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Rindi LV, Zaçe D, Braccialarghe N, Massa B, Barchi V, Iannazzo R, Fato I, De Maria F, Kontogiannis D, Malagnino V, Sarmati L, Iannetta M. Drug-Induced Progressive Multifocal Leukoencephalopathy (PML): A Systematic Review and Meta-Analysis. Drug Saf 2024; 47:333-354. [PMID: 38321317 DOI: 10.1007/s40264-023-01383-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION Progressive multifocal leukoencephalopathy (PML) was first described among patients affected by hematological or solid tumors. Following the human immunodeficiency virus (HIV) epidemic, people living with HIV have represented most cases for more than a decade. With the diffusion of highly active antiretroviral therapy, this group progressively decreased in favor of patients undergoing treatment with targeted therapy/immunomodulators. In this systematic review and meta-analysis, the objective was to assess which drugs are most frequently related to PML development, and report the incidence of drug-induced PML through a meta-analytic approach. METHODS The electronic databases MEDLINE, EMBASE, ClinicalTrials.gov, Web of Science and the Canadian Agency for Drugs and Technologies in Health Database (CADTH) were searched up to May 10, 2022. Articles that reported the risk of PML development after treatment with immunomodulatory drugs, including patients of both sexes under the age of 80 years, affected by any pathology except HIV, primary immunodeficiencies or malignancies, were included in the review. The incidence of drug-induced PML was calculated based on PML cases and total number of patients observed per 100 persons and the observation time. Random-effect metanalyses were conducted for each drug reporting pooled incidence with 95% confidence intervals (CI) and median (interquartile range [IQR]) of the observation time. Heterogeneity was measured by I2 statistics. Publication bias was examined through funnel plots and Egger's test. RESULTS A total of 103 studies were included in the systematic review. In our analysis, we found no includible study reporting cases of PML during the course of treatment with ocrelizumab, vedolizumab, abrilumab, ontamalimab, teriflunomide, daclizumab, inebilizumab, basiliximab, tacrolimus, belimumab, infliximab, firategrast, disulone, azathioprine or danazole. Dalfampridine, glatiramer acetate, dimethyl fumarate and fingolimod show a relatively safe profile, although some cases of PML have been reported. The meta-analysis showed an incidence of PML cases among patients undergoing rituximab treatment for multiple sclerosis (MS) of 0.01 cases/100 persons (95% CI - 0.08 to 0.09; I2 = 20.4%; p = 0.25) for a median observation period of 23.5 months (IQR 22.1-42.1). Treatment of MS with natalizumab carried a PML risk of 0.33 cases/100 persons (95% CI 0.29-0.37; I2 = 50%; p = 0.003) for a median observation period of 44.1 months (IQR 28.4-60) and a mean number of doses of 36.3 (standard deviation [SD] ± 20.7). When comparing data about patients treated with standard interval dosing (SID) and extended interval dosing (EID), the latter appears to carry a smaller risk of PML, that is, 0.08 cases/100 persons (95% CI 0.0-0.15) for EID versus 0.3 cases/100 persons (95% CI 0.25-0.34) for SID. CONCLUSIONS A higher risk of drug-related PML in patients whose immune system is not additionally depressed by means of neoplasms, HIV or concomitant medications is found in the neurological field. This risk is higher in MS treatment, and specifically during long-term natalizumab therapy. While this drug is still routinely prescribed in this field, considering the efficacy in reducing MS relapses, in other areas it could play a smaller role, and be gradually replaced by other safer and more recently approved agents.
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Affiliation(s)
- Lorenzo Vittorio Rindi
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
| | - Drieda Zaçe
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
| | - Neva Braccialarghe
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
| | - Barbara Massa
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
| | - Virginia Barchi
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
| | - Roberta Iannazzo
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
| | - Ilenia Fato
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
| | - Francesco De Maria
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
| | - Dimitra Kontogiannis
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
| | - Vincenzo Malagnino
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
- Infectious Disease Clinic, Policlinico Tor Vergata, Viale Oxford, 81, 00133, Rome, Italy
| | - Loredana Sarmati
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy
- Infectious Disease Clinic, Policlinico Tor Vergata, Viale Oxford, 81, 00133, Rome, Italy
| | - Marco Iannetta
- Department of Systems Medicine, Tor Vergata University, Via Montpellier, 1, 00133, Rome, Italy.
