1
|
Toorop AA, Wessels MHJ, Gelissen LMY, Hoitsma E, Zeinstra EMPE, van Rooij LC, van Munster CEP, Vennegoor A, Mostert JP, Wokke BHA, Kalkers NF, Hoogervorst ELJ, van Eijk JJJ, Roosendaal CM, Kragt JJ, Eurelings M, van Genugten J, Nielsen J, Sinnige LGF, Kloosterziel ME, Arnoldus EPJ, van Dijk GW, Bouvy WH, Strijbis EMM, van Oosten BW, de Jong BA, Lissenberg-Witte BI, Rispens T, Uitdehaag BMJ, Killestein J, van Kempen ZLE. Influence of personalized extended interval dosing on the natalizumab wearing-off effect - a sub-study of the NEXT-MS trial. J Neurol Sci 2024; 462:123102. [PMID: 38925067 DOI: 10.1016/j.jns.2024.123102] [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: 03/15/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND AND OBJECTIVES Wearing-off symptoms during natalizumab treatment in multiple sclerosis are characterized by an increase of MS-related symptoms prior to natalizumab administration. The influence of extended interval dosing (EID) on wearing-off symptoms are important to consider, as this might cause hesitancy in initiating or continuing EID. METHODS Participants of the NEXT-MS trial, in which treatment intervals are adjusted based on drug concentrations, were divided into two groups: an extended group containing participants with at least one week of additional interval extension, and a group with a fixed interval during the trial (range 4-7 weeks). Changes in the occurrence, frequency, onset, and severity of wearing-off symptoms were evaluated. RESULTS 255 participants were included (extended group n = 171, fixed group n = 84). The odds on occurrence of wearing-off symptoms in the extended group did not increase after extending the treatment interval. Additional analyses for frequency, onset, and severity of wearing-off symptoms showed no changes over time. Mean decrease in natalizumab drug concentration did not influence the frequency of wearing-off symptoms. DISCUSSION Wearing-off symptoms were not reinforced by further extending the natalizumab interval. Wearing-off symptoms might increase in a minority of patients after EID, although our data support the view that wearing-off symptoms appear to be unrelated to the decrease in natalizumab trough drug concentrations.
Collapse
Affiliation(s)
- A A Toorop
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, the Netherlands
| | - M H J Wessels
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, the Netherlands
| | - L M Y Gelissen
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, the Netherlands
| | - E Hoitsma
- Department of Neurology, MS center Alrijne Hospital, Leiden, the Netherlands
| | | | - L C van Rooij
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - A Vennegoor
- Department of Neurology, Flevoziekenhuis, Almere, the Netherlands
| | - J P Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
| | - B H A Wokke
- Department of Neurology, ErasMS, Erasmus Medical Center, Rotterdam, the Netherlands
| | - N F Kalkers
- Department of Neurology, OLVG, Amsterdam, the Netherlands
| | - E L J Hoogervorst
- Department of Neurology, St Antonius Ziekenhuis, Utrecht, the Netherlands
| | - J J J van Eijk
- Department of Neurology, Jeroen Bosch Ziekenhuis / Hospital, 's Hertogenbosch, the Netherlands
| | - C M Roosendaal
- Department of Neurology, Slingeland Hospital, Doetinchem, the Netherlands
| | - J J Kragt
- Department of Neurology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - M Eurelings
- Department of Neurology, Spaarne Gasthuis, Haarlem, the Netherlands
| | - J van Genugten
- Department of Neurology, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - J Nielsen
- Department of Neurology, Ommelander Ziekenhuis, Scheemda, the Netherlands
| | - L G F Sinnige
- Department of Neurology, Medisch Centrum Leeuwarden, Leeuwarden, the Netherlands
| | - M E Kloosterziel
- Department of Neurology, Wilhelmina Hospital, Assen, the Netherlands
| | - E P J Arnoldus
- Department of Neurology, Elizabeth TweeSteden Hospital, Tilburg, the Netherlands
| | - G W van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - W H Bouvy
- Department of Neurology, Diakonessenhuis Hospital, Utrecht, the Netherlands
| | - E M M Strijbis
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, the Netherlands
| | - B W van Oosten
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, the Netherlands
| | - B A de Jong
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, the Netherlands
| | - B I Lissenberg-Witte
- Department of Epidemiology and Data Science, Amsterdam. University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - T Rispens
- Sanquin Diagnostic Services, Amsterdam, the Netherlands; Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - B M J Uitdehaag
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, the Netherlands
| | - J Killestein
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, the Netherlands
| | - Z L E van Kempen
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, the Netherlands.
