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Nasr Z, Casper TC, Waltz M, Virupakshaiah A, Lotze T, Shukla N, Chitnis T, Gorman M, Benson LA, Rodriguez M, Tillema JM, Krupp L, Schreiner T, Mar S, Rensel M, Rose J, Liu C, Guye S, Manlius C, Waubant E. Clinical and magnetic resonance imaging outcomes in pediatric-onset MS patients on fingolimod and ocrelizumab. Mult Scler Relat Disord 2024; 87:105647. [PMID: 38838422 DOI: 10.1016/j.msard.2024.105647] [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: 07/20/2023] [Revised: 03/25/2024] [Accepted: 04/25/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Observational studies looking at clinical a++nd MRI outcomes of treatments in pediatric MS, could assess current treatment algorithms, and provide insights for designing future clinical trials. OBJECTIVE To describe baseline characteristics and clinical and MRI outcomes in MS patients initiating ocrelizumab and fingolimod under 18 years of age. METHODS MS patients seen at 12 centers of US Network of Pediatric MS were included in this study if they had clinical and MRI follow-up and started treatment with either ocrelizumab or fingolimod prior to the age of 18. RESULTS Eighty-seven patients initiating fingolimod and 52 initiating ocrelizumab met the inclusion criteria. Before starting fingolimod, mean annualized relapse rate was 0.43 (95 % CI: 0.29 - 0.65) and 78 % developed new T2 lesions while during treatment it was 0.12 (95 % CI: 0.08 - 1.9) and 47 % developed new T2 lesions. In the ocrelizumab group, the mean annualized relapse rate prior to initiation of treatment was 0.64 (95 % CI: 0.38-1.09) and a total of 83 % of patients developed new T2 lesions while during treatment it was 0.09 (95 % CI: 0.04-0.21) and none developed new T2 lesions. CONCLUSION This study highlights the importance of evaluating current treatment methods and provides insights about the agents in the ongoing phase III trial comparing fingolimod and ocrelizumab.
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Affiliation(s)
- Zahra Nasr
- UCSF, Weill Institute for Neurosciences, San Francisco, United States.
| | - T Charles Casper
- University of Utah, Department of Pediatrics, Salt Lake City, United States
| | - Michael Waltz
- University of Utah, Department of Pediatrics, Salt Lake City, United States
| | | | - Tim Lotze
- Baylor College of Medicine/Texas Children's Hospital, Neurology and Developmental Neuroscience, Houston, United States
| | - Nikita Shukla
- Baylor College of Medicine/Texas Children's Hospital, Neurology and Developmental Neuroscience, Houston, United States
| | - Tanuja Chitnis
- Massachusetts General Hospital for Children, Mass General Brigham Pediatric MS Center, Boston, United States
| | - Mark Gorman
- Boston Children's Hospital, Pediatric Multiple Sclerosis and Related Disorders Program, Boston, United States
| | - Leslie A Benson
- Boston Children's Hospital, Pediatric Multiple Sclerosis and Related Disorders Program, Boston, United States
| | | | - Jan M Tillema
- Mayo Clinic, Pediatric MS Center, Rochester, United States
| | - Lauren Krupp
- New York University Langone Medical Center, Pediatric Multiple Sclerosis Center, New York, United States
| | - Teri Schreiner
- University of Colorado, Rocky Mountain MS Center, Aurora, United States
| | - Soe Mar
- Washington University, Pediatric MS and other Demyelinating Disease Center, St. Louis, United States
| | - Mary Rensel
- Cleveland Clinic, Mellen Center for Multiple Sclerosis, Cleveland, United States
| | - John Rose
- University of Utah, Department of Neurology, Salt Lake City, United States
| | - Chuang Liu
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
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2
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Breu M, Sandesjö F, Milos RI, Svoboda J, Salzer J, Schneider L, Reichelt JB, Bertolini A, Blaschek A, Fink K, Höftberger R, Lycke J, Rostásy K, Seidl R, Siegert S, Wickström R, Kornek B. Rituximab treatment in pediatric-onset multiple sclerosis. Eur J Neurol 2024; 31:e16228. [PMID: 38375947 DOI: 10.1111/ene.16228] [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: 09/08/2023] [Revised: 12/05/2023] [Accepted: 01/15/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND PURPOSE Rituximab (RTX) is frequently used off-label in multiple sclerosis. However, studies on the risk-benefit profile of RTX in pediatric-onset multiple sclerosis are scarce. METHODS In this multicenter retrospective cohort study, patients with pediatric-onset multiple sclerosis from Sweden, Austria and Germany, who received RTX treatment were identified by chart review. Annualized relapse rates, Expanded Disability Status Scale scores and magnetic resonance imaging parameters (new T2 lesions and contrast-enhancing lesions) were assessed before and during RTX treatment. The proportion of patients who remained free from clinical and disease activity (NEDA-3) during RTX treatment was calculated. Side effects such as infusion-related reactions, infections and laboratory abnormalities were assessed. RESULTS Sixty-one patients received RTX during a median (interquartile range) follow-up period of 20.9 (35.6) months. The annualized relapse rate decreased from 0.6 (95% confidence interval [CI] 0.38-0.92) to 0.03 (95% CI 0.02-0.14). The annual rate of new T2 lesions decreased from 1.25 (95% CI 0.70-2.48) to 0.08 (95% CI 0.03-0.25) and annual rates of new contrast-enhancing lesions decreased from 0.86 (95% CI 0.30-3.96) to 0. Overall, 70% of patients displayed no evidence of disease activity (NEDA-3). Adverse events were observed in 67% of patients. Six patients discontinued treatment due to ongoing disease activity or adverse events. CONCLUSION Our study provides class IV evidence that RTX reduces clinical and radiological activity in pediatric-onset multiple sclerosis.
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Affiliation(s)
- Markus Breu
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Fredrik Sandesjö
- Neuropediatric Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ruxandra-Iulia Milos
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Jan Svoboda
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jonatan Salzer
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Lisa Schneider
- Division of Infectious Diseases, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Julian Benedikt Reichelt
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Annikki Bertolini
- Department of Pediatric Neurology, University Witten/Herdecke, Children's Hospital Datteln, Datteln, Germany
| | - Astrid Blaschek
- Paediatric Neurology and Developmental Medicine, Ludwig Maximilian University of Munich, Dr. von Hauner Children's Hospital, Munich, Germany
| | - Katharina Fink
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kevin Rostásy
- Department of Pediatric Neurology, University Witten/Herdecke, Children's Hospital Datteln, Datteln, Germany
| | - Rainer Seidl
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Sandy Siegert
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ronny Wickström
- Neuropediatric Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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3
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Kornbluh AB, Kahn I. Pediatric Multiple Sclerosis. Semin Pediatr Neurol 2023; 46:101054. [PMID: 37451754 DOI: 10.1016/j.spen.2023.101054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/07/2023] [Accepted: 05/07/2023] [Indexed: 07/18/2023]
Abstract
The current diagnostic criteria for pediatric onset multiple sclerosis (POMS) are summarized, as well as the evidence for performance of the most recent iteration of McDonald criteria in the pediatric population. Next, the varied roles of MRI in POMS are reviewed, including diagnostic considerations and research-based utilization. The primary role of bloodwork and cerebrospinal fluid studies in the diagnosis of POMS is to rule out disease mimics. Prognostically, POMS portends a more inflammatory course with higher relapse rate and disability reached at younger ages compared with AOMS counterparts. As such, there is an emerging trend toward the earlier use of highly efficacious disease modifying therapies to target prompt immunomodulatory disease control. Current POMS disease modifying therapies (DMTs) and active clinical POMS trials are detailed.