- Infectious Disease Clinic, Policlinico Tor Vergata, Viale Oxford, 81, 00133, Rome, Italy.
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A decade of fingolimod in multiple sclerosis: Insights from a large real-world cohort study. Rev Neurol (Paris) 2023:S0035-3787(23)00821-4. [PMID: 36841644 DOI: 10.1016/j.neurol.2022.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/21/2022] [Accepted: 11/17/2022] [Indexed: 02/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Ten years after its authorization, data about fingolimod use in real-world setting is still scarce. Here we describe the long-term evolution of fingolimod-treated relapsing-remitting MS (RRMS) patients and determine baseline characteristics associated with risk of relapses or disability. METHODS We analyzed baseline characteristics and clinical evolution of 1227 patients with RRMS treated with fingolimod from 2010 to 2019 in 4 French MS referral centers. We used Cox models to determine risks factors of relapses and sustained EDSS worsening. RESULTS Median follow-up duration was 50 months, and 63% of patients remained fingolimod-treated at the end of follow-up. Mean 5-years annualized relapse rate (ARR) decreased from 0.63 (0.60-0.67) to 0.26 (0.24-0.29, P<0.001), while the mean EDSS rose from 2.5 (2.4-2.6) to 3.0 (2.8-3.1, P<0.001). Female sex, lower age, higher EDSS and use of natalizumab were associated with relapse risk. Female sex was associated with sustained EDSS increase risk. CONCLUSIONS Based on a large real-world cohort, our results confirm the durable reduction of the ARR described in pivot studies. Switching from moderate-efficacy DMT to fingolimod decreased the relapse risk. Switching patients from high-efficacy DMT increased risk of relapse, but the overall five-years ARR remained stable.
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Constantinescu V, Akgün K, Ziemssen T. Current status and new developments in sphingosine-1-phosphate receptor antagonism: fingolimod and more. Expert Opin Drug Metab Toxicol 2022; 18:675-693. [PMID: 36260948 DOI: 10.1080/17425255.2022.2138330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Fingolimod was the first oral disease-modifying treatment approved for relapsing-remitting multiple sclerosis (MS) that serves as a sphingosine-1-phosphate receptor (S1PR) agonist. The efficacy is primarily mediated by S1PR subtype 1 activation, leading to agonist-induced down-modulation of receptor expression and further functional antagonism, blocking the egression of auto-aggressive lymphocytes from the lymph nodes in the peripheral compartment. The role of S1P signaling in the regulation of other pathways in human organisms through different S1PR subtypes has received much attention due to its immune-modulatory function and its significance for the regeneration of the central nervous system (CNS). The more selective second-generation S1PR modulators have improved safety and tolerability profiles. AREAS COVERED This review has been carried out based on current data on S1PR modulators, emphasizing the benefits of recent advances in this emergent class of immunomodulatory treatment for MS. EXPERT OPINION Ongoing clinical research suggests that S1PR modulators represent an alternative to first-line therapies in selected cases of MS. A better understanding of the relevance of selective S1PR pathways and the ambition to optimize selective modulation has improved the safety and tolerability of S1PR modulators in MS therapy and opened new perspectives for the treatment of other diseases.
