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Nixon M, Menger RP, Kalakoti P, Thakur JD, Dossani RH, Sharma K, Nanda A, Guthikonda B. Natalizumab-Associated Primary Central Nervous System Lymphoma. World Neurosurg 2017; 109:152-159. [PMID: 28962961 DOI: 10.1016/j.wneu.2017.09.131] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Natalizumab, a selective adhesion molecule inhibitor binding to an α-4 subunit of integrin, has emerged to be an effective immunomodulator, especially in the treatment of relapsing-remitting multiple sclerosis and Crohn disease. Recent reports documenting the development of primary central nervous system lymphoma (PCNSL) as a result of its administration have been concerning, and they trigger a debate about a possible causal association. In our report, we provide a comprehensive review of the literature on lymphoma development after natalizumab use, and we report an additional case of PCNSL development in a young woman who received natalizumab for her Crohn disease. METHODS A systematic (qualitative) review of literature on lymphoma development after natalizumab therapy was performed by use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data on patient characteristics, indication for drug therapy, dosages, radiologic findings, potential risk factors for PCNSL, and tumor markers were synthesized. Additionally, we present the findings from the case of a young woman who received natalizumab therapy (4 doses, 300 mg each) for Crohn disease and in whom PCNSL developed. RESULTS Overall, 8 reports including our index case document lymphoma development after natalizumab use. Our case finding revisits the debate suggesting a remote possibility of association that warrants further evaluation and validation. CONCLUSIONS Evidence documenting a causal association of natalizumab and PCNSL is weak. Considering the potential benefits of using natalizumab for current indications, we recommend vigilant monitoring of patients receiving the drug for PCNSL outlook.
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Affiliation(s)
- Menarvia Nixon
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Richard P Menger
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Piyush Kalakoti
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Jai Deep Thakur
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Rimal H Dossani
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Kanika Sharma
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
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Ziemssen T, Derfuss T, de Stefano N, Giovannoni G, Palavra F, Tomic D, Vollmer T, Schippling S. Optimizing treatment success in multiple sclerosis. J Neurol 2015; 263:1053-65. [PMID: 26705122 PMCID: PMC4893374 DOI: 10.1007/s00415-015-7986-y] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 11/25/2015] [Indexed: 01/01/2023]
Abstract
Despite important advances in the treatment of multiple sclerosis (MS) over recent years, the introduction of several disease-modifying therapies (DMTs), the burden of progressive disability and premature mortality associated with the condition remains substantial. This burden, together with the high healthcare and societal costs associated with MS, creates a compelling case for early treatment optimization with highly efficacious therapies. Often, patients receive several first-line therapies, while more recent and in part more effective treatments are still being introduced only after these have failed. However, with the availability of highly efficacious therapies, a novel treatment strategy has emerged, where the aim is to achieve no evidence of disease activity (NEDA). Achieving NEDA necessitates regular monitoring of relapses, disability and functionality. However, there is only a poor correlation between conventional magnetic resonance imaging measures like T2 hyperintense lesion burden and the level of clinical disability. Hence, MRI-based measures of brain atrophy have emerged in recent years potentially reflecting the magnitude of MS-related neuroaxonal damage. Currently available DMTs differ markedly in their effects on brain atrophy: some, such as fingolimod, have been shown to significantly slow brain volume loss, compared to placebo, whereas others have shown either no, inconsistent, or delayed effects. In addition to regular monitoring, treatment optimization also requires early intervention with efficacious therapies, because accumulating evidence shows that effective intervention during a limited period early in the course of MS is critical for maintaining neurological function and preventing subsequent disability. Together, the advent of new MS therapies and evolving management strategies offer exciting new opportunities to optimize treatment outcomes.
