hospital, 600 North Wolfe St., Pathology 627, Baltimore, MD 21287 USA
| |
Collapse
|
43
|
Baird-Gunning J, Yun J, Stevenson W, Ng K. Severe Delayed-Onset Neutropenia Induced by Ocrelizumab. Neurohospitalist 2021; 11:59-61. [PMID: 33868559 DOI: 10.1177/1941874420936438] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Ocrelizumab is an anti-CD20 monoclonal antibody that has been shown to reduce disability progression in primary progressive multiple sclerosis (MS). The adverse event profile is still being determined through postmarketing surveillance and case reports. Objective To report a case of severe late-onset neutropenia associated with ocrelizumab in a patient with primary progressive MS. Methods Case report. Result A 34-year-old male with primary progressive MS developed severe late-onset neutropenia 42 days after infusion of ocrelizumab, which necessitated hospital admission and administration of broad-spectrum antibiotics and granulocyte colony-stimulating factor. Conclusion Late-onset neutropenia is a rare complication of ocrelizumab. Patients should be counseled to present for urgent evaluation if they develop fever.
Collapse
Affiliation(s)
| | - James Yun
- Nepean Hospital, Nepean Hospital, Penrith, New South Wales, Australia
| | - William Stevenson
- Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Karl Ng
- Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| |
Collapse
|
44
|
Bermel RA, Waubant E, Pardo G, Bass A, Repovic P, Newsome S, Lindsey JW, Kile D, Pradhan A, Musch B, Zabeti A. Safety evaluation of shorter infusion for ocrelizumab in a substudy of the Phase IIIb CHORDS trial. Ann Clin Transl Neurol 2021; 8:711-715. [PMID: 33621404 PMCID: PMC7951110 DOI: 10.1002/acn3.51310] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/14/2021] [Indexed: 11/24/2022] Open
Abstract
The CHORDS trial evaluated ocrelizumab (OCR) in patients with relapsing‐remitting multiple sclerosis who had a suboptimal response to previous disease‐modifying treatment. The objective of the present study was to assess the safety of shorter OCR infusions in a substudy of CHORDS. After completing four doses of OCR per initial US prescribing recommendations in the main study, participants in the substudy (N = 129) received a fifth dose over a 2‐h duration (vs. 3.5 h). Infusion‐related reactions occurred in 12.4% of patients. None were severe, life‐threatening or led to treatment discontinuation. Shorter infusion time did not change the safety profile of OCR. Clinicaltrials.gov (NCT0237856).
Collapse
Affiliation(s)
- Robert A Bermel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emmanuelle Waubant
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Gabriel Pardo
- Multiple Sclerosis Center of Excellence, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Ann Bass
- Neurology Center of San Antonio, San Antonio, TX, USA
| | | | - Scott Newsome
- Division of Neuroimmunology and Neuroinfectious Diseases, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John W Lindsey
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Deidre Kile
- Genentech, Inc., South San Francisco, CA, USA
| | | | - Bruno Musch
- Genentech, Inc., South San Francisco, CA, USA
| | - Aram Zabeti
- UC Waddell Center for Multiple Sclerosis, Cincinnati, OH, USA
| |
Collapse
|
45
|
Lee DSW, Rojas OL, Gommerman JL. B cell depletion therapies in autoimmune disease: advances and mechanistic insights. Nat Rev Drug Discov 2021; 20:179-199. [PMID: 33324003 PMCID: PMC7737718 DOI: 10.1038/s41573-020-00092-2] [Citation(s) in RCA: 295] [Impact Index Per Article: 98.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 01/30/2023]
Abstract
In the past 15 years, B cells have been rediscovered to be not merely bystanders but rather active participants in autoimmune aetiology. This has been fuelled in part by the clinical success of B cell depletion therapies (BCDTs). Originally conceived as a method of eliminating cancerous B cells, BCDTs such as those targeting CD20, CD19 and BAFF are now used to treat autoimmune diseases, including systemic lupus erythematosus and multiple sclerosis. The use of BCDTs in autoimmune disease has led to some surprises. For example, although antibody-secreting plasma cells are thought to have a negative pathogenic role in autoimmune disease, BCDT, even when it controls the disease, has limited impact on these cells and on antibody levels. In this Review, we update our understanding of B cell biology, review the results of clinical trials using BCDT in autoimmune indications, discuss hypotheses for the mechanism of action of BCDT and speculate on evolving strategies for targeting B cells beyond depletion.