| |
Collapse
|
2
|
Kister I, Oh C, Douglas EA, Bacon TE, O'Shea IL, Parrotta EH, Bouley A, Lathi E, Katz J. No Increase in Symptoms Toward the End of the Ocrelizumab Infusion Cycle in Patients With Multiple Sclerosis: Symptom Burden on Ocrelizumab: A Longitudinal Study (SymBOLS). Neurol Clin Pract 2023; 13:e200185. [PMID: 37674871 PMCID: PMC10479935 DOI: 10.1212/cpj.0000000000200185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/07/2023] [Indexed: 09/08/2023]
Abstract
Background and Objectives Some patients with multiple sclerosis (MS) receiving ocrelizumab (OCR) report worsening symptoms toward the end of the 6-month infusion cycle ('wearing off'). The objective of our study was to comprehensively assess changes in symptom burden across 2 consecutive OCR infusion cycles. Methods SYMptom Burden on Ocrelizumab, a Longitudinal Study (SymBOLS; NCT04855617) was an investigator-initiated, 2-center study of patients with MS starting or receiving OCR. Patients' symptoms were assessed with NeuroQoL short forms, SymptoMScreen, and Work Productivity and Activity Impairment Questionnaire at the start-cycle, mid-cycle, and end-cycle time points in each of the 2 infusion cycles. Symptom scores at the 3 time points within each cycle were compared with repeated-measures ANOVA or the Friedman rank-sum test for non-normal variables. The proportions of patients with a meaningful symptomatic change from the start to the end of each infusion cycle were calculated, and patients whose symptoms improved, worsened, and stayed the same from the start to the end of the cycle were compared with respect to demographic and clinical characteristics. Results One hundred three patients with MS provided longitudinal data for analyses (mean age [SD]: 46.7 [12.2] years, 68% female, 33% non-White, disease duration: 15.5 [5] years, 41% with the Extended Disability Status Scale score >3). On a group level, NeuroQoL and SymptoMScreen scores mostly remained stable or even improved slightly toward the end of each cycle. On an individual level, symptoms remained unchanged across either cycle for most patients, and meaningful symptom worsening from the start to the end of the cycle was no more common than improvement. Meaningful change in symptoms in both cycles was very rare and generally in the direction of improvement toward the end cycle. Despite the lack of evidence for symptom worsening with a longer time from infusion, 54% of patients endorsed feeling of "wearing off" at least sometimes, most commonly as an increase in fatigue. Discussion Our prospective study failed to uncover evidence for the worsening of symptoms with a longer time from OCR infusion. These findings cast doubt on the existence of wearing off as a physiologic phenomenon in OCR-treated patients with MS. The perception of wearing off is likely the result of natural fluctuations in MS symptoms and attribution bias.
