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Prevention and management of adverse effects of disease modifying treatments in multiple sclerosis. Curr Opin Neurol 2021; 33:286-294. [PMID: 32374570 DOI: 10.1097/wco.0000000000000824] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To summarize the currently known side effects of the approved therapies of multiple sclerosis and to suggest monitoring procedures. RECENT FINDINGS The progress in the treatment of multiple sclerosis with new very effective therapies is accompanied by a number of side effects. Some of these have already been described in the approval studies, but some only after approval in a real world situation. The reason for this is the short duration of the clinical studies, the very heterogeneous patient profile in the real world setting with a number of comorbidities, pretherapies, and wider age range. The side effects may occur during application of therapies or afterwards during the course of the treatment. The side effects may range from mild infections, mild laboratory abnormalities, secondary autoimmune diseases to life-threatening side effects such as progressive multifocal leukoencephalopathy. SUMMARY It has to be pointed out that these side effects are not to be considered as final and neurologists should be vigilant against new unknown side effects. The doctor should be aware of these undesirable effects, should weigh the benefits of the therapies against the risks, but at the same time she/he should keep in mind that multiple sclerosis can be a very disabling disease if not treated properly.
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Förster M, Küry P, Aktas O, Warnke C, Havla J, Hohlfeld R, Mares J, Hartung HP, Kremer D. Managing Risks with Immune Therapies in Multiple Sclerosis. Drug Saf 2020; 42:633-647. [PMID: 30607830 DOI: 10.1007/s40264-018-0782-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Since the introduction of the interferons in the 1990s, a multitude of different immunomodulatory and immunosuppressant disease-modifying therapies for multiple sclerosis (MS) have been developed. They have all shown positive effects on clinical endpoints such as relapse rate and disease progression and are a heterogeneous group of therapeutics comprising recombinant pegylated and non-pegylated interferon-β variants, peptide combinations, monoclonal antibodies, and small molecules. However, they have relevant side effect profiles, which necessitate thorough monitoring and straightforward patient education. In individual cases, side effects can be severe and potentially life-threatening, which is why knowledge about (neurological and non-neurological) adverse drug reactions is essential for prescribing neurologists as well as general practitioners. This paper aims to provide an overview of currently available MS therapies, their modes of action and safety profiles, and the necessary therapy monitoring.
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Affiliation(s)
- Moritz Förster
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Patrick Küry
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Clemens Warnke
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilian-Universität München, Munich, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilian-Universität München, Munich, Germany.,The Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Jan Mares
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - David Kremer
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
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Mozafari N, Saffaei A, Alizadeh M, Shabani M. Cutaneous necrotic lesion: A wonderful delay adverse effect of interferon beta-1b injection for multiple sclerosis treatment. J Cosmet Dermatol 2019; 19:951-953. [PMID: 31436377 DOI: 10.1111/jocd.13104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 07/24/2019] [Indexed: 11/26/2022]
Abstract
Multiple sclerosis (MS) is a chronic and inflammatory autoimmune disease. These patients may manifest severe inflammatory cutaneous reactions after using interferon beta-1b. This article describes a 55-year-old man with severe injection site reactions after 10 years administration of interferon beta-1b. The biopsy specimens revealed skin and subcutaneous tissue necrosis. Histologic evaluation revealed nonspecific inflammatory reactions with no evidence of vasculitis or granulomatous reactions. Based on clinical and pathological findings, the diagnosis of skin and soft tissue necrosis due to interferon injection was given. The injection of interferon beta-1b in the affected areas was stopped, and the patient's clinical condition improved by wound care. This report is aimed to increase awareness about severe adverse skin reactions, which may infrequently occur with subcutaneous interferon beta-1b injection after several years. Early diagnosis of this reaction can help to prevent associated complications.
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Affiliation(s)
- Nikoo Mozafari
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Saffaei
- Student Research Committee, Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Alizadeh
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Minoosh Shabani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Wang F, Liu JH, Zhao YK, Luo DQ. Interferon-gamma-induced local leukocytoclastic vasculitis at the subcutaneous injection site. An Bras Dermatol 2017; 91:76-78. [PMID: 28300901 PMCID: PMC5325000 DOI: 10.1590/abd1806-4841.20164985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/04/2015] [Indexed: 12/17/2022] Open
Abstract
Cutaneous reactions associated with interferons (IFNs) treatment are either
localized or generalized. The most common presentation of localized reactions at
IFNs injection site is usually an erythematous patch or plaque. Local
leukocytoclastic vasculitis presenting with cutaneous necrosis is extremely
rare. We report a 19-year-old man with hepatitis B who had local
leukocytoclastic vasculitis induced by interferon-gama injection at the
injection site. After changing the injection sites and using the combined
treatment of prednisone and colchicine, the previous lesion healed and no other
cutaneous lesion occurred. We also made a mini review of such cases.