Collapse
Affiliation(s)
- Dennis S. W. Lee
- grid.17063.330000 0001 2157 2938Department of Immunology, University of Toronto, Toronto, ON Canada
| | - Olga L. Rojas
- grid.17063.330000 0001 2157 2938Department of Immunology, University of Toronto, Toronto, ON Canada
| | - Jennifer L. Gommerman
- grid.17063.330000 0001 2157 2938Department of Immunology, University of Toronto, Toronto, ON Canada
| |
Collapse
|
46
|
Jalkh G, Abi Nahed R, Macaron G, Rensel M. Safety of Newer Disease Modifying Therapies in Multiple Sclerosis. Vaccines (Basel) 2020; 9:12. [PMID: 33375365 PMCID: PMC7823546 DOI: 10.3390/vaccines9010012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022] Open
Abstract
In the past decade, the therapeutic arsenal for multiple sclerosis has expanded greatly. Newer more potent disease modifying therapies (DMTs) with varying mechanisms of actions are increasingly used early in the disease course. These newer DMTs include oral therapies (teriflunomide, dimethyl fumarate, fingolimod, siponimod, ozanimod, and cladribine) and infusion therapies (natalizumab, alemtuzumab, and ocrelizumab), and are associated with better control of disease activity and long-term outcomes in patients with MS compared to older injectable therapies (interferon beta and glatiramer acetate). However, they are associated with safety concerns and subsequent monitoring requirements. Adverse events are initially observed in phase 2 and 3 clinical trials, and further long-term data are collected in phase 3 extension studies, case series, and post-marketing reports, which highlight the need to periodically re-evaluate and adjust monitoring strategies to optimize treatment safety in an individualized approach.
Collapse
Affiliation(s)
- Georges Jalkh
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Rachelle Abi Nahed
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| |
Collapse
|
47
|
Patient-Reported Outcomes in ATLAS and FLAIR Participants on Long-Acting Regimens of Cabotegravir and Rilpivirine Over 48 Weeks. AIDS Behav 2020; 24:3533-3544. [PMID: 32447500 PMCID: PMC7667137 DOI: 10.1007/s10461-020-02929-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The phase 3 ATLAS and FLAIR studies demonstrated that maintenance with Long-Acting (LA) intramuscular cabotegravir and rilpivirine is non-inferior in efficacy to current antiretroviral (CAR) oral therapy. Both studies utilized Patient-Reported Outcome instruments to measure treatment satisfaction (HIVTSQ) and acceptance (ACCEPT general domain), health status (SF-12), injection tolerability/acceptance (PIN), and treatment preference. In pooled analyses, LA-treated patients (n = 591) demonstrated greater mean improvements from baseline than the CAR group (n = 591) in treatment satisfaction (Week 44, + 3.9 vs. +0.5 HIVTSQs-points; p < 0.001) and acceptance (Week 48, +8.8 vs. +2.0 ACCEPT-points; p < 0.001). The acceptability of injection site reactions (PIN) significantly improved from week 5 (2.10 points) to week 48 (1.62 points; p < 0.001). In both studies, ≥ 97% of LA group participants with recorded data preferred LA treatment compared with prior oral therapy. These results further support the potential of a monthly injectable option for people living with HIV seeking an alternative to daily oral treatment.
Collapse
|
48
|
Rath L, Bui MV, Ellis J, Carey J, Baker J, Taylor L, Fernando H, Taylor N, Savage P, Richards J, Zhong M, Kalincik T, Skibina O, Wesselingh R, Nguyen AL, Monif M, Butzkueven H, van der Walt A. Fast and safe: Optimising multiple sclerosis infusions during COVID-19 pandemic. Mult Scler Relat Disord 2020; 47:102642. [PMID: 33321356 PMCID: PMC7955770 DOI: 10.1016/j.msard.2020.102642] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/13/2020] [Accepted: 11/22/2020] [Indexed: 12/29/2022]
Abstract
Background: The COVID-19 pandemic challenges multiple sclerosis services to be innovative in delivering infusible therapies. To reduce time in clinical settings, and potential staff or space losses, we implemented rapid infusion protocols for selected patients. Objective: To analyse the rate of infusion related reactions and patient experience of rapid infusions of natalizumab and ocrelizumab. To document time reduction patients spent in clinical settings during the COVID-19 pandemic. Methods: Patients with prior exposure to at least three natalizumab or two 300mg ocrelizumab infusions were approved for rapid protocols. A retrospective audit and survey were completed. Results: We analysed 269 rapid natalizumab infusions and 100 rapid ocrelizumab infusions. Infusion related reactions during the natalizumab or ocrelizumab infusions occurred in two patients (1.52%) and eight patients (8%), respectively. All infusion related reactions were mild to moderate and did not require infusion discontinuation. No infusion reactions occurred during the post-infusion observation. Patient experience was positive. Conclusion: Frequency or severity of infusion related reactions in rapid infusions were no different compared to published data. In the setting of COVID-19, pandemic rapid infusion protocols could potentially save hospital resources and limit patient exposure to a high-risk clinical setting while still maintaining ongoing treatment of multiple sclerosis.