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Affiliation(s)
- Tjalf Ziemssen
- MS Center Dresden, Center of Clinical Neuroscience, Neurological Clinic, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Tobias Derfuss
- MS Center Dresden, Center of Clinical Neuroscience, Neurological Clinic, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Nicola de Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Gavin Giovannoni
- Queen Mary University London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Filipe Palavra
- Neurology-Neuroimmunology Department, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Tim Vollmer
- University of Colorado Health Sciences Center, Aurora, CO, USA
| | - Sven Schippling
- Department of Neurology, Neuroimmunology and Multiple Sclerosis Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Fernández O, García-Merino JA, Arroyo R, Álvarez-Cermeño JC, Izquierdo G, Saiz A, Olascoaga J, Rodríguez-Antigüedad A, Prieto JM, Oreja-Guevara C, Hernández MA, Moral E, Meca J, Montalbán X. Spanish consensus on the use of natalizumab (Tysabri®)-2013. Neurologia 2013; 30:302-14. [PMID: 24360652 DOI: 10.1016/j.nrl.2013.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 10/13/2013] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Natalizumab treatment has been shown to be very efficacious in clinical trials and very effective in clinical practice in patients with relapsing-remitting multiple sclerosis, by reducing relapses, slowing disease progression, and improving magnetic resonance imaging patterns. However, the drug has also been associated with a risk of progressive multifocal leukoencephalopathy (PML). The first consensus statement on natalizumab use, published in 2011, has been updated to include new data on diagnostic procedures, monitoring for patients undergoing treatment, PML management, and other topics of interest including the management of patients discontinuing natalizumab. MATERIAL AND METHODS This updated version followed the method used in the first consensus. A group of Spanish experts in multiple sclerosis (the authors of the present document) reviewed all currently available literature on natalizumab and identified the relevant topics would need updating based on their clinical experience. The initial draft passed through review cycles until the final version was completed. RESULTS AND CONCLUSIONS Studies in clinical practice have demonstrated that changing to natalizumab is more effective than switching between immunomodulators. They favour early treatment with natalizumab rather than using natalizumab in a later stage as a rescue therapy. Although the drug is very effective, its potential adverse effects need to be considered, with particular attention to the patient's likelihood of developing PML. The neurologist should carefully explain the risks and benefits of the treatment, comparing them to the risks of multiple sclerosis in terms the patient can understand. Before treatment is started, laboratory tests and magnetic resonance images should be available to permit proper follow-up. The risk of PML should be stratified as high, medium, or low according to presence or absence of anti-JC virus antibodies, history of immunosuppressive therapy, and treatment duration. Although the presence of anti-JC virus antibodies is a significant finding, it should not be considered an absolute contraindication for natalizumab. This update provides general recommendations, but neurologists must use their clinical expertise to provide personalised follow-up for each patient.
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Affiliation(s)
- O Fernández
- Instituto de Neurociencias Clínicas, Servicio de Neurología, Hospital Regional Universitario Carlos Haya, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud, Málaga, España.
| | - J A García-Merino
- Servicio de Neurología, Hospital Universitario Puerta de Hierro, Madrid, España
| | - R Arroyo
- Servicio de Neurología, Hospital Clínico Universitario San Carlos, Madrid, España
| | - J C Álvarez-Cermeño
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - G Izquierdo
- Servicio de Neurología, Hospital Universitario Virgen Macarena, Sevilla, España
| | - A Saiz
- Servicio de Neurología, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer, Barcelona, España
| | - J Olascoaga
- Servicio de Neurología, Hospital Universitario de Donostia, San Sebastián, España
| | | | - J M Prieto
- Servicio de Neurología, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela, España
| | - C Oreja-Guevara
- Servicio de Neurología, Hospital Clínico Universitario San Carlos, Madrid, España
| | - M A Hernández
- Servicio de Neurología, Hospital Universitario Ntra. Sra. de la Candelaria, Tenerife, España
| | - E Moral
- Servicio de Neurología, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, España
| | - J Meca
- Servicio de Neurología, Hospital Universitario Virgen de la Arrixaca, Murcia, España
| | - X Montalbán
- Centre d'Esclerosi Múltiple de Catalunya (CEMCAT), Hospital Universitari Vall d'Hebron, Barcelona, España
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Abstract
Natalizumab is approved for the treatment of patients with relapsing-remitting multiple sclerosis who have failed first-line treatment with traditional disease-modifying therapies or who have highly active disease. The drug has proved highly effective, both in a clinical trial setting and in clinical practice, with marked reductions in the rate of clinical relapses and slowed disease progression. These clinical outcomes are mirrored by a marked reduction in disease activity as evidenced by magnetic resonance imaging of the brain. However, natalizumab treatment has been associated with a risk of progressive multifocal leukoencephalopathy (PML), a potentially fatal condition caused by JC virus (JCV) activation. When this condition was detected in a clinical trial shortly after approval, the drug was immediately and voluntarily withdrawn from the market. As a condition of its reinstatement, stringent pharmacovigilance measures and a risk management plan were enforced. The recent availability of a two-step enzyme-linked immunosorbent assay (ELISA) test for the presence of anti-JCV antibodies (free testing is available in a central laboratory for registered centers), along with an ever-improving understanding of other risk factors such as prior immunosuppressant use and duration of treatment, allow an increasingly refined stratification of the risk of PML. This improved stratification of risk can help guide decisions about treatment. This review will also deal with other topics of relevance to clinical practice such as the development of antinatalizumab antibodies and their negative implications in terms of hypersensitivity reactions and loss of efficacy, withdrawal of treatment, and compassionate pediatric use.