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Affiliation(s)
- Alexandra B Kornbluh
- Children's National Hospital, Washington, DC; George Washington School of Medicine and Health Sciences, Washington, DC
| | - Ilana Kahn
- Children's National Hospital, Washington, DC; George Washington School of Medicine and Health Sciences, Washington, DC.
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4
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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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Abstract
PURPOSE OF REVIEW This article reviews the clinical presentation, diagnostic evaluation, treatment, and prognosis of the most common monophasic and relapsing acquired demyelinating disorders presenting in childhood. RECENT FINDINGS Our understanding of neuroimmune disorders of the central nervous system is rapidly expanding. Several clinical and paraclinical factors help to inform the diagnosis and ultimately the suspicion for a monophasic versus relapsing course, including the age of the patient (prepubertal versus postpubertal), presence or absence of clinical encephalopathy, identification of serum autoantibodies (eg, myelin oligodendrocyte glycoprotein [MOG] and aquaporin-4), presence of intrathecally unique oligoclonal bands, and location/extent of radiologic abnormalities. Collaborative international research efforts have facilitated understanding of the safety and efficacy of currently available immunotherapies in children with acquired demyelinating disorders, particularly multiple sclerosis. SUMMARY Although many of the demyelinating disorders presented in this article can affect children and adults across the age spectrum, the clinical and radiologic phenotypes, treatment considerations, and long-term prognoses are often distinct in children.
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6
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Comi G, Bar-Or A, Lassmann H, Uccelli A, Hartung HP, Montalban X, Sørensen PS, Hohlfeld R, Hauser SL. Role of B Cells in Multiple Sclerosis and Related Disorders. Ann Neurol 2020; 89:13-23. [PMID: 33091175 DOI: 10.1002/ana.25927] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/05/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022]
Abstract
The success of clinical trials of selective B-cell depletion in patients with relapsing multiple sclerosis (MS) and primary progressive MS has led to a conceptual shift in the understanding of MS pathogenesis, away from the classical model in which T cells were the sole central actors and toward a more complex paradigm with B cells having an essential role in both the inflammatory and neurodegenerative components of the disease process. The role of B cells in MS was selected as the topic of the 27th Annual Meeting of the European Charcot Foundation. Results of the meeting are presented in this concise review, which recaps current concepts underlying the biology and therapeutic rationale behind B-cell-directed therapeutics in MS, and proposes strategies to optimize the use of existing anti-B-cell treatments and provide future directions for research in this area. ANN NEUROL 2021;89:13-23.
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Affiliation(s)
- Giancarlo Comi
- Institute of Experimental Neurology, San Raffaele Hospital, Milan, Italy
| | - Amit Bar-Or
- Department of Neurology, Center for Neuroinflammation and Neurotherapeutics, University of Pennsylvania, Philadelphia, PA
| | - Hans Lassmann
- Department of Neuroimmunology (Center for Brain Research), University Hospital Vienna, Vienna, Austria
| | - Antonio Uccelli
- Department of Neuroscience, Genetic Ophthalmology, and Infant Maternity Science, San Martino Polyclinic Hospital, Genoa, Italy
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Xavier Montalban
- Neurology-Neuroimmunology Department and Neurorehabilitation Unit, Multiple Sclerosis Center of Catalonia, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Per Solberg Sørensen
- Department of Neurology, Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Ludwig Maximilians University of Munich and Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Stephen L Hauser
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
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7
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Xue T, Yang Y, Lu Q, Gao B, Chen Z, Wang Z. Efficacy and Safety of Monoclonal Antibody Therapy in Neuromyelitis Optica Spectrum Disorders: Evidence from Randomized Controlled Trials. Mult Scler Relat Disord 2020; 43:102166. [DOI: 10.1016/j.msard.2020.102166] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/10/2020] [Accepted: 04/27/2020] [Indexed: 12/13/2022]
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8
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Ghezzi A, Banwell B, Bar-Or A, Chitnis T, Dale RC, Gorman M, Kornek B, Krupp L, Krysko KM, Nosadini M, Rostasy K, Salzer J, Schreiner T, Tenembaum S, Waubant E. Rituximab in patients with pediatric multiple sclerosis and other demyelinating disorders of the CNS: Practical considerations. Mult Scler 2020; 27:1814-1822. [PMID: 32552353 DOI: 10.1177/1352458520932798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Anti-CD20 therapies have established efficacy in the treatment of immune-mediated neurological and non-neurological diseases. Rituximab, one of the first B-cell-directed therapies, is relatively inexpensive compared to newer anti-CD20 molecules, is available in many countries, and has been used off-label in pediatric patients with neuroimmune conditions. The objective of this paper is to describe the experience with rituximab in pediatric multiple sclerosis and other inflammatory immune-mediated disorders of the central nervous system (CNS), and to define a protocol for its use in clinical practice, in particular addressing doses, interval of administration, duration of treatment, and tests to perform at baseline and during follow-up.
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Affiliation(s)
- Angelo Ghezzi
- Centro Studi Sclerosi Multipla, Ospedale di Gallarate, ASST Valleolona, Gallarate, Italy
| | - Brenda Banwell
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Bar-Or
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA/Center for Neuroinflammation and Experimental Therapeutics and the Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tanuja Chitnis
- Partners Pediatric MS Center, Massachusetts General Hospital, Boston, MA, USA
| | - Russell C Dale
- Kids Neuroscience Centre and Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Mark Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Lauren Krupp
- Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Margherita Nosadini
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Kevin Rostasy
- Department of Pediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Witten, Germany
| | - Jonatan Salzer
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Teri Schreiner
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Silvia Tenembaum
- Pediatric Neuroimmunology Program, Department of Neurology, National Pediatric Hospital Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Emmanuelle Waubant
- UCSF Pediatric MS Clinic and UCSF Adult MS Clinic, Department of Neurology, University of California at San Francisco, San Francisco CA, USA
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Arrambide G, Iacobaeus E, Amato MP, Derfuss T, Vukusic S, Hemmer B, Brundin L, Tintore M. Aggressive multiple sclerosis (2): Treatment. Mult Scler 2020; 26:1352458520924595. [PMID: 32530366 PMCID: PMC7412878 DOI: 10.1177/1352458520924595] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/18/2020] [Accepted: 04/16/2020] [Indexed: 01/04/2023]
Abstract
The natural history of multiple sclerosis (MS) is highly heterogeneous. A subgroup of patients has what might be termed aggressive MS. These patients may have frequent, severe relapses with incomplete recovery and are at risk of developing greater and permanent disability at the earlier stages of the disease. Their therapeutic window of opportunity may be narrow, and while it is generally considered that they will benefit from starting early with a highly efficacious treatment, a unified definition of aggressive MS does not exist and data on its treatment are largely lacking. Based on discussions at an international focused workshop sponsored by the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS), we review our current knowledge about treatment of individuals with aggressive MS. We analyse the available evidence, identify gaps in knowledge and suggest future research needed to fill those gaps. A companion paper details the difficulties in developing a consensus about what defines aggressive MS.