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Affiliation(s)
- Fang Wang
- The First Affiliated Hospital, SunYat-sen University - Guangzhou, China
| | - Juan-Hua Liu
- The Eastern Hospital of The First Affiliated Hospital, Sun Yat-sen University - Guangzhou, China
| | - Yu-Kun Zhao
- The Eastern Hospital of The First Affiliated Hospital, Sun Yat-sen University - Guangzhou, China
| | - Di-Qing Luo
- The Eastern Hospital of The First Affiliated Hospital, Sun Yat-sen University - Guangzhou, China
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Kumar N, Rodriguez M. Scleromyxedema in a patient with multiple sclerosis and monoclonal gammopathy on interferon beta-1a. Mult Scler 2016; 10:85-6. [PMID: 14760958 DOI: 10.1191/1352458504ms987cr] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: Animal studies have shown that some human monoclonal antibodies promote myelin repair in models of demyelinating disease. Scleromyxedema is a dermatologic disorder associated with a monoclonal gammopathy and neurologic manifestations. The reason for occurrence of cutaneous reactio ns in interferon treated patients is unknown. Case description: A 37-year-o ld woman was started on weekly interferon beta-1a (IFN beta-1a) following a diagnosis of multiple sclerosis (MS). A fter having been on interferon therapy for three years, she developed skin lesions secondary to scleromyxedema. Her IFN beta-1a was discontinued and intravenous immunoglobulin therapy was started for her scleromyxedema. A t a six-month follow up, her skin lesions improved and there was no recurrence of neurologic symptoms. Conclusions: This is the first report of occurrence of scleromyxedema in a patient with MS. While this could be a chance association, it does raise the question if her neurologic manifestations could be secondary to scleromyxedema. Further research into the mechanism of IFN related cutaneo us side effects is needed. Evidence regarding the remyelinating nature of human monoclonal antibodies raises interest in the potential therapeutic role these antibodies may have.
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Affiliation(s)
- Neeraj Kumar
- Department of Neurology, Mayo Medical and Graduate Schools, Rochester, MN 55905, USA.
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Frohman EM, Brannon K, Alexander S, Sims D, Phillips JT, O'Leary S, Hawker K, Racke MK. Disease modifying agent related skin reactions in multiple sclerosis: prevention, assessment, and management. Mult Scler 2016; 10:302-7. [PMID: 15222696 DOI: 10.1191/1352458504ms1002oa] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: The objective for this article is to highlight some of the adverse skin manifestations associated with injectable disease modifying therapy for multiple sclerosis (MS). Early identification and intervention can often lead to minimal consequences and prolonged patient tolerance and compliance with these agents. A t the University of Texas Southwestern Medical C enter at Dallas and Texas Neurology in Dallas we actively follow appro ximately 5000 MS patients. The majority of our patients with relapsing-remitting MS (RRMS) or secondary progressive MS (SPMS) are treated with one of the currently available disease modifying agents (DMA s). O ur experience with these patients, and the challenges they face in continuing long-term treatment, constitutes the basis of our proposed treatment strategies. Conclusion: Skin reactio ns in response to injectable DMA therapy in MS are generally mild. However, some reactio ns can evolve into potentially serious lesions culminating in infection, necro sis, and in some circumstances requiring surgical repair.
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Affiliation(s)
- E M Frohman
- Department of Neurology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75235, USA.
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Abstract
Life-threatening and benign drug reactions occur frequently in the skin, affecting 8 % of the general population and 2-3 % of all hospitalized patients, emphasizing the need for physicians to effectively recognize and manage patients with drug-induced eruptions. Neurologic medications represent a vast array of drug classes with cutaneous side effects. Approximately 7 % of the United States (US) adult population is affected by adult-onset neurological disorders, reflecting a large number of patients on neurologic drug therapies. This review elucidates the cutaneous reactions associated with medications approved by the US Food and Drug Administration (FDA) to treat the following neurologic pathologies: Alzheimer disease, amyotrophic lateral sclerosis, epilepsy, Huntington disease, migraine, multiple sclerosis, Parkinson disease, and pseudobulbar affect. A search of the literature was performed using the specific FDA-approved drug or drug classes in combination with the terms 'dermatologic,' 'cutaneous,' 'skin,' or 'rash.' Both PubMed and the Cochrane Database of Systematic Reviews were utilized, with side effects ranging from those cited in randomized controlled trials to case reports. It behooves neurologists, dermatologists, and primary care physicians to be aware of the recorded cutaneous adverse reactions and their severity for proper management and potential need to withdraw the offending medication.
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Affiliation(s)
| | | | - Sylvia Hsu
- Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
| | - Joseph S Kass
- Department of Neurology, Baylor College of Medicine, 7200 Cambridge St., 9th Floor, Houston, TX, 77030, USA.
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Cutaneous Adverse Events Associated with Interferon-β Treatment of Multiple Sclerosis. Int J Mol Sci 2015; 16:14951-60. [PMID: 26147425 PMCID: PMC4519881 DOI: 10.3390/ijms160714951] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 06/23/2015] [Accepted: 06/26/2015] [Indexed: 12/19/2022] Open
Abstract
Interferons are widely used platform therapies as disease-modifying treatment of patients with multiple sclerosis. Although interferons are usually safe and well tolerated, they frequently cause dermatological side effects. Here, we present a multiple sclerosis (MS) patient treated with interferon-β who developed new-onset psoriasis. Both her MS as well as her psoriasis finally responded to treatment with fumarates. This case illustrates that interferons not only cause local but also systemic adverse events of the skin. These systemic side effects might indicate that the Th17/IL-17 axis plays a prominent role in the immunopathogenesis of this individual case and that the autoimmune process might be deteriorated by further administration of interferons. In conclusion, we think that neurologists should be aware of systemic cutaneous side effects and have a closer look on interferon-associated skin lesions. Detection of psoriasiform lesions might indicate that interferons are probably not beneficial in the individual situation. We suggest that skin lesions may serve as biomarkers to allocate MS patients to adequate disease-modifying drugs.
