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Krbot Skorić M, Bašić Kes V, Grbić N, Lazibat I, Pavelin S, Mirošević Zubonja T, Komšo M, Kiđemet Piskač S, Abičić A, Piskač D, Adamec I, Barun B, Gabelić T, Habek M. Ocrelizumab in people with primary progressive multiple sclerosis: A real-world multicentric study. Mult Scler Relat Disord 2024; 89:105776. [PMID: 39047339 DOI: 10.1016/j.msard.2024.105776] [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: 04/10/2024] [Accepted: 07/18/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Ocrelizumab is the only disease-modifying therapy (DMT) approved for the treatment of people with primary progressive multiple sclerosis (pwPPMS). OBJECTIVES To provide real-world evidence of ocrelizumab effectiveness and safety in pwPPMS in Croatian MS centers. METHODS A retrospective observational multi-center study of pwPPMS who were started on ocrelizumab in 7 MS centers in Croatia. RESULTS We identified 230 pwPPMS of whom 176 fulfilled the inclusion criteria. The median follow-up of the cohort was 2.73 (0.51-5.77) years. During the follow-up, 50 (28.4%) pwPPMS experienced confirmed disability worsening (CDW) and 19 (10.8%) stopped treatment with ocrelizumab. Baseline EDSS >5 was a statistically significant positive predictor for the development of CDW and/or stop of the treatment due to any cause (OR 2.482, 95% C.I. 1.192-5.166, p = 0.015). However, there was no significant difference in the development of CDW and/or stop of the treatment due to any cause if stratifying the patients based on active PPMS, age at treatment start (≤55 years vs >55 years), disease duration at treatment start (≤10 years vs >10 years), or EDSS at treatment start (≤5.0 vs >5.0). During the follow-up, 26 (14.8%) pwPPMS experienced infusion reactions, 64 (36.4%) had an infection and 4 (2.3%) developed a tumor. The percentage of pwPPMS with low levels of IgG was persistently above 10% and with low levels of IgM was persistently above 20% after cycle 4. CONCLUSION Our real-world data support the use of ocrelizumab in a much broader pwPPMS population than in the original randomized controlled trial.
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Affiliation(s)
- Magdalena Krbot Skorić
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia; Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia
| | - Vanja Bašić Kes
- Department of Neurology, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Nevena Grbić
- Department of Neurology, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ines Lazibat
- Department of Neurology, University Hospital Dubrava, Zagreb, Croatia
| | - Sanda Pavelin
- Department of Neurology, University Hospital Center Split, Split, Croatia
| | | | - Milica Komšo
- Department of Neurology, General Hospital Zadar, Zadar, Croatia
| | | | | | - Dominik Piskač
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Adamec
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Barbara Barun
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Tereza Gabelić
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Mario Habek
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia.
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Meng D, Sacco R, Disanto G, Widmer F, Jacober SLS, Gobbi C, Zecca C. Memory B cell-guided extended interval dosing of ocrelizumab in multiple sclerosis. Mult Scler 2024; 30:857-867. [PMID: 38767224 DOI: 10.1177/13524585241250199] [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] [Indexed: 05/22/2024]
Abstract
BACKGROUND Ocrelizumab (OCR) is an anti-CD20 monoclonal antibody approved for the treatment of relapsing-remitting and primary-progressive multiple sclerosis (MS). We aimed to evaluate the effectiveness of an individualized OCR extended interval dosing (EID), after switching from standard interval dosing (SID). METHODS This was a retrospective, observational, single-centre study including MS patients regularly followed at the Neurocenter of Southern Switzerland. After a cumulative OCR dose ⩾1200 mg, stable patients were switched to EID (OCR infusions following CD19+ 27+ memory B cell repopulation). RESULTS A total of 128 patients were included in the study, and 113 (88.3%) were switched to EID with a median interval of 9.9 (8.8-11.8) months between infusions. No clinical relapses occurred; 2 (1.8%) patients experienced disability worsening. Three (2.7%) and 2 (1.8%) patients experienced new T2 brain and spinal lesions, respectively. There was a mild decrease in IgG and IgM concentrations during both SID and EID OCR regimens (β = -0.23, p = 0.001 and β = -0.07, p < 0.001, respectively). CONCLUSION Switch to personalized dosing of OCR based on CD19+ 27+ memory B cell repopulation led to a great extension of the interval between infusions, with maintained clinical and radiological efficacy. Given the potential advantages in terms of safety and health costs, EID OCR regimens should be further investigated.