Collapse
Affiliation(s)
- Louise Rath
- Alfred Health, Clinical Neurosciences, Melbourne, Australia.
| | - Minh Viet Bui
- Alfred Health, Clinical Neurosciences, Melbourne, Australia
| | - Julian Ellis
- Alfred Health, Clinical Neurosciences, Melbourne, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne Australia
| | - John Carey
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Lisa Taylor
- Royal Melbourne Hospital, Melbourne, Australia
| | | | | | | | | | - Michael Zhong
- Alfred Health, Clinical Neurosciences, Melbourne, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne Australia
| | - Tomas Kalincik
- Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Olga Skibina
- Alfred Health, Clinical Neurosciences, Melbourne, Australia
| | - Robb Wesselingh
- Alfred Health, Clinical Neurosciences, Melbourne, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne Australia
| | - Ai-Lan Nguyen
- Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Mastura Monif
- Alfred Health, Clinical Neurosciences, Melbourne, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne Australia
| | - Helmut Butzkueven
- Alfred Health, Clinical Neurosciences, Melbourne, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne Australia
| | - Anneke van der Walt
- Alfred Health, Clinical Neurosciences, Melbourne, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne Australia
| |
Collapse
|
49
|
Najafi S, Rajaei E, Moallemian R, Nokhostin F. The potential similarities of COVID-19 and autoimmune disease pathogenesis and therapeutic options: new insights approach. Clin Rheumatol 2020; 39:3223-3235. [PMID: 32885345 PMCID: PMC7471540 DOI: 10.1007/s10067-020-05376-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/23/2020] [Accepted: 08/27/2020] [Indexed: 12/29/2022]
Abstract
Cytokine pathways and their signaling disorders can be the cause of onset and pathogenesis of many diseases such as autoimmune diseases and COVID-19 infection. Autoimmune patients may be at higher risk of developing infection due to the impaired immune responses, the use of immunosuppressive drugs, and damage to various organs. Increased secretion of inflammatory cytokines and intolerance of the patient's immune system to COVID-19 infection are the leading causes of hospitalization of these patients. The content used in this paper has been taken from English language articles (2005-2020) retrieved from the PubMed database and Google Scholar search engine using "COVID-19," "Autoimmune disease," "Therapeutic," "Pathogenesis," and "Pathway" keywords. The emergence of COVID-19 and its association with autoimmune disorders is a major challenge in the management of these diseases. The results showed that the use of corticosteroids in the treatment of autoimmune diseases can make diagnosis and treatment of COVID-19 more challenging by preventing the fever. Due to the common pathogenesis of COVID-19 and autoimmune diseases, the use of autoimmune drugs as a possible treatment option could help control the virus. KEY POINTS: • Inflammatory cytokines play an essential role in the pathogenesis of COVID-19 • ACE2 dysfunctions are related to the with COVID-19 and autoimmune diseases • The use autoimmune diseases drugs can be useful in treating COVID-19.
Collapse
Affiliation(s)
- Sahar Najafi
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Elham Rajaei
- Golestan Hospital Clinical Research Development Unit, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Rezvan Moallemian
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic & Developmental Sciences, Sheng Yushou Center of Cell Biology and Immunology, School of Life Science and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240 China
| | - Forough Nokhostin
- Internal medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran
| |
Collapse
|
50
|
Vollmer TL, Cohen JA, Alvarez E, Nair KV, Boster A, Katz J, Pardo G, Pei J, Raut P, Merchant S, MacLean E, Pradhan A, Moss B. Safety results of administering ocrelizumab per a shorter infusion protocol in patients with primary progressive and relapsing multiple sclerosis. Mult Scler Relat Disord 2020; 46:102454. [DOI: 10.1016/j.msard.2020.102454] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 11/17/2022]
|