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Page LJ, Pay IF, Castellana ET, Heussen R, Hoyt T, Foley J, Messmer BT. Intact natalizumab pharmacokinetics is impacted by endogenous IgG4 concentration. Mult Scler Relat Disord 2024; 87:105667. [PMID: 38759421 DOI: 10.1016/j.msard.2024.105667] [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: 01/04/2024] [Revised: 05/02/2024] [Accepted: 05/05/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Natalizumab (NAT) pharmacokinetics and pharmacodynamics are complicated by arm exchange with endogenous IgG4, resulting in a mixture of a more potent intact, bivalent form and a less potent, functionally monovalent form. Total NAT and endogenous IgG4 concentrations vary considerably across patients. This study assessed the concentration of intact NAT, and how it relates to total NAT and endogenous IgG4 levels in blood and saliva. METHODS Paired serum and saliva samples from a small cohort of relapsing-remitting multiple sclerosis patients were measured for levels of intact NAT, total NAT, IgG and IgG4. RESULTS Intact NAT concentration was dependent on both total NAT and endogenous IgG4 levels. Low endogenous IgG4 led to a higher ratio of intact NAT to total NAT, while the opposite was observed in subjects with high endogenous IgG4. Serum and saliva measurements show good concordance. CONCLUSIONS Intact NAT concentration is influenced by both NAT pharmacokinetics and endogenous IgG4 levels. Patients with low IgG4 levels can have high concentrations of intact NAT even with lower levels of total NAT, which may explain cases of NAT-associated progressive multifocal leukoencephalopathy (PML) in such patients. Monitoring both forms of NAT could better guide dosing, maximizing drug efficacy and safety.
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Affiliation(s)
- Lesley J Page
- Abreos Biosciences, 3550 General Atomics Court(,) G02/rm140, San Diego, CA, USA.
| | - Iona F Pay
- Abreos Biosciences, 3550 General Atomics Court(,) G02/rm140, San Diego, CA, USA
| | - Edward T Castellana
- Abreos Biosciences, 3550 General Atomics Court(,) G02/rm140, San Diego, CA, USA
| | - Raphaela Heussen
- Abreos Biosciences, 3550 General Atomics Court(,) G02/rm140, San Diego, CA, USA
| | - Tamara Hoyt
- Rocky Mountain MS Clinic, 370 E 9th Ave, Salt Lake City, Utah 84103
| | - John Foley
- Rocky Mountain MS Clinic, 370 E 9th Ave, Salt Lake City, Utah 84103
| | - Bradley T Messmer
- Abreos Biosciences, 3550 General Atomics Court(,) G02/rm140, San Diego, CA, USA
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2
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Aliyu M, Zohora FT, Ceylan A, Hossain F, Yazdani R, Azizi G. Immunopathogenesis of multiple sclerosis: molecular and cellular mechanisms and new immunotherapeutic approaches. Immunopharmacol Immunotoxicol 2024; 46:355-377. [PMID: 38634438 DOI: 10.1080/08923973.2024.2330642] [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: 09/21/2023] [Accepted: 03/09/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Multiple sclerosis (MS) is a central nervous system (CNS) demyelinating autoimmune disease with increasing global prevalence. It predominantly affects females, especially those of European descent. The interplay between environmental factors and genetic predisposition plays a crucial role in MS etiopathogenesis. METHODS We searched recent relevant literature on reputable databases, which include, PubMed, Embase, Web of Science, Scopus, and ScienceDirect using the following keywords: multiple sclerosis, pathogenesis, autoimmunity, demyelination, therapy, and immunotherapy. RESULTS Various animal models have been employed to investigate the MS etiopathogenesis and therapeutics. Autoreactive T cells within the CNS recruit myeloid cells through chemokine expression, leading to the secretion of inflammatory cytokines driving the MS pathogenesis, resulting in demyelination, gliosis, and axonal loss. Key players include T cell lymphocytes (CD4+ and CD8+), B cells, and neutrophils. Signaling dysregulation in inflammatory pathways and the immunogenetic basis of MS are essential considerations for any successful therapy to MS. Data indicates that B cells and neutrophils also have significant roles in MS, despite the common belief that T cells are essential. High neutrophil-to-lymphocyte ratios correlate with MS severity, indicating their contribution to disease progression. Dysregulated signaling pathways further exacerbate MS progression. CONCLUSION MS remains incurable, but disease-modifying therapies, monoclonal antibodies, and immunomodulatory drugs offer hope for patients. Research on the immunogenetics and immunoregulatory functions of gut microbiota is continuing to provide light on possible treatment avenues. Understanding the complex interplay between genetic predisposition, environmental factors, and immune dysregulation is critical for developing effective treatments for MS.
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Affiliation(s)
- Mansur Aliyu
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, International Campus, TUMS-IC, Tehran, Iran
- Department of Medical Microbiology, Faculty of Clinical Science, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Fatema Tuz Zohora
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
| | - Ayca Ceylan
- Medical Faculty, Department of Pediatrics, Division of Immunology and Allergy, Selcuk University, Konya, Turkey
| | - Fariha Hossain
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
| | - Reza Yazdani
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gholamreza Azizi
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
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3
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Thiel S, Litvin N, Haben S, Gold R, Hellwig K. Disease activity and neonatal outcomes after exposure to natalizumab throughout pregnancy. J Neurol Neurosurg Psychiatry 2024; 95:561-570. [PMID: 38124108 PMCID: PMC11103322 DOI: 10.1136/jnnp-2023-332804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND After natalizumab discontinuation severe relapses can occur despite pregnancy, but third trimester exposure is associated with neonatal haematological abnormalities (HA). The best time point for stopping natalizumab during pregnancy is unclear. METHODS Prospective, observational cohort with 350 natalizumab exposed pregnancies from the German Multiple Sclerosis and Pregnancy Registry. Clinical disease activity and neonatal outcomes are compared between women with natalizumab discontinuation during (1st Trim-group) versus after the first trimester (maintaining-group) and for subgroup analysis before (<30-subgroup) or after (≥30-subgroup) the 30th gestational week (gw). RESULTS Baseline characteristics did not significantly differ between the 1st Trim-group (n=179; median exposure duration: 2.60 gw, IQR 1.30-3.60) and the maintaining-group (n=171; median exposure duration: 30.9 gw, IQR 26.9-33.3). Fewer relapses occurred during pregnancy and the postpartum year in the maintaining-group (25.7%) compared with the 1st Trim-group (62.6%; p<0.001). Women in ≥30-subgroup had a significantly lower relapse risk in the first 6 months postpartum (relapse rate ratio: 0.36, 95% CI: 0.15 to 0.84). In total, 7.5% retained meaningful disability 12 months postpartum. No significant effect on neonatal outcomes were observed, but anaemia (OR: 2.62, 95% CI: 1.12 to 6.52) and thrombocytopaenia (OR: 2.64, 95% CI: 1.15 to 6.46) were significantly more common in the ≥30-subgroup. 21.8% of all neonates were born small for gestational age, independent of the timing of natalizumab discontinuation. CONCLUSION Continuing natalizumab during pregnancy after gw 30 decreases the relapse risk postpartum going along with a higher risk for HA in the newborns. These results add relevant knowledge as a basis for informed risk-benefit discussion.
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Affiliation(s)
- Sandra Thiel
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Nastassja Litvin
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Sabrina Haben
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Ralf Gold
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Kerstin Hellwig
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
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4
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Brown JD, Muston BT, Massey J. Switching from natalizumab to an anti-CD20 monoclonal antibody in relapsing remitting multiple sclerosis: A systematic review. Mult Scler Relat Disord 2024; 86:105605. [PMID: 38640586 DOI: 10.1016/j.msard.2024.105605] [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: 11/22/2023] [Revised: 04/04/2024] [Accepted: 04/07/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Use of natalizumab (NTZ) is precluded in many Multiple Sclerosis (MS) patients by the risk of progressive multifocal leukoencephalopathy (PML). Regardless, some patients may commence natalizumab for short term disease control in spite of being seropositive, and others may seroconvert whilst on treatment. In these circumstances, discontinuation of NTZ should not occur until a clear exit strategy is established to prevent post-NTZ disease reactivation, which often exceeds the severity of disease activity prior to NTZ treatment. The objective of this systematic review was to summarise the available evidence for CD20-monoclonal antibodies (CD20mAb) as a suitable NTZ exit strategy, and to identify whether a superior switch protocol can be established. METHODS In accordance with PRISMA guidelines, a total of 2393 references were extracted from a search of three online databases (PubMed, Scopus, MEDLINE). Following the application of inclusion/exclusion criteria, a total of 5 studies representing 331 patients were included. RESULTS The overall incidence of clinical relapse during washout periods ranging from 4.4-10.7 weeks was 0 %. The incidence of clinical relapse during two-year follow-up ranged from 1.8 % to 10 % for switches to all types of CD20 monoclonal antibody. The weighted mean for clinical relapse at 12 months was 8.8 %. Three studies reported an annualised relapse rate (ARR) ranging from 0.02-0.12 with a weighted mean ARR of 0.07. The overall incidence of PML during washout was 0 % and the overall incidence of PML within 6 months follow-up was 0.6 %. CONCLUSIONS This systematic review provides the first attempt at identifying a superior switch protocol in patients at risk of PML transitioning from NTZ to a CD20mAb. Our results indicate that CD20mAb's are a suitable transitional option for patients who discontinue NTZ, with our cohort demonstrating very low rates of carryover PML and low rates of clinical relapse. The most appropriate washout period is unclear due to confounding factors but is likely between 4 and 12 weeks.
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Affiliation(s)
| | - Benjamin T Muston
- Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; The Collaborative Research Group (CORE), Sydney, Australia
| | - Jennifer Massey
- Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Neurology Department, St Vincent's Hospital Sydney, Australia
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5
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Koch M. Prospective trial of natalizumab personalised extended interval dosing by therapeutic drug monitoring in relapsing-remitting multiple sclerosis (NEXT-MS). J Neurol Neurosurg Psychiatry 2024; 95:391. [PMID: 37963724 DOI: 10.1136/jnnp-2023-332758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 10/29/2023] [Indexed: 11/16/2023]
Affiliation(s)
- Marcus Koch
- Clinical Neurosciences, University of Calgary, Calgary, AB T2N 1N4, Canada
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6
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Toorop AA, van Lierop ZY, Gelissen LM, Hoitsma E, Zeinstra EM, van Rooij LC, van Munster CE, Vennegoor A, Mostert JP, Wokke BH, Kalkers NF, Hoogervorst EL, van Eijk JJ, Roosendaal CM, Kragt JJ, Eurelings M, van Genugten J, Nielsen J, Sinnige L, Kloosterziel ME, Arnoldus EP, van Dijk GW, Bouvy WH, Wessels MH, Boonkamp L, Strijbis EM, van Oosten BW, De Jong BA, Lissenberg-Witte BI, Barkhof F, Moraal B, Teunissen CE, Rispens T, Uitdehaag BM, Killestein J, van Kempen ZLE. Prospective trial of natalizumab personalised extended interval dosing by therapeutic drug monitoring in relapsing-remitting multiple sclerosis (NEXT-MS). J Neurol Neurosurg Psychiatry 2024; 95:392-400. [PMID: 37963723 DOI: 10.1136/jnnp-2023-332119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/05/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Extended interval dosing (EID) of natalizumab is a promising strategy to optimise treatment in multiple sclerosis (MS). Personalised EID by therapeutic drug monitoring can enable further extension of treatment intervals. METHODS The NEXT-MS trial is an investigator-initiated prospective phase IV non-randomised study. Adults with a diagnosis of relapsing-remitting MS who received ≥6 natalizumab infusions were included in three groups: personalised EID with a target drug trough concentration of 10 µg/mL (EID10), an exploratory group of personalised EID with a target of 5 µg/mL (EID5) and standard interval dosing (SID) of 4 weeks. The primary outcome is radiological disease activity (new/newly enlarged T2 lesions) comparing the EID10 group to a historical cohort of SID (HSID). RESULTS Results of the first phase of the NEXT-MS trial are reported here (n=376) as the study will continue with an amended protocol. In the EID10 group (n=251), incidence rate of radiological activity was 10.0 per 1000 person-years, which was non-inferior to the HSID cohort (24.7 per 1000 person-years (n=87), incidence rate difference 14.7, 90% CI -4.5 to 34.0). Incidence rate of radiological activity was 10.0 per 1000 person-years in the EID5 group (n=65), and 47.0 per 1000 person-years in the SID group (n=60). Serum neurofilament light levels did not increase over time within the EID groups. There were no cases of progressive multifocal leukoencephalopathy. CONCLUSIONS MS disease activity is adequately controlled with personalised natalizumab EID. Interval extension to a drug trough concentration of 5 µg/mL is likely a safe target to extend natalizumab treatment intervals >6 weeks. TRIAL REGISTRATION NUMBER NCT04225312.
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Affiliation(s)
- Alyssa A Toorop
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Zoë Ygj van Lierop
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Liza My Gelissen
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Elske Hoitsma
- Department of Neurology, MS Center, Alrijne Hospital, Leiden, The Netherlands
| | | | - Luuk C van Rooij
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Anke Vennegoor
- Department of Neurology, Flevoziekenhuis, Almere, The Netherlands
| | - Jop P Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Beatrijs Ha Wokke
- Department of Neurology, ErasMS, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nynke F Kalkers
- Department of Neurology, OLVG Hospital, Amsterdam, The Netherlands
| | | | - Jeroen Jj van Eijk
- Department of Neurology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | | | - Jolijn J Kragt
- Department of Neurology, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | | | - Jessica Nielsen
- Department of Neurology, Ommelander Hospital Groningen, Scheemda, The Netherlands
| | - Lgf Sinnige
- Department of Neurology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | | | - Edo Pj Arnoldus
- Department of Neurology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Gert W van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Willem H Bouvy
- Department of Neurology, Diakonessenhuis Hospital, Utrecht, The Netherlands
| | - Mark Hj Wessels
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Lynn Boonkamp
- Neurochemistry Laboratory, Department of Clinical Chemistry, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Eva Mm Strijbis
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Bob W van Oosten
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Brigit A De Jong
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Data Science, Vrije Universiteit Amsterdam, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
- Queen Square MS Centre, Department of Neuroinflammation, Faculty of Brain Sciences, University College London Hospitals and National Institute for Health Research, London, UK
| | - Bastiaan Moraal
- Department of Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Charlotte E Teunissen
- Neurochemistry Laboratory, Department of Clinical Chemistry, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Theo Rispens
- Diagnostic Services and Immunopathology, Sanquin Research, Amsterdam, The Netherlands
- Department of Immunopathology, Landsteiner Laboratory, University of Amsterdam, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Bernard Mj Uitdehaag
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Joep Killestein
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Zoé LE van Kempen
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
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Wu Y, Wang Q, Jia S, Lu Q, Zhao M. Gut-tropic T cells and extra-intestinal autoimmune diseases. Autoimmun Rev 2024:103544. [PMID: 38604462 DOI: 10.1016/j.autrev.2024.103544] [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: 01/11/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/13/2024]
Abstract
Gut-tropic T cells primarily originate from gut-associated lymphoid tissue (GALT), and gut-tropic integrins mediate the trafficking of the T cells to the gastrointestinal tract, where their interplay with local hormones dictates the residence of the immune cells in both normal and compromised gastrointestinal tissues. Targeting gut-tropic integrins is an effective therapy for inflammatory bowel disease (IBD). Gut-tropic T cells are further capable of entering the peripheral circulatory system and relocating to multiple organs. There is mounting evidence indicating a correlation between gut-tropic T cells and extra-intestinal autoimmune disorders. This review aims to systematically discuss the origin, migration, and residence of gut-tropic T cells and their association with extra-intestinal autoimmune-related diseases. These discoveries are expected to offer new understandings into the development of a range of autoimmune disorders, as well as innovative approaches for preventing and treating the diseases.