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Affiliation(s)
- Victor Constantinescu
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Katja Akgün
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
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Butzkueven H, Giacomini PS, Cohan S, Ziemssen T, Sienkiewicz D, Zhang Y, Geissbühler Y, Silva D, Tomic D, Kropshofer H, Trojano M. Safety of Fingolimod in Patients with Multiple Sclerosis Switched from Natalizumab: Results from TRANSITION―A 2-Year, Multicenter, Observational, Cohort Study. Brain Sci 2022; 12:brainsci12020215. [PMID: 35203978 PMCID: PMC8870332 DOI: 10.3390/brainsci12020215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 12/10/2022] Open
Abstract
Multiple sclerosis (MS) patients receiving natalizumab and who are at risk of developing progressive multifocal leukoencephalopathy (PML) often switch to other high-efficacy disease-modifying therapies including fingolimod as a risk mitigation strategy, which could impact treatment safety and effectiveness. The TRANSITION study aimed to evaluate the safety of fingolimod over two years in patients with MS after switching from natalizumab in a real-world setting. The safety and effectiveness were assessed by monitoring serious and other adverse events (SAEs, AEs). We assessed effectiveness by recording relapses, Expanded Disability Status Scale (EDSS) scores, and MRI activity. Of 637 patients enrolled, 505 completed the study (mean age, 42 years). Overall, 72.8% and 12.7% experienced AEs and SAEs respectively. The most common AEs were fatigue, headache, and urinary tract infection; no cases of PML were observed. Fingolimod treatment resulted in low disease activity. Patients with ≤8 weeks washout period had a markedly lower risk of relapses (4.5%) than those with >8 weeks (51.4%). In patients switching from natalizumab to fingolimod, no new safety signals with overall low relapse activity were observed in patients with washout latencies of ≤8 weeks before fingolimod initiation. Fingolimod was found to be safe and effective in patients transitioning from natalizumab.
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Affiliation(s)
- Helmut Butzkueven
- Department of Neuroscience, Monash University, Melbourne, VIC 3004, Australia
- Department of Neurology, Alfred Hospital, Melbourne, VIC 3004, Australia
- Correspondence:
| | - Paul S. Giacomini
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC H3A 0G4, Canada;
- Multiple Sclerosis Clinic, Montreal Neurological Institute and Hospital, Montreal, QC H3A 2B4, Canada
| | - Stanley Cohan
- Providence Multiple Sclerosis Center, Portland, OR 97225, USA;
| | - Tjalf Ziemssen
- Center of Clinical Neurosciences, University Hospital Carl Gustav Carus, 01307 Dresden, Germany;
| | - Daniel Sienkiewicz
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA; (D.S.); (Y.Z.)
| | - Ying Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA; (D.S.); (Y.Z.)
| | - Yvonne Geissbühler
- Novartis Pharma AG, 4056 Basel, Switzerland; (Y.G.); (D.S.); (D.T.); (H.K.)
| | - Diego Silva
- Novartis Pharma AG, 4056 Basel, Switzerland; (Y.G.); (D.S.); (D.T.); (H.K.)
| | - Davorka Tomic
- Novartis Pharma AG, 4056 Basel, Switzerland; (Y.G.); (D.S.); (D.T.); (H.K.)
| | - Harald Kropshofer
- Novartis Pharma AG, 4056 Basel, Switzerland; (Y.G.); (D.S.); (D.T.); (H.K.)
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, 70121 Bari, Italy;
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Experiences in treatment of multiple sclerosis with natalizumab from a real-life cohort over 15 years. Sci Rep 2021; 11:23317. [PMID: 34857795 PMCID: PMC8639988 DOI: 10.1038/s41598-021-02665-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/16/2021] [Indexed: 11/29/2022] Open
Abstract
Natalizumab (NTZ) has been used for treatment of highly active relapsing–remitting multiple sclerosis (MS). When stopping NTZ the risk of severe rebound phenomenon has to be considered. We aimed to investigate the use of NTZ in clinical routine and focused on identification of potential risk factors for disease reactivation after treatment discontinuation. At the Medical University of Innsbruck, Austria, we identified all MS patients who were treated with NTZ and performed a retrospective analysis on therapeutic decision making, disease course before, during and after treatment with NTZ and on risk factors for disease reactivation after NTZ discontinuation. 235 NTZ treated MS patients were included, of whom 105 had discontinued treatment. At NTZ start disease duration was 5.09 (IQR 2.09–10.57) years, average number of total relapses was 4 (IQR 3–6) and median EDSS 2.0 (range 0–6.5), whereby these values significantly decreased over time. Reduction of annualized relapse rate (ARR) on treatment was 93% and EDSS remained stable in 64%. In multivariate regression models only conversion to secondary progressive MS (SPMS) on treatment was significantly associated with lower risk of disease reactivation after NTZ, while ARR before treatment was associated with earlier disease reactivation. We could confirm the high therapeutic efficacy of NTZ which trends to be used earlier in the disease course nowadays. Discontinuation of NTZ seems safe only in patients who convert to SPMS during treatment, while higher ARR before NTZ increases the risk of disease reactivation after treatment discontinuation.