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Faghihi G, Basiri A, Pourazizi M, Abtahi-Naeini B, Saffaei A. Multiple cutaneous necrotic lesions associated with Interferon beta-1b injection for multiple sclerosis treatment: A case report and literature review. J Res Pharm Pract 2015; 4:99-103. [PMID: 25984549 PMCID: PMC4418144 DOI: 10.4103/2279-042x.155762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic and debilitating inflammatory autoimmune disorder of the central nervous system. MS patients may experience severe local inflammatory skin reactions during disease-modifying therapy with subcutaneously injected interferon-beta-1b (IFN-β). We report the case of a 49-year-old woman with relapsing-remitting MS, who developed multiple cutaneous necrotic ulcers on both arms and thighs after 3 months of treatment with subcutaneous IFN-β-1b. The biopsy specimens showed skin and subcutaneous tissue necrosis. We diagnosed the skin lesions as cutaneous necrotic ulcerations associated with IFN-β-1b injection. The treatment included ending the use of subcutaneously injected IFN-β-1b and switching to intramuscularly injected IFN-β-1a because of the multiple cutaneous necrotic ulcers. The injection of IFN-β-1b in the areas with lesions was stopped, and the patient's clinical condition improved with the addition of routine wound care, surgical debridement, and skin grafting. This report is intended to raise awareness about severe adverse skin reactions which may rarely occur with subcutaneous IFN-β-1b injection. Early recognition and correction of the injection technique and switching to other forms of interferon can help to prevent these complications.
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Affiliation(s)
- Gita Faghihi
- Department of Dermatology, Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Akram Basiri
- Department of Dermatology, Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Pourazizi
- Students' Research Committee, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Bahareh Abtahi-Naeini
- Department of Dermatology, Skin Diseases and Leishmaniasis Research Center, Students' Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Saffaei
- Pharmacy Students' Research Committee, School of Pharmacy, Isfahan University of Medical sciences, Isfahan, Iran
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Mazzon E, Guarneri C, Giacoppo S, Rifici C, Tchernev G, Polimeni G, Wollina U. Severe septal panniculitis in a multiple sclerosis patient treated with interferon-beta. Int J Immunopathol Pharmacol 2015; 27:669-74. [PMID: 25572749 DOI: 10.1177/039463201402700425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report a memorable case of severe septal panniculitis in an MS patient following the subcutaneous administration of interferon beta-1b, manifesting as a painful, indurated, erythematous lesion of the thigh, which appeared at the injection site.
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Affiliation(s)
- E Mazzon
- Experimental Neurology Laboratory, IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - C Guarneri
- Department of Clinical Experimental Medicine, University of Messina, Messina, Italy
| | - S Giacoppo
- Experimental Neurology Laboratory, IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - C Rifici
- Experimental Neurology Laboratory, IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - G Tchernev
- Policlinic for Dermatology and Venerology, Saint KlimentOhridski University, Sofia, Bulgaria
| | - G Polimeni
- Department of Clinical Experimental Medicine, University of Messina, Messina, Italy
| | - U Wollina
- Department of Dermatology and Allergology, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany
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Inafuku H, Kasem Khan MA, Nagata T, Nonaka S. Cutaneous Ulcerations Following Subcutaneous Interferon β Injection to a Patient with Multiple Sclerosis. J Dermatol 2014; 31:671-7. [PMID: 15492442 DOI: 10.1111/j.1346-8138.2004.tb00575.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2003] [Accepted: 03/23/2004] [Indexed: 11/27/2022]
Abstract
We report a case treated with interferon beta-1b for multiple sclerosis (MS), who developed severe cutaneous ulcers after six months of therapy. Interferon beta-1b had been used in a regimen of 8 million IU administered subcutaneously through oblique direction of the needle, twice a week. The cutaneous ulcers developed at inoculation sites, as a result of penetration of interferon beta into dermis. Other underlying diseases of coagulative or bleeding disorders or secondary infection were excluded. Histological features of non-specific inflammatory reactions including hyperplastic changes of blood vessels without any evidence of vasculitis were the prominent features in this case. Corticosteroid and interferon beta-1b therapy was continued on restricted sites on the extremities with care not to repeat injections at the same sites previously used. The administration of interferon beta into subcutaneous fatty tissues vertically reduced the incidence of dermal penetration of drug and occurrence of ulcerations in this patient. We review other case reports of severe cutaneous reactions associated with interferon beta-1b therapy in MS patients and conclude that local cytokine-mediated, adverse, immune reaction or non-specific cutaneous inflammatory reaction to interferon beta-1b initiated the skin ulceration long after institution of therapy at the injection sites, and the reaction might be related to the depth of injection.