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Affiliation(s)
- Yutong Wu
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing 210042, China; Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, Second Xiangya Hospital, Central South University, 410011 Changsha, China
| | - Qiaolin Wang
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing 210042, China; Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing 210042, China
| | - Sujie Jia
- Department of Pharmacy, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing 210042, China
| | - Qianjin Lu
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing 210042, China; Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, Second Xiangya Hospital, Central South University, 410011 Changsha, China; Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing 210042, China.
| | - Ming Zhao
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing 210042, China; Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, Second Xiangya Hospital, Central South University, 410011 Changsha, China; Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing 210042, China.
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8
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Rabea EM, Belal MM, Hafez AH, Elbanna AH, Khalifa MA, Nourelden AZ, Mahmoud NH, Zaazouee MS. Safety and efficacy of extended versus standard interval dosing of natalizumab in multiple sclerosis patients: a systematic review and meta-analysis. Acta Neurol Belg 2024; 124:407-417. [PMID: 38457005 DOI: 10.1007/s13760-024-02480-6] [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: 09/19/2023] [Accepted: 01/12/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic inflammatory, immune-mediated disease affecting the central nervous system. Natalizumab, an FDA-approved monoclonal antibody for MS, has been explored for its off-label extended interval dosing (EID), suggesting a potential reduction in the risk of progressive multifocal leukoencephalopathy (PML) compared to standard interval dosing (SID). Our objective was to assess the efficacy and safety of EID in comparison to SID for natalizumab treatment in patients with MS. METHODS We searched PubMed, Embase, WOS, Scopus, Ovid, Science Direct, Clinical trials.gov, and Cochrane Library. Our assessed outcomes were clinical relapses, MRI activity, change in expanded disability status scale [EDSS], and the risk of PML. The EID group was defined as 5 to 8 weeks [EID (Q5-8W)]. The analysis was conducted using RevMan ver. 5.4. The effect estimates were presented as a risk ratio [RR] or mean difference with 95% confidence intervals [CI] using SID group as the reference for comparisons. RESULTS Fourteen studies met our inclusion criteria: 2 RCTs, 1 switched single-arm trial, and 12 observational studies. No significant differences were found in all efficacy outcomes of interest. Risk of clinical relapses [RR = 0.90, (95%CI 0.80, 1.02)], risk of new or newly enlarging T2 hyperintense MRI lesions [RR = 0.78, (95%CI 0.59, 1.04)], risk gadolinium enhancing lesions [RR = 1.30, (95%CI 0.98, 1.72)], change in EDSS [MD = 0.09 (95%CI - 0.57, 0.76)], risk of PML [RR = 1.09, 95%CI (0.24, 4.94)]. CONCLUSION In summary, our meta-analysis indicates that natalizumab maintains its effectiveness under extended interval dosing [up to 8 weeks], presenting comparable risks for clinical relapses, MRI lesions, EDSS, and PML. Caution is advised given study limitations and heterogeneity. Robust conclusions necessitate well-designed high-quality prospective studies.
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Affiliation(s)
| | | | | | | | | | | | - Nada H Mahmoud
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
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9
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Toljan K, Conway DS. Extended interval dosing of natalizumab: More evidence in support. Neurotherapeutics 2024; 21:e00351. [PMID: 38531713 PMCID: PMC11070702 DOI: 10.1016/j.neurot.2024.e00351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 03/17/2024] [Indexed: 03/28/2024] Open
Affiliation(s)
- Karlo Toljan
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue / U10, Cleveland, OH, 44195, USA
| | - Devon S Conway
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue / U10, Cleveland, OH, 44195, USA.
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10
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Ruggieri S, Ianniello A, Copetti M, Altieri M, Buscarinu MC, Centonze D, Cortese A, De Giglio L, Fantozzi R, Gasperini C, Grimaldi LME, Landi D, Marfia GA, Mirabella M, Nistri R, Nociti V, Oddo O, Romano S, Salemi G, Tortorella C, Pozzilli C, Petracca M. Treatment modifiers across different regimens of natalizumab treatment in MS: An Italian real-world experience. Neurotherapeutics 2024; 21:e00338. [PMID: 38413275 PMCID: PMC11070710 DOI: 10.1016/j.neurot.2024.e00338] [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: 09/25/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 02/29/2024] Open
Abstract
Despite its widespread use in clinical practice, the effectiveness of natalizumab extended interval dosing (EID) adopted from treatment start across different treatment intervals and individual modifiers (body mass index - BMI) is still under-investigated. Here, seven-hundred and forty-five multiple sclerosis (MS) patients, exposed to natalizumab for 3.30 ± 1.34 years, were retrospectively enrolled in an observational multicenter study. After stratifying patients in EID or standard interval dosing (SID), we assessed differences in time to relapse, MRI activity and Expanded Disability Status Scale (EDSS) progression. The primary analysis was conducted on patients exposed to EID interval from 5 weeks and 1 day to 7 weeks, while a secondary analysis included also EID periods up to 8 weeks. An additional analysis explored the impact of BMI. No differences in time to first relapse, time to radiological activity, time to EDSS progression or time to EDA (evidence of disease activity) were detected between SID and EID group (EID interval from 5 weeks to 1 day to 7 weeks). When including EID periods from 7 weeks and 1 day to 8 weeks, the EID group showed a trend towards higher risk of experience clinical relapses than the SID group. A higher EDA risk was also identified in EID patients with BMI above median. In conclusion, a higher risk of relapses seems to occur for EID above 7 weeks. Independently from the EID scheme adopted, higher BMI increases the risk of EDA in these patients.
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Affiliation(s)
- Serena Ruggieri
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Antonio Ianniello
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Massimiliano Copetti
- Unit of Biostatistics, IRCCS - "Casa Sollievo della Sofferenza" - Hospital, San Giovanni Rotondo (FG), Italy
| | - Marta Altieri
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Maria Chiara Buscarinu
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), "Sapienza" University of Rome, Rome, Italy; Neurology Unit, S. Andrea University Hospital, Rome, Italy
| | - Diego Centonze
- IRCCS Neuromed, Pozzilli (IS), Italy; Department of Systems Medicine, Multiple Sclerosis Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Antonio Cortese
- Multiple Sclerosis Center, Neurology Unit, San Filippo Neri Hospital, Rome, Italy
| | - Laura De Giglio
- Multiple Sclerosis Center, Neurology Unit, San Filippo Neri Hospital, Rome, Italy
| | | | - Claudio Gasperini
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Luigi M E Grimaldi
- Neurology and Multiple Sclerosis Center, Fondazione Instituto "G. Giglio", Cefalù, Italy
| | - Doriana Landi
- Department of Systems Medicine, Multiple Sclerosis Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Girolama A Marfia
- Multiple Sclerosis Center, Neurology Unit, San Filippo Neri Hospital, Rome, Italy
| | - Massimiliano Mirabella
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Riccardo Nistri
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Viviana Nociti
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Oscar Oddo
- Neurology and Multiple Sclerosis Center, Fondazione Instituto "G. Giglio", Cefalù, Italy
| | - Silvia Romano
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), "Sapienza" University of Rome, Rome, Italy; Neurology Unit, S. Andrea University Hospital, Rome, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Carlo Pozzilli
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Maria Petracca
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy.
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11
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Bernardes C, Fernandes C, Cunha C, Nunes C, Macário C, Sousa L, Batista S, Correia I. Natalizumab extended interval dosing: what about wearing-off effect? J Neurol Sci 2024; 458:122930. [PMID: 38368641 DOI: 10.1016/j.jns.2024.122930] [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: 01/08/2024] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Up to two thirds of patients with multiple sclerosis (MS) under natalizumab report a resurgence of symptoms at the end of the natalizumab cycle (wearing-off (WO) effect). At the outbreak of COVID-19, in line with the international recommendations for MS management, our centre switched all clinically stable patients on natalizumab therapy for more than one year from standard interval dosing (SID) to extended interval dosing (EID) with every six weeks infusions. This study aimed to evaluate the impact of EID in WO in MS patients under natalizumab. METHODS An observational retrospective study in patients with MS under natalizumab on EID was conducted. A questionnaire regarding current (on EID) and past (on SID) experience of WO effect was applied. RESULTS Seventy-six patients were included. No significant differences were found in the annual relapse rate after the switch to EID (p = 0.083). However, there was a significant increase in the proportion of patients complaining of WO from 38.2% to 56.6% (p = 0.001). Moreover, patients with WO on SID, referred a significant increase in severity (p = 0.019) and duration of WO symptoms (p = 0.029), due to an anticipation of the symptoms relative to the day of natalizumab infusion (p = 0.019), when switching to EID. Symptoms improved with treatment maintenance in 23.3% of patients; instead, a reduction in interval dosing was needed in 54.8% with symptom improvement. CONCLUSION WO affects a significant proportion of MS patients under natalizumab. Its prevalence, severity, and duration increase on EID, therefore despite clinical effectiveness maintenance of this posology should be individualized.
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Affiliation(s)
- Catarina Bernardes
- Neurology Department, Coimbra University Hospital Centre, Coimbra, Portugal.
| | - Catarina Fernandes
- Neurology Department, Coimbra University Hospital Centre, Coimbra, Portugal
| | - Carolina Cunha
- Neurology Department, Coimbra University Hospital Centre, Coimbra, Portugal
| | - Carla Nunes
- Neurology Department, Coimbra University Hospital Centre, Coimbra, Portugal
| | - Carmo Macário
- Neurology Department, Coimbra University Hospital Centre, Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Lívia Sousa
- Neurology Department, Coimbra University Hospital Centre, Coimbra, Portugal
| | - Sónia Batista
- Neurology Department, Coimbra University Hospital Centre, Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Inês Correia
- Neurology Department, Coimbra University Hospital Centre, Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal
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12
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Yamout B, Al-Jumah M, Sahraian MA, Almalik Y, Khaburi JA, Shalaby N, Aljarallah S, Bohlega S, Dahdaleh M, Almahdawi A, Khoury SJ, Koussa S, Slassi E, Daoudi S, Aref H, Mrabet S, Zeineddine M, Zakaria M, Inshasi J, Gouider R, Alroughani R. Consensus recommendations for diagnosis and treatment of Multiple Sclerosis: 2023 revision of the MENACTRIMS guidelines. Mult Scler Relat Disord 2024; 83:105435. [PMID: 38245998 DOI: 10.1016/j.msard.2024.105435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/21/2023] [Accepted: 01/06/2024] [Indexed: 01/23/2024]
Abstract
With evolving diagnostic criteria and the advent of new oral and parenteral therapies for Multiple Sclerosis (MS), most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and time and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of MS therapies is critical to maximize patient benefit. The current guidelines review the current diagnostic criteria for MS and the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, progressive MS, pediatric cases and pregnant women. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.
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Affiliation(s)
- B Yamout
- Neurology Institute and Multiple Sclerosis Center, Harley Street Medical Center, Abu Dhabi, United Arab Emirates.
| | - M Al-Jumah
- InterHealth hospital, Multiple Sclerosis Center, Riyadh, Saudi Arabia
| | - M A Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Y Almalik
- Division of Neurology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - J Al Khaburi
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - N Shalaby
- Neurology Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | | | - S Bohlega
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - A Almahdawi
- Consultant Neurologist, Neurology Unit, Baghdad Teaching Hospital, Medical City Complex, Iraq
| | - S J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - S Koussa
- Multiple Sclerosis Center, Geitaoui Lebanese University Hospital, Beirut, Lebanon
| | - E Slassi
- Hôpital Cheikh Khalifa Ibn Zaid, Casablanca, Morocco
| | - S Daoudi
- Hospital Center Nedir Mohamed, Faculty of Medicine, University Mouloud Mammeri Tizi-Ouzou, Algeria
| | - H Aref
- Neurology Department, Ain Shams University, Cairo, Egypt
| | - S Mrabet
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - M Zeineddine
- Middle East and North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS), Beirut, Lebanon
| | | | - J Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - R Gouider
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - R Alroughani
- Amiri Hospital, Arabian Gulf Street, Sharq, Kuwait
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13
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Abdelrahman A, Alvarez E. Advances in Multiple Sclerosis Neurotherapeutics, Neuroprotection, and Risk Mitigation Strategies. Neurol Clin 2024; 42:115-135. [PMID: 37980110 DOI: 10.1016/j.ncl.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
The treatment of patients with relapsing multiple sclerosis (MS) has advanced tremendously over the past few decades. More efficacious therapies have been approved, which can significantly reduce the inflammatory process of relapsing MS. Neuroprotection by controlling this pathophysiology is important given our current limitations to control progressive MS and induce neurorepair. Here, the authors discuss the current landscape of neurotherapeutics for relapsing MS focusing on newer disease-modifying treatments and their use. Risk mitigation of these medications can greatly improve their safety and improve their benefit-risk balance. The authors discuss treatment strategies for risk mitigation including treatment discontinuation and de-escalation.
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Affiliation(s)
- Ahmad Abdelrahman
- Department of Neurology, Rocky Mountain MS Center at the University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Enrique Alvarez
- Department of Neurology, Rocky Mountain MS Center at the University of Colorado Anschutz Medical Center, University of Colorado, Aurora, CO, USA.
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14
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Krett JD, Salter A, Newsome SD. Era of COVID-19 in Multiple Sclerosis Care. Neurol Clin 2024; 42:319-340. [PMID: 37980121 PMCID: PMC10288315 DOI: 10.1016/j.ncl.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
The unprecedented scope of the coronavirus disease 2019 (COVID-19) pandemic resulted in numerous disruptions to daily life, including for people with multiple sclerosis (PwMS). This article reviews how disruptions in multiple sclerosis (MS) care prompted innovations in delivery of care (eg, via telemedicine) and mobilized the global MS community to rapidly adopt safe and effective practices. We discuss how our understanding of the risks of COVID-19 in PwMS has evolved along with recommendations pertaining to disease-modifying therapies and vaccines. With lessons learned during the COVID-19 pandemic, we examine potential questions for future research in this new era of MS care.
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Affiliation(s)
- Jonathan D Krett
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Pathology 627, Baltimore, MD 21287, USA
| | - Amber Salter
- Section on Statistical Planning & Analysis, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Scott D Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Pathology 627, Baltimore, MD 21287, USA.
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15
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Toorop AA, Noteboom S, Steenwijk MD, Gravendeel JW, Jasperse B, Barkhof F, Strijbis EMM, Rispens T, Schoonheim MM, van Kempen ZLE, Killestein J. Exploring the effects of extended interval dosing of natalizumab and drug concentrations on brain atrophy in multiple sclerosis. Mult Scler 2024; 30:266-271. [PMID: 38235514 PMCID: PMC10851624 DOI: 10.1177/13524585231225855] [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: 11/07/2023] [Revised: 12/01/2023] [Accepted: 12/19/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Extended interval dosing (EID) of natalizumab treatment is increasingly used in multiple sclerosis. Besides the clear anti-inflammatory effect, natalizumab is considered to have neuroprotective properties as well. OBJECTIVES This study aimed to study the longitudinal effects of EID compared to standard interval dosing (SID) and natalizumab drug concentrations on brain atrophy. METHODS Patients receiving EID or SID of natalizumab with a minimum radiological follow-up of 2 years were included. Changes in brain atrophy measures over time were derived from clinical routine 3D-Fluid Attenuated Inversion Recovery (FLAIR)-weighted magnetic resonance imaging (MRI) scans using SynthSeg. RESULTS We found no differences between EID (n = 32) and SID (n = 50) for whole brain (-0.21% vs -0.16%, p = 0.42), ventricular (1.84% vs 1.13%, p = 0.24), and thalamic (-0.32% vs -0.32%, p = 0.97) annualized volume change over a median follow-up of 3.2 years. No associations between natalizumab drug concentration and brain atrophy rate were found. CONCLUSION We found no clear evidence that EID compared to SID or lower natalizumab drug concentrations have a negative impact on the development of brain atrophy over time.
