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Wandall-Holm MF, Holm RP, Heick A, Langkilde AR, Magyari M. Risk of T 2 lesions when discontinuing fingolimod: a nationwide predictive and comparative study. Brain Commun 2024; 6:fcad358. [PMID: 38214014 PMCID: PMC10783644 DOI: 10.1093/braincomms/fcad358] [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: 03/28/2023] [Revised: 10/25/2023] [Accepted: 01/01/2024] [Indexed: 01/13/2024] Open
Abstract
Fingolimod is a frequently used disease-modifying therapy in relapsing-remitting multiple sclerosis. However, case reports and small observational studies indicate a highly increased risk of disease reactivation after discontinuation. We aimed to investigate the risk of radiological disease reactivation in patients discontinuing fingolimod. We performed a nationwide cohort study in Denmark, including patients who discontinued fingolimod between January 2014 and January 2023. Eligibility was a diagnosis with relapsing-remitting multiple sclerosis and two MRIs performed respectively within 1 year before and after discontinuing fingolimod. The included patients were compared with those discontinuing dimethyl fumarate with the same eligibility criteria in an unadjusted and matched propensity score analysis. Matching was done on age, sex, Expanded Disability Status Scale, MRI data, cause for treatment discontinuation, treatment duration and relapse rate. The main outcome was the presence of new T2 lesions on the first MRI after treatment discontinuation. To identify high-risk patients among those discontinuing fingolimod, we made a predictive model assessing risk factors for obtaining new T2 lesions. Of 1324 patients discontinuing fingolimod in the study period, 752 were eligible for inclusion [mean age (standard deviation), years, 41 (10); 552 females (73%); median Expanded Disability Status Scale (Q1-Q3), 2.5 (2.0-3.5); mean disease duration (standard deviation), years, 12 (8)]. Of 2044 patients discontinuing dimethyl fumarate in the study period, 957 were eligible for inclusion, presenting similar baseline characteristics. Among patients discontinuing fingolimod, 127 (17%) had 1-2 new T2 lesions, and 124 (17%) had ≥3 new T2 lesions compared with 114 (12%) and 45 (5%), respectively, for those discontinuing dimethyl fumarate, corresponding to odds ratios (95% confidence interval) of 1.8 (1.3-2.3) and 4.4 (3.1-6.3). The predictive model, including 509 of the 752 patients discontinuing fingolimod, showed a highly increased risk of new T2 lesions among those with disease activity during fingolimod treatment and among females under 40 years. This nationwide study suggests that discontinuing fingolimod in some cases carries a risk of developing new T2 lesions, emphasizing the importance of clinical awareness. If feasible, clinicians should prioritize the prompt initiation of new disease-modifying therapies, particularly among young females.
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Affiliation(s)
- Malthe Faurschou Wandall-Holm
- Department of Neurology, Danish Multiple Sclerosis Registry, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
| | - Rolf Pringler Holm
- Department of Neurology, Danish Multiple Sclerosis Registry, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
| | - Alex Heick
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
| | - Annika Reynberg Langkilde
- Department of Radiology, Diagnostic Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen DK-2100, Denmark
| | - Melinda Magyari
- Department of Neurology, Danish Multiple Sclerosis Registry, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
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Maunula A, Atula S, Laakso SM, Tienari PJ. Frequency and risk factors of rebound after fingolimod discontinuation - A retrospective study. Mult Scler Relat Disord 2024; 81:105134. [PMID: 37980790 DOI: 10.1016/j.msard.2023.105134] [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: 06/28/2023] [Revised: 08/18/2023] [Accepted: 11/10/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Fingolimod (FTY) rebound, a phenomenon of unexpectedly severe disease activity following FTY discontinuation, has been reported to occur in 5-43 % of patients. Only a few larger cohorts have been analyzed. We aimed to determine the frequency and risk factors of FTY rebound in our hospital district in Southern Finland with a population of 1.7 million. METHODS We searched the Finnish MS-register for patients who were previous or current users of FTY for at least 6 months by November 2020. We assessed medical records and collected basic demographic data for the whole cohort. Criteria for a rebound were: (i) the most severe relapse in patient's history and an increase of at least 2 EDSS points during the relapse occurring within 6 months from FTY cessation, or (ii) more than one relapse within 6 months after FTY discontinuation, this being the highest relapse rate observed during the patient's lifetime. RESULTS Among 3496 MS patients, we found 331 patients ever starting FTY and 283 of them had used FTY for at least 6 months. Among these 283 patients we discovered a total of 114 discontinuation events in 110 patients. Of the discontinuations, 32 (28 %) were followed by a relapse: 20 (17.5 %) were ordinary relapses not fulfilling rebound criteria, and 12 (10.5 %) were rebounds. The median time to an ordinary relapse and rebound were similar: 8.5 weeks (range 1.3-23) and 9.9 weeks (range 5.9-15.9), respectively. The rebound group was younger at diagnosis (p = 0.034) and had used FTY for a longer time (p = 0.048) before discontinuation compared to the group without a relapse. After discontinuation, rebound group had lower lymphocyte values as compared to both ordinary relapse group (p = 0.027) and no-relapse group (p = 0.006) and neutrophil to lymphocyte ratio (NLR) was increased compared to the no-relapse group (p = 0.019). CONCLUSION In this study, 10.5 % of patients experienced a rebound, which is similar to the frequencies (10.3-12.5 %) obtained in other larger studies with >100 discontinuations. Relapses of any severity occurred in 28 % of patients discontinuing FTY, and therefore initiation of subsequent disease modifying therapies should occur promptly after discontinuation. Younger age at diagnosis, longer exposure to FTY and lower lymphocyte count as well as higher NLR after discontinuation were identified as risk factors for a rebound. The differences in blood leukocytes indicate that rebound might be a distinct pathophysiological phenomenon compared to an ordinary relapse.