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Meca-Lallana JE, Oreja-Guevara C, Muñoz D, Olascoaga J, Pato A, Ramió-Torrentà L, Meca-Lallana V, Hernández MA, Marzo ME, Álvarez- Cermeño JC, Rodríguez-Antigüedad A, Montalbán X, Fernández O. Four-year safety and effectiveness data from patients with multiple sclerosis treated with fingolimod: The Spanish GILENYA registry. PLoS One 2021; 16:e0258437. [PMID: 34644366 PMCID: PMC8513911 DOI: 10.1371/journal.pone.0258437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/27/2021] [Indexed: 11/21/2022] Open
Abstract
Objective To describe the profile of patients with multiple sclerosis (MS) treated with fingolimod in Spain and to assess the effectiveness and safety of fingolimod after 4 years of inclusion in the Spanish Gilenya Registry. Methods An observational, retrospective/prospective, multicenter case registry, including all patients with relapsing-remitting MS (RRMS) starting treatment with fingolimod in 43 centers in Spain. Analyses were performed in the overall population and in subgroups according to prior disease-modifying therapy (DMT): glatiramer acetate/interferon beta-1 (BRACE), natalizumab, other treatment, or naïve. Results Six hundred and sixty-six evaluable patients were included (91.1% previously treated with at least one DMT). The mean annualized relapse rate (ARR) prior to fingolimod was 1.12, and the mean EDSS at fingolimod initiation was 3.03. Fingolimod reduced the ARR by 71.4%, 75%, 75.5%, and 80.3%, after 1, 2, 3 and 4 years, respectively (p<0.001). This significant reduction in the ARR continued to be observed in all subgroups. After 4 years, the EDSS showed a minimal deterioration, with the EDSS scores from year 1 to year 4 remaining mostly stable. The percentage of patients without T1 Gd+ lesions progressively increased from 45.6% during the year prior to fingolimod initiation to 88.2% at year 4. The proportion of patients free from new/enlarged T2 lesions after 4 years of fingolimod treatment was 80.3%. This trend in both radiological measures was also observed in the subgroups. Adverse events (AEs) were experienced by up to 41.6% of patients (most commonly: lymphopenia [12.5%] and urinary tract infection [3.7%]). Most AEs were mild in severity, 3.6% of patients had serious AEs. Conclusions The patient profile was similar to other observational studies. The results obtained from the long-term use of fingolimod showed that it was effective, regardless of prior DMT, and it had adequate safety results, with a positive benefit-risk balance.