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Affiliation(s)
- Alyssa A Toorop
- MS Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Samantha Noteboom
- MS Center Amsterdam, Department of Anatomy & Neurosciences, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Martijn D Steenwijk
- MS Center Amsterdam, Department of Anatomy & Neurosciences, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Job W Gravendeel
- MS Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bas Jasperse
- MS Center Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Frederik Barkhof
- MS Center Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Queen Square Institute of Neurology and Centre for Medical Image Computing, University College London, London, UK
| | - Eva MM Strijbis
- MS Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Theo Rispens
- Biologics Laboratory and Department of Immunopathology, Sanquin Diagnostic Services, Amsterdam, The Netherlands
- Landsteiner Laboratory, Academic Medical Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Menno M Schoonheim
- MS Center Amsterdam, Department of Anatomy & Neurosciences, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Zoé LE van Kempen
- MS Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Joep Killestein
- MS Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
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16
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Inojosa H, Ziemssen T. [Current and innovative Approaches to Multiple Sclerosis Therapy]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024; 92:41-60. [PMID: 38272020 DOI: 10.1055/a-2167-1391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
The landscape of immunotherapies in the management of Multiple Sclerosis (MS) is currently particularly dynamic. Over 21 immunotherapeutic options are approved by the European Meidcines Agency (EMA), Food and Drug Administration (FDA) and newer approaches are ongoing in clinical trials. With advancements in the understanding of MS pathophysiology and further development of diagnosis criteria, newer and more specific disease-modifying therapies (DMTs) have emerged in recent years. The selection and timing of proper therapeutic approaches is increasingly complex. We provide an overview of the available immunotherapies for a personalized MS treatment and discuss practical insights into their application. The importance of early intervention, distinction between escalation and induction approaches, and consideration of high-efficacy treatments for specific patient groups are in discussed. We emphasize the significance of a patient-centered approach, taking into account various factors such as comorbidities, family planning, administration preferences and potential side effects in treatment decision-making.
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17
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Khatri BO, Olapo T, Beals S, Lindman E, Perea T, Van Zealand P, Metzger RR. Lessons learned after 20 years of real-world experience with natalizumab. Mult Scler Relat Disord 2023; 80:105048. [PMID: 37866023 DOI: 10.1016/j.msard.2023.105048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/04/2023] [Accepted: 09/30/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND While natalizumab (NTZ) is an effective therapy for multiple sclerosis (MS), it is associated with an increased risk of progressive multifocal leukoencephalopathy (PML). After 20 years (2002-2022) of experience with NTZ at our center, we observed no cases of PML. OBJECTIVES We evaluated the likelihood of experiencing PML in a subset of our treatment cohort, as well as reviewed treatment practices at our center that may mitigate PML risk. METHODS For this retrospective study, we reviewed patient characteristics, treatment practices, and clinical and MRI findings in patients receiving NTZ from 2006 to 2020. Observation of no PML cases was compared to the global and US PML incidences, and to the expected incidence based on published risk estimates. RESULTS 766 patients were evaluated. The number of NTZ infusions received ranged from 1 to 126, with a mean of 28. Patients received neurological examination prior to each infusion, which sometimes resulted in a pause in therapy to rule out PML if clinical worsening occurred. Extended interval dosing (EID) was the overall dosing schedule for 31% of patients. EID did not result in higher rates of radiological disease worsening than standard interval dosing (SID) patients. Depending on the analysis conducted, the finding of 0 PML cases in our cohort ranged from slightly unexpected to slightly expected. CONCLUSIONS The utilization of EID as well as regular clinical monitoring of patients may have lowered PML risk while still maintaining NTZ efficacy.
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Affiliation(s)
- Bhupendra O Khatri
- The Regional MS Center, Center for Neurological Disorders SC, Ascension St. Francis Hospital, 3237 S. 16th Street, Milwaukee, WI 53215, United States.
| | - Tayo Olapo
- The Regional MS Center, Center for Neurological Disorders SC, Ascension St. Francis Hospital, 3237 S. 16th Street, Milwaukee, WI 53215, United States
| | - Sara Beals
- The Regional MS Center, Center for Neurological Disorders SC, Ascension St. Francis Hospital, 3237 S. 16th Street, Milwaukee, WI 53215, United States
| | - Emily Lindman
- The Regional MS Center, Center for Neurological Disorders SC, Ascension St. Francis Hospital, 3237 S. 16th Street, Milwaukee, WI 53215, United States
| | - Toni Perea
- The Regional MS Center, Center for Neurological Disorders SC, Ascension St. Francis Hospital, 3237 S. 16th Street, Milwaukee, WI 53215, United States
| | - Pamela Van Zealand
- The Regional MS Center, Center for Neurological Disorders SC, Ascension St. Francis Hospital, 3237 S. 16th Street, Milwaukee, WI 53215, United States
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18
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Rempe T, Elfasi A, Rodriguez E, Vasquez M, Graves J, Kinkel R. Ocrelizumab B-cell repopulation-guided extended interval dosing versus standard dosing - similar clinical efficacy with decreased immunoglobulin M deficiency rates. Mult Scler Relat Disord 2023; 79:105028. [PMID: 37813071 DOI: 10.1016/j.msard.2023.105028] [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: 05/14/2023] [Revised: 09/07/2023] [Accepted: 09/23/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Ocrelizumab (OCR) is a humanized anti-CD20 monoclonal antibody used in treatment of multiple sclerosis. The standard dosing (SD) regimen consists of OCR maintenance infusions every 6 months. In B-cell repopulation-guided extended interval dosing (EID), repeat infusions are delayed until there is evidence for B-cell repopulation. OBJECTIVES To compare frequencies of 'no evidence of disease activity' (NEDA-3) and immunoglobulin G (hypo-IgG; <600 mg/dL) and M (hypo-IgM; <40 mg/dL) deficiencies in persons with multiple sclerosis (PwMS) treated with OCR B-cell repopulation-guided EID versus SD. METHODS Two-center retrospective study comparing frequencies of NEDA-3 and hypo-IgG and hypo-IgM in PwMS treated with OCR B-cell repopulation-guided EID versus SD using a multivariate generalized linear model adjusted for age, sex, and treatment duration. RESULTS A total of 112 OCR-treated PwMS were included (B-cell repopulation-guided EID n = 52; SD n = 60) with average infusion intervals of 319 (246-485) days (EID) and 184 (170-218) days (SD). There was no significant difference in NEDA-3 (EID: 47/52 [90.4 %]; SD: 50/60 [83.3 %]; p = 0.161) or hypo-IgG (EID: 1/52 [1.9 %]; SD: 4/60 [6.7 %]; p = 0.298) rates. Hypo-IgM was significantly less common in EID (EID: 9/52 [17.3 %] vs. SD: 34/60 [55 %]; p<0.001) upon assessment 1099 (475-1436) days (EID) and 980 (409-1846) days (SD) post-initiation of OCR. Hypo-IgM was associated with average infusion interval length (p = 0.005) and total number of OCR cycles (p = 0.003). CONCLUSIONS OCR B-cell repopulation-guided EID may be a safe alternative to traditional SD with similar efficacy and significantly less hypo-IgM rates.
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Affiliation(s)
- Torge Rempe
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA; Department of Neurosciences, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Aisha Elfasi
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Elsa Rodriguez
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Matthew Vasquez
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Jennifer Graves
- Department of Neurosciences, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Revere Kinkel
- Department of Neurosciences, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
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O'Leary S, Brugger HT, Wallentine D, Sershon L, Goff E, Saldana-King T, Beavin J, Avila RL, Rutledge D, Moore M. Practical Clinical Guidelines for Natalizumab Treatment in Patients With Relapsing Multiple Sclerosis. JOURNAL OF INFUSION NURSING 2023; 46:347-359. [PMID: 37920108 PMCID: PMC10635346 DOI: 10.1097/nan.0000000000000519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Natalizumab (TYSABRI®) was the first high-efficacy monoclonal antibody disease-modifying therapy (DMT) approved as a monotherapy for the treatment of adults with relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome, relapsing-remitting MS, and active secondary progressive MS. Because natalizumab is administered by intravenous infusion, infusion nurses play a key role in the care of natalizumab-treated patients. In the 16 years since approval, substantial data have been gathered on the long-term, real-world effectiveness and safety of natalizumab. This article provides a synopsis of this data, as well as practical information for optimizing patient care. This includes information on strategies to mitigate the risk of progressive multifocal leukoencephalopathy in natalizumab-treated patients, natalizumab use during pregnancy, and use with vaccines. It also includes guidance on the preparation and administration of natalizumab and monitoring of natalizumab-treated patients.
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Affiliation(s)
- Shirley O'Leary
- Corresponding Author: Shirley O'Leary, MS, APN-C, MSCN, Dallas VA Medical Center, MS Center, 4500 S Lancaster Road, Dallas, TX 75216 ()
| | - Helen T. Brugger
- Dallas VA Medical Center MS Center, Dallas, Texas (Ms O'Leary); Long Ridge Medical Center, Neurology, Greenwich Hospital, Stamford, Connecticut (Ms Brugger); Rocky Mountain MS Clinic, Salt Lake City, Utah (Mr Wallentine); The Regional MS Center & The Center for Neurological Disorders, Milwaukee, Wisconsin (Ms Sershon); University of Alabama at Birmingham, Birmingham, Alabama (Ms Goff); Biogen, Cambridge, Massachusetts (Mss Saldana-King and Beavin; Drs Avila and Rutledge); Novant MS Care Center, Charlotte, North Carolina (Ms Moore)
- Shirley O'Leary, MS, APN-C, MSCN, has practiced as a provider, subinvestigator/researcher, and neurology infusion manager for 7 years at the MS Center of Excellence at the Dallas VA Medical Center. She has 27 years of experience in the area of multiple sclerosis (MS) and has authored articles, given numerous invited talks, and is a longstanding member of the International Organization of MS Nurses
- Helen T. Brugger, DNP, MSN, RN, Coordinator of Long Ridge Infusion Center at Long Ridge Medical Center, Greenwich Hospital, has worked on 2 intravenous teams and currently treats a population of neurological patients at an outpatient infusion center. She is a member of the Eastern Nursing Research Society and Sigma Theta Tau International
- Dale Wallentine, BSN, RN, MSCN, is an infusion nurse and the infusion department operation manager at the Rocky Mountain Multiple Sclerosis Clinic in Salt Lake City. He has more than 13 years of multiple sclerosis infusion experience and is certified in multiple sclerosis nursing
- Lisa Sershon, PA-C, MMS, MSCS,* practiced for 11 years as a physician's assistant specializing in neuroimmunology, at the Center for Neurological Disorders at Ascension St. Francis in Milwaukee, Wisconsin. She participated in the management and protocol development for infusion therapies as a multiple sclerosis–certified specialist
- Erica Goff, PharmD, BCPS, MSCS, is a specialty pharmacist covering the multiple sclerosis population at the outpatient neurology division at University of Alabama at Birmingham Health System. Her professional responsibilities include clinical guidance, oversight, and patient education for pharmacotherapy prescribed in her ambulatory clinic, as well as facilitating access to medication, providing side-effect mitigation strategies and reductions in patient financial burden
- Toni Saldana-King, RN, BSN, MSCN, was a senior medical science liaison at Biogen at the time of submission. Prior to Biogen, she was a practicing nurse at the Maxine Mesinger MS Comprehensive Care Center at Baylor College of Medicine in Houston, Texas, the first Comprehensive Care Center to be recognized by the National MS Society
- Jill Beavin, BSN, RN, MSCN, is a principle medical science liaison at Biogen. Prior to Biogen, she worked as an MS nurse and clinical director in a private neurology practice, where she developed and maintained a 22-chair infusion suite and MS Center
- Robin L. Avila, PhD, is a medical director at Biogen and has been involved in MS clinical research for the last 6 years. Prior to Biogen, she conducted preclinical MS research in the areas of myelin biology, myelin repair, and the development of novel models of MS
- Danette Rutledge, BSP, PhD, is an associate medical director at Biogen, where she has been involved in MS clinical research for the last 3 years. Prior to joining industry, she conducted basic science research in multiple sclerosis for over 10 years
- Marie Moore, FNP-C, MSCN, President of the International Organization of Multiple Sclerosis Nurses, is a nurse practitioner at the Novant Health Multiple Sclerosis Care center in Charlotte, North Carolina, where she participates in research and oversight of the infusion center. She has specialized in the care of multiple sclerosis patients since 2011
| | - Dale Wallentine
- Dallas VA Medical Center MS Center, Dallas, Texas (Ms O'Leary); Long Ridge Medical Center, Neurology, Greenwich Hospital, Stamford, Connecticut (Ms Brugger); Rocky Mountain MS Clinic, Salt Lake City, Utah (Mr Wallentine); The Regional MS Center & The Center for Neurological Disorders, Milwaukee, Wisconsin (Ms Sershon); University of Alabama at Birmingham, Birmingham, Alabama (Ms Goff); Biogen, Cambridge, Massachusetts (Mss Saldana-King and Beavin; Drs Avila and Rutledge); Novant MS Care Center, Charlotte, North Carolina (Ms Moore)
- Shirley O'Leary, MS, APN-C, MSCN, has practiced as a provider, subinvestigator/researcher, and neurology infusion manager for 7 years at the MS Center of Excellence at the Dallas VA Medical Center. She has 27 years of experience in the area of multiple sclerosis (MS) and has authored articles, given numerous invited talks, and is a longstanding member of the International Organization of MS Nurses
- Helen T. Brugger, DNP, MSN, RN, Coordinator of Long Ridge Infusion Center at Long Ridge Medical Center, Greenwich Hospital, has worked on 2 intravenous teams and currently treats a population of neurological patients at an outpatient infusion center. She is a member of the Eastern Nursing Research Society and Sigma Theta Tau International
- Dale Wallentine, BSN, RN, MSCN, is an infusion nurse and the infusion department operation manager at the Rocky Mountain Multiple Sclerosis Clinic in Salt Lake City. He has more than 13 years of multiple sclerosis infusion experience and is certified in multiple sclerosis nursing
- Lisa Sershon, PA-C, MMS, MSCS,* practiced for 11 years as a physician's assistant specializing in neuroimmunology, at the Center for Neurological Disorders at Ascension St. Francis in Milwaukee, Wisconsin. She participated in the management and protocol development for infusion therapies as a multiple sclerosis–certified specialist
- Erica Goff, PharmD, BCPS, MSCS, is a specialty pharmacist covering the multiple sclerosis population at the outpatient neurology division at University of Alabama at Birmingham Health System. Her professional responsibilities include clinical guidance, oversight, and patient education for pharmacotherapy prescribed in her ambulatory clinic, as well as facilitating access to medication, providing side-effect mitigation strategies and reductions in patient financial burden