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Affiliation(s)
- A Maunula
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland; HUS Brain Center, Department of Neurology, Hyvinkää Hospital, Hyvinkää, Finland.
| | - S Atula
- HUS Brain Center, Department of Neurology, Helsinki University Hospital, Helsinki, Finland; Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - S M Laakso
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland; HUS Brain Center, Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - P J Tienari
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland; HUS Brain Center, Department of Neurology, Helsinki University Hospital, Helsinki, Finland
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Geiger CK, Sheinson D, To TM, Jones D, Bonine NG. Real-World Clinical and Economic Outcomes Among Persons With Multiple Sclerosis Initiating First- Versus Second- or Later-Line Treatment With Ocrelizumab. Neurol Ther 2023; 12:1709-1728. [PMID: 37458897 PMCID: PMC10444704 DOI: 10.1007/s40120-023-00523-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/29/2023] [Indexed: 08/24/2023] Open
Abstract
INTRODUCTION Prior research has demonstrated that early treatment with high-efficacy disease-modifying therapies (DMTs), including ocrelizumab (OCR), can reduce relapses and delay disease progression among persons with multiple sclerosis (pwMS) compared with escalation from low-/moderate-efficacy DMTs. However, there is a lack of research examining the impact of early use of OCR on real-world clinical and economic outcomes. This study aimed to evaluate differences in events often associated with a relapse (EOAR) as well as non-DMT healthcare resource use (HCRU) and costs among pwMS who received OCR as a first-line treatment compared with later-line treatment after diagnosis. METHODS Newly diagnosed adult pwMS were selected from deidentified Optum Market Clarity claims data (study period: January 1, 2015-June 30, 2021). All pwMS were required to have initiated OCR after diagnosis and have 12 months of continuous eligibility prior to diagnosis. The index date was the date of initiation of the first-line DMT after diagnosis. pwMS who initiated OCR as first-line (1L OCR cohort) or a second- or later-line treatment (2L + OCR cohort) were matched 1:1 based on length of continuous eligibility after the first-line DMT and weighted using stabilized inverse probability of treatment. In the follow-up period, differences in outcomes, including annualized EOAR, non-DMT HCRU and costs, were evaluated for pwMS in the 1L vs. 2L + OCR cohorts. RESULTS The sample included 748 pwMS. During the follow-up period, pwMS in the 1L OCR cohort had a significantly lower annual rate of EOAR compared with pwMS in the 2L + OCR cohort (0.37 vs. 0.56; difference: 0.20 [95% CI 0.08, 0.32]). pwMS in the 1L OCR cohort had a significantly lower probability of any hospitalization within 1 year, fewer non-DMT outpatient visits and lower all-cause and MS-related, non-DMT costs compared with pwMS in the 2L + OCR cohort. CONCLUSIONS First-line initiation OCR was associated with improvements in clinical and non-DMT economic outcomes compared with later-line initiation of OCR, suggesting that early initiation may benefit both patients and the healthcare system.