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Affiliation(s)
- Hisashi Inafuku
- Division of Dermatology, Organ-oriented Medicine, School of Medicine, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
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Starossom SC, Veremeyko T, Dukhinova M, Yung AWY, Ponomarev ED. Glatiramer acetate (copaxone) modulates platelet activation and inhibits thrombin-induced calcium influx: possible role of copaxone in targeting platelets during autoimmune neuroinflammation. PLoS One 2014; 9:e96256. [PMID: 24788965 PMCID: PMC4008572 DOI: 10.1371/journal.pone.0096256] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 04/07/2014] [Indexed: 11/18/2022] Open
Abstract
Background Glatiramer acetate (GA, Copaxone, Copolymer-1) is an FDA approved drug for the treatment of MS and it is very effective in suppressing neuroinflammation in experimental autoimmune encephalitis (EAE), an animal model of MS. Although this drug was designed to inhibit pathogenic T cells, the exact mechanism of EAE/MS suppression by GA is still not well understood. Previously we presented evidence that platelets become activated and promote neuroinflammation in EAE, suggesting a possible pathogenic role of platelets in MS and EAE. We hypothesized that GA could inhibit neuroinflammation by affecting not only immune cells but also platelets. Methodology/Principal Findings We investigated the effect of GA on the activation of human platelets in vitro: calcium influx, platelet aggregation and expression of activation markers. Our results in human platelets were confirmed by in-vitro and in-vivo studies of modulation of functions of platelets in mouse model. We found that GA inhibited thrombin-induced calcium influx in human and mouse platelets. GA also decreased thrombin-induced CD31, CD62P, CD63, and active form of αIIbβ3 integrin surface expression and formation of platelet aggregates for both mouse and human platelets, and prolonged the bleeding time in mice by 2.7-fold. In addition, we found that GA decreased the extent of macrophage activation induced by co-culture of macrophages with platelets. Conclusions GA inhibited the activation of platelets, which suggests a new mechanism of GA action in suppression of EAE/MS by targeting platelets and possibly preventing their interaction with immune cells such as macrophages. Furthermore, the reduction in platelet activation by GA may have additional cardiovascular benefits to prevent thrombosis.
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Affiliation(s)
- Sarah C. Starossom
- Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Institute for Medical Immunology and NeuroCure, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tatyana Veremeyko
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Marina Dukhinova
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Amanda W. Y. Yung
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Eugene D. Ponomarev
- Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
- * E-mail:
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Balak DMW, Hengstman GJD, Çakmak A, Thio HB. Cutaneous adverse events associated with disease-modifying treatment in multiple sclerosis: a systematic review. Mult Scler 2012; 18:1705-17. [PMID: 22371220 DOI: 10.1177/1352458512438239] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Glatiramer acetate and interferon-beta are approved first-line disease-modifying treatments (DMTs) for multiple sclerosis (MS). DMTs can be associated with cutaneous adverse events, which may influence treatment adherence and patient quality of life. In this systematic review, we aimed to provide an overview of the clinical spectrum and the incidence of skin reactions associated with DMTs. A systematic literature search was performed up to May 2011 in Medline, Embase, and Cochrane databases without applying restrictions in study design, language, or publishing date. Eligible for inclusion were articles describing any skin reaction related to DMTs in MS patients. Selection of articles and data extraction were performed by two authors independently. One hundred and six articles were included, of which 41 (39%) were randomized controlled trials or cohort studies reporting incidences of mainly local injection-site reactions. A large number of patients had experienced some form of localized injection-site reaction: up to 90% for those using subcutaneous formulations and up to 33% for those using an intramuscular formulation. Sixty-five case-reports involving 106 MS patients described a wide spectrum of cutaneous adverse events, the most frequently reported being lipoatrophy, cutaneous necrosis and ulcers, and various immune-mediated inflammatory skin diseases. DMTs for MS are frequently associated with local injection-site reactions and a wide spectrum of generalized cutaneous adverse events, in particular, the subcutaneous formulations. Although some of the skin reactions may be severe and persistent, most of them are mild and do not require cessation of DMT.
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Affiliation(s)
- Deepak M W Balak
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands
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OHATA U, HARA H, YOSHITAKE M, TERUI T. Cutaneous reactions following subcutaneous β-interferon-1b injection. J Dermatol 2010; 37:179-81. [DOI: 10.1111/j.1346-8138.2009.00783.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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Recombinant interferon-beta therapy and neuromuscular disorders. J Neuroimmunol 2009; 212:132-41. [DOI: 10.1016/j.jneuroim.2009.04.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 04/21/2009] [Accepted: 04/22/2009] [Indexed: 11/20/2022]
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Ball NJ, Cowan BJ, Hashimoto SA. Lobular panniculitis at the site of subcutaneous interferon beta injections for the treatment of multiple sclerosis can histologically mimic pancreatic panniculitis. A study of 12 cases. J Cutan Pathol 2008; 36:331-7. [PMID: 19032383 DOI: 10.1111/j.1600-0560.2008.01019.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Thrombosis, mucinosis and necrosis are well-described complications of subcutaneous interferon beta injections. METHODS We report 12 incisional biopsies from subcutaneous interferon beta injection sites in 12 multiple sclerosis (MS) patients from a single neurologist's practice. RESULTS We identified abscesses (two cases) or induration (two cases) in acute clinical lesions and lipoatrophy (eight cases) in chronic lesions (biopsied over a year after symptom onset at injection sites). Biopsies from three acute lesions showed vascular thrombosis, dermal mucinosis, lobular neutrophilic panniculitis, necrosis, calcification and hemosiderin deposition (biopsied 2 weeks to 2 months after symptom onset). Two cases contained sterile abscesses. Five of the eight chronic cases presented as hard, indurated lipoatrophy with livedo reticularis. Their biopsies showed subcutaneous calcification and lipoatrophy. Biopsies from the early calcific suppurative and late calcific atrophic phases histologically resembled the early and late phases of subcutaneous saponification in pancreatic panniculitis. CONCLUSIONS Reactions at the site of subcutaneous interferon beta injections are common. Lipoatrophy can be clinically identified in 39 of 85 MS patients (46%) receiving subcutaneous interferon beta injections for 1 year or longer in our practice. A reaction to interferon should be considered in the differential diagnosis of biopsies that show features of pancreatic panniculitis.