- Toni Saldana-King, RN, BSN, MSCN, was a senior medical science liaison at Biogen at the time of submission. Prior to Biogen, she was a practicing nurse at the Maxine Mesinger MS Comprehensive Care Center at Baylor College of Medicine in Houston, Texas, the first Comprehensive Care Center to be recognized by the National MS Society
- Jill Beavin, BSN, RN, MSCN, is a principle medical science liaison at Biogen. Prior to Biogen, she worked as an MS nurse and clinical director in a private neurology practice, where she developed and maintained a 22-chair infusion suite and MS Center
- Robin L. Avila, PhD, is a medical director at Biogen and has been involved in MS clinical research for the last 6 years. Prior to Biogen, she conducted preclinical MS research in the areas of myelin biology, myelin repair, and the development of novel models of MS
- Danette Rutledge, BSP, PhD, is an associate medical director at Biogen, where she has been involved in MS clinical research for the last 3 years. Prior to joining industry, she conducted basic science research in multiple sclerosis for over 10 years
- Marie Moore, FNP-C, MSCN, President of the International Organization of Multiple Sclerosis Nurses, is a nurse practitioner at the Novant Health Multiple Sclerosis Care center in Charlotte, North Carolina, where she participates in research and oversight of the infusion center. She has specialized in the care of multiple sclerosis patients since 2011
| | - Lisa Sershon
- Dallas VA Medical Center MS Center, Dallas, Texas (Ms O'Leary); Long Ridge Medical Center, Neurology, Greenwich Hospital, Stamford, Connecticut (Ms Brugger); Rocky Mountain MS Clinic, Salt Lake City, Utah (Mr Wallentine); The Regional MS Center & The Center for Neurological Disorders, Milwaukee, Wisconsin (Ms Sershon); University of Alabama at Birmingham, Birmingham, Alabama (Ms Goff); Biogen, Cambridge, Massachusetts (Mss Saldana-King and Beavin; Drs Avila and Rutledge); Novant MS Care Center, Charlotte, North Carolina (Ms Moore)
- Shirley O'Leary, MS, APN-C, MSCN, has practiced as a provider, subinvestigator/researcher, and neurology infusion manager for 7 years at the MS Center of Excellence at the Dallas VA Medical Center. She has 27 years of experience in the area of multiple sclerosis (MS) and has authored articles, given numerous invited talks, and is a longstanding member of the International Organization of MS Nurses
- Helen T. Brugger, DNP, MSN, RN, Coordinator of Long Ridge Infusion Center at Long Ridge Medical Center, Greenwich Hospital, has worked on 2 intravenous teams and currently treats a population of neurological patients at an outpatient infusion center. She is a member of the Eastern Nursing Research Society and Sigma Theta Tau International
- Dale Wallentine, BSN, RN, MSCN, is an infusion nurse and the infusion department operation manager at the Rocky Mountain Multiple Sclerosis Clinic in Salt Lake City. He has more than 13 years of multiple sclerosis infusion experience and is certified in multiple sclerosis nursing
- Lisa Sershon, PA-C, MMS, MSCS,* practiced for 11 years as a physician's assistant specializing in neuroimmunology, at the Center for Neurological Disorders at Ascension St. Francis in Milwaukee, Wisconsin. She participated in the management and protocol development for infusion therapies as a multiple sclerosis–certified specialist
- Erica Goff, PharmD, BCPS, MSCS, is a specialty pharmacist covering the multiple sclerosis population at the outpatient neurology division at University of Alabama at Birmingham Health System. Her professional responsibilities include clinical guidance, oversight, and patient education for pharmacotherapy prescribed in her ambulatory clinic, as well as facilitating access to medication, providing side-effect mitigation strategies and reductions in patient financial burden
- Toni Saldana-King, RN, BSN, MSCN, was a senior medical science liaison at Biogen at the time of submission. Prior to Biogen, she was a practicing nurse at the Maxine Mesinger MS Comprehensive Care Center at Baylor College of Medicine in Houston, Texas, the first Comprehensive Care Center to be recognized by the National MS Society
- Jill Beavin, BSN, RN, MSCN, is a principle medical science liaison at Biogen. Prior to Biogen, she worked as an MS nurse and clinical director in a private neurology practice, where she developed and maintained a 22-chair infusion suite and MS Center
- Robin L. Avila, PhD, is a medical director at Biogen and has been involved in MS clinical research for the last 6 years. Prior to Biogen, she conducted preclinical MS research in the areas of myelin biology, myelin repair, and the development of novel models of MS
- Danette Rutledge, BSP, PhD, is an associate medical director at Biogen, where she has been involved in MS clinical research for the last 3 years. Prior to joining industry, she conducted basic science research in multiple sclerosis for over 10 years
- Marie Moore, FNP-C, MSCN, President of the International Organization of Multiple Sclerosis Nurses, is a nurse practitioner at the Novant Health Multiple Sclerosis Care center in Charlotte, North Carolina, where she participates in research and oversight of the infusion center. She has specialized in the care of multiple sclerosis patients since 2011
| | - Erica Goff
- Dallas VA Medical Center MS Center, Dallas, Texas (Ms O'Leary); Long Ridge Medical Center, Neurology, Greenwich Hospital, Stamford, Connecticut (Ms Brugger); Rocky Mountain MS Clinic, Salt Lake City, Utah (Mr Wallentine); The Regional MS Center & The Center for Neurological Disorders, Milwaukee, Wisconsin (Ms Sershon); University of Alabama at Birmingham, Birmingham, Alabama (Ms Goff); Biogen, Cambridge, Massachusetts (Mss Saldana-King and Beavin; Drs Avila and Rutledge); Novant MS Care Center, Charlotte, North Carolina (Ms Moore)
- Shirley O'Leary, MS, APN-C, MSCN, has practiced as a provider, subinvestigator/researcher, and neurology infusion manager for 7 years at the MS Center of Excellence at the Dallas VA Medical Center. She has 27 years of experience in the area of multiple sclerosis (MS) and has authored articles, given numerous invited talks, and is a longstanding member of the International Organization of MS Nurses
- Helen T. Brugger, DNP, MSN, RN, Coordinator of Long Ridge Infusion Center at Long Ridge Medical Center, Greenwich Hospital, has worked on 2 intravenous teams and currently treats a population of neurological patients at an outpatient infusion center. She is a member of the Eastern Nursing Research Society and Sigma Theta Tau International
- Dale Wallentine, BSN, RN, MSCN, is an infusion nurse and the infusion department operation manager at the Rocky Mountain Multiple Sclerosis Clinic in Salt Lake City. He has more than 13 years of multiple sclerosis infusion experience and is certified in multiple sclerosis nursing
- Lisa Sershon, PA-C, MMS, MSCS,* practiced for 11 years as a physician's assistant specializing in neuroimmunology, at the Center for Neurological Disorders at Ascension St. Francis in Milwaukee, Wisconsin. She participated in the management and protocol development for infusion therapies as a multiple sclerosis–certified specialist
- Erica Goff, PharmD, BCPS, MSCS, is a specialty pharmacist covering the multiple sclerosis population at the outpatient neurology division at University of Alabama at Birmingham Health System. Her professional responsibilities include clinical guidance, oversight, and patient education for pharmacotherapy prescribed in her ambulatory clinic, as well as facilitating access to medication, providing side-effect mitigation strategies and reductions in patient financial burden
- Toni Saldana-King, RN, BSN, MSCN, was a senior medical science liaison at Biogen at the time of submission. Prior to Biogen, she was a practicing nurse at the Maxine Mesinger MS Comprehensive Care Center at Baylor College of Medicine in Houston, Texas, the first Comprehensive Care Center to be recognized by the National MS Society
- Jill Beavin, BSN, RN, MSCN, is a principle medical science liaison at Biogen. Prior to Biogen, she worked as an MS nurse and clinical director in a private neurology practice, where she developed and maintained a 22-chair infusion suite and MS Center
- Robin L. Avila, PhD, is a medical director at Biogen and has been involved in MS clinical research for the last 6 years. Prior to Biogen, she conducted preclinical MS research in the areas of myelin biology, myelin repair, and the development of novel models of MS
- Danette Rutledge, BSP, PhD, is an associate medical director at Biogen, where she has been involved in MS clinical research for the last 3 years. Prior to joining industry, she conducted basic science research in multiple sclerosis for over 10 years
- Marie Moore, FNP-C, MSCN, President of the International Organization of Multiple Sclerosis Nurses, is a nurse practitioner at the Novant Health Multiple Sclerosis Care center in Charlotte, North Carolina, where she participates in research and oversight of the infusion center. She has specialized in the care of multiple sclerosis patients since 2011
| | - Toni Saldana-King
- Dallas VA Medical Center MS Center, Dallas, Texas (Ms O'Leary); Long Ridge Medical Center, Neurology, Greenwich Hospital, Stamford, Connecticut (Ms Brugger); Rocky Mountain MS Clinic, Salt Lake City, Utah (Mr Wallentine); The Regional MS Center & The Center for Neurological Disorders, Milwaukee, Wisconsin (Ms Sershon); University of Alabama at Birmingham, Birmingham, Alabama (Ms Goff); Biogen, Cambridge, Massachusetts (Mss Saldana-King and Beavin; Drs Avila and Rutledge); Novant MS Care Center, Charlotte, North Carolina (Ms Moore)
- Shirley O'Leary, MS, APN-C, MSCN, has practiced as a provider, subinvestigator/researcher, and neurology infusion manager for 7 years at the MS Center of Excellence at the Dallas VA Medical Center. She has 27 years of experience in the area of multiple sclerosis (MS) and has authored articles, given numerous invited talks, and is a longstanding member of the International Organization of MS Nurses
- Helen T. Brugger, DNP, MSN, RN, Coordinator of Long Ridge Infusion Center at Long Ridge Medical Center, Greenwich Hospital, has worked on 2 intravenous teams and currently treats a population of neurological patients at an outpatient infusion center. She is a member of the Eastern Nursing Research Society and Sigma Theta Tau International
- Dale Wallentine, BSN, RN, MSCN, is an infusion nurse and the infusion department operation manager at the Rocky Mountain Multiple Sclerosis Clinic in Salt Lake City. He has more than 13 years of multiple sclerosis infusion experience and is certified in multiple sclerosis nursing
- Lisa Sershon, PA-C, MMS, MSCS,* practiced for 11 years as a physician's assistant specializing in neuroimmunology, at the Center for Neurological Disorders at Ascension St. Francis in Milwaukee, Wisconsin. She participated in the management and protocol development for infusion therapies as a multiple sclerosis–certified specialist
- Erica Goff, PharmD, BCPS, MSCS, is a specialty pharmacist covering the multiple sclerosis population at the outpatient neurology division at University of Alabama at Birmingham Health System. Her professional responsibilities include clinical guidance, oversight, and patient education for pharmacotherapy prescribed in her ambulatory clinic, as well as facilitating access to medication, providing side-effect mitigation strategies and reductions in patient financial burden
- Toni Saldana-King, RN, BSN, MSCN, was a senior medical science liaison at Biogen at the time of submission. Prior to Biogen, she was a practicing nurse at the Maxine Mesinger MS Comprehensive Care Center at Baylor College of Medicine in Houston, Texas, the first Comprehensive Care Center to be recognized by the National MS Society
- Jill Beavin, BSN, RN, MSCN, is a principle medical science liaison at Biogen. Prior to Biogen, she worked as an MS nurse and clinical director in a private neurology practice, where she developed and maintained a 22-chair infusion suite and MS Center
- Robin L. Avila, PhD, is a medical director at Biogen and has been involved in MS clinical research for the last 6 years. Prior to Biogen, she conducted preclinical MS research in the areas of myelin biology, myelin repair, and the development of novel models of MS
- Danette Rutledge, BSP, PhD, is an associate medical director at Biogen, where she has been involved in MS clinical research for the last 3 years. Prior to joining industry, she conducted basic science research in multiple sclerosis for over 10 years
- Marie Moore, FNP-C, MSCN, President of the International Organization of Multiple Sclerosis Nurses, is a nurse practitioner at the Novant Health Multiple Sclerosis Care center in Charlotte, North Carolina, where she participates in research and oversight of the infusion center. She has specialized in the care of multiple sclerosis patients since 2011
| | - Jill Beavin
- Dallas VA Medical Center MS Center, Dallas, Texas (Ms O'Leary); Long Ridge Medical Center, Neurology, Greenwich Hospital, Stamford, Connecticut (Ms Brugger); Rocky Mountain MS Clinic, Salt Lake City, Utah (Mr Wallentine); The Regional MS Center & The Center for Neurological Disorders, Milwaukee, Wisconsin (Ms Sershon); University of Alabama at Birmingham, Birmingham, Alabama (Ms Goff); Biogen, Cambridge, Massachusetts (Mss Saldana-King and Beavin; Drs Avila and Rutledge); Novant MS Care Center, Charlotte, North Carolina (Ms Moore)
- Shirley O'Leary, MS, APN-C, MSCN, has practiced as a provider, subinvestigator/researcher, and neurology infusion manager for 7 years at the MS Center of Excellence at the Dallas VA Medical Center. She has 27 years of experience in the area of multiple sclerosis (MS) and has authored articles, given numerous invited talks, and is a longstanding member of the International Organization of MS Nurses
- Helen T. Brugger, DNP, MSN, RN, Coordinator of Long Ridge Infusion Center at Long Ridge Medical Center, Greenwich Hospital, has worked on 2 intravenous teams and currently treats a population of neurological patients at an outpatient infusion center. She is a member of the Eastern Nursing Research Society and Sigma Theta Tau International
- Dale Wallentine, BSN, RN, MSCN, is an infusion nurse and the infusion department operation manager at the Rocky Mountain Multiple Sclerosis Clinic in Salt Lake City. He has more than 13 years of multiple sclerosis infusion experience and is certified in multiple sclerosis nursing
- Lisa Sershon, PA-C, MMS, MSCS,* practiced for 11 years as a physician's assistant specializing in neuroimmunology, at the Center for Neurological Disorders at Ascension St. Francis in Milwaukee, Wisconsin. She participated in the management and protocol development for infusion therapies as a multiple sclerosis–certified specialist
- Erica Goff, PharmD, BCPS, MSCS, is a specialty pharmacist covering the multiple sclerosis population at the outpatient neurology division at University of Alabama at Birmingham Health System. Her professional responsibilities include clinical guidance, oversight, and patient education for pharmacotherapy prescribed in her ambulatory clinic, as well as facilitating access to medication, providing side-effect mitigation strategies and reductions in patient financial burden
- Toni Saldana-King, RN, BSN, MSCN, was a senior medical science liaison at Biogen at the time of submission. Prior to Biogen, she was a practicing nurse at the Maxine Mesinger MS Comprehensive Care Center at Baylor College of Medicine in Houston, Texas, the first Comprehensive Care Center to be recognized by the National MS Society
- Jill Beavin, BSN, RN, MSCN, is a principle medical science liaison at Biogen. Prior to Biogen, she worked as an MS nurse and clinical director in a private neurology practice, where she developed and maintained a 22-chair infusion suite and MS Center
- Robin L. Avila, PhD, is a medical director at Biogen and has been involved in MS clinical research for the last 6 years. Prior to Biogen, she conducted preclinical MS research in the areas of myelin biology, myelin repair, and the development of novel models of MS
- Danette Rutledge, BSP, PhD, is an associate medical director at Biogen, where she has been involved in MS clinical research for the last 3 years. Prior to joining industry, she conducted basic science research in multiple sclerosis for over 10 years
- Marie Moore, FNP-C, MSCN, President of the International Organization of Multiple Sclerosis Nurses, is a nurse practitioner at the Novant Health Multiple Sclerosis Care center in Charlotte, North Carolina, where she participates in research and oversight of the infusion center. She has specialized in the care of multiple sclerosis patients since 2011