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Affiliation(s)
- Delania Meng
- Multiple Sclerosis Center (MSC), Department of Neurology, Neurocenter of Southern Switzerland (NSI), Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Rosaria Sacco
- Multiple Sclerosis Center (MSC), Department of Neurology, Neurocenter of Southern Switzerland (NSI), Lugano, Switzerland
| | - Giulio Disanto
- Multiple Sclerosis Center (MSC), Department of Neurology, Neurocenter of Southern Switzerland (NSI), Lugano, Switzerland
| | - Fausto Widmer
- Multiple Sclerosis Center (MSC), Department of Neurology, Neurocenter of Southern Switzerland (NSI), Lugano, Switzerland
| | - Sarah Lena Susanna Jacober
- Multiple Sclerosis Center (MSC), Department of Neurology, Neurocenter of Southern Switzerland (NSI), Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Claudio Gobbi
- Multiple Sclerosis Center (MSC), Department of Neurology, Neurocenter of Southern Switzerland (NSI), Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Chiara Zecca
- Multiple Sclerosis Center (MSC), Department of Neurology, Neurocenter of Southern Switzerland (NSI), Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Goereci Y, Ellenberger D, Rommer P, Dunkl V, Golla H, Zettl U, Stahmann A, Warnke C. Persons with multiple sclerosis older than 55 years: an analysis from the German MS registry. J Neurol 2024; 271:3409-3416. [PMID: 38517521 PMCID: PMC11136707 DOI: 10.1007/s00415-024-12286-4] [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: 02/13/2024] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Persons with MS (PwMS) ≥ 55 years are underrepresented in therapy studies leading to a lack of evidence. OBJECTIVE AND METHODS To study the subgroup of PwMS ≥ 55 years in the German MS registry in comparison with PwMS < 55 years. Endpoints of interest were the grade of disability, leading symptoms, clinical and magnetic resonance imaging activity, and use of disease modifying therapy. RESULTS At the time of analysis, data from 40,428 PwMS were available for analysis. In PwMS aged ≥ 65 and PwMS aged ≥ 55 to 64 years, compared with PwMS aged < 55 years, the mean Expanded Disability Status Scale Scores were higher (5.3, 4.2 and 2.7, respectively), while the proportion of individuals with current use of disease modifying therapy was lower (42.6%, 60.9% and 76.7%, respectively). The older patient groups were more likely to be labeled with progressive MS and the frequency of occupational invalidity was high (38.8% in PwMS aged ≥ 55 to 64 years). Gait disorder, fatigue, bladder dysfunction, and spasticity were among the leading symptoms in PwMS aged ≥ 55 years. CONCLUSION PwMS ≥ 55 years have a high degree of disability, but a large proportion do not receive disease modifying therapy, exposing an unmet need.
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Affiliation(s)
- Yasemin Goereci
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - David Ellenberger
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hannover, Germany
| | - Paulus Rommer
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Veronika Dunkl
- Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Uwe Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
| | - Alexander Stahmann
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hannover, Germany
| | - Clemens Warnke
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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Elgenidy A, Abdelhalim NN, Al-kurdi MAM, Mohamed LA, Ghoneim MM, Fathy AW, Hassaan HK, Anan A, Alomari O. Hypogammaglobulinemia and infections in patients with multiple sclerosis treated with anti-CD20 treatments: a systematic review and meta-analysis of 19,139 multiple sclerosis patients. Front Neurol 2024; 15:1380654. [PMID: 38699050 PMCID: PMC11063306 DOI: 10.3389/fneur.2024.1380654] [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: 02/01/2024] [Accepted: 04/03/2024] [Indexed: 05/05/2024] Open
Abstract
Background Recent years have seen the emergence of disease-modifying therapies in multiple sclerosis (MS), such as anti-cluster of differentiation 20 (anti-CD20) monoclonal antibodies, aiming to modulate the immune response and effectively manage MS. However, the relationship between anti-CD20 treatments and immunoglobulin G (IgG) levels, particularly the development of hypogammaglobulinemia and subsequent infection risks, remains a subject of scientific interest and variability. We aimed to investigate the intricate connection between anti-CD20 MS treatments, changes in IgG levels, and the associated risk of hypogammaglobulinemia and subsequent infections. Method PubMed, Scopus, Embase, Cochrane, and Web of Science databases have been searched for relevant studies. The "R" software utilized to analyze the occurrence of hypogammaglobulinemia, infections and mean differences in IgG levels pre- and post-treatment. The subgrouping analyses were done based on drug type and treatment duration. The assessment of heterogeneity utilized the I2 and chi-squared tests, applying the random effect model. Results Thirty-nine articles fulfilled our inclusion criteria and were included in our review which included a total of 20,501 MS patients. The