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Affiliation(s)
- Georgina Arrambide
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Vall d’Hebron Institut de Recerca, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ellen Iacobaeus
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Tobias Derfuss
- Departments of Neurology and Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sandra Vukusic
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France/Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR5292, Lyon, France/Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany/Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Lou Brundin
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Mar Tintore
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Vall d’Hebron Institut de Recerca, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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10
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Krysko KM, Graves JS, Rensel M, Weinstock-Guttman B, Rutatangwa A, Aaen G, Belman A, Benson L, Chitnis T, Gorman M, Goyal MS, Harris Y, Krupp L, Lotze T, Mar S, Moodley M, Ness J, Rodriguez M, Rose J, Schreiner T, Tillema JM, Waltz M, Casper TC, Waubant E. Real-World Effectiveness of Initial Disease-Modifying Therapies in Pediatric Multiple Sclerosis. Ann Neurol 2020; 88:42-55. [PMID: 32267005 DOI: 10.1002/ana.25737] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To assess real-world effectiveness of initial treatment with newer compared to injectable disease-modifying therapies (DMTs) on disease activity in pediatric multiple sclerosis (MS) and clinically isolated syndrome (CIS). METHODS This is a cohort study of children with MS/CIS followed at 12 clinics in the US Network of Pediatric MS Centers, who received initial therapy with newer (fingolimod, dimethyl fumarate, teriflunomide, natalizumab, rituximab, ocrelizumab) or injectable (interferon-β, glatiramer acetate) DMTs. Propensity scores (PSs) were computed, including preidentified confounders. Relapse rate while on initial DMT was modeled with negative binomial regression, adjusted for PS-quintile. Time to new/enlarging T2-hyperintense and gadolinium-enhancing lesions on brain magnetic resonance imaging were modeled with midpoint survival analyses, adjusted for PS-quintile. RESULTS A total of 741 children began therapy before 18 years, 197 with newer and 544 with injectable DMTs. Those started on newer DMTs were older (15.2 vs injectable 14.4 years, p = 0.001) and less likely to have a monofocal presentation. In PS-quintile-adjusted analysis, those on newer DMTs had a lower relapse rate than those on injectables (rate ratio = 0.45, 95% confidence interval (CI) = 0.29-0.70, p < 0.001; rate difference = 0.27, 95% CI = 0.14-0.40, p = 0.004). One would need to treat with newer rather than injectable DMTs for 3.7 person-years to prevent 1 relapse. Those started on newer DMTs had a lower rate of new/enlarging T2 (hazard ratio [HR] = 0.51, 95% CI = 0.36-0.72, p < 0.001) and gadolinium-enhancing lesions (HR = 0.38, 95% CI = 0.23-0.63, p < 0.001) than those on injectables. INTERPRETATION Initial treatment of pediatric MS/CIS with newer DMTs led to better disease activity control compared to injectables, supporting greater effectiveness of newer therapies. Long-term safety data for newer DMTs are required. ANN NEUROL 2020 ANN NEUROL 2020;88:42-55.
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Affiliation(s)
- Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Jennifer S Graves
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA.,Department of Neurology, University of California, San Diego, La Jolla, CA
| | - Mary Rensel
- Department of Neurology, Cleveland Clinic, Cleveland, OH
| | | | - Alice Rutatangwa
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Gregory Aaen
- Department of Pediatrics, Loma Linda University, San Bernardino, CA
| | - Anita Belman
- Department of Neurology, New York University Langone Medical Center, New York, NY
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Tanuja Chitnis
- Department of Pediatric Neurology, Massachusetts General Hospital, Boston, MA
| | - Mark Gorman
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Manu S Goyal
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, St Louis, MO
| | - Yolanda Harris
- Department of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Lauren Krupp
- Department of Neurology, New York University Langone Medical Center, New York, NY
| | - Timothy Lotze
- Department of Neurology, Texas Children's Hospital, Houston, TX
| | - Soe Mar
- Department of Neurology, Washington University in Saint Louis, St Louis, MO
| | - Manikum Moodley
- Department of Pediatrics and Neurology, Dell Children's Hospital, University of Texas, Austin, TX
| | - Jayne Ness
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | | | - John Rose
- Department of Neurology, University of Utah, Salt Lake City, UT
| | - Teri Schreiner
- Departments of Neurology and Pediatrics, University of Colorado, Aurora, CO
| | | | - Michael Waltz
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Emmanuelle Waubant
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
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11
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Current Advances in Pediatric Onset Multiple Sclerosis. Biomedicines 2020; 8:biomedicines8040071. [PMID: 32231060 PMCID: PMC7235875 DOI: 10.3390/biomedicines8040071] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 01/01/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune inflammatory disease affecting the central nervous system leading to demyelination. MS in the pediatric population is rare, but has been shown to lead to significant disability over the duration of the disease. As we have learned more about pediatric MS, there has been a development of improved diagnostic criteria leading to earlier diagnosis, earlier initiation of disease-modifying therapies (DMT), and an increasing number of DMT used in the treatment of pediatric MS. Over time, treatment with DMT has trended towards the initiation of higher efficacy treatment at time of diagnosis to help prevent further disease progression and accrual of disability over time, and there is evidence in current literature that supports this change in treatment patterns. In this review, we discuss the current knowledge in diagnosis, treatment, and clinical outcomes in pediatric MS.
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Ko YJ, Shim YK, Kim WJ, Kim SY, Kim H, Hwang H, Chae JH, Choi JE, Kim KJ, Lim BC. The Efficacy and Safety of Rituximab for the Treatment of Pediatric Autoimmune Neuroinflammatory Disorders at a Single Center. ANNALS OF CHILD NEUROLOGY 2020. [DOI: 10.26815/acn.2019.00290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Abstract
In this chapter, we will review monophasic and recurrent demyelinating disorders in children. We will first review consensus definitions and provide an approach to the evaluation of children with first episode of acquired demyelinating disorder. We will discuss typical clinical and radiological features of these syndromes. In the second section, we will review features of recurrent demyelinating syndromes in children, focusing on clinical presentation and treatment options.
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Affiliation(s)
- Mustafa A.M. Salih
- College of Medicine Division of Pediatric Neurology, King Saud University, Riyadh, Saudi Arabia
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14
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Abstract
PURPOSE OF REVIEW To summarize recent developments in the classification, investigation and management of pediatric optic neuritis (PON). RECENT FINDINGS A recent surge in interest surrounding antibodies to myelin oligodendrocyte glycoprotein antibody (MOG-Ab) has instigated a paradigm shift in our assessment of children with PON. This serological marker is associated with a broad spectrum of demyelinating syndromes that are clinically and radiologically distinct from multiple sclerosis (MS) and aquaporin-4 antibody positive neuromyelitis optica spectrum disorder (AQP4+NMOSD). Optic neuritis is the most common presenting phenotype of MOG-Ab positive-associated disease (MOG+AD). MOG-Ab seropositivity is much more common in the pediatric population and it predicts a better prognosis than MS or AQP4+NMOSD, except in the subset that exhibit a recurrent phenotype. SUMMARY A better grasp of MOG+AD features and its natural history has facilitated more accurate risk stratification of children after a presenting episode of PON. Consequently, the initial investigation of PON has broadened to include serology, along with neuroimaging and cerebrospinal fluid analysis. Acute treatment of PON and chronic immunotherapy is also becoming better tailored to the suspected or confirmed diagnoses of MS, AQP4+NMOSD and MOG+AD.