| | - Robin L. Avila
- Dallas VA Medical Center MS Center, Dallas, Texas (Ms O'Leary); Long Ridge Medical Center, Neurology, Greenwich Hospital, Stamford, Connecticut (Ms Brugger); Rocky Mountain MS Clinic, Salt Lake City, Utah (Mr Wallentine); The Regional MS Center & The Center for Neurological Disorders, Milwaukee, Wisconsin (Ms Sershon); University of Alabama at Birmingham, Birmingham, Alabama (Ms Goff); Biogen, Cambridge, Massachusetts (Mss Saldana-King and Beavin; Drs Avila and Rutledge); Novant MS Care Center, Charlotte, North Carolina (Ms Moore)
- Shirley O'Leary, MS, APN-C, MSCN, has practiced as a provider, subinvestigator/researcher, and neurology infusion manager for 7 years at the MS Center of Excellence at the Dallas VA Medical Center. She has 27 years of experience in the area of multiple sclerosis (MS) and has authored articles, given numerous invited talks, and is a longstanding member of the International Organization of MS Nurses
- Helen T. Brugger, DNP, MSN, RN, Coordinator of Long Ridge Infusion Center at Long Ridge Medical Center, Greenwich Hospital, has worked on 2 intravenous teams and currently treats a population of neurological patients at an outpatient infusion center. She is a member of the Eastern Nursing Research Society and Sigma Theta Tau International
- Dale Wallentine, BSN, RN, MSCN, is an infusion nurse and the infusion department operation manager at the Rocky Mountain Multiple Sclerosis Clinic in Salt Lake City. He has more than 13 years of multiple sclerosis infusion experience and is certified in multiple sclerosis nursing
- Lisa Sershon, PA-C, MMS, MSCS,* practiced for 11 years as a physician's assistant specializing in neuroimmunology, at the Center for Neurological Disorders at Ascension St. Francis in Milwaukee, Wisconsin. She participated in the management and protocol development for infusion therapies as a multiple sclerosis–certified specialist
- Erica Goff, PharmD, BCPS, MSCS, is a specialty pharmacist covering the multiple sclerosis population at the outpatient neurology division at University of Alabama at Birmingham Health System. Her professional responsibilities include clinical guidance, oversight, and patient education for pharmacotherapy prescribed in her ambulatory clinic, as well as facilitating access to medication, providing side-effect mitigation strategies and reductions in patient financial burden
- Toni Saldana-King, RN, BSN, MSCN, was a senior medical science liaison at Biogen at the time of submission. Prior to Biogen, she was a practicing nurse at the Maxine Mesinger MS Comprehensive Care Center at Baylor College of Medicine in Houston, Texas, the first Comprehensive Care Center to be recognized by the National MS Society
- Jill Beavin, BSN, RN, MSCN, is a principle medical science liaison at Biogen. Prior to Biogen, she worked as an MS nurse and clinical director in a private neurology practice, where she developed and maintained a 22-chair infusion suite and MS Center
- Robin L. Avila, PhD, is a medical director at Biogen and has been involved in MS clinical research for the last 6 years. Prior to Biogen, she conducted preclinical MS research in the areas of myelin biology, myelin repair, and the development of novel models of MS
- Danette Rutledge, BSP, PhD, is an associate medical director at Biogen, where she has been involved in MS clinical research for the last 3 years. Prior to joining industry, she conducted basic science research in multiple sclerosis for over 10 years
- Marie Moore, FNP-C, MSCN, President of the International Organization of Multiple Sclerosis Nurses, is a nurse practitioner at the Novant Health Multiple Sclerosis Care center in Charlotte, North Carolina, where she participates in research and oversight of the infusion center. She has specialized in the care of multiple sclerosis patients since 2011
| | - Danette Rutledge
- Dallas VA Medical Center MS Center, Dallas, Texas (Ms O'Leary); Long Ridge Medical Center, Neurology, Greenwich Hospital, Stamford, Connecticut (Ms Brugger); Rocky Mountain MS Clinic, Salt Lake City, Utah (Mr Wallentine); The Regional MS Center & The Center for Neurological Disorders, Milwaukee, Wisconsin (Ms Sershon); University of Alabama at Birmingham, Birmingham, Alabama (Ms Goff); Biogen, Cambridge, Massachusetts (Mss Saldana-King and Beavin; Drs Avila and Rutledge); Novant MS Care Center, Charlotte, North Carolina (Ms Moore)
- Shirley O'Leary, MS, APN-C, MSCN, has practiced as a provider, subinvestigator/researcher, and neurology infusion manager for 7 years at the MS Center of Excellence at the Dallas VA Medical Center. She has 27 years of experience in the area of multiple sclerosis (MS) and has authored articles, given numerous invited talks, and is a longstanding member of the International Organization of MS Nurses
- Helen T. Brugger, DNP, MSN, RN, Coordinator of Long Ridge Infusion Center at Long Ridge Medical Center, Greenwich Hospital, has worked on 2 intravenous teams and currently treats a population of neurological patients at an outpatient infusion center. She is a member of the Eastern Nursing Research Society and Sigma Theta Tau International
- Dale Wallentine, BSN, RN, MSCN, is an infusion nurse and the infusion department operation manager at the Rocky Mountain Multiple Sclerosis Clinic in Salt Lake City. He has more than 13 years of multiple sclerosis infusion experience and is certified in multiple sclerosis nursing
- Lisa Sershon, PA-C, MMS, MSCS,* practiced for 11 years as a physician's assistant specializing in neuroimmunology, at the Center for Neurological Disorders at Ascension St. Francis in Milwaukee, Wisconsin. She participated in the management and protocol development for infusion therapies as a multiple sclerosis–certified specialist
- Erica Goff, PharmD, BCPS, MSCS, is a specialty pharmacist covering the multiple sclerosis population at the outpatient neurology division at University of Alabama at Birmingham Health System. Her professional responsibilities include clinical guidance, oversight, and patient education for pharmacotherapy prescribed in her ambulatory clinic, as well as facilitating access to medication, providing side-effect mitigation strategies and reductions in patient financial burden
- Toni Saldana-King, RN, BSN, MSCN, was a senior medical science liaison at Biogen at the time of submission. Prior to Biogen, she was a practicing nurse at the Maxine Mesinger MS Comprehensive Care Center at Baylor College of Medicine in Houston, Texas, the first Comprehensive Care Center to be recognized by the National MS Society
- Jill Beavin, BSN, RN, MSCN, is a principle medical science liaison at Biogen. Prior to Biogen, she worked as an MS nurse and clinical director in a private neurology practice, where she developed and maintained a 22-chair infusion suite and MS Center
- Robin L. Avila, PhD, is a medical director at Biogen and has been involved in MS clinical research for the last 6 years. Prior to Biogen, she conducted preclinical MS research in the areas of myelin biology, myelin repair, and the development of novel models of MS
- Danette Rutledge, BSP, PhD, is an associate medical director at Biogen, where she has been involved in MS clinical research for the last 3 years. Prior to joining industry, she conducted basic science research in multiple sclerosis for over 10 years
- Marie Moore, FNP-C, MSCN, President of the International Organization of Multiple Sclerosis Nurses, is a nurse practitioner at the Novant Health Multiple Sclerosis Care center in Charlotte, North Carolina, where she participates in research and oversight of the infusion center. She has specialized in the care of multiple sclerosis patients since 2011
| | - Marie Moore
- Dallas VA Medical Center MS Center, Dallas, Texas (Ms O'Leary); Long Ridge Medical Center, Neurology, Greenwich Hospital, Stamford, Connecticut (Ms Brugger); Rocky Mountain MS Clinic, Salt Lake City, Utah (Mr Wallentine); The Regional MS Center & The Center for Neurological Disorders, Milwaukee, Wisconsin (Ms Sershon); University of Alabama at Birmingham, Birmingham, Alabama (Ms Goff); Biogen, Cambridge, Massachusetts (Mss Saldana-King and Beavin; Drs Avila and Rutledge); Novant MS Care Center, Charlotte, North Carolina (Ms Moore)
- Shirley O'Leary, MS, APN-C, MSCN, has practiced as a provider, subinvestigator/researcher, and neurology infusion manager for 7 years at the MS Center of Excellence at the Dallas VA Medical Center. She has 27 years of experience in the area of multiple sclerosis (MS) and has authored articles, given numerous invited talks, and is a longstanding member of the International Organization of MS Nurses
- Helen T. Brugger, DNP, MSN, RN, Coordinator of Long Ridge Infusion Center at Long Ridge Medical Center, Greenwich Hospital, has worked on 2 intravenous teams and currently treats a population of neurological patients at an outpatient infusion center. She is a member of the Eastern Nursing Research Society and Sigma Theta Tau International
- Dale Wallentine, BSN, RN, MSCN, is an infusion nurse and the infusion department operation manager at the Rocky Mountain Multiple Sclerosis Clinic in Salt Lake City. He has more than 13 years of multiple sclerosis infusion experience and is certified in multiple sclerosis nursing
- Lisa Sershon, PA-C, MMS, MSCS,* practiced for 11 years as a physician's assistant specializing in neuroimmunology, at the Center for Neurological Disorders at Ascension St. Francis in Milwaukee, Wisconsin. She participated in the management and protocol development for infusion therapies as a multiple sclerosis–certified specialist
- Erica Goff, PharmD, BCPS, MSCS, is a specialty pharmacist covering the multiple sclerosis population at the outpatient neurology division at University of Alabama at Birmingham Health System. Her professional responsibilities include clinical guidance, oversight, and patient education for pharmacotherapy prescribed in her ambulatory clinic, as well as facilitating access to medication, providing side-effect mitigation strategies and reductions in patient financial burden
- Toni Saldana-King, RN, BSN, MSCN, was a senior medical science liaison at Biogen at the time of submission. Prior to Biogen, she was a practicing nurse at the Maxine Mesinger MS Comprehensive Care Center at Baylor College of Medicine in Houston, Texas, the first Comprehensive Care Center to be recognized by the National MS Society
- Jill Beavin, BSN, RN, MSCN, is a principle medical science liaison at Biogen. Prior to Biogen, she worked as an MS nurse and clinical director in a private neurology practice, where she developed and maintained a 22-chair infusion suite and MS Center
- Robin L. Avila, PhD, is a medical director at Biogen and has been involved in MS clinical research for the last 6 years. Prior to Biogen, she conducted preclinical MS research in the areas of myelin biology, myelin repair, and the development of novel models of MS
- Danette Rutledge, BSP, PhD, is an associate medical director at Biogen, where she has been involved in MS clinical research for the last 3 years. Prior to joining industry, she conducted basic science research in multiple sclerosis for over 10 years
- Marie Moore, FNP-C, MSCN, President of the International Organization of Multiple Sclerosis Nurses, is a nurse practitioner at the Novant Health Multiple Sclerosis Care center in Charlotte, North Carolina, where she participates in research and oversight of the infusion center. She has specialized in the care of multiple sclerosis patients since 2011
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Schweitzer F, Laurent S, Cortese I, Fink GR, Silling S, Skripuletz T, Metz I, Wattjes MP, Warnke C. Progressive Multifocal Leukoencephalopathy: Pathogenesis, Diagnostic Tools, and Potential Biomarkers of Response to Therapy. Neurology 2023; 101:700-713. [PMID: 37487750 PMCID: PMC10585672 DOI: 10.1212/wnl.0000000000207622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/19/2023] [Indexed: 07/26/2023] Open
Abstract
JC polyomavirus (JCV) establishes an asymptomatic latent and/or persistent infection in most of the adult population. However, in immunocompromised individuals, JCV can cause a symptomatic infection of the brain, foremost progressive multifocal leukoencephalopathy (PML). In the past 2 decades, there has been increasing concern among patients and the medical community because PML was observed as an adverse event in individuals treated with modern (selective) immune suppressive treatments for various immune-mediated diseases, especially multiple sclerosis. It became evident that this devastating complication also needs to be considered beyond the patient populations historically at risk, including those with hematologic malignancies or HIV-infected individuals. We review the clinical presentation of PML, its variants, pathogenesis, and current diagnostic approaches. We further discuss the need to validate JCV-directed interventions and highlight current management strategies based on early diagnosis and restoring JCV-specific cellular immunity, which is crucial for viral clearance and survival. Finally, we discuss the importance of biomarkers for diagnosis and response to therapy, instrumental in defining sensitive study end points for successful clinical trials of curative or preventive therapeutics. Advances in understanding PML pathophysiology, host and viral genetics, and diagnostics in conjunction with novel immunotherapeutic approaches indicate that the time is right to design and perform definitive trials to develop preventive options and curative therapy for JCV-associated diseases.
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Affiliation(s)
- Finja Schweitzer
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Sarah Laurent
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Irene Cortese
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Gereon R Fink
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Steffi Silling
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Thomas Skripuletz
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Imke Metz
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Mike P Wattjes
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Clemens Warnke
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany.
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21
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Macaron G, Larochelle C, Arbour N, Galmard M, Girard JM, Prat A, Duquette P. Impact of aging on treatment considerations for multiple sclerosis patients. Front Neurol 2023; 14:1197212. [PMID: 37483447 PMCID: PMC10361071 DOI: 10.3389/fneur.2023.1197212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/18/2023] [Indexed: 07/25/2023] Open
Abstract
With a rapidly aging global population and improvement of outcomes with newer multiple sclerosis (MS)-specific disease-modifying therapies (DMTs), the epidemiology of MS has shifted to an older than previously described population, with a peak prevalence of the disease seen in the 55-65 years age group. Changes in the pathophysiology of MS appear to be age-dependent. Several studies have identified a consistent phase of disability worsening around the fifth decade of life. The latter appears to be independent of prior disease duration and inflammatory activity and concomitant to pathological changes from acute focal active demyelination to chronic smoldering plaques, slow-expanding lesions, and compartmentalized inflammation within the central nervous system (CNS). On the other hand, decreased CNS tissue reserve and poorer remyelinating capacity with aging lead to loss of relapse recovery potential. Aging with MS may imply longer exposure to DMTs, although treatment efficacy in patients >55 years has not been evaluated in pivotal randomized controlled trials and appears to decrease with age. Older individuals are more prone to adverse effects of DMTs, an important aspect of treatment individualization. Aging with MS also implies a higher global burden of comorbid illnesses that contribute to overall impairments and represent a crucial confounder in interpreting clinical worsening. Discontinuation of DMTs after age 55, when no evidence of clinical or radiological activity is detected, is currently under the spotlight. In this review, we will discuss the impact of aging on MS pathobiology, the effect of comorbidities and other confounders on clinical worsening, and focus on current therapeutic considerations in this age group.