Collapse
Affiliation(s)
- Ilya Kister
- NYU Multiple Sclerosis Comprehensive Care Center (IK, TEB), Department of Neurology; Department of Population Health (CO), NYU Grossman School of Medicine, New York; The Elliot Lewis Center for Multiple Sclerosis Care (EAD, ILOS, AB, EL, JK), Wellesley, MA; and St. Peter's MS and Headache Center (EHP), Albany, NY
| | - Cheongeun Oh
- NYU Multiple Sclerosis Comprehensive Care Center (IK, TEB), Department of Neurology; Department of Population Health (CO), NYU Grossman School of Medicine, New York; The Elliot Lewis Center for Multiple Sclerosis Care (EAD, ILOS, AB, EL, JK), Wellesley, MA; and St. Peter's MS and Headache Center (EHP), Albany, NY
| | - Elizabeth A Douglas
- NYU Multiple Sclerosis Comprehensive Care Center (IK, TEB), Department of Neurology; Department of Population Health (CO), NYU Grossman School of Medicine, New York; The Elliot Lewis Center for Multiple Sclerosis Care (EAD, ILOS, AB, EL, JK), Wellesley, MA; and St. Peter's MS and Headache Center (EHP), Albany, NY
| | - Tamar E Bacon
- NYU Multiple Sclerosis Comprehensive Care Center (IK, TEB), Department of Neurology; Department of Population Health (CO), NYU Grossman School of Medicine, New York; The Elliot Lewis Center for Multiple Sclerosis Care (EAD, ILOS, AB, EL, JK), Wellesley, MA; and St. Peter's MS and Headache Center (EHP), Albany, NY
| | - Isabella L O'Shea
- NYU Multiple Sclerosis Comprehensive Care Center (IK, TEB), Department of Neurology; Department of Population Health (CO), NYU Grossman School of Medicine, New York; The Elliot Lewis Center for Multiple Sclerosis Care (EAD, ILOS, AB, EL, JK), Wellesley, MA; and St. Peter's MS and Headache Center (EHP), Albany, NY
| | - Erica H Parrotta
- NYU Multiple Sclerosis Comprehensive Care Center (IK, TEB), Department of Neurology; Department of Population Health (CO), NYU Grossman School of Medicine, New York; The Elliot Lewis Center for Multiple Sclerosis Care (EAD, ILOS, AB, EL, JK), Wellesley, MA; and St. Peter's MS and Headache Center (EHP), Albany, NY
| | - Andrew Bouley
- NYU Multiple Sclerosis Comprehensive Care Center (IK, TEB), Department of Neurology; Department of Population Health (CO), NYU Grossman School of Medicine, New York; The Elliot Lewis Center for Multiple Sclerosis Care (EAD, ILOS, AB, EL, JK), Wellesley, MA; and St. Peter's MS and Headache Center (EHP), Albany, NY
| | - Ellen Lathi
- NYU Multiple Sclerosis Comprehensive Care Center (IK, TEB), Department of Neurology; Department of Population Health (CO), NYU Grossman School of Medicine, New York; The Elliot Lewis Center for Multiple Sclerosis Care (EAD, ILOS, AB, EL, JK), Wellesley, MA; and St. Peter's MS and Headache Center (EHP), Albany, NY
| | - Joshua Katz
- NYU Multiple Sclerosis Comprehensive Care Center (IK, TEB), Department of Neurology; Department of Population Health (CO), NYU Grossman School of Medicine, New York; The Elliot Lewis Center for Multiple Sclerosis Care (EAD, ILOS, AB, EL, JK), Wellesley, MA; and St. Peter's MS and Headache Center (EHP), Albany, NY
| |
Collapse
|
3
|
Perncezky J, Sellner J. Natalizumab extended-interval dosing in multiple sclerosis to mitigate progressive multifocal leukoencephalopathy risk: initial study evidence and real-world experience. J Cent Nerv Syst Dis 2022; 14:11795735221135485. [PMID: 36277271 PMCID: PMC9580073 DOI: 10.1177/11795735221135485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The high efficacy of natalizumab in the treatment of relapsing-remitting multiple sclerosis (MS) is without controversy. Indeed, effective disease control was not only demonstrated in the pivotal trials but has been corroborated impressively in real-world observations. This monoclonal IgG4 antibody blocks the α4β1 integrin-mediated leukocyte-endothelial interaction and thereby inhibits the migration of immune cells to the brain parenchyma. However, treatment with natalizumab carries the risk of progressive multifocal leukoencephalopathy (PML). This potentially lethal side effect is a significant limitation for treatment initiation and long-term therapy. Natalizumab is given intravenously or subcutaneously in the standard dose of 300 mg every 4 weeks, allowing drug concentrations at levels that ensure continuous α4β1 integrin receptor saturation on the surface of immune cells. Extended-interval dosing (EID) is an emerging treatment approach that aims to mitigate the natalizumab-related PML risk by prolonging the standard infusion intervals to 6 weeks or even more. This treatment approach may abrogate the PML risk due to improved immune surveillance within the central nervous system while maintaining clinical efficacy. Moreover, even an individual interval dosing can be envisioned based on the availability of a biomarker that is capable of monitoring both safety and efficacy aspects. This review summarizes the early and encouraging evidence for EID from observational and randomized-controlled trials and discusses current limitations and upcoming challenges for introducing a tailored treatment approach.