overall prevalence rate of hypogammaglobulinemia was found to be 11% (95% CI: 0.08 to 0.15). Subgroup analysis based on drug type revealed varying prevalence rates, with rituximab showing the highest at 18%. Subgroup analysis based on drug usage duration revealed that the highest proportion of hypogammaglobulinemia occurred in individuals taking the drugs for 1 year or less (19%). The prevalence of infections in MS patients with a focus on different infection types stratified by the MS drug used revealed that pulmonary infections were the most prevalent (9%) followed by urinary tract infections (6%), gastrointestinal infections (2%), and skin and mucous membrane infections (2%). Additionally, a significant decrease in mean IgG levels after treatment compared to before treatment, with a mean difference of 0.57 (95% CI: 0.22 to 0.93). Conclusion This study provides a comprehensive analysis of the impact of anti-CD20 drugs on serum IgG levels in MS patients, exploring the prevalence of hypogammaglobulinemia, based on different drug types, treatment durations, and infection patterns. The identified rates and patterns offer a foundation for clinicians to consider in their risk-benefit. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=518239, CRD42024518239.
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Affiliation(s)
- Anas Elgenidy
- Faculty of Medicine, Cairo University, Giza, Egypt
- Karl-Jaspers-Klinik, Bad Zwischenahn, Germany
| | | | | | | | | | | | | | - Ahmed Anan
- Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Omar Alomari
- Hamidiye International School of Medicine, University of Health Sciences, Istanbul, Türkiye
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Fernández Ó, Sörensen PS, Comi G, Vermersch P, Hartung HP, Leocani L, Berger T, Van Wijmeersch B, Oreja-Guevara C. Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review. Front Immunol 2024; 15:1379538. [PMID: 38646534 PMCID: PMC11032020 DOI: 10.3389/fimmu.2024.1379538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.
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Affiliation(s)
- Óscar Fernández
- Departament of Pharmacology, Faculty of Medicine; Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, Malaga, Spain
- Department of Pharmacology and Pediatry, Faculty of Medicine, University of Malaga, Malaga, Spain
| | - Per Soelberg Sörensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Copenhagen and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Giancarlo Comi
- Department of Neurorehabilitation Sciences, Multiple Sclerosis Centre Casa di Cura Igea, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Palacky University Olomouc, Olomouc, Czechia
| | - Letizia Leocani
- Department of Neurorehabilitation Sciences, Multiple Sclerosis Centre Casa di Cura Igea, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Bart Van Wijmeersch
- University MS Centre, Hasselt-Pelt, Belgium
- Rehabilitation and Multiple Sclerosis (MS), Noorderhart Hospitals, Pelt, Belgium
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico Universitario San Carlos, IdISSC, Madrid, Spain
- Department of Medicine, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Nobile S, Beauchemin P. Hypogammaglobulinemia and Infection Risk in an Ocrelizumab-treated Multiple Sclerosis Cohort. Can J Neurol Sci 2024:1-8. [PMID: 38343112 DOI: 10.1017/cjn.2024.21] [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: 03/06/2024]
Abstract
BACKGROUND Ocrelizumab is an effective anti-CD20 therapy approved for Relapsing Remitting (RRMS) and Primary Progressive Multiple Sclerosis (PPMS). In clinical trials, a proportion of patients developed hypogammaglobulinemia which could contribute to infection risk. This study aimed to identify hypogammaglobulinemia and its risk factors and evaluate potentially associated serious infection risk in a real-world cohort of patients. METHODS All MS patients treated with ocrelizumab in a Quebec City MS clinic from January 2017 to August 2021 were included and detailed patient characteristics were collected by chart review. Levels of immunoglobulins (IgM, IgA and IgG) were assessed prior to each treatment. Serious infection was defined as an infection requiring hospitalization or emergency room treatment. Association between hypogammaglobulinemia and serious infection was analyzed. RESULTS A total of 266 patients (average follow-up 2.05 years) were included (87% RRMS). After 6 infusions, 32.8%, 3.5% and 4.2% of patients had at least one IgM, IgA and IgG hypogammaglobulinemia event respectively. Aside from pre-treatment hypogammaglobulinemia, there were no variables associated with on-treatment hypogammaglobulinemia. There was a total of 21 serious infections (3.36 and 12.33 per 100-person-years in RRMS and PPMS). Developing hypogammaglobulinemia during treatment was not associated with serious infection. A regression analysis did not show associations between serious infection and key disease characteristics. CONCLUSION Similar to ocrelizumab extension studies, our cohort demonstrated a significant rate of hypogammaglobulinemia over time, mostly with IgM. No association was found between hypogammaglobulinemia and serious infection.