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Affiliation(s)
- Gabrielle Macaron
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Faculté de Médecine, Université Saint-Joseph de Beyrouth, Beirut, Lebanon
| | - Catherine Larochelle
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Nathalie Arbour
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Manon Galmard
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Jean Marc Girard
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Alexandre Prat
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Pierre Duquette
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
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22
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Costa GD, Comi G. A safety review of current monoclonal antibodies used to treat multiple sclerosis. Expert Opin Drug Saf 2023; 22:1011-1024. [PMID: 37314699 DOI: 10.1080/14740338.2023.2224556] [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: 02/16/2023] [Accepted: 06/08/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system. Monoclonal antibodies (mAbs) have shown efficacy in reducing MS relapse rates, disease progression, and brain lesion activity. AREAS COVERED This article reviews the literature on the use of mAbs for the treatment of MS, including their mechanisms of action, clinical trial data, safety profiles, and long-term outcomes. The review focuses on the three main categories of mAbs used in MS: alemtuzumab, natalizumab, and anti-CD20 drugs. A literature search was conducted using relevant keywords and guidelines and reports from regulatory agencies were reviewed. The search covered studies published from inception to 31 December 202231 December 2022. The article also discusses the potential risks and benefits of these therapies, including their effects on infection rates, malignancies, and vaccination efficacy. EXPERT OPINION Monoclonal antibodies have revolutionized the treatment of MS, but safety concerns must be considered, particularly with regards to infection rates, malignancy risk, and vaccination efficacy. Clinicians must weigh the potential benefits and risks of mAbs on an individual patient basis, taking into account factors such as age, disease severity, and comorbidities. Ongoing monitoring and surveillance are essential to ensure the long-term safety and effectiveness of monoclonal antibody therapies in MS.
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Affiliation(s)
| | - Giancarlo Comi
- Vita-Salute San Raffaele University, Milan, Italy
- Multiple Sclerosis Center, Casa di Cura Igea, Milan, Italy
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23
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Soldati S, Bär A, Vladymyrov M, Glavin D, McGrath JL, Gosselet F, Nishihara H, Goelz S, Engelhardt B. High levels of endothelial ICAM-1 prohibit natalizumab mediated abrogation of CD4 + T cell arrest on the inflamed BBB under flow in vitro. J Neuroinflammation 2023; 20:123. [PMID: 37221552 DOI: 10.1186/s12974-023-02797-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/02/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION The humanized anti-α4 integrin blocking antibody natalizumab (NTZ) is an effective treatment for relapsing-remitting multiple sclerosis (RRMS) that is associated with the risk of progressive multifocal leukoencephalopathy (PML). While extended interval dosing (EID) of NTZ reduces the risk for PML, the minimal dose of NTZ required to maintain its therapeutic efficacy remains unknown. OBJECTIVE Here we aimed to identify the minimal NTZ concentration required to inhibit the arrest of human effector/memory CD4+ T cell subsets or of PBMCs to the blood-brain barrier (BBB) under physiological flow in vitro. RESULTS Making use of three different human in vitro BBB models and in vitro live-cell imaging we observed that NTZ mediated inhibition of α4-integrins failed to abrogate T cell arrest to the inflamed BBB under physiological flow. Complete inhibition of shear resistant T cell arrest required additional inhibition of β2-integrins, which correlated with a strong upregulation of endothelial intercellular adhesion molecule (ICAM)-1 on the respective BBB models investigated. Indeed, NTZ mediated inhibition of shear resistant T cell arrest to combinations of immobilized recombinant vascular cell adhesion molecule (VCAM)-1 and ICAM-1 was abrogated in the presence of tenfold higher molar concentrations of ICAM-1 over VCAM-1. Also, monovalent NTZ was less potent than bivalent NTZ in inhibiting T cell arrest to VCAM-1 under physiological flow. In accordance with our previous observations ICAM-1 but not VCAM-1 mediated T cell crawling against the direction of flow. CONCLUSION Taken together, our in vitro observations show that high levels of endothelial ICAM-1 abrogate NTZ mediated inhibition of T cell interaction with the BBB. EID of NTZ in MS patients may thus require consideration of the inflammatory status of the BBB as high levels of ICAM-1 may provide an alternative molecular cue allowing for pathogenic T cell entry into the CNS in the presence of NTZ.
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Affiliation(s)
- Sasha Soldati
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
| | - Alexander Bär
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
| | - Mykhailo Vladymyrov
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
| | - Dale Glavin
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA
| | - James L McGrath
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA
| | - Fabien Gosselet
- Blood-Brain Barrier Laboratory, University of Artois, Lens, France
| | - Hideaki Nishihara
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
- Department of Neurotherapeutics, Yamaguchi University, Yamaguchi, Japan
| | | | - Britta Engelhardt
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland.
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24
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Gklinos P, Dobson R. Monoclonal Antibodies in Pregnancy and Breastfeeding in Patients with Multiple Sclerosis: A Review and an Updated Clinical Guide. Pharmaceuticals (Basel) 2023; 16:ph16050770. [PMID: 37242553 DOI: 10.3390/ph16050770] [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: 04/22/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
The use of high-efficacy disease-modifying therapies (DMTs) early in the course of multiple sclerosis (MS) has been shown to improve clinical outcomes and is becoming an increasingly popular treatment strategy. As a result, monoclonal antibodies, including natalizumab, alemtuzumab, ocrelizumab, ofatumumab, and ublituximab, are frequently used for the treatment of MS in women of childbearing age. To date, only limited evidence is available on the use of these DMTs in pregnancy. We aim to provide an updated overview of the mechanisms of action, risks of exposure and treatment withdrawal, and pre-conception counseling and management during pregnancy and post-partum of monoclonal antibodies in women with MS. Discussing treatment options and family planning with women of childbearing age is essential before commencing a DMT in order to make the most suitable choice for each individual patient.
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Affiliation(s)
- Panagiotis Gklinos
- Department of Neurology, Aeginition University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, London EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London E1 1FR, UK
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25
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Jeantin L, Boudot de la Motte M, Deschamps R, Gueguen A, Gout O, Lecler A, Papeix C, Bensa C. Natalizumab extended-interval dosing in a real-life setting. J Neurol Sci 2023; 450:120689. [PMID: 37210938 DOI: 10.1016/j.jns.2023.120689] [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: 03/23/2023] [Revised: 05/01/2023] [Accepted: 05/11/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Natalizumab is a high-efficacy therapy for recurrent multiple sclerosis (RMS) with a four-week administration interval. Controlled trials have shown that extending this interval to six weeks led to better safety without increasing the risk of relapse. We aimed to analyze the safety of extending the natalizumab interdose interval from 4 to 6 weeks in a real-life setting. METHODS This monocentric retrospective self-controlled study included adult patients with RMS treated with natalizumab with a four-week interval between infusions for a minimum of six months, before switching to a six-week interval. The main outcomes were the incidence of MS relapse, new MRI lesions, and MRI activity signs during the two periods, with patients being their own controls. RESULTS Fifty-seven patients were included in the analysis. The mean (95%CI) annualized relapse rate (AAR) before natalizumab introduction was 1.03 (0.52; 1.55). During the four-week interval dosing period, no patient presented with an MS relapse, and seven (13.5%) patients had new MRI lesions. During the six-week interval dosing period, no relapse was observed and two (3.6%) patients had new MRI lesions. CONCLUSION We did not observe more relapses or signs of MRI activity when extending the interval between natalizumab infusions from four to six weeks.
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Affiliation(s)
- Lina Jeantin
- Neurology department, Hopital Fondation Adolphe de Rothschild, 25-29 rue Manin, Paris, France
| | | | - Romain Deschamps
- Neurology department, Hopital Fondation Adolphe de Rothschild, 25-29 rue Manin, Paris, France
| | - Antoine Gueguen
- Neurology department, Hopital Fondation Adolphe de Rothschild, 25-29 rue Manin, Paris, France
| | - Olivier Gout
- Neurology department, Hopital Fondation Adolphe de Rothschild, 25-29 rue Manin, Paris, France
| | - Augustin Lecler
- Neuroradiology department, Hopital Fondation Adolphe de Rothschild, 25-29 rue Manin, Paris, France
| | - Caroline Papeix
- Neurology department, Hopital Fondation Adolphe de Rothschild, 25-29 rue Manin, Paris, France
| | - Caroline Bensa
- Neurology department, Hopital Fondation Adolphe de Rothschild, 25-29 rue Manin, Paris, France.
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26
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Alonso Torres AM, Arévalo Bernabé AG, Becerril Ríos N, Hellín Gil MF, Martínez Sesmero JM, Meca Lallana V, Ramió-Torrentà L, Rodríguez-Antigüedad A, Gómez Maldonado L, Triana Junco I, Gómez-Barrera M, Espinoza Cámac N, Oyagüez I. Cost-Analysis of Subcutaneous vs Intravenous Administration of Natalizumab Based on Patient Care Pathway in Multiple Sclerosis in Spain. PHARMACOECONOMICS - OPEN 2023; 7:431-441. [PMID: 36802327 PMCID: PMC10169937 DOI: 10.1007/s41669-023-00394-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION A subcutaneous (SC) formulation of natalizumab has been recently authorised for multiple sclerosis patients. This study aimed to assess the implications of the new SC formulation, and to compare the annual treatment costs of SC versus intravenous (IV) natalizumab therapy from both the Spanish healthcare system (direct health cost) and the patient (indirect cost) perspectives. METHODS A patient care pathway map and a cost-minimisation analysis were developed to estimate SC and IV natalizumab annual costs over a 2-year time horizon. Considering the patient care pathway and according to natalizumab experience (IV) or estimation (SC), a national expert panel involving neurologists, pharmacists, and nurses provided information/data regarding resource consumption for drug and patient preparation, administration, and documentation. One hour of observation was applied to the first six (SC) or 12 (IV) doses, and 5 min for successive doses. The Day hospital (infusion suite) facilities at a reference hospital were considered for IV administrations and the first six SC injections. For successive SC injections, either a reference hospital or regional hospital in a consulting room was considered. Productivity time associated with travel (56 min to reference hospital, 24 min to regional hospital) and waiting time pre- and post-treatment (SC 15 min, IV 25 min) were assessed for patients and caregivers (accompanying 20% of SC and 35% of IV administrations). National salaries for healthcare professionals were used for cost estimation (€, year 2021). RESULTS At years 1 and 2, total time and cost savings (excluding drug acquisition cost) per patient, driven by saving on administration and patient and caregiver productivity for SC at a reference hospital versus IV at a reference hospital, were 116 h (a reduction of 54.6%) and €3682.82 (a reduction of 66.2%). In the case of natalizumab SC at a regional hospital, the total time and cost saving were 129 h (a reduction of 60.6%) and €3883.47 (a reduction of 69.8%). CONCLUSIONS Besides the potential benefits of convenient administration and improving work-life balance, as suggested by the expert panel, natalizumab SC was associated with cost savings for the healthcare system by avoiding drug preparation, reducing administration time, and freeing up infusion suite capacity. Additional cost savings could be derived with regional hospital administration of natalizumab SC by reducing productivity loss.
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Affiliation(s)
- A M Alonso Torres
- Neurology Department, Hospital Universitario de Málaga, Málaga, Spain
| | | | | | - M F Hellín Gil
- Specialised Nurse, Hospital Virgen Arrixaca, Murcia, Spain
| | | | - V Meca Lallana
- Neurology Department, Hospital Universitario La Princesa, Madrid, Spain
| | - Ll Ramió-Torrentà
- Neurology Department, Hospital Universitario Josep Trueta, Girona, Spain
| | | | | | | | - M Gómez-Barrera
- Pharmacoeconomics and Outcomes Research Iberia (PORIB), Madrid, Spain
| | - N Espinoza Cámac
- Pharmacoeconomics and Outcomes Research Iberia (PORIB), Madrid, Spain.
| | - I Oyagüez
- Pharmacoeconomics and Outcomes Research Iberia (PORIB), Madrid, Spain
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27
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Stüve O, Tugemann B. Extended-interval dosing of natalizumab in NOVA. Lancet Neurol 2023; 22:199-200. [PMID: 36804084 DOI: 10.1016/s1474-4422(23)00032-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 12/19/2022] [Accepted: 01/17/2023] [Indexed: 02/17/2023]
Affiliation(s)
- Olaf Stüve
- Peter O'Donnell Jr Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA; VA North Texas Health Care System, Dallas, TX, USA
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28
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Foley JF, Campbell N, Kong G. Extended-interval dosing of natalizumab in NOVA - Authors' reply. Lancet Neurol 2023; 22:200-201. [PMID: 36804085 DOI: 10.1016/s1474-4422(23)00034-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/23/2022] [Accepted: 01/17/2023] [Indexed: 02/17/2023]
Affiliation(s)
- John F Foley
- Rocky Mountain Multiple Sclerosis Clinic, Salt Lake City, UT 84103, USA.
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29
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Ryerson LZ, Foley JF, Defer G, Cohen JA, Arnold DL, Butzkueven H, Cutter G, Giovannoni G, Killestein J, Wiendl H, Sinks S, Kuhelj R, Bodhinathan K, Lasky T. Exploratory clinical efficacy and patient-reported outcomes from NOVA: A randomized controlled study of intravenous natalizumab 6-week dosing versus continued 4-week dosing for relapsing-remitting multiple sclerosis. Mult Scler Relat Disord 2023; 72:104561. [PMID: 36931078 DOI: 10.1016/j.msard.2023.104561] [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: 01/27/2023] [Accepted: 02/09/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Natalizumab (TYSABRI®) 300 mg administered intravenously every-4-weeks (Q4W) is approved for treatment of relapsing-remitting multiple sclerosis but is associated with increased risk of progressive multifocal leukoencephalopathy (PML). Extended natalizumab dosing intervals of approximately every-6-weeks (Q6W) are associated with a lower risk of PML. Primary and secondary clinical outcomes from the NOVA randomized clinical trial (NCT03689972) suggest that effective disease control is maintained in patients who were stable during treatment with natalizumab Q4W for ≥12 months and who then switched to Q6W dosing. We compared additional exploratory clinical and patient-reported outcomes (PROs) from NOVA to assess the efficacy of Q6W dosing. METHODS Prespecified exploratory clinical efficacy endpoints in NOVA included change from baseline in Expanded Disability Status Scale (EDSS) score, Timed 25-Foot Walk (T25FW), dominant- and nondominant-hand 9-Hole Peg Test (9HPT), and Symbol Digit Modalities Test (SDMT). Exploratory patient-reported outcome (PRO) efficacy endpoints included change from baseline in the Treatment Satisfaction Questionnaire for Medication (TSQM), Neuro-QoL fatigue questionnaire, Multiple Sclerosis Impact Scale (MSIS-29), EuroQol 5 Dimensions (EQ-5D-5 L) index score, Clinical Global Impression (CGI)-Improvement (patient- and clinician-assessed) and CGI-Severity (clinician-assessed) rating scales. Estimated proportions of patients with confirmed EDSS improvement were based on Kaplan-Meier methods. Estimates of mean treatment differences for Q6W versus Q4W in other outcomes were assessed by least squares mean (LSM) and analyzed using a linear mixed model of repeated measures or ordinal logistic regression (CGI-scale). RESULTS Exploratory clinical and patient-reported outcomes were assessed in patients who received ≥1 dose of randomly assigned study treatment and had ≥1 postbaseline efficacy assessment (Q6W group, n = 247, and Q4W group, n = 242). Estimated proportions of patients with EDSS improvement at week 72 were similar for Q6W and Q4W groups (11.7% [19/163] vs 10.8% [17/158]; HR 1.02 [95% confidence interval [CI], 0.53-1.98]; P = 0.9501). At week 72, there were no significant differences between Q6W and Q4W groups in LSM change from baseline for T25FW (0.00, P = 0.975), 9HPT (dominant [0.22, P = 0.533] or nondominant [0.09, P = 0.862] hand), or SDMT (-1.03, P = 0.194). Similarly, there were no significant differences between Q6W and Q4W groups in LSM change from baseline for any PRO (TSQM, -1.00, P = 0.410; Neuro-QoL fatigue, 0.52, P = 0.292; MSIS-29 Psychological, 0.67, P = 0.572; MSIS-29 Physical, 0.74, P = 0.429; EQ-5D-5 L, 0.00, P = 0.978). For the EQ-5D-5 L, a higher proportion of Q6W patients than Q4W patients demonstrated worsening (≥0.5 standard deviation increase in the EQ-5D-5 L index score; P = 0.0475). From baseline to week 72 for Q6W versus Q4W, odds ratio (ORs) of LSM change in CGI scores did not show meaningful differences between groups (CGI-Improvement [patient]: OR [95% CI] 1.2 [0.80-1.73]; CGI-Improvement [physician]: 0.8 [0.47-1.36]; CGI-Severity [physician]: 1.0 [0.71-1.54]). CONCLUSIONS No significant differences were observed in change from baseline to week 72 between natalizumab Q6W and Q4W groups for all exploratory clinical or PRO-related endpoints assessed. For the EQ-5D-5 L, a higher proportion of Q6W than Q4W patients demonstrated worsening.