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Affiliation(s)
- Jane H. Lock
- Departments of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Nancy J. Newman
- Departments of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, United States
- Departments of Ophthalmology, Neurology, Emory University School of Medicine, Atlanta, Georgia, United States
- Departments of Ophthalmology, Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Valérie Biousse
- Departments of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, United States
- Departments of Ophthalmology, Neurology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Jason H. Peragallo
- Departments of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, United States
- Departments of Ophthalmology, Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
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Abstract
PURPOSE OF REVIEW With the recognition that pediatric-onset multiple sclerosis (POMS) is characterized by more prominent disease activity, earlier age at onset of disability milestones, and more prominent cognitive impairment compared with physical disability earlier in the disease course compared with adult-onset multiple sclerosis (AOMS), there has been increasing interest in identifying optimal and safe treatment approaches to achieve better disease control in this group. Injectable therapies have been traditionally used as first line in this population, although not formally approved. This review focuses on current treatment and monitoring approaches in POMS. RECENT FINDINGS In the past few years, and despite the paucity of FDA-approved medications for use in POMS, an increasing trend toward using newer disease-modifying therapies (DMTs) in this group is observed. However, escalation (as opposed to induction) remains the most frequent approach, and many children continue to be untreated before age 18, particularly before age 12. The only FDA- and EMA-approved disease-modifying therapy in POMS is fingolimod; however, dimethyl fumarate, teriflunomide, natalizumab, ocrelizumab, and alemtuzumab either have been evaluated in observational studies or are being currently investigated in formal randomized controlled trials for use in POMS and appear to be safe in this group. Autologous hematopoietic stem cell transplantation has also been evaluated in a small series. Clinical outcome measures and MS biomarkers have been poorly studied in POMS; however, the use of composite functional scores, neurofilament light chain, optical coherence tomography, and imaging findings is being increasingly investigated to improve early diagnosis and efficient monitoring of POMS. Off-label use of newer DMTs in POMS is increasing, and based on retrospective data, and phase 2 trials, this approach appears to be safe in children. Results from ongoing trials will help clarify the safety and efficacy of these therapies in the future. Fingolimod is the only FDA-approved medication for use in POMS. Outcome measures and biomarkers used in AOMS are being studied in POMS and are greatly needed to quantify treatment response in this group.
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Krupp LB, Vieira MC, Toledano H, Peneva D, Druyts E, Wu P, Boulos FC. A Review of Available Treatments, Clinical Evidence, and Guidelines for Diagnosis and Treatment of Pediatric Multiple Sclerosis in the United States. J Child Neurol 2019; 34:612-620. [PMID: 31234708 DOI: 10.1177/0883073819855592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pediatric multiple sclerosis is associated with challenges in prompt diagnosis and uncertainty regarding optimal treatment. This review aimed to identify treatment guidelines or consensus statements for pediatric patients with multiple sclerosis, US Food and Drug Administration (FDA)-approved treatment options for pediatric multiple sclerosis, and any randomized controlled trials and observational studies examining available pharmacologic treatments in the pediatric multiple sclerosis population. Literature searches were performed in MEDLINE (1946-2016), EMBASE (1974-2016), and the Cochrane Central Register of Controlled Trials to identify treatment guidelines or consensus statements, pediatric multiple sclerosis treatment approvals, and randomized controlled trials and observation studies that examine the safety and effectiveness of available disease-modifying therapies. Only 3 consensus statements provided recommendations for pharmacologic treatments for children, all 3 published before the most recent revisions of the pediatric multiple sclerosis diagnostic guidelines. Despite the changes to the clinical landscape of pediatric multiple sclerosis with the introduction of diagnostic guidelines, fingolimod is the only FDA-approved treatment for pediatric multiple sclerosis in the United States. The effectiveness and safety of other disease-modifying therapies suggested by consensus statements have been reported in relatively small prospective and retrospective observational studies. Clinical evidence from a recently completed randomized controlled trial and future global registries can inform treatment decisions for the pediatric multiple sclerosis population.
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Affiliation(s)
| | | | - Haley Toledano
- 2 Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Desi Peneva
- 3 Precision Health Economics, Los Angeles, CA, USA
| | | | - Ping Wu
- 4 Precision Xtract, Vancouver, BC, USA
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Rituximab as Rescue Therapy for Aggressive Pediatric Multiple Sclerosis. Case Rep Pediatr 2019; 2019:8731613. [PMID: 31428499 PMCID: PMC6679848 DOI: 10.1155/2019/8731613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 07/07/2019] [Indexed: 02/08/2023] Open
Abstract
Multiple sclerosis is a chronic, debilitating disease. Almost one in ten patients with MS has a history of disease onset during childhood. Although numerous therapeutic options exist for adult MS, the available treatments for pediatric patients are still limited. One of the emerging therapies is rituximab, a monoclonal anti-CD20 chimeric antibody that can deplete the CD20+ lymphocyte populations. A 12-year-old boy presented with ataxia, paresthesias, and headache while his brain MRI showed numerous T2 contrast-enhancing lesions. Gamma globulin, steroids, and cyclophosphamide failed to intercept his disease, and he progressed to a rapid clinical and radiological deterioration. Treatment with rituximab reversed the disease course in a dramatic fashion, leading to complete remission.
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18
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Abstract
Pediatric-onset multiple sclerosis (MS) comprises 2-5% of MS cases, and is known to be associated with high disease activity and the accumulation of disability at an earlier age than their adult-onset counterparts. Appropriate therapy leading to disease control has the potential to alter the known trajectory of adverse long-term physical, cognitive, and psychosocial outcomes in this population. Thus, optimizing treatment for children and adolescents with MS is of paramount importance. The last decade has seen a growing number of disease-modifying therapies approved for relapsing MS in adults, and available agents now include oral, injectable, and infusion therapies. Recently, the development of randomized controlled MS trials in youth has led to the first agent approved by the US FDA for the treatment of pediatric MS-fingolimod. With this, we have entered a new era of knowledge and treatment in this population and ongoing pediatric trials are expected to further inform clinical management. With the emergence of highly effective therapies targeting the inflammatory component of the disease, there has been increased interest in identifying treatment strategies that instead target mechanisms such as remyelination/repair, neuroprotection, or rehabilitation. The potential role for such emerging therapies in the treatment of pediatric MS remains an important area of study. In this review, we discuss current evidence for MS therapies in children including the treatment of acute relapses, disease-modifying therapies, and symptomatic management. We will also discuss evidence for emerging therapies, including remyelinating and neuroprotective agents.
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Affiliation(s)
- Colin Wilbur
- Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Division of Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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20
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Efficacy and safety of rituximab for relapsing-remitting multiple sclerosis: A systematic review and meta-analysis. Autoimmun Rev 2019; 18:542-548. [PMID: 30844555 DOI: 10.1016/j.autrev.2019.03.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 12/29/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of rituximab for relapsing-remitting multiple sclerosis. RESULTS Fifteen studies that collectively included 946 patients were selected for the meta-analysis. Rituximab therapy was associated with the mean annualized relapse rates decreasing by 0.80 (95% confidence interval, 0.45-1.15) and the mean Expanded Disability Status Scale score decreasing by 0.46 (95% confidence interval, 0.05-0.87). The likelihood of patients experiencing a relapse after starting rituximab therapy was only 15% (95% confidence interval, 7%-26%). Although mild-to-moderate adverse events occurred in 29.6% of the patients, there were no severe adverse events. CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis shows that rituximab is associated with reduced annualized relapse rates and disability levels in patients with relapsing-remitting multiple sclerosis. It is also well tolerated and is not associated with serious adverse events.