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Affiliation(s)
- Nigel J Ball
- Department of Pathology, The University of Britsih Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada.
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Interferon-beta injection site reaction: Review of the histology and report of a lupus-like pattern. J Am Acad Dermatol 2008; 59:S48-9. [DOI: 10.1016/j.jaad.2007.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Revised: 11/01/2007] [Accepted: 12/09/2007] [Indexed: 11/21/2022]
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18
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Sheremata WA, Jy W, Horstman LL, Ahn YS, Alexander JS, Minagar A. Evidence of platelet activation in multiple sclerosis. J Neuroinflammation 2008; 5:27. [PMID: 18588683 PMCID: PMC2474601 DOI: 10.1186/1742-2094-5-27] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Accepted: 06/27/2008] [Indexed: 12/12/2022] Open
Abstract
Objective A fatality in one multiple sclerosis (MS) patient due to acute idiopathic thrombocytopenic purpura (ITP) and a near fatality in another stimulated our interest in platelet function abnormalities in MS. Previously, we presented evidence of platelet activation in a small cohort of treatment-naive MS patients. Methods In this report, 92 normal controls and 33 stable, untreated MS patients were studied. Platelet counts, measures of platelet activation [plasma platelet microparticles (PMP), P-selectin expression (CD62p), circulating platelet microaggragtes (PAg)], as well as platelet-associated IgG/IgM, were carried out. In addition, plasma protein S activity was measured. Results Compared to controls, PMP were significantly elevated in MS (p < 0.001) and CD62p expression was also markedly elevated (p < 0.001). Both are markers of platelet activation. Platelet-associated IgM, but not IgG, was marginally elevated in MS (p = 0.01). Protein S in MS patients did not differ significantly from normal values. Conclusion Platelets are significantly activated in MS patients. The mechanisms underlying this activation and its significance to MS are unknown. Additional study of platelet activation and function in MS patients is warranted.
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Affiliation(s)
- William A Sheremata
- Multiple Sclerosis Center and Department of Neurology Miller School of Medicine, University of Miami, Miami, Florida, USA.
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19
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Abstract
Problems in patient care with regard to route of administration and dosing of currently approved drugs are reviewed. Dose, frequency and route of administration can make a difference in efficacy, side effects, quality of life, antigenicity, cost, and compliance.
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Affiliation(s)
- Stuart D Cook
- University of Medicine and Dentistry of NJ, 65 Bergen Street, Room 1435, Newark NJ 07101-1709, USA.
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20
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Kremenchutzky M, Morrow S, Rush C. The safety and efficacy of IFN-beta products for the treatment of multiple sclerosis. Expert Opin Drug Saf 2007; 6:279-88. [PMID: 17480177 DOI: 10.1517/14740338.6.3.279] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Multiple sclerosis, a chronic demyelinating disease of the CNS, is now a treatable disease. Phase III clinical trials of three recombinant IFN-beta products conducted in relapsing-remitting multiple sclerosis have shown, albeit modest, significant effects on relapses and short-term progression of disability, and a more substantial effect on MRI parameters. However, these effects do not correlate well with clinical disease activity or long-term disability. Overall, IFN-beta is safe and generally well tolerated, and reported adverse events were comparable between preparations. Systemic side effects can be effectively managed by dose escalation, use of an auto-injector and careful clinical monitoring.