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Affiliation(s)
- J. E. Meca-Lallana
- Neurology Department, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - C. Oreja-Guevara
- Neurology Department, Hospital Clínico San Carlos, Madrid, Spain
| | - D. Muñoz
- Neurology Department, Hospital Xeral de Vigo, Vigo, Spain
| | - J. Olascoaga
- Neurology Department, Hospital Universitario Donostia, San Sebastián, Spain
| | - A. Pato
- Neurology Department, Hospital Povisa, Vigo, Spain
| | - L. Ramió-Torrentà
- Neurology Department, Hospital Universitari de Girona Dr. Josep Trueta, IDIBGI; Medical Sciences Department, University of Girona, Girona, Spain
| | - V. Meca-Lallana
- Neurology Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - M. A. Hernández
- Neurology Department, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | | | | | - X. Montalbán
- Neurology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - O. Fernández
- Department of Pharmacology, Faculty of Medicine, Universidad de Málaga; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- * E-mail:
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The Change of Fingolimod Patient Profiles over Time: A Descriptive Analysis of Two Non-Interventional Studies PANGAEA and PANGAEA 2.0. J Pers Med 2021; 11:jpm11060561. [PMID: 34208513 PMCID: PMC8233755 DOI: 10.3390/jpm11060561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 11/23/2022] Open
Abstract
(1) Background: Fingolimod (Gilenya®) was the first oral treatment for patients with relapsing-remitting multiple sclerosis (RRMS). Since its approval, the treatment landscape has changed enormously. (2) Methods: Data of PANGAEA and PANGAEA 2.0, two German real-world studies, were descriptively analysed for possible evolution of patient profiles and treatment behavior. Both are prospective, multi-center, non-interventional, long-term studies on fingolimod use in RRMS in real life. Data of 4229 PANGAEA patients (recruited 2011–2013) and 2441 PANGAEA 2.0 patients (recruited 2015–2018) were available. Baseline data included demographics, RRMS characteristics and disease severity. (3) Results: The mean age of PANGAEA and PANGAEA 2.0 patients was similar (38.8 vs. 39.2 years). Patients in PANGAEA 2.0 had shorter disease duration (7.1 vs. 8.2 years) and fewer relapses in the year before baseline (1.2 vs. 1.6). Disease severity at baseline estimated by EDSS and SDMT was lower in PANGAEA 2.0 patients compared to PANGAEA (EDSS difference 1.0 points; SDMT difference 3.3 points). (4) Conclusions: The results hint at an influence of changes in the treatment guidelines and the label on fingolimod patients profiles over time. Patients tended to have lower disease activity at fingolimod initiation, suggesting an earlier intervention. This indicates increased experience in using fingolimod for sub-optimally treated RRMS patients and a change in mindset towards an early treatment optimization.
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Uzunköprü C, Beckmann Y, Türe S. Long-Term Effectiveness of Fingolimod for Multiple Sclerosis in a Real-World Clinical Setting. Eur Neurol 2021; 84:200-205. [PMID: 33827097 DOI: 10.1159/000514828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 01/27/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The primary aim of the present study was to evaluate the long-term efficacy of fingolimod in patients with multiple sclerosis (MS); secondary aims were to describe the safety of fingolimod with the evaluation of treatment satisfaction and impact on the quality of life in real life. METHODS We collected clinical, demographical, neuroradiological, and treatment data, including pre- and posttreatment status health-related quality of life from 286 MS patients consecutively treated with fingolimod. Clinical assessment was based on the Expanded Disability Status Scale (EDSS), and quality of life assessment was performed with MS-related quality of life inventory (MSQOLI). The data were recorded at baseline and every 6 months for 2 years. RESULTS One hundred and fourteen males and 172 females were enrolled. The annualized relapse rate and EDSS showed a statistically significant reduction during the observation period (p < 0.001). The patients also demonstrated substantial improvements in magnetic resonance imaging (MRI) outcomes (p < 0.001). Health-related quality of life scores improved significantly between baseline and 24-month visit (p < 0.001). No serious adverse events occurred. CONCLUSION In our cohort, fingolimod treatment was associated with reduced relapse, MRI activity, and improved EDSS and MSQOLI scores. Additionally, fingolimod has been able to maintain its effectiveness over a considerable long period of treatment.
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Affiliation(s)
- Cihat Uzunköprü
- Department of Neurology, Izmir Katip Çelebi University, Izmir, Turkey
| | - Yesim Beckmann
- Department of Neurology, Izmir Katip Çelebi University, Izmir, Turkey
| | - Sabiha Türe
- Department of Neurology, Izmir Katip Çelebi University, Izmir, Turkey
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Progressive multifocal leukoencephalopathy in the era of new disease-modifying treatments for multiple sclerosis. Med Clin (Barc) 2021; 156:509-514. [PMID: 33431183 DOI: 10.1016/j.medcli.2020.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 11/22/2022]
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