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21
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Krysko KM, Graves J, Rensel M, Weinstock-Guttman B, Aaen G, Benson L, Chitnis T, Gorman M, Goyal M, Krupp L, Lotze T, Mar S, Rodriguez M, Rose J, Waltz M, Charles Casper T, Waubant E. Use of newer disease-modifying therapies in pediatric multiple sclerosis in the US. Neurology 2018; 91:e1778-e1787. [PMID: 30333163 PMCID: PMC6251604 DOI: 10.1212/wnl.0000000000006471] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/25/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To characterize the use and safety of newer disease-modifying therapies (DMTs) in children with multiple sclerosis (MS) and clinically isolated syndrome (CIS) treated under 18 years of age. METHODS This is a cohort study including children with MS or CIS followed at 12 outpatient practices participating in the US Network of Pediatric MS Centers. DMT use, including duration, dose, and side effects, was analyzed. Newer DMTs were defined as agents receiving Food and Drug Administration approval or with increased use in adult MS after 2005. RESULTS As of July 2017, 1,019 pediatric patients with MS (n = 748) or CIS (n = 271) were enrolled (65% female, mean onset 13.0 ± 3.9 years, mean follow-up 3.5 ± 3.1 years, median 1.6 visits per year). Of these, 78% (n = 587) with MS and 11% (n = 31) with CIS received DMT before 18 years of age. This consisted of at least one newer DMT in 42%, including dimethyl fumarate (n = 102), natalizumab (n = 101), rituximab (n = 57), fingolimod (n = 37), daclizumab (n = 5), and teriflunomide (n = 3). Among 17%, the initial DMT prescribed was a newer agent (36 dimethyl fumarate, 30 natalizumab, 22 rituximab, 14 fingolimod, 2 teriflunomide). Over the last 10 years, the use of newer agents has increased, particularly in those ≥12 years and to lesser extent in those <12 years. The short-term side effect profiles of newer DMTs did not differ from those reported in adults. CONCLUSION Newer DMTs are often used in pediatric MS, and have similar short-term safety, tolerability, and side effect profiles as in adults. These findings may help inform pediatric MS management.
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Affiliation(s)
- Kristen M Krysko
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City.
| | - Jennifer Graves
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Mary Rensel
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Bianca Weinstock-Guttman
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Gregory Aaen
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Leslie Benson
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Tanuja Chitnis
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Mark Gorman
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Manu Goyal
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Lauren Krupp
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Timothy Lotze
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Soe Mar
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Moses Rodriguez
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - John Rose
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Michael Waltz
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - T Charles Casper
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Emmanuelle Waubant
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
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22
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Wang CX, Greenberg BM. Pediatric Multiple Sclerosis: From Recognition to Practical Clinical Management. Neurol Clin 2018; 36:135-149. [PMID: 29157395 DOI: 10.1016/j.ncl.2017.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pediatric-onset multiple sclerosis (MS) is a rare but increasingly recognized condition that both parallels and diverges from adult-onset MS. Exposure to key risk determinants for MS disease pathogenesis may occur during childhood. The diagnosis of pediatric MS can be challenging due to potential for atypical presentations and a broad differential diagnosis. MS disease-modifying therapies have not been rigorously studied in children and raise difficult questions on how to manage a chronic inflammatory neurologic disease in a population of patients with developing central nervous and immune systems.
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Affiliation(s)
- Cynthia X Wang
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8806, USA
| | - Benjamin M Greenberg
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8806, USA.
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Abstract
Pediatric-onset multiple sclerosis (POMS), once thought to be rare, is now being diagnosed in increasing numbers in children. Despite improvements to diagnostic criteria, the diagnosis and management of POMS remains challenging. The aim of this study is to retrospectively describe a growing POMS patient population seen at a single center over a 13 year period. Epidemiologic, clinical, neuroimaging, laboratory features and therapeutic management and outcome data were collected and analyzed. These data support associations between MS and environmental triggers such as obesity and vitamin D deficiency. Presenting symptoms, magnetic resonance imaging and laboratory findings were consistent with the existing literature; however, the prevalence of cortical lesions and abnormal saccadic pursuit is higher than other reports. Data also demonstrate a shift in practice from first- to second-line therapies over the observed period.
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Affiliation(s)
- Erin Yamamoto
- 1 Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Matthew Ginsberg
- 2 Children's Hospital of Pittsburgh Department of Pediatric Neurology, Pittsburgh, PA, USA
| | - Mary Rensel
- 3 Mellen Center, Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | - Manikum Moodley
- 4 Center for Pediatric Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Cappa R, Theroux L, Brenton JN. Pediatric Multiple Sclerosis: Genes, Environment, and a Comprehensive Therapeutic Approach. Pediatr Neurol 2017; 75:17-28. [PMID: 28843454 DOI: 10.1016/j.pediatrneurol.2017.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/03/2017] [Accepted: 07/06/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pediatric multiple sclerosis is an increasingly recognized and studied disorder that accounts for 3% to 10% of all patients with multiple sclerosis. The risk for pediatric multiple sclerosis is thought to reflect a complex interplay between environmental and genetic risk factors. MAIN FINDINGS Environmental exposures, including sunlight (ultraviolet radiation, vitamin D levels), infections (Epstein-Barr virus), passive smoking, and obesity, have been identified as potential risk factors in youth. Genetic predisposition contributes to the risk of multiple sclerosis, and the major histocompatibility complex on chromosome 6 makes the single largest contribution to susceptibility to multiple sclerosis. With the use of large-scale genome-wide association studies, other non-major histocompatibility complex alleles have been identified as independent risk factors for the disease. The bridge between environment and genes likely lies in the study of epigenetic processes, which are environmentally-influenced mechanisms through which gene expression may be modified. CONCLUSIONS This article will review these topics to provide a framework for discussion of a comprehensive approach to counseling and ultimately treating the pediatric patient with multiple sclerosis.
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Affiliation(s)
- Ryan Cappa
- Department of Neurology, Division of Pediatric Neurology, University of Virginia, Charlottesville, Virginia
| | - Liana Theroux
- Department of Neurology, Division of Pediatric Neurology, University of Virginia, Charlottesville, Virginia
| | - J Nicholas Brenton
- Department of Neurology, Division of Pediatric Neurology, University of Virginia, Charlottesville, Virginia.
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McGinley M, Rossman IT. Bringing the HEET: The Argument for High-Efficacy Early Treatment for Pediatric-Onset Multiple Sclerosis. Neurotherapeutics 2017; 14:985-998. [PMID: 28895071 PMCID: PMC5722772 DOI: 10.1007/s13311-017-0568-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Pediatric-onset multiple sclerosis (POMS) is rarer than adult-onset disease, and represents a different diagnostic and treatment challenge to clinicians. We review POMS clinical and radiographic presentations, and explore important differences between POMS and adult-onset MS natural histories and long-term outcomes. Despite having more active disease, current treatment guidelines for patients with POMS endorse the off-label use of lower-efficacy disease-modifying therapies (DMTs) as first line. We review the available MS DMTs, their evidence for use in POMS, and the contrasting treatment strategies of high-efficacy early treatment and escalation therapy. We introduce a new treatment approach, the "high-efficacy early treatment", or HEET strategy, based on using directly observed, high-efficacy intravenously infused DMTs as first-line therapies. Like other proposed POMS treatment strategies, HEET will need to be prospectively studied, and all treatment decisions should be determined by an experienced neurologist, the patient, and his/her parents.
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Affiliation(s)
- Marisa McGinley
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, 9500 Euclid Avenue U10, Cleveland, OH, 44195, USA
| | - Ian T Rossman
- NeuroDevelopmental Science Center, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308, USA.