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Affiliation(s)
- Marcelo Kremenchutzky
- University of Western Ontario, Department of Clinical Neurological Sciences, London Health Sciences Centre, Canada
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21
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Baum K, O'Leary C, Coret Ferrer F, Klimova E, Prochazkova L, Bugge J. Comparison of injection site pain and injection site reactions in relapsing-remitting multiple sclerosis patients treated with interferon beta-1a or 1b. Mult Scler 2007; 13:1153-60. [DOI: 10.1177/1352458507079291] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This prospective, multicentre, international, observational, cohort study compared injection site pain (ISP) and injection site reactions (ISRS) between interferon beta-1b (IFNB-1b; Betaferon ®) 250 μg subcutaneously every other day and interferon beta-1a (IFNB-1a; Rebif®) 44 μg subcutaneously three times weekly in patients with relapsing-remitting MS. Patients started treatment within 3 months before recruitment and were on full dose of therapy at inclusion. Patients self-injected IFNB and self-assessed ISP for 15 consecutive injections immediately, 30 and 60 min after injection, using a visual analogue scale diary. Study staff assessed ISRS. Of 445 patients (valid cases), ~90% used autoinjectors. More patients were pain-free at all timepoints with IFNB-1b than with IFNB-1a (eg, 30 min: 42.6% versus 19.7%; P< 0.0001). The mean proportion of pain-free injections was greater for IFNB-1b (eg, 30 min: 79.0%) than for IFNB-1a (53.3%; P < 0.0001). The proportion of patients without ISRS was greater for IFNB-1b (second visit 51.8% versus 33.8%; P < 0.0001). Compared with IFNB-1a, more IFNB-1b patients either had no pain or their ISP had no influence on treatment satisfaction (76.9% versus 64.1%; P = 0.006). The impact on tolerability and patient acceptability of any new IFNB product formulations would, however, have to be evaluated in comparative studies. Multiple Sclerosis 2007; 13 : 1153—1160. http://msj.sagepub.com
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Affiliation(s)
- K. Baum
- Department of Neurology, Klinik Hennigsdorf, Hennigsdorf, Germany,
| | - C. O'Leary
- Department of Neurology, Southern General Hospital NHS Trust, Glasgow, UK
| | - F. Coret Ferrer
- Servicio de Neurologia, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - E. Klimova
- Department of Neurology, J. A. Reiman Teaching Hospital, Presov, Kosice, Slovak Republic
| | - L. Prochazkova
- Department of Neurology, University Hospital ak Derera, Bratislava, Slovak Republic
| | - J. Bugge
- Bayer Schering Pharma AG, Berlin, Germany
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22
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Soria A, Maubec E, Henry-Feugeas MC, Marinho E, Le Bozec P, Huisse MG, Pocidalo MA, Descamps V, Crickx B. Panniculites secondaires à la toxicité vasculaire de l’interféron béta-1a. Ann Dermatol Venereol 2007; 134:374-7. [PMID: 17483759 DOI: 10.1016/s0151-9638(07)89194-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Interferon-beta-1b is a valuable first-line therapy for patients with relapsing-remitting multiple sclerosis. Many non-severe cutaneous reactions to recombinant interferon beta are described at injection sites. Panniculitis after subcutaneous injection of beta interferon is a rare adverse event; we describe two such cases at beta interferon injection sites. CASE-REPORTS Two women aged 22 years and 45 years with severe multiple sclerosis receiving immunotherapy with beta interferon were admitted to an emergency department following the appearance of extremely painful induration at injection sites rendering walking impossible after several months of interferon injections. One of the patients had fever. Histology tests showed vasculitis and capillary thrombosis in one-woman and dermal oedema in the other. MRI scanners showed extensive avascular necrosis of soft tissue without fasciitis in both patients. Interferon withdrawal and surgical debridement was carried out in one case and beta interferon was successfully reintroduced in both cases. DISCUSSION Only two cases have been reported of panniculitis induced by subcutaneous beta interferon injection. Clinically, such cases may mimic infectious processes. The present cases show that MRI may be useful in diagnosis and that the vascular toxicity of interferon beta probably plays a role in panniculitis. Temporary withdrawal of treatment, rotation of several injection sites and alternative routes of administration may all be proposed.
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Affiliation(s)
- A Soria
- Service de Dermatologie, Hôpital Bichat, Assistance Publique Hôpitaux de Paris, Université Paris 7-Denis-Diderot
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23
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Capasso M, Caulo M, De Luca G, Magarelli N, Lugaresi A. Mononeuropathy following subcutaneous interferon–β injection. J Neurol 2006; 253:961-2. [PMID: 16511643 DOI: 10.1007/s00415-006-0136-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Revised: 09/06/2005] [Accepted: 09/15/2005] [Indexed: 11/30/2022]
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24
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Abstract
Alpha interferon causes frequent and multiple cutaneous side effects that affect both the skin and mucous membranes. Patients receiving this treatment must be informed of the principal adverse reactions (dryness and hair loss or discoloration) and must receive care for them if the underlying treatment is to remain acceptable. Alpha interferon may induce, reveal, or worsen some dermatoses and related inflammatory disorders (atopic dermatitis, psoriasis, sarcoidosis).
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Affiliation(s)
- V Descamps
- Service de dermatologie, Hôpital Bichat, APHP, 46, rue Henri Huchard, 75018 Paris.
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25
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Ruiz-Genao DP, García-F-Villalta MJ, Hernández-Núñez A, Ríos-Buceta L, Fernández-Herrera J, García-Díez A. Livedo reticularis associated with interferon alpha therapy in two melanoma patients. J Eur Acad Dermatol Venereol 2005; 19:252-4. [PMID: 15752306 DOI: 10.1111/j.1468-3083.2004.01128.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report two patients who developed intense livedo reticularis clearly related to the administration of interferon alpha 2b as an adjuvant therapy for melanoma. Histological studies showed scattered perivascular infiltrates without vasculitis. Laboratory tests excluded any underlying condition. Resolution of the symptoms was observed in both patients when interferon alpha was withdrawn. These cases highlight the occurrence of livedo reticularis as an uncommon side-effect of interferon alpha treatment.
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Affiliation(s)
- D P Ruiz-Genao
- Department of Dermatology, Hospital Universitario de La Princesa, 28006 Madrid, Spain.
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26
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Wells J, Kossard S, McGrath M. Abdominal wall ulceration and mucinosis secondary to recombinant human interferon-beta-1b. Australas J Dermatol 2005; 46:202-4. [PMID: 16008658 DOI: 10.1111/j.1440-0960.2005.00181.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
46-year-old woman developed painful ulcers over her lower abdomen in the form of reticulate erythema after injecting interferon beta-1b subcutaneously for multiple sclerosis. Skin biopsy revealed multiple superficial thrombosed vessels with focal epidermal necrosis as well as prominent interstitial mucinosis. Treatment with low-molecular-weight heparin followed by a heparinoid resulted in slow healing of the ulcers but also allowed the subcutaneous interferon injections to be continued.