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Affiliation(s)
- Oscar Fernández
- Instituto de Neurociencias Clínicas, Servicio de Neurologia, Hospital Regional Universitario Carlos Haya, Avenida Carlos Haya s/n, 29010 Málaga, Spain
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Mecha M, Carrillo-Salinas FJ, Mestre L, Feliú A, Guaza C. Viral models of multiple sclerosis: neurodegeneration and demyelination in mice infected with Theiler's virus. Prog Neurobiol 2013; 101-102:46-64. [PMID: 23201558 PMCID: PMC7117056 DOI: 10.1016/j.pneurobio.2012.11.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 10/30/2012] [Accepted: 11/12/2012] [Indexed: 11/02/2022]
Abstract
Multiple sclerosis (MS) is a complex inflammatory disease of unknown etiology that affects the central nervous system (CNS) white matter, and for which no effective cure exists. Indeed, whether the primary event in MS pathology affects myelin or axons of the CNS remains unclear. Animal models are necessary to identify the immunopathological mechanisms involved in MS and to develop novel therapeutic and reparative approaches. Specifically, viral models of chronic demyelination and axonal damage have been used to study the contribution of viruses in human MS, and they have led to important breakthroughs in our understanding of MS pathology. The Theiler's murine encephalomyelitis virus (TMEV) model is one of the most commonly used MS models, although other viral models are also used, including neurotropic strains of mouse hepatitis virus (MHV) that induce chronic inflammatory demyelination with similar histological features to those observed in MS. This review will discuss the immunopathological mechanisms involved in TMEV-induced demyelinating disease (TMEV-IDD). The TMEV model reproduces a chronic progressive disease due to the persistence of the virus for the entire lifespan in susceptible mice. The evolution and significance of the axonal damage and neuroinflammation, the importance of epitope spread from viral to myelin epitopes, the presence of abortive remyelination and the existence of a brain pathology in addition to the classical spinal cord demyelination, are some of the findings that will be discussed in the context of this TMEV-IDD model. Despite their limitations, viral models remain an important tool to study the etiology of MS, and to understand the clinical and pathological variability associated with this disease.
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Key Words
- ab, antibody
- ag, antigen
- apc, antigen presenting cell
- bbb, blood–brain barrier
- cns, central nervous system
- cox-2, cyclooxygenase-2
- ctl, cytotoxic t lymphocytes
- dpi, days post-infection
- da, daniels strain of theiler's virus
- eae, experimental autoimmune encephalomyelitis
- galc, galactocerebroside
- mbp, myelin basic protein
- mnc, mononuclear cells
- mhc, major histocompatibility complex
- mhv, mouse hepatitis virus
- mog, myelin oligodendrocyte glycoprotein
- ms, multiple sclerosis
- naa, n-acetylaspartate
- no, nitric oxide
- pcr, polymerase chain reaction
- plp, myelin proteolipid protein
- pprs, pattern recognition receptors
- sfv, semliki forest virus
- sv, sindbis virus
- tmev, theiler's murine encephalomyelitis virus
- tmev-idd, theiler's murine encephalomyelitis virus-induced demyelinating disease
- tregs, regulatory t cells
- theiler's virus
- multiple sclerosis
- demyelination
- axonal damage
- neuroinflammation
- spinal cord pathology
- brain pathology
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Affiliation(s)
| | | | | | | | - Carmen Guaza
- Neuroimmunology Group, Functional and System Neurobiology Department, Instituto Cajal, Consejo Superior de Investigaciones Científicas, Avda Dr Arce 37, 28002 Madrid, Spain
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Arnal-Garcia C, García-Montero MR, Málaga I, Millán-Pascual J, Oliva-Nacarino P, Ramió-Torrentà L, Oreja-Guevara C. Natalizumab use in pediatric patients with relapsing-remitting multiple sclerosis. Eur J Paediatr Neurol 2013; 17:50-4. [PMID: 23021975 DOI: 10.1016/j.ejpn.2012.09.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 08/01/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Not all pediatric patients with relapsing-remitting multiple sclerosis (MS) may respond to traditional disease-modifying therapies. Natalizumab has been shown to be effective but is currently only approved in adults. OBJECTIVE To analyze the safety and efficacy of natalizumab in patients under 18 years of age diagnosed with MS. METHOD Data for pediatric patients with MS treated with natalizumab in a compassionate use setting were retrospectively collected and analyzed. RESULTS Valid data were obtained for nine patients under 18 years from seven different centers (mean age, 15 years 4 months [range 9.8-17.7]; 5 were boys). Patients received a median of 17 infusions of natalizumab (range, 2-31) and eight received at least 12 infusions. For these 8 patients, the median score on the Expanded Disability Status Scale decreased from 3.0 to 1.0 and the median annualized relapse rate decreased from 3.0 to 0. After 12 months, no patients reported gadolinium-enhancing lesions compared to seven at baseline. Four post-baseline adverse events occurred and one patient discontinued due to hypersensitivity reaction. CONCLUSION Natalizumab is a highly effective treatment as a second-line option in pediatric patients. In as far as the limited numbers allowed comparisons, the safety and efficacy of natalizumab in children was in line with the experience published in adult populations.
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