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Affiliation(s)
- Steven Nobile
- Department of Neurology, Montreal Neurological Institute (McGill University), Montreal, QC, Canada
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Beckers L, Baeten P, Popescu V, Swinnen D, Cardilli A, Hamad I, Van Wijmeersch B, Tavernier SJ, Kleinewietfeld M, Broux B, Fraussen J, Somers V. Alterations in the innate and adaptive immune system in a real-world cohort of multiple sclerosis patients treated with ocrelizumab. Clin Immunol 2024; 259:109894. [PMID: 38185268 DOI: 10.1016/j.clim.2024.109894] [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: 10/18/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 01/09/2024]
Abstract
B cell depletion by the anti-CD20 antibody ocrelizumab is effective in relapsing-remitting (RR) and primary progressive (PP) multiple sclerosis (MS). We investigated immunological changes in peripheral blood of a real-world MS cohort after 6 and 12 months of ocrelizumab. All RRMS and most PPMS patients (15/20) showed treatment response. Ocrelizumab not only reduced CD20+ B cells, but also numbers of CD20+ T cells. Absolute numbers of monocytes, dendritic cells and CD8+ T cells were increased, while CD56hi natural killer cells were reduced after ocrelizumab. The residual B cell population shifted towards transitional and activated, IgA+ switched memory B cells, double negative B cells, and antibody-secreting cells. Delaying the treatment interval by 2-3 months increased mean B cell frequencies and enhanced naive B cell repopulation. Ocrelizumab reduced plasma levels of interleukin(IL)-12p70 and interferon(IFN)-α2. These findings will contribute to understanding ineffective treatment responses, dealing with life-threatening infections and further unravelling MS pathogenesis.
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Affiliation(s)
- L Beckers
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - P Baeten
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - V Popescu
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium; Noorderhart, Rehabilitation and MS Center, Pelt, Belgium
| | - D Swinnen
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium; VIB Laboratory of Translational Immunomodulation, Center for Inflammation Research (IRC), Diepenbeek, Belgium
| | - A Cardilli
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium; VIB Laboratory of Translational Immunomodulation, Center for Inflammation Research (IRC), Diepenbeek, Belgium
| | - I Hamad
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium; VIB Laboratory of Translational Immunomodulation, Center for Inflammation Research (IRC), Diepenbeek, Belgium
| | - B Van Wijmeersch
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium; Noorderhart, Rehabilitation and MS Center, Pelt, Belgium
| | - S J Tavernier
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Unit of Molecular Signal Transduction in Inflammation, VIB-UGent Center for Inflammation Research (IRC), Ghent, Belgium
| | - M Kleinewietfeld
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium; VIB Laboratory of Translational Immunomodulation, Center for Inflammation Research (IRC), Diepenbeek, Belgium
| | - B Broux
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - J Fraussen
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - V Somers
- University MS Center (UMSC), Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Hasselt, Belgium.