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Affiliation(s)
- Jillian Wells
- Department of Dermatology, St Vincent's Hospital, Sydney, New South Wales, Australia
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27
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Abstract
A 32-year-old woman with multiple sclerosis who developed non-injection-site-related fixed drug eruption with interferon-beta-1b. Erythematous plaques started appearing 1 month after the drug was introduced, and increased in number following each administration. The histopathology of a skin biopsy was consistent with fixed drug eruption. The drug was subsequently ceased, with resolution of the rash 6 weeks later.
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Affiliation(s)
- Yee J Tai
- Department of Dermatology, St. Vincent's Hospital, Melbourne, Victoria, Australia.
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28
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Débat Zoguéreh D, Boucraut J, Beau-Salinas F, Bodiguel E, Lechapois D, Pomet E. Vascularite cutanée avec atteinte rénale compliquant un traitement par interféron bêta-1a pour une sclérose en plaques. Rev Neurol (Paris) 2004; 160:1081-4. [PMID: 15602352 DOI: 10.1016/s0035-3787(04)71147-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Cutaneous tolerance of the interferon beta used in the treatment of relapsing-remitting multiple sclerosis is good. However, among the rare adverse effects, vasculitis and glomerular impairment have been described for interferon beta-1b. CASE REPORT A 36-year-old woman had been given subcutaneous injections of interferon beta 1-1a (Rebif, Serono) three times a week for ten weeks. A local transient cutaneous erythema was observed at the injection's sites. A few days after a new injection a erythematous plaques developed at the injection sites followed by pruritus, then purpura with edema on the leg in addition to an increase in body weight of 3 kg. Biological data showed proteinuria and hematuria. The histology study of skin specimens suggested non-specific lymphocytic vasculitis. Outcome was favorable after discontinuing interferon beta-1a. CONCLUSION The etiology of the cutaneous and renal impairment is not formally established but the drug-induced hypothesis is proposed for interferon beta-1a.
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Affiliation(s)
- D Débat Zoguéreh
- Service de Neurologie, Centre Hospitalier Générale (CHG) Jacques Coeur, Bourges.
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29
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Casoni F, Merelli E, Bedin R, Martella A, Cesinaro A, Bertolotto A. Necrotizing skin lesions and NABs development in a multiple sclerosis patient treated with IFNbeta 1b. Mult Scler 2003; 9:420-3. [PMID: 12926849 DOI: 10.1191/1352458503ms933sr] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A case of a severe necrotizing vasculopathic skin lesions occurred in a 43 year old women affected by multiple sclerosis (MS) submitted to IFNbeta-1b has been described. After two months of therapy the patient presented, in injection sites of the abdomen, arms and legs, numerous ulcers. A biopsy of the lesions was performed and evidenced confluent necrosis of the superficial and deep skin tissue with mild infiltration by inflammatory cells and thrombosis in deep blood vessels. The IFNbeta-1b was immediately discontinued and therapy with corticosteroids was started. After 12 months from the onset of the adverse reaction, the skin vasculopathic lesions cicatrised leaving sclerotic areas on the abdomen. Neutralizing antibodies against IFNbeta-1b (NABs) were strongly positive at the onset of the skin ulcers and slowly decreased until the recovery. A possible role of NABs in the development of the skin lesions has been considered.
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Affiliation(s)
- Federica Casoni
- Clinica Neurologica, Policinico, Via Del Pozzo 71, 41100 Modena, Italy.
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30
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Frohman E, Phillips T, Kokel K, Van Pelt J, O'Leary S, Gross S, Hawker K, Racke M. Disease-modifying therapy in multiple sclerosis: strategies for optimizing management. Neurologist 2002; 8:227-36. [PMID: 12803682 DOI: 10.1097/00127893-200207000-00003] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective for this article is to highlight several challenges faced by patients and providers in the utilization of disease-modifying agent (DMA) therapy in multiple sclerosis (MS) and to offer practical management strategies that can effectively mitigate or even prevent limiting adverse reactions and enhance treatment compliance. REVIEW SUMMARY Our discussion will be limited to the use of interferon beta1a (Avonex, Rebif), interferon beta1b (Betaseron), and glatiramer acetate (Copoxane) as these are the primary agents used in the United States for primary disease-modifying therapy in relapsing forms of MS. Some of the recommendations contained herein are derived from evidence-based studies, while others are contingent upon our collective clinical experiences. At the University of Texas Southwestern Medical Center at Dallas and Texas Neurology in Dallas we actively follow approximately 5000 MS patients. The majority of our patients with relapsing-remitting MS (RRMS) or secondary progressive MS (SPMS) are treated with one of the currently available DMAs. Our experience with these patients, and the challenges they face in continuing long-term treatment, constitutes the basis of our proposed treatment strategies. As part of this effort we formulated an assessment and intervention instrument that can be used in the clinic and by telephone to enhance compliance and minimize adverse events. CONCLUSION A comprehensive treatment approach to the utilization of disease-modifying therapy in MS can serve to optimize the management of our patients and effectively meet the challenges that arise during the course of treatment.
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Affiliation(s)
- Elliot Frohman
- Department of Neurology, University of Texas Southwestern Medical Center at Dallas, 75235, USA.