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26
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Fraga MM, de Oliveira EML, Len CA, Campos MF, Terreri MT. Devic's disease in an adolescent girl with juvenile dermatomyositis. REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57:475-478. [PMID: 29037319 DOI: 10.1016/j.rbre.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 12/01/2014] [Indexed: 06/07/2023] Open
Affiliation(s)
- Melissa Mariti Fraga
- Universidade Federal de São Paulo, Departamento de Pediatria, Unidade de Reumatologia Pediátrica, São Paulo, SP, Brazil
| | | | - Claudio Arnaldo Len
- Universidade Federal de São Paulo, Departamento de Pediatria, Unidade de Reumatologia Pediátrica, São Paulo, SP, Brazil
| | - Maria Fernanda Campos
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo, SP, Brazil
| | - Maria Teresa Terreri
- Universidade Federal de São Paulo, Departamento de Pediatria, Unidade de Reumatologia Pediátrica, São Paulo, SP, Brazil.
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27
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Neuteboom R, Wilbur C, Van Pelt D, Rodriguez M, Yeh A. The Spectrum of Inflammatory Acquired Demyelinating Syndromes in Children. Semin Pediatr Neurol 2017; 24:189-200. [PMID: 29103426 DOI: 10.1016/j.spen.2017.08.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Acquired demyelinating syndromes in childhood comprise a spectrum of monophasic and recurrent inflammatory conditions of the central nervous system. Examples of monophasic conditions include, clinically isolated syndromes such as optic neuritis and transverse myelitis, as well as acute disseminated encephalomyelitis, whereas recurrent disorders include entities such as multiple sclerosis and neuromyelitis optica spectrum disorder. Knowledge about these disorders has expanded due to rigorously evaluated diagnostic criteria, magnetic resonance imaging features, outcomes, and serum biomarkers in these disorders. This review aims to provide a summary of clinical developments in pediatric acquired demyelinating syndromes, with a special focus on diagnostic criteria, neuroinflammatory markers, burden of disease in addition to current and potential future treatment options.
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Affiliation(s)
- Rinze Neuteboom
- Department of Pediatric Neurology, Dutch Pediatric MS Center, Sophia's Children's Hospital, Erasmus MC, Rotterdam, The Netherlands.
| | - Colin Wilbur
- Department of Pediatric Neurology, Sick Kids Children's Hospital, Toronto, Canada
| | | | | | - Ann Yeh
- Department of Pediatric Neurology, Sick Kids Children's Hospital, Toronto, Canada
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28
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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29
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Pediatric Multiple Sclerosis. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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30
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Etemadifar M, Salari M, Mirmosayyeb O, Serati M, Nikkhah R, Askari M, Fayyazi E. Efficacy and safety of rituximab in neuromyelitis optica: Review of evidence. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 22:18. [PMID: 28458709 PMCID: PMC5367207 DOI: 10.4103/1735-1995.200275] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/01/2016] [Accepted: 11/16/2016] [Indexed: 12/22/2022]
Abstract
Neuromyelitis optica (NMO) is an autoimmune inflammatory disease of the central nervous system with preferential involvement in the optic nerve and spinal cord with a widespread spectrum of clinical features; multiple therapeutic agents have been used with different results. Recent evidence points to B-cell-mediated humoral immunity in the pathogenesis of NMO. Rituximab targets the CD20 antigen on B-cells. Treatment leads to profound B-cell depletion, principally over an antibody-dependent cell cytotoxicity mechanism. The aim of our study was to review clinical trials to elucidate the impact of rituximab on the relapse rate, Expanded Disability Status Scale (EDSS), and progression of disability in NMO. We performed a comprehensive review of all studies that evaluated clinical and paraclinical effects of rituximab on NMO. MEDLINE-PubMed, Web of Sciences, EMBASE, and Cochrane databases up to June 2016 included in our searches. In addition, reference lists from articles identified by search as well as a key review article to identify additional articles included in the study. Rituximab targets the CD20 antigen on B-cells and decreases attack frequency and severity in patients with NMO; however, it does not remove attacks, even when modifying treatment to achieve B-cell depletion. Most of the investigations revealed that EDSS significantly in all patients with rituximab treatment will be decreased after treatment with rituximab. No new or enlarged lesions or pathological gadolinium enhancement was observed in serial brain and spinal cord magnetic resonance imaging, except for those observed concomitantly with clinical relapses and the median length of spinal cord lesions was significantly reduced after therapy. Rituximab targets the CD20 antigen and decreases attack frequency and severity in patients with NMO.
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Affiliation(s)
- Masoud Etemadifar
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran.,Isfahan Research Committee of Multiple Sclerosis, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehri Salari
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Mirmosayyeb
- Isfahan Research Committee of Multiple Sclerosis, Isfahan University of Medical Sciences, Isfahan, Iran.,Medical Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Serati
- Isfahan Research Committee of Multiple Sclerosis, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Roham Nikkhah
- Isfahan Research Committee of Multiple Sclerosis, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mozhde Askari
- Isfahan Research Committee of Multiple Sclerosis, Isfahan University of Medical Sciences, Isfahan, Iran.,Medical Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Emad Fayyazi
- Isfahan Research Committee of Multiple Sclerosis, Isfahan University of Medical Sciences, Isfahan, Iran
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31
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Lin J, Xue B, Li X, Xia J. Monoclonal antibody therapy for neuromyelitis optica spectrum disorder: current and future. Int J Neurosci 2016; 127:735-744. [PMID: 27680606 DOI: 10.1080/00207454.2016.1242587] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Monoclonal-antibody has been used for patients with autoimmune disorders for several years, and efficacy and safety were appreciated for these patients. Neuromyelitis optica specturm disorder (NMOSD) has been defined as an autoimmune demyelination disorder of the central nervous system (CNS) with a course of relapse-remission. Treatment of prevention is important for patients with NMOSD because of the increased disability after several attacks. Multiple factors were involved in the pathogenesis of NMOSD. Currently, targeting specific factor was favored in the research into the treatment for NMOSD. Previous studies reported the efficacy and tolerance in NMOSD for drugs such as rituximab, tocilizumab, and eculizumab. The aim of this article is to review the current monoclonal therapies for NMOSD patients, and also future alternative options.
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Affiliation(s)
- Jie Lin
- a Department of Neurology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Binbin Xue
- b Department of Anesthesiology , The First Affiliated Hospital of Wenzhou Medical University , Zhejiang , Wenzhou , China
| | - Xiang Li
- a Department of Neurology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Junhui Xia
- a Department of Neurology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang , China
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32
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Jancic J, Nikolic B, Ivancevic N, Djuric V, Zaletel I, Stevanovic D, Peric S, van den Anker JN, Samardzic J. Multiple Sclerosis in Pediatrics: Current Concepts and Treatment Options. Neurol Ther 2016; 5:131-143. [PMID: 27640189 PMCID: PMC5130919 DOI: 10.1007/s40120-016-0052-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Indexed: 02/03/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, autoimmune, inflammatory, demyelinating disease of the central nervous system. MS is increasingly recognized in the pediatric population, and it is usually diagnosed around 15 years of age. The exact etiology of MS is still not known, although autoimmune, genetic, and environmental factors play important roles in its development, making it a multifactorial disease. The disease in children almost always presents in the relapsing-remittent form. The therapy involves treatment of relapses, and immunomodulatory and symptomatic treatment. The treatment of children with MS has to be multidisciplinary and include pediatric neurologists, ophthalmologists, psychologists, physiotherapists, and if necessary, pediatric psychiatrists and pharmacologists. The basis of MS therapy should rely on drugs that are able to modify the course of the disease, i.e. immunomodulatory drugs. These drugs can be subdivided into two general categories: first-line immunomodulatory therapy (interferon beta-1a, interferon beta-1b, glatiramer acetate) and second-line immunomodulatory therapy (natalizumab, mitoxantrone, fingolimod, teriflunomide, azathioprine, rituximab, dimethyl fumarate, daclizumab). Treatment of relapses involves the use of high intravenous doses of corticosteroids, administration of intravenous immunoglobulins, and plasmapheresis. We summarize here the current available information related to the etiology and treatment options in MS. Early administration of immunomodulatory therapy is beneficial in adults, while more studies are needed to prove their effectiveness in pediatric populations. Therefore, pediatric MS still represents a great challenge for both, the early and correct diagnosis, as well as its treatment.