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Affiliation(s)
- Lana Zhovtis Ryerson
- Hackensack Meridian Medical Group - Neurology, Jersey Shore University Medical Center, Neptune City, NJ, United States of America.
| | - John F Foley
- Rocky Mountain MS Clinic, Salt Lake City, UT, United States of America
| | - Gilles Defer
- Department of Neurology, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Jeffrey A Cohen
- Mellen MS Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Douglas L Arnold
- Montréal Neurological Institute, McGill University, Montréal, QC, Canada; NeuroRx Research, Montréal, QC, Canada
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Gary Cutter
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL, United States of America
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK; Queen Mary University of London, London, UK
| | - Joep Killestein
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Susie Sinks
- Biogen, Cambridge, MA, United States of America
| | | | | | - Tyler Lasky
- Biogen, Cambridge, MA, United States of America
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30
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Pelle J, Briant AR, Branger P, Derache N, Arnaud C, Lebrun-Frenay C, Cohen M, Mondot L, De Seze J, Bigaut K, Collongues N, Kremer L, Ricard D, Bompaire F, Ohlmann C, Sallansonnet-Froment M, Ciron J, Biotti D, Pignolet B, Parienti JJ, Defer G. Real-World Effectiveness of Natalizumab Extended Interval Dosing in a French Cohort. Neurol Ther 2023; 12:529-542. [PMID: 36763307 PMCID: PMC10043118 DOI: 10.1007/s40120-023-00440-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023] Open
Abstract
INTRODUCTION Natalizumab, a therapy for relapsing-remitting multiple sclerosis (RRMS), is associated with a risk of progressive multifocal leukoencephalopathy (PML). Over the last several years, practitioners have used off-label extended interval dosing (EID) of natalizumab to reduce PML risk, despite the absence of a large-scale efficacy evaluation. METHODS We conducted a retrospective, multicenter cohort study among adults with RRMS receiving stable standard interval dosing (SID), defined as a ≥ 12-month consecutive period of ≥ 11 natalizumab infusions/year in France. We compared the 12-month risk difference of remaining relapse-free (primary endpoint) between patients who switched to EID (≤ 9 natalizumab infusions) and those who remained on SID, with a noninferiority margin of - 11%. We used propensity score methods such as inverse probability treatment weighting (IPTW) and 1:1 propensity score matching (PSM). Secondary endpoints were annualized relapse rate, disease progression, and safety. RESULTS Baseline characteristics were similar between patients receiving EID (n = 147) and SID (n = 156). The proportion of relapse-free patients 12 months postbaseline was 142/147 in the EID (96.6%) and 144/156 in the SID group (92.3%); risk difference (95% CI) 4.3% (- 1.3 to 9.8%); p < 0.001 for non-inferiority. There were no significant differences between relapse rates (0.043 vs. 0.083 per year, respectively; p = 0.14) or Expanded Disability Status Scale mean scores (2.43 vs. 2.72, respectively; p = 0.18); anti-JC virus index values were similar (p = 0.23); and no instances of PML were reported. The comparisons using IPTW (n = 306) and PSM (n = 204) were consistent. CONCLUSION These results support the pertinence of using an EID strategy for RRMS patients treated with natalizumab. CLINICAL TRIALS gov identifier (NCT04580381).
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Affiliation(s)
- Juliette Pelle
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France
| | - Anais R Briant
- Unité de Biostatistiques et de Recherche Clinique, CHU de Caen-Cote de Nacre, Caen, France
| | - Pierre Branger
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France
| | - Nathalie Derache
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France
| | - Charlotte Arnaud
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France
| | - Christine Lebrun-Frenay
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Unité de Recherche Clinique Côte d'azur (UR2CA), Équipe URRIS, CHU Pasteur 2, Nice, France
| | - Mikael Cohen
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Unité de Recherche Clinique Côte d'azur (UR2CA), Équipe URRIS, CHU Pasteur 2, Nice, France
| | - Lydiane Mondot
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Unité de Recherche Clinique Côte d'azur (UR2CA), Équipe URRIS, CHU Pasteur 2, Nice, France
| | - Jerome De Seze
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Département de Neurologie, CHRU de Strasbourg Hôpital de Hautepierre, Strasbourg, France
| | - Kevin Bigaut
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Département de Neurologie, CHRU de Strasbourg Hôpital de Hautepierre, Strasbourg, France
| | - Nicolas Collongues
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Département de Neurologie, CHRU de Strasbourg Hôpital de Hautepierre, Strasbourg, France
| | - Laurent Kremer
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Département de Neurologie, CHRU de Strasbourg Hôpital de Hautepierre, Strasbourg, France
| | - Damien Ricard
- Département de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France
| | - Flavie Bompaire
- Département de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France
| | - Charlotte Ohlmann
- Département de Radiologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France
| | - Magali Sallansonnet-Froment
- Département de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France
| | - Jonathan Ciron
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP)-Département des Neurosciences, CHU Toulouse-Purpan, and Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, UPS, Toulouse, France
| | - Damien Biotti
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP)-Département des Neurosciences, CHU Toulouse-Purpan, and Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, UPS, Toulouse, France
| | - Beatrice Pignolet
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP)-Département des Neurosciences, CHU Toulouse-Purpan, and Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, UPS, Toulouse, France
| | - Jean-Jacques Parienti
- Unité de Biostatistiques et de Recherche Clinique, CHU de Caen-Cote de Nacre, Caen, France
| | - Gilles Defer
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France.
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Abstract
The multiple sclerosis (MS) neurotherapeutic landscape is rapidly evolving. New disease-modifying therapies (DMTs) with improved efficacy and safety, in addition to an expanding pipeline of agents with novel mechanisms, provide more options for patients with MS. While treatment of MS neuroinflammation is well tailored in the existing DMT armamentarium, concerted efforts are currently underway for identifying neuropathological targets and drug discovery for progressive MS. There is also ongoing research to develop agents for remyelination and neuroprotection. Further insights are needed to guide DMT initiation and sequencing as well as to determine the role of autologous stem cell transplantation in relapsing and progressive MS. This review provides a summary of these updates.
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Affiliation(s)
- Moein Amin
- Cleveland Clinic, Department of Neurology, Cleveland, OH 44195, USA
| | - Carrie M Hersh
- Cleveland Clinic, Lou Ruvo Center for Brain Health, Las Vegas, NV 89106, USA
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Peptide Mimotope-Enabled Quantification of Natalizumab Arm Exchange During Multiple Sclerosis Treatment. Ther Drug Monit 2023; 45:55-60. [PMID: 36201847 DOI: 10.1097/ftd.0000000000001038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Natalizumab, a therapeutic antibody used to treat multiple sclerosis, undergoes in vivo Fab arm exchange to form a monovalent bispecific antibody. Although highly efficacious, the immunosuppressive activity of natalizumab has been associated with JC polyomavirus-driven progressive multifocal leukoencephalopathy (PML). Development of assays that can distinguish between and quantify bivalent (unexchanged) and monovalent (exchanged) forms of natalizumab in clinical samples may be useful for optimizing extended interval dosing and reducing the risk of PML. METHODS In vitro natalizumab arm exchange was conducted, along with peptide mimotope and anti-idiotype surface capture chemistry, to enable the development of enzyme-linked immunosorbent assays. RESULTS An assay using a unique peptide Veritope TM was developed, which can exclusively bind to bivalent natalizumab. In combination with enzyme-linked immunosorbent assays that quantifies total natalizumab, the assay system allows quantification of both natalizumab forms. CONCLUSIONS In this article, a novel assay for the quantification of unexchanged and exchanged natalizumab variants in clinical samples was developed. This assay will enable investigations into the clinical significance of the relationship of PK/PD with the monovalent-to-bivalent ratio, as it relates to the efficacy of the drug and risk of PML.
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Toorop AA, van Kempen ZLE, Steenhuis M, Nielsen J, Sinnige LGF, van Dijk G, Roosendaal CM, Arnoldus EPJ, Hoitsma E, Lissenberg-Witte BI, de Jong BA, Oosten BWV, Strijbis EMM, Uitdehaag BMJ, Rispens T, Killestein J. Decrease of natalizumab drug levels after switching from intravenous to subcutaneous administration in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 2023; 94:482-486. [PMID: 36639226 DOI: 10.1136/jnnp-2022-330467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Natalizumab is effective in the treatment of multiple sclerosis (MS). In 2021, the European Medicines Agency approved the subcutaneous (SC) variant of natalizumab which can be used instead of intravenous administration. However, the course of drug levels varies between administration routes, and the Food and Drug Administration rejected the request for approval of natalizumab SC for reasons that were not disclosed. Our objective was to evaluate the course of natalizumab trough drug levels in patients who switched from natalizumab intravenous to SC on various treatment intervals. METHODS The NEXT-MS trial (N=382) investigates personalised treatment of natalizumab, in which infusion intervals are prolonged based on individual natalizumab trough drug levels. In 2021, an amendment was approved allowing participants to switch from intravenous to SC administration with frequent measurements of natalizumab drug levels and antidrug antibodies (ADAs). Results were compared with linear mixed model analyses. RESULTS Until December 2022, 15 participants switched to SC natalizumab. Natalizumab drug levels with SC administration were on average 55% lower compared with intravenous administration (Exp (estimate) 0.45, 95% CI 0.39 to 0.53, p<0.001), leading to very low trough drug levels in three patients on extended treatment intervals. No natalizumab ADAs were detected during intravenous or SC treatment. None of the participants on natalizumab SC showed evidence of MS disease activity. CONCLUSIONS Natalizumab trough drug levels can decrease after switching from natalizumab intravenous to SC administration. We advise to monitor trough drug levels in patients with low natalizumab drug levels during intravenous treatment, patients with higher body mass index or patients on extended treatment intervals who switch to SC administration of natalizumab.
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Affiliation(s)
- Alyssa A Toorop
- Department of Neurology, MS Center Amsterdam, Amsterdam UMC Location VUMC, Amsterdam, The Netherlands
| | - Zoé L E van Kempen
- Department of Neurology, MS Center Amsterdam, Amsterdam UMC Location VUMC, Amsterdam, The Netherlands
| | - Maurice Steenhuis
- Biologics Laboratory, Department of Immunopathology, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Jessica Nielsen
- Department of Neurology, Ommelander Hospital Groningen, Scheemda, The Netherlands
| | - L G F Sinnige
- Department of Neurology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Gert van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Edo P J Arnoldus
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Elske Hoitsma
- Department of Neurology, Alrijne Hospital, Leiden, The Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Data Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Brigit A de Jong
- Department of Neurology, MS Center Amsterdam, Amsterdam UMC Location VUMC, Amsterdam, The Netherlands
| | - Bob W van Oosten
- Department of Neurology, MS Center Amsterdam, Amsterdam UMC Location VUMC, Amsterdam, The Netherlands
| | - Eva M M Strijbis
- Department of Neurology, MS Center Amsterdam, Amsterdam UMC Location VUMC, Amsterdam, The Netherlands
| | - Bernard M J Uitdehaag
- Department of Neurology, MS Center Amsterdam, Amsterdam UMC Location VUMC, Amsterdam, The Netherlands
| | - Theo Rispens
- Biologics Laboratory, Department of Immunopathology, Sanquin Diagnostic Services, Amsterdam, The Netherlands.,Landsteiner Laboratory, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, Amsterdam UMC Location VUMC, Amsterdam, The Netherlands
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Kohle F, Dalakas MC, Lehmann HC. Repurposing MS immunotherapies for CIDP and other autoimmune neuropathies: unfulfilled promise or efficient strategy? Ther Adv Neurol Disord 2023; 16:17562864221137129. [PMID: 36620728 PMCID: PMC9810996 DOI: 10.1177/17562864221137129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/19/2022] [Indexed: 01/03/2023] Open
Abstract
Despite advances in the treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and other common autoimmune neuropathies (AN), still-many patients with these diseases do not respond satisfactorily to the available treatments. Repurposing of disease-modifying therapies (DMTs) from other autoimmune conditions, particularly multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD), is a promising strategy that may accelerate the establishment of novel treatment choices for AN. This approach appears attractive due to homologies in the pathogenesis of these diseases and the extensive post-marketing experience that has been gathered from treating MS and NMOSD patients. The idea is also strengthened by a number of studies that explored the efficacy of DMTs in animal models of AN but also in some CIDP patients. We here review the available preclinical and clinical data of approved MS therapeutics in terms of their applicability to AN, especially CIDP. Promising therapeutic approaches appear to be B cell-directed and complement-targeting strategies, such as anti-CD20/anti-CD19 agents, Bruton's tyrosine kinase inhibitors and anti-C5 agents, as they exert their effects in the periphery. This is a major advantage because, in contrast to MS, their action in the periphery is sufficient to exert significant immunomodulation.
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Affiliation(s)
- Felix Kohle
- Department of Neurology, Faculty of Medicine,
University of Cologne and University Hospital Cologne, Cologne,
Germany
| | - Marinos C. Dalakas
- Department of Neurology, Thomas Jefferson
University, Philadelphia, PA, USA,Neuroimmunology Unit, National and Kapodistrian
University of Athens Medical School, Athens, Greece
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Santiago-Setien P, Barquín-Rego C, Hernández-Martínez P, Ezquerra-Marigomez M, Torres-Barquin M, Menéndez-Garcia C, Uriarte F, Jiménez-López Y, Misiego M, Sánchez de la Torre JR, Setien S, Delgado-Alvarado M, Riancho J. Switch to ocrelizumab in MS patients treated with natalizumab in extended interval dosing at high risk of PML: A 96-week follow-up pilot study. Front Immunol 2023; 14:1086028. [PMID: 36817456 PMCID: PMC9929864 DOI: 10.3389/fimmu.2023.1086028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/23/2023] [Indexed: 02/04/2023] Open
Abstract
We aimed to assess the long-term safety and effectiveness of ocrelizumab in a cohort of patients with multiple sclerosis (MS) at high risk of progressive multifocal leukoencephalopathy (PML), previously treated with natalizumab in extending interval dosing (EID), who switched to ocrelizumab and to compare them with patients who continued EID-natalizumab. Thirty MS patients previously treated with natalizumab in EID (every 8 weeks) were included in this observational retrospective cohort study. Among them, 17 patients were switched to ocrelizumab and 13 continued with EID-natalizumab. Except for the John Cunningham virus (JCV) index, no significant differences were detected between both groups. Main outcome measures included: annualized relapse rate (ARR), radiological activity, disability progression, and the NEDA-3 index. Patients were followed for 96 weeks. The median washout period in ocrelizumab-switchers was 6 weeks. Among them, AAR and radiological activity during follow-up were 0.03, without significant differences in comparison with the previous period on natalizumab-EID. The comparison between ocrelizumab-switchers and patients continuing on EID-natalizumab showed no significant differences in AAR, radiological activity, or disability progression. However, the proportion of patients maintaining a NEDA-3 status in week 96 was slightly superior among ocrelizumab-switchers (94 vs 69%). No serious adverse events were observed in any group. In conclusion, switching from EID-natalizumab to ocrelizumab can be considered as a therapeutic option, particularly in patients with MS at high risk of PML, to mitigate the risks of both PML and disease reactivation.