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Alvarez E, Longbrake EE, Rammohan KW, Stankiewicz J, Hersh CM. Secondary hypogammaglobulinemia in patients with multiple sclerosis on anti-CD20 therapy: Pathogenesis, risk of infection, and disease management. Mult Scler Relat Disord 2023; 79:105009. [PMID: 37783194 DOI: 10.1016/j.msard.2023.105009] [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: 04/24/2023] [Revised: 08/31/2023] [Accepted: 09/13/2023] [Indexed: 10/04/2023]
Abstract
Hypogammaglobulinemia is characterized by reduced serum immunoglobulin levels. Secondary hypogammaglobulinemia is of considerable interest to the practicing physician because it is a potential complication of some medications and may predispose patients to serious infections. Patients with multiple sclerosis (MS) treated with B-cell-depleting anti-CD20 therapies are particularly at risk of developing hypogammaglobulinemia. Among these patients, hypogammaglobulinemia has been associated with an increased risk of infections. The mechanism by which hypogammaglobulinemia arises with anti-CD20 therapies (ocrelizumab, ofatumumab, ublituximab, rituximab) remains unclear and does not appear to be simply due to the reduction in circulating B-cell levels. Further, despite the association between anti-CD20 therapies, hypogammaglobulinemia, and infections, there is currently no generally accepted monitoring and treatment approach among clinicians treating patients with MS. Here, we review the literature and discuss possible mechanisms of secondary hypogammaglobulinemia in patients with MS, hypogammaglobulinemia results in MS anti-CD20 therapy clinical trials, the risk of infection for patients with hypogammaglobulinemia, and possible strategies for disease management. We also include a suggested best-practice approach to specifically address secondary hypogammaglobulinemia in patients with MS treated with anti-CD20 therapies.
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Affiliation(s)
- Enrique Alvarez
- The Rocky Mountain MS Center at the University of Colorado Anschutz Medical Campus, Academic Office 1 Building, Room 5512, 12631 East 17th Avenue, B185, Aurora, CO 80045, United States
| | - Erin E Longbrake
- Department of Neurology, Yale School of Medicine, 6 Devine Street, Suite 2B, New Haven, CT 06473, United States
| | - Kottil W Rammohan
- Multiple Sclerosis Division, University of Miami Miller School of Medicine, 1120 NW 14th street, Suite 1322, Miami, FL 33136, United States
| | - James Stankiewicz
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Carrie M Hersh
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W Bonneville Road, Las Vegas, NV 89106, United States.
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Poulsen EE, Jensen-Fangel S, Rudolf F. Severe Ureaplasma urealyticum infection in a patient with ocrelizumab-induced hypogammaglobulinaemia. BMJ Case Rep 2023; 16:e256029. [PMID: 37751973 PMCID: PMC10533684 DOI: 10.1136/bcr-2023-256029] [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] [Indexed: 09/30/2023] Open
Abstract
Infections caused by Ureaplasma urealyticum in immune-competent people are typically simple and uncomplicated. However, in cases of immunosuppression, severe disseminated infections can occur.This case report describes the case of a severe, disseminated infection caused by U. urealyticum in a young female with unacknowledged humoral immunosuppression due to treatment with ocrelizumab for multiple sclerosis.The patient was admitted due to a recurrent episode of a tubo-ovarian abscess. Throughout the following 2 months of hospitalisation, treatment with several types of antibiotics and the placement of various drains led to no improvement. As extensive investigations indicated hypogammaglobulinaemia, U. urealyticum was suspected, and tests came back positive. Treatment with doxycycline and moxifloxacin led to a full recovery.This demonstrates how humoral immunosuppression is a risk factor for severe disseminated infections and how these may be avoided through monitoring of immunoglobulin levels in patients treated with ocrelizumab.
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Affiliation(s)
| | - Søren Jensen-Fangel
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark
| | - Frauke Rudolf
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark
- Clinical institute, Aarhus University, Aarhus, Denmark
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10
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Confirmation of CD19+ B-Lymphocyte Depletion Prior to Intake of the Second Dose of Ocrelizumab in Multiple Sclerosis Patients. Biomedicines 2023; 11:biomedicines11020353. [PMID: 36830890 PMCID: PMC9953738 DOI: 10.3390/biomedicines11020353] [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: 01/05/2023] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
The aim of the retrospective study was to compare the immunophenotyping of T-lymphocytes, B-lymphocytes, and natural killer cells before the administration of the first and the second dose of ocrelizumab in 22 patients with multiple sclerosis in a three-year period (2019-2021) at the Department of Neurology of the University Hospital of Split. The values of cell immunophenotyping and protein electrophoresis, as well as laboratory parameters, were investigated. There was no significant decrease in serum albumin and globulins before the second dose of ocrelizumab (p > 0,05). A decrease in the number of T-lymphocytes before administration of the second dose of ocrelizumab was observed, but without statistical significance (p = 0.274). Significant depletion occurred in median CD19+ B-lymphocytes (p < 0.001) before the intake of the second dose of ocrelizumab confirming the primary action of ocrelizumab on the B cell lineage.
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