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Affiliation(s)
| | - Danny Sheinson
- Genentech, Inc., 350 DNA Way, South San Francisco, CA, 94080, USA
| | - Tu My To
- Genentech, Inc., 350 DNA Way, South San Francisco, CA, 94080, USA
| | - David Jones
- Genentech, Inc., 350 DNA Way, South San Francisco, CA, 94080, USA
| | - Nicole G Bonine
- Genentech, Inc., 350 DNA Way, South San Francisco, CA, 94080, USA
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Soni N, Ora M, Mangla R, Singh R, Ellika S, Agarwal A, Meyers SP, Bathla G. Radiological abnormalities in progressive multifocal leukoencephalopathy: Identifying typical and atypical imaging patterns for early diagnosis and differential considerations. Mult Scler Relat Disord 2023; 77:104830. [PMID: 37418930 DOI: 10.1016/j.msard.2023.104830] [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: 03/29/2023] [Revised: 05/22/2023] [Accepted: 06/11/2023] [Indexed: 07/09/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare viral central nervous system (CNS) demyelinating disease primarily associated with a compromised immune system. PML is seen mainly in individuals with human immunodeficiency virus, lymphoproliferative disease, and multiple sclerosis. Patients on immunomodulators, chemotherapy, and solid organ or bone marrow transplants are predisposed to PML. Recognition of various PML-associated typical and atypical imaging abnormalities is critical for early diagnosis and differentiating it from other conditions, especially in high-risk populations. Early PML recognition should expedite efforts at immune-system restoration, allowing for a favorable outcome. This review aims to provide a practical overview of radiological abnormalities in PML patients and address differential considerations.
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Affiliation(s)
- Neetu Soni
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA.
| | - Manish Ora
- Department of Nuclear Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | - Rohit Singh
- Division of Hematology-Oncology at the University of Vermont Medical Center, Burlington, VT, USA
| | - Shehanaz Ellika
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA
| | - Amit Agarwal
- Radiology, Mayo Clinic in Florida, San Pablo Dr, Jacksonville, FL 32224-1865, USA
| | - Steven P Meyers
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA
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Dumitrescu L, Papathanasiou A, Coclitu C, Garjani A, Evangelou N, Constantinescu CS, Popescu BO, Tanasescu R. An update on the use of sphingosine 1-phosphate receptor modulators for the treatment of relapsing multiple sclerosis. Expert Opin Pharmacother 2023; 24:495-509. [PMID: 36946625 PMCID: PMC10069376 DOI: 10.1080/14656566.2023.2178898] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an immune-mediated disorder of the CNS manifested by recurrent attacks of neurological symptoms (related to focal inflammation) and gradual disability accrual (related to progressive neurodegeneration and neuroinflammation). Sphingosine-1-phosphate-receptor (S1PR) modulators are a class of oral disease-modifying therapies (DMTs) for relapsing MS. The first S1PR modulator developed and approved for MS was fingolimod, followed by siponimod, ozanimod, and ponesimod. All are S1P analogues with different S1PR-subtype selectivity. They restrain the S1P-dependent lymphocyte egress from lymph nodes by binding the lymphocytic S1P-subtype-1-receptor. Depending on their pharmacodynamics and pharmacokinetics, they can also interfere with other biological functions. AREAS COVERED Our narrative review covers the PubMed English literature on S1PR modulators in MS until August 2022. We discuss their pharmacology, efficacy, safety profile, and risk management recommendations based on the results of phase II and III clinical trials. We briefly address their impact on the risk of infections and vaccines efficacy. EXPERT OPINION S1PR modulators decrease relapse rate and may modestly delay disease progression in people with relapsing MS. Aside their established benefit, their place and timing within the long-term DMT strategy in MS, as well as their immunological effects in the new and evolving context of the post-COVID-19 pandemic and vaccination campaigns warrant further study.
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Affiliation(s)
- Laura Dumitrescu
- Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania
| | - Athanasios Papathanasiou
- Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, UK
| | - Catalina Coclitu
- Department of Multiple Sclerosis and Neuroimmunology, CHU Grenoble, Grenoble, France
| | - Afagh Garjani
- Academic Clinical Neurology, Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nikos Evangelou
- Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, UK
- Academic Clinical Neurology, Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Cris S Constantinescu
- Academic Clinical Neurology, Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Neurology, Cooper Neurological Institute, Camden, NJ, USA
| | - Bogdan Ovidiu Popescu
- Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania
| | - Radu Tanasescu
- Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, UK
- Academic Clinical Neurology, Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
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Nygaard GO, Torgauten H, Skattebøl L, Høgestøl EA, Sowa P, Myhr KM, Torkildsen Ø, Celius EG. Risk of fingolimod rebound after switching to cladribine or rituximab in multiple sclerosis. Mult Scler Relat Disord 2022; 62:103812. [DOI: 10.1016/j.msard.2022.103812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/12/2022] [Accepted: 04/16/2022] [Indexed: 11/29/2022]
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