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Affiliation(s)
- Jasna Jancic
- Clinic of Neurology and Psychiatry for Children and Youth, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Blazo Nikolic
- Clinic of Neurology and Psychiatry for Children and Youth, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Nikola Ivancevic
- Clinic of Neurology and Psychiatry for Children and Youth, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Vesna Djuric
- Clinic of Neurology and Psychiatry for Children and Youth, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Ivan Zaletel
- Institute of Histology and Embryology "Aleksandar Đ. Kostić", Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Dejan Stevanovic
- Clinic of Neurology and Psychiatry for Children and Youth, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Sasa Peric
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Belgrade, Serbia
| | - John N van den Anker
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Division of Pediatric Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA.,Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Janko Samardzic
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland. .,Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical Faculty, University of Belgrade, Dr Subotica 1, 11129, Belgrade, Serbia.
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34
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Nosadini M, Alper G, Riney CJ, Benson LA, Mohammad SS, Ramanathan S, Nolan M, Appleton R, Leventer RJ, Deiva K, Brilot F, Gorman MP, Waldman AT, Banwell B, Dale RC. Rituximab monitoring and redosing in pediatric neuromyelitis optica spectrum disorder. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e188. [PMID: 26819962 PMCID: PMC4723136 DOI: 10.1212/nxi.0000000000000188] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/29/2015] [Indexed: 01/01/2023]
Abstract
Objective: To study rituximab in pediatric neuromyelitis optica (NMO)/NMO spectrum disorders (NMOSD) and the relationship between rituximab, B cell repopulation, and relapses in order to improve rituximab monitoring and redosing. Methods: Multicenter retrospective study of 16 children with NMO/NMOSD receiving ≥2 rituximab courses. According to CD19 counts, events during rituximab were categorized as “repopulation,” “depletion,” or “depletion failure” relapses (repopulation threshold CD19 ≥10 × 106 cells/L). Results: The 16 patients (14 girls; mean age 9.6 years, range 1.8–15.3) had a mean of 6.1 events (range 1–11) during a mean follow-up of 6.1 years (range 1.6–13.6) and received a total of 76 rituximab courses (mean 4.7, range 2–9) in 42.6-year cohort treatment. Before rituximab, 62.5% had received azathioprine, mycophenolate mofetil, or cyclophosphamide. Mean time from rituximab to last documented B cell depletion and first repopulation was 4.5 and 6.8 months, respectively, with large interpatient variability. Earliest repopulations occurred with the lowest doses. Significant reduction between pre- and post-rituximab annualized relapse rate (ARR) was observed (p = 0.003). During rituximab, 6 patients were relapse-free, although 21 relapses occurred in 10 patients, including 13 “repopulation,” 3 “depletion,” and 4 “depletion failure” relapses. Of the 13 “repopulation” relapses, 4 had CD19 10–50 × 106 cells/L, 10 had inadequate monitoring (≤1 CD19 in the 4 months before relapses), and 5 had delayed redosing after repopulation detection. Conclusion: Rituximab is effective in relapse prevention, but B cell repopulation creates a risk of relapse. Redosing before B cell repopulation could reduce the relapse risk further. Classification of evidence: This study provides Class IV evidence that rituximab significantly reduces ARR in pediatric NMO/NMOSD. This study also demonstrates a relationship between B cell repopulation and relapses.
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Affiliation(s)
- Margherita Nosadini
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Gulay Alper
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Catherine J Riney
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Leslie A Benson
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Shekeeb S Mohammad
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Sudarshini Ramanathan
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Melinda Nolan
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Richard Appleton
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Richard J Leventer
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Kumaran Deiva
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Fabienne Brilot
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Mark P Gorman
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Amy T Waldman
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Brenda Banwell
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Russell C Dale
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
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Brenton JN, Banwell BL. Therapeutic Approach to the Management of Pediatric Demyelinating Disease: Multiple Sclerosis and Acute Disseminated Encephalomyelitis. Neurotherapeutics 2016; 13:84-95. [PMID: 26496907 PMCID: PMC4720662 DOI: 10.1007/s13311-015-0396-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Acquired pediatric demyelinating diseases manifest acutely with optic neuritis, transverse myelitis, acute disseminated encephalomyelitis, or with various other acute deficits in focal or polyfocal areas of the central nervous system. Patients may experience a monophasic illness (as in the case of acute disseminated encephalomyelitis) or one that may manifest as a chronic, relapsing disease [e.g., multiple sclerosis (MS)]. The diagnosis of pediatric MS and other demyelinating disorders of childhood has been facilitated by consensus statements regarding diagnostic definitions. Treatment of pediatric MS has been modeled after data obtained from clinical trials in adult-onset MS. There are now an increasing number of new therapeutic agents for MS, and many will be formally studied for use in pediatric patients. There are important efficacy and safety concerns regarding the use of these therapies in children and young adults. This review will discuss acute management as well as chronic immunotherapies in acquired pediatric demyelination.
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Affiliation(s)
- J. Nicholas Brenton
- grid.27755.32000000009136933XDepartment of Neurology, Division of Pediatric Neurology, University of Virginia, PO Box 800394, Charlottesville, VA 22908 USA
| | - Brenda L. Banwell
- grid.239552.a0000000106808770Division of Neurology, Children’s Hospital of Philadelphia, 3501 Civic Center Boulevard, Colket Translational Research Building, 10th floor, Philadelphia, PA 19104 USA
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Alexopoulos H, Biba A, Dalakas MC. Anti-B-Cell Therapies in Autoimmune Neurological Diseases: Rationale and Efficacy Trials. Neurotherapeutics 2016; 13:20-33. [PMID: 26566961 PMCID: PMC4720683 DOI: 10.1007/s13311-015-0402-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
B cells have an ever-increasing role in the etiopathology of a number of autoimmune neurological disorders, acting as antibody-producing cells and, most importantly, as sensors, coordinators, and regulators of the immune response. B cells, among other functions, regulate the T-cell activation process through their participation in antigen presentation and production of cytokines. The availability of monoclonal antibodies or fusion proteins against B-cell surface molecules or B-cell trophic factors bestows a rational approach for treating autoimmune neurological disorders, even when T cells are the main effector cells. This review summarizes basic aspects of B-cell biology, discusses the role(s) of B cells in neurological autoimmunity, and presents anti-B-cell drugs that are either currently on the market or are expected to be available in the near future for treating neurological autoimmune disorders.