Collapse
Affiliation(s)
- Julian Perncezky
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria,Johann Sellner, Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstr 67, Mistelbach 2130, Austria.
| |
Collapse
|
4
|
The wearing-off phenomenon of ocrelizumab in patients with multiple sclerosis. Mult Scler Relat Disord 2022; 57:103364. [PMID: 35158470 DOI: 10.1016/j.msard.2021.103364] [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: 09/28/2021] [Revised: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients with multiple sclerosis (MS) who are treated with monoclonal antibodies frequently report an increase of MS-related symptoms prior to the next dose known as the wearing-off phenomenon. The objective of this study was to assess the prevalence and predicting factors of the wearing-off phenomenon in patients with MS using ocrelizumab. METHODS This was a prospective cohort study in patients with MS receiving ocrelizumab ≥1 year. Most participants received B-cell guided personalized extended interval dosing to limit ocrelizumab exposure and hospital visits during the COVID-19 pandemic (cut-off ≥ 10 cells/µL). Participants completed questionnaires during ocrelizumab infusion and 2 weeks thereafter. Demographics, clinical and radiological characteristics, CD19 B-cell counts, and serum neurofilament light (sNfL) levels were collected. Data were analyzed using logistic regression analyses. RESULTS Seventy-one (61%) out of 117 participants reported the wearing-off phenomenon during ocrelizumab treatment. The most frequently reported symptoms were fatigue, cognitive disability and sensory symptoms. Wearing-off symptoms started < 1 week (11%), 1-4 weeks (49%) or more than 4 weeks (37%) before ocrelizumab infusion. Fifty participants (43%) reported a current wearing-off phenomenon at the first questionnaire. Higher body mass index (threshold BMI ≥ 25) increased the odds of reporting a current wearing-off phenomenon (OR 2.70, 95% CI 1.26 to 5.80, p = .011). Infusion interval, EDSS score, MRI disease activity, clinical relapses, CD19 B-cell counts, and sNfL levels were no predictors. Disappearance of the wearing-off phenomenon occurred in the first week after ocrelizumab infusion in most participants. Participants with a current wearing-off phenomenon significantly improved in self-reported physical and psychological functioning after ocrelizumab infusion. Reporting the wearing-off phenomenon did not influence treatment satisfaction. Forty of 109 participants (37%) reported post-infusion symptoms, such as fatigue, flu-like symptoms or walking difficulties. These post-infusion symptoms started directly or in the first week after ocrelizumab infusion and disappeared within 2 weeks. CONCLUSIONS The wearing-off phenomenon is reported by more than half of patients with MS using ocrelizumab. Only BMI was identified as a predicting factor. The wearing-off phenomenon was not elicited by extending infusion intervals or higher B-cell counts. The wearing-off phenomenon of ocrelizumab therefore does not seem to reflect suboptimal control of MS disease activity.
Collapse
|