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31
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Sanders S, Busam K, Tahan SR, Johnson RA, Sachs D. Granulomatous and suppurative dermatitis at interferon alfa injection sites: report of 2 cases. J Am Acad Dermatol 2002; 46:611-6. [PMID: 11907520 DOI: 10.1067/mjd.2002.119087] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
It has previously been reported that interferon alfa injection sites may develop pyoderma gangrenosum, interface dermatitis, vasculitis, or, more commonly, ulcers characterized by intravascular thrombi and a mixed inflammatory cell infiltrate. We describe 2 patients in whom granulomatous and suppurative dermatitis developed at interferon alfa injection sites. These cases extend the spectrum of interferon alfa injection site reactions. The histologic and clinical similarities of these cases with pyoderma gangrenosum and cutaneous Crohn's disease are explored.
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Affiliation(s)
- Scott Sanders
- Department of Dermatology, New York Hospital, NY, USA
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32
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Abstract
The task of evaluating a cutaneous eruption in the patient receiving chemotherapy can be quite formidable. Most of the time, these patients are receiving a multitude of agents and have profound immunosuppression. These factors may alter the more common manifestations of cutaneous eruptions. This article presents some of the more common cutaneous eruptions that may occur in an oncology patient receiving chemotherapy. It is hoped we may recognize clinical patterns seen with chemotherapeutic agents in the immunosuppressed population and, by recognizing these cutaneous eruptions, we may avoid the pitfalls of discontinuing medicines that may certainly be needed or altering the treatment course in a patient.
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Affiliation(s)
- R A Koppel
- Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA
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33
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Abstract
Interferon-beta is an established therapy in relapsing-remitting multiple sclerosis. Recently, it has also been shown that interferon-beta-1b is effective in secondary progressive multiple sclerosis. However, adverse effects of interferon-beta treatment are common, particularly during the first weeks of treatment, and are a major concern. Flu-like symptoms, injection site reactions and laboratory abnormalities are the most common adverse effects, and may result in reduced compliance or even discontinuation of treatment in a number of patients. Therefore, efforts to minimise these reactions, e.g. appropriate comedication with analgesic/antipyretic drugs, use of correct preparation and injection technique and sometimes modification of the dosage of interferon-beta, are of considerable importance. This article provides an overview of the management of clinically relevant adverse effects related to treatment with interferon-beta, based on a literature review and personal experience. Essential aspects of patient information are also stressed. If these recommendations are followed, adverse effects related to interferon-beta may be substantially reduced in the majority of patients.
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Affiliation(s)
- A Bayas
- Department of Neurology, University of Würzburg, Germany
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34
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Abstract
BACKGROUND Due to advances in recombinant DNA technology, interferons are now readily available and are frequently used in all branches of medicine. These potent biologic response modifiers carry a number of systemic and local side effects. These cytokines are usually administered subcutaneously, and recent studies have described the occurrence of inflammation or necrosis at the site of injection. OBJECTIVE We report a case of cutaneous necrosis at the sites of interferon injections in a 35-year-old man treated for chronic myeloid leukemia with high, daily doses of interferon alfa. In addition, we review the existing literature on interferon-induced cutaneous necrosis and discuss preventive strategies. CONCLUSION Cutaneous inflammation or necrosis at interferon injection sites is not uncommon. Although interferon beta-1b is most commonly responsible for this complication, it is now increasingly reported with interferon alfa. It appears to be secondary to the proinflammatory effects of these cytokines or to their unmasking of a subtle hypercoagulable state.
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Affiliation(s)
- D Sasseville
- The Division of Dermatology, Department of Medicine, Royal Victoria Hospital, Montréal, Quebec, Canada
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35
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Abstract
Cutaneous reactions to drug therapy may be of either immunologic or nonimmunologic etiology. It is important that the dermatologist and pathologist be familiar with these types of cutaneous reactions. This article discusses the clinical features, pathogenesis, and histopathology of various cutaneous drug eruptions.
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Affiliation(s)
- A N Crowson
- Central Medical Laboratories, Misericordia General Hospital, Winnipeg, Manitoba, Canada
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36
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Abstract
Symptomatic treatment of multiple sclerosis (MS) includes a diverse range of drugs intended to relieve the specific symptoms with which a patient may present at a particular point in the progression of the disease. These drugs, not specifically designed for the treatment of MS, may include antispastic agents (e.g. baclofen), drugs to reduce tremor (e.g. clonazepam), anticholinergics (e.g. oxybutynin) which relieve urinary symptoms, anti-epileptics (e.g. carbamazepine) to control neuralgia, stimulants to reduce fatigue (e.g. amantadine), and antidepressants (e.g. fluoxetine) to treat depression. The treatment of acute relapses or exacerbations is dominated by corticosteroids such as methylprednisolone. The most active area of current investigation is the development of drugs which will inhibit the progression of the disease process itself, and in this category the beta- and alpha-interferons are the most effective drugs currently available, although many new treatments are currently in trials, including immunoglobulin, copolymer-1. bovine myelin, T-cell receptor (TCR) peptide vaccines, platelet activating factor (PAF) antagonists, matrix metallo-proteinase inhibitors, campath-1, and insulin-like growth factor (IGF).
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Affiliation(s)
- P F Smith
- Department of Pharmacology, School of Medical Sciences, University of Otago Medical School, Dunedin, New Zealand
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