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Affiliation(s)
- Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Angie Biba
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
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Rituximab in paediatric onset multiple sclerosis: a case series. J Neurol 2015; 263:322-326. [DOI: 10.1007/s00415-015-7979-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/09/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
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Rommer PS, Dörner T, Freivogel K, Haas J, Kieseier BC, Kümpfel T, Paul F, Proft F, Schulze-Koops H, Schmidt E, Wiendl H, Ziemann U, Zettl UK. Safety and Clinical Outcomes of Rituximab Treatment in Patients with Multiple Sclerosis and Neuromyelitis Optica: Experience from a National Online Registry (GRAID). J Neuroimmune Pharmacol 2015; 11:1-8. [PMID: 26589235 DOI: 10.1007/s11481-015-9646-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 11/13/2015] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an immune-mediated disease. Over the last decades therapeutic options have broadened tremendously. Nevertheless, various therapeutic agents, e.g., rituximab, are currently used in the treatment of MS off label. Disease or health registries are useful methods to collect information about off-label treatments. The German registry for autoimmune disease (GRAID) is a multicenter, retrospective, non-interventional database of patients with various autoimmune diseases. AIM/METHODS The aim of this observational analysis is to present safety data of rituximab in the treatment of MS and neuromyelitis optica (NMO) in a real life clinical setting based on the available registry data. RESULTS Data were collected nationwide in patients who received rituximab. 56 patients were treated with rituximab for MS or NMO. Average observation period was 9.6 months (SD 7.6, ranging from 6 to 29.7 months). Interval between treatments cycles differed tremendously (ranging from 0 to 21 months, median 10 months). Number of infusions ranged from 1 up to more than 8. The analysis provides experience on almost 50 patient years. Infusion related reactions were most common and reported in four patients; infections were seen in three patients (two of them were hospitalized for urinary tract infection and urosepsis). All patients recovered from infection. Full treatment response was attested in a quarter of the patients; two thirds benefited partially from treatment. DISCUSSION Safety data of almost 50 patient years of treatment with rituximab show that rituximab is tolerated well in MS/NMO patients. Infections and infusion reactions are the most common adverse events. Our data may help the individual physician to balance efficacy of rituximab against the risk. • Data on rituximab in MS and NMO are provided for almost 50 patientyears • Rituximab was tolerated well • No unexpected side effects were seen • Almost 80% of the patients benefited at least partially from treatment.
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Affiliation(s)
- P S Rommer
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany. .,Department of Neurology, Medical University of Vienna, Vienna, Austria.
| | - T Dörner
- Department of Medicine/Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - J Haas
- Department of Neurology, Jewish Hospital Berlin, Berlin, Germany
| | - B C Kieseier
- Department of Neurology, Medical Faculty, Heinrich Heine-University, Düsseldorf, Germany
| | - T Kümpfel
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University, Munich, Germany
| | - F Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - F Proft
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, University of Munich, Munich, Germany
| | - H Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, University of Munich, Munich, Germany
| | | | - H Wiendl
- Department of Neurology, University of Muenster, Muenster, Germany
| | - U Ziemann
- Department of Neurology & Stroke, Hertie Institute for Clinical Brain Research, Eberhard-Karls-University, Tübingen, Germany.,Department of Neurology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - U K Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
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D’Amico E, Caserta C, Patti F. Monoclonal antibody therapy in multiple sclerosis: critical appraisal and new perspectives. Expert Rev Neurother 2015; 15:251-68. [DOI: 10.1586/14737175.2015.1008458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fraga MM, Oliveira EMLD, Len CA, Campos MF, Terreri MT. [Devic's disease in an adolescent girl with juvenile dermatomyositis]. REVISTA BRASILEIRA DE REUMATOLOGIA 2015; 57:S0482-5004(15)00020-0. [PMID: 25772655 DOI: 10.1016/j.rbr.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 10/23/2014] [Accepted: 12/01/2014] [Indexed: 11/17/2022] Open
Abstract
Devic's disease, also known as neuromyelitis optica, is an autoimmune inflammatory demyelinating disorder of the central nervous system that mainly affects the optic nerve and spinal cord. Recently, Devic's disease was demonstrated to be a channelopathy due to the presence of antibodies against the water channel aquaporin-4 in the blood-brain barrier. There have been reports of Devic's disease in infancy, but there are few reported associations of Devic's disease with other diseases. The association of Devic's disease with dermatomyositis has not yet been described in the literature. The aim of this paper is to describe the first case of Devic's disease in an adolescent with juvenile dermatomyositis.
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Affiliation(s)
- Melissa Mariti Fraga
- Unidade de Reumatologia Pediátrica do Departamento de Pediatria, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | | | - Claudio Arnaldo Len
- Unidade de Reumatologia Pediátrica do Departamento de Pediatria, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Maria Fernanda Campos
- Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Maria Teresa Terreri
- Unidade de Reumatologia Pediátrica do Departamento de Pediatria, Universidade Federal de São Paulo, São Paulo, SP, Brasil.
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Longoni G, Banwell B, Filippi M, Yeh EA. Rituximab as a first-line preventive treatment in pediatric NMOSDs: Preliminary results in 5 children. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2014; 1:e46. [PMID: 25520954 PMCID: PMC4268036 DOI: 10.1212/nxi.0000000000000046] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 10/13/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE No established therapeutic protocol has been proposed to date for childhood-onset neuromyelitis optica (NMO) spectrum disorders (NMOSDs). We report the response of 5 NMO immunoglobulin (Ig)G-positive pediatric cases to a standardized B-cell-targeted first-line immunosuppressive protocol with rituximab for prevention of relapses. METHODS Retrospective observational cohort study. RESULTS All patients included in the study showed disease remission after rituximab induction. Relapses always occurred in conjunction with CD19(+) B-cell repopulation and appeared less severe than prior to treatment. At the end of follow-up, neurologic disability and MRI findings stabilized or improved in all the patients, with only minor and transient side effects. Oral steroid discontinuation was possible in all the patients. CONCLUSIONS Our protocol is well-tolerated and has provided encouraging results in terms of control of relapses and progression of disability. An early intervention with rituximab might affect the disease course in pediatric NMO-IgG-positive NMOSDs. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for children with NMOSDs, rituximab is well-tolerated and stabilizes or improves neurologic disability.
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Affiliation(s)
- Giulia Longoni
- Neuroimaging Research Unit, Institute of Experimental Neurology, and Department of Neurology, Division of Neuroscience (G.L., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Department of Pediatrics (G.L., E.A.Y.), University of Toronto, and Division of Neurology (G.L., E.A.Y.), The Hospital for Sick Children, Toronto, Ontario, Canada; and Division of Neurology (B.B.), Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Brenda Banwell
- Neuroimaging Research Unit, Institute of Experimental Neurology, and Department of Neurology, Division of Neuroscience (G.L., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Department of Pediatrics (G.L., E.A.Y.), University of Toronto, and Division of Neurology (G.L., E.A.Y.), The Hospital for Sick Children, Toronto, Ontario, Canada; and Division of Neurology (B.B.), Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, and Department of Neurology, Division of Neuroscience (G.L., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Department of Pediatrics (G.L., E.A.Y.), University of Toronto, and Division of Neurology (G.L., E.A.Y.), The Hospital for Sick Children, Toronto, Ontario, Canada; and Division of Neurology (B.B.), Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - E Ann Yeh
- Neuroimaging Research Unit, Institute of Experimental Neurology, and Department of Neurology, Division of Neuroscience (G.L., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Department of Pediatrics (G.L., E.A.Y.), University of Toronto, and Division of Neurology (G.L., E.A.Y.), The Hospital for Sick Children, Toronto, Ontario, Canada; and Division of Neurology (B.B.), Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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