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Affiliation(s)
- Pilar Santiago-Setien
- Service of Neurology, Hospital Sierrallana-Institute of Research Valdecilla (IDIVAL), Torrelavega, Spain
| | - Cristina Barquín-Rego
- Service of Neurology, Hospital Sierrallana-Institute of Research Valdecilla (IDIVAL), Torrelavega, Spain
| | | | | | | | | | | | - Yésica Jiménez-López
- Service of Neurology, Hospital Sierrallana-Institute of Research Valdecilla (IDIVAL), Torrelavega, Spain
| | - Mercedes Misiego
- Service of Neurology, Hospital Sierrallana-Institute of Research Valdecilla (IDIVAL), Torrelavega, Spain
| | | | - Sonia Setien
- Service of Neurology, Hospital Sierrallana-Institute of Research Valdecilla (IDIVAL), Torrelavega, Spain
| | - Manuel Delgado-Alvarado
- Service of Neurology, Hospital Sierrallana-Institute of Research Valdecilla (IDIVAL), Torrelavega, Spain.,Centro de Investigación en Red de Enfermedades Neurodegenerativas, CIBERNED, Instituto Carlos III, Madrid, Spain
| | - Javier Riancho
- Service of Neurology, Hospital Sierrallana-Institute of Research Valdecilla (IDIVAL), Torrelavega, Spain.,Centro de Investigación en Red de Enfermedades Neurodegenerativas, CIBERNED, Instituto Carlos III, Madrid, Spain.,Department of Medicine and Psychiatry, University of Cantabria, Santander, Spain.,Red Española de Esclerosis Múltiple, Madrid, Spain
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36
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Mitteilungen der Deutschen Gesellschaft für Neurologie. DGNEUROLOGIE 2023; 6. [PMCID: PMC9951165 DOI: 10.1007/s42451-023-00546-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
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Specific Aspects of Immunotherapy for Multiple Sclerosis in Switzerland—A Structured Commentary, Update 2022. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2022. [DOI: 10.3390/ctn7010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Multiple sclerosis (MS), particularly relapsing MS (RMS), has become a treatable disease in recent decades, and immunotherapies are now able to influence long-term disease course. A wide range of disease-modifying drugs are available, which makes the choice of therapy in individual cases considerably more complex. Due to specific regulatory aspects (partly diverging approvals by Swissmedic compared to the European Medicines Agency (EMA), and an independent evaluation process for the Federal Office of Public Health (FOPH) specialities list (SL)), we issued a consensus recommendation regarding specific aspects of immunotherapy for MS in Switzerland in 2019. Here, we present revised recommendations with an update on newly approved drugs and new safety aspects, also in reference to the risk of COVID-19 infection and vaccination.
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Pape K, Rolfes L, Steffen F, Muthuraman M, Korsen M, Meuth SG, Zipp F, Bittner S. Comparative effectiveness of natalizumab versus ocrelizumab in multiple sclerosis: a real-world propensity score-matched study. Ther Adv Neurol Disord 2022; 15:17562864221142924. [PMID: 36568489 PMCID: PMC9772974 DOI: 10.1177/17562864221142924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
Background For treatment of relapsing-remitting multiple sclerosis (RRMS), a broad range of disease-modifying therapies (DMT) is available. However, few comparative effectiveness studies between different drugs have been performed. Objectives This study aimed to compare the efficacy and treatment continuation of natalizumab and ocrelizumab in a real-world cohort of patients with relapsing-remitting multiple sclerosis (RRMS) from two German university hospitals. Methods We performed a retrospective analysis of RRMS patients who initiated treatment with natalizumab or ocrelizumab between January 2016 and April 2019 at the German university hospitals of Mainz and Düsseldorf. Bayesian propensity score matching was conducted to correct for differences in baseline characteristics. Our primary outcome was no evidence of disease activity [NEDA-3: no relapses, no confirmed disability progression, and no magnetic resonance imaging (MRI) activity] and its subcomponents. Secondary outcomes included measurement of neurofilament light chain (NfL) in serum, analysis of premature discontinuation, and evidence of rebound activity in patients switching from natalizumab to ocrelizumab. Results We identified 63 patients starting treatment with natalizumab and 76 patients starting with ocrelizumab. Binary logistic regression showed that treatment with natalizumab or a higher number of relapses in the previous year were independently associated with a higher risk for relapses. Patients receiving natalizumab had a higher probability of premature discontinuation of therapy (p = 0.002). After propensity score matching of the two treatment arms, 55 patients remained per group. NEDA-3 after 30 months of follow-up was reached by 53.1% in the ocrelizumab group and 36.1% in the natalizumab group (p = 0.177). Ocrelizumab was superior to natalizumab concerning the occurrence of relapses in log-rank test (p = 0.019). NfL levels in serum were low under both treatments. Patients who switched from natalizumab to ocrelizumab showed no increased rebound activity. Discussion This study provides class IV evidence that treatment of RRMS patients with ocrelizumab and natalizumab show comparable effectiveness in combined endpoints, while ocrelizumab might be more effective in preventing the occurrence of relapses.
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Affiliation(s)
- Katrin Pape
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Leoni Rolfes
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Falk Steffen
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Muthuraman Muthuraman
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Melanie Korsen
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Immovilli P, De Mitri P, Bazzurri V, Vollaro S, Morelli N, Biasucci G, Magnifico F, Marchesi E, Lombardelli ML, Gelati L, Guidetti D. The Impact of Highly Effective Treatment in Pediatric-Onset Multiple Sclerosis: A Case Series. CHILDREN 2022; 9:children9111698. [PMID: 36360426 PMCID: PMC9688929 DOI: 10.3390/children9111698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/24/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022]
Abstract
Introduction: Pediatric-onset multiple sclerosis (POMS) is characterized by high inflammatory disease activity. Our aim was to describe the treatment sequencing and report the impact highly effective disease-modifying treatment (HET) had on disease activity. Materials and Methods: Five consecutive patients with POMS were administered HET following lower efficacy drug or as initial therapy. Data on treatment sequencing, relapses and MRIs were collected during the follow-up. Results: Our patients had an average age of 13.8 years (range 9–17) at diagnosis and 13.4 years (range 9–16) at disease onset, and 2/5 (40%) POMS were female. The pre-treatment average annualized relapse rate was 1.6 (range 0.8–2.8), and the average follow-up length was 5 years (range 3–7). A total of 2/5 (40%) patients were stable on HET at initial therapy, and 3/5 (60%) required an escalation to more aggressive treatment, even if two of them had been put on HET as initial treatment. Four out of five patients (80%) had No Evidence of Disease Activity-3 status (NEDA-3) at an average follow-up of 3 years (range 2–5). Conclusion: It has been observed that in a recent time period all the cases had prompt diagnosis, early HET or escalation to HET with a good outcome in 80% of the cases.
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Affiliation(s)
- Paolo Immovilli
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
- Correspondence: ; Tel.: +39-0523-302408
| | - Paola De Mitri
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
| | - Veronica Bazzurri
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
| | - Stefano Vollaro
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
| | - Nicola Morelli
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
| | - Giacomo Biasucci
- The Pediatric Unit, Maternal and Child Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
| | - Fabiola Magnifico
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
| | - Elena Marchesi
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
| | - Maria Lara Lombardelli
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
| | - Lorenza Gelati
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
| | - Donata Guidetti
- The Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Via Taverna 39, 29121 Piacenza, Italy
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Valentino P, Malucchi S, Martire S, Bava CI, Capobianco MA, Bertolotto A. sNFL applicability as additional monitoring tool in natalizumab extended interval dosing regimen for RRMS patients. Mult Scler Relat Disord 2022; 67:104176. [PMID: 36126541 DOI: 10.1016/j.msard.2022.104176] [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: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Extended interval dosing (EID) of Natalizumab (NAT) has been proposed to reduce progressive multifocal leukoencephalopathy (PML) risk associated with standard interval dosing (SID) in people with multiple sclerosis (MS). Previous studies have suggested that NAT effectiveness is maintained in the great majority of patients who switch from SID to EID; monitoring of disease activity is currently based exclusively on clinical and MRI parameters. Frequent MRI are expensive and not always applicable, underlining the need for biological markers able to detect central nervous system lesions. Serum Neurofilament-light chain (sNFL) currently represents the most promising biomarker of disease activity, prognosis and treatment response in MS, and their clinical suitability is increasingly evident. The objective of the present study is to assess the applicability of sNFL as additional/alternative measure of treatment efficacy during EID regimen. METHODS We measured sNFL by Simoa technology in longitudinal samples from 63 Relapsing Remitting (RR) MS patients switched from SID to EID. INCLUSION CRITERIA diagnosis of RRMS, age 18-60 years; NAT SID for at least 12 months; NEDA-3 (no evidence of disease activity) for at least 12 months; availability of at least 2 serum samples collected 6 months apart. Patients' follow-up time during EID was at least 12 months and 2 blood samples were collected after at least 6 and 12 months. Clinical examination was performed before each infusion, while MRI 6 and 12 months after NAT initiation and according to PML risk during the whole study. RESULTS No patients showed clinical or MRI activity during the whole follow-up. sNFL levels measured during SID and EID were comparable, without significant difference between groups. The effect of EID on NFL levels did not show significant effects (LMM, p> 0.05) and sNFL levels did not vary with time during SID or EID protocols (LMM, p> 0.05). Intra-individual sNFL levels demonstrated overall stability during SID and EID (median CV=11% between SID and EID samples). According to our previously published reference values, sNFL levels were in the normal range in all samples, both during SID and EID. CONCLUSIONS Our results suggest that sNFL quantification can be used as an alternative/additional approach to MRI in managing individual patients. The present work provides a new clinical application of sNFL to monitor NAT efficacy.
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Affiliation(s)
- Paola Valentino
- Neuroscience Institute Cavalieri Ottolenghi (NICO), Regione Gonzole 10, Orbassano 10043, Italy; CRESM Biobank, University Hospital San Luigi Gonzaga, Regione Gonzole 10, Orbassano 10043, Italy.
| | - Simona Malucchi
- Department of Neurology and CRESM, University Hospital San Luigi Gonzaga, Regione Gonzole 10, Orbassano 10043, Italy
| | - Serena Martire
- Neuroscience Institute Cavalieri Ottolenghi (NICO), Regione Gonzole 10, Orbassano 10043, Italy; Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, Turin 10100, Italy
| | - Cecilia Irene Bava
- Neuroscience Institute Cavalieri Ottolenghi (NICO), Regione Gonzole 10, Orbassano 10043, Italy
| | - Marco Alfonso Capobianco
- CRESM Biobank, University Hospital San Luigi Gonzaga, Regione Gonzole 10, Orbassano 10043, Italy; Department of Neurology, S. Croce e Carle Hospital, Via Michele Coppino, 26, Cuneo 12100, Italy
| | - Antonio Bertolotto
- Neuroscience Institute Cavalieri Ottolenghi (NICO), Regione Gonzole 10, Orbassano 10043, Italy; Department of Neurology, Koelliker Hospital, C.so Galileo Ferraris, 247/255, Turin 10134, Italy
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Perncezky J, Sellner J. Natalizumab extended-interval dosing in multiple sclerosis to mitigate progressive multifocal leukoencephalopathy risk: initial study evidence and real-world experience. J Cent Nerv Syst Dis 2022; 14:11795735221135485. [PMID: 36277271 PMCID: PMC9580073 DOI: 10.1177/11795735221135485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The high efficacy of natalizumab in the treatment of relapsing-remitting multiple sclerosis (MS) is without controversy. Indeed, effective disease control was not only demonstrated in the pivotal trials but has been corroborated impressively in real-world observations. This monoclonal IgG4 antibody blocks the α4β1 integrin-mediated leukocyte-endothelial interaction and thereby inhibits the migration of immune cells to the brain parenchyma. However, treatment with natalizumab carries the risk of progressive multifocal leukoencephalopathy (PML). This potentially lethal side effect is a significant limitation for treatment initiation and long-term therapy. Natalizumab is given intravenously or subcutaneously in the standard dose of 300 mg every 4 weeks, allowing drug concentrations at levels that ensure continuous α4β1 integrin receptor saturation on the surface of immune cells. Extended-interval dosing (EID) is an emerging treatment approach that aims to mitigate the natalizumab-related PML risk by prolonging the standard infusion intervals to 6 weeks or even more. This treatment approach may abrogate the PML risk due to improved immune surveillance within the central nervous system while maintaining clinical efficacy. Moreover, even an individual interval dosing can be envisioned based on the availability of a biomarker that is capable of monitoring both safety and efficacy aspects. This review summarizes the early and encouraging evidence for EID from observational and randomized-controlled trials and discusses current limitations and upcoming challenges for introducing a tailored treatment approach.
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Affiliation(s)
- Julian Perncezky
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria,Johann Sellner, Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstr 67, Mistelbach 2130, Austria.
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Johnsson M, Farman HH, Blennow K, Zetterberg H, Malmeström C, Axelsson M, Lycke J. No increase of serum neurofilament light in relapsing-remitting multiple sclerosis patients switching from standard to extended-interval dosing of natalizumab. Mult Scler 2022; 28:2070-2080. [PMID: 35856574 PMCID: PMC9574231 DOI: 10.1177/13524585221108080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Accumulating evidence supports the efficacy of administering natalizumab (NZ) with extended-interval dosing (EID) in patients with relapsing-remitting multiple sclerosis (RRMS). Objectives: We switched NZ dosing from 4-week to 6-week intervals in patients with RRMS, and investigated the effect on serum neurofilament light chain (sNfL) concentrations. Methods: We included two cohorts of patients with RRMS treated with NZ: one received the standard-interval dosing (4 weeks) at baseline, and were switched to 6-week intervals (EID4–6, N = 45). The other cohort received EID (5- or 6-week intervals) both at baseline and during follow-up (EID5/6, N = 25). Serum samples were collected in the EID4–6 cohort at every NZ infusion, for 12 months. The primary outcome was the change in sNfL concentrations after switching to EID. Results: The baseline mean sNfL concentration in the EID4–6 cohort was 10.5 ng/L (standard deviation (SD) = 6.1), and it remained unchanged at 12 months. Moreover, individual sNfL concentrations did not change significantly after extending the NZ dosing intervals. In addition, the EID4–6 and EID5/6 cohorts had similar baseline sNfL concentrations. Conclusion: We concluded that extending the NZ dosing interval did not increase axonal damage, as determined with sNfL, in patients with RRMS.
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Affiliation(s)
- Magnus Johnsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden/Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Helen H Farman
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden/Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden/Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden/Department of Molecular Neuroscience, Institute of Neurology, University College London, London, UK/UK Dementia Research Institute, University College London, London, UK
| | - Clas Malmeström
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Markus Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Hellwig K. Natalizumab for multiple sclerosis: the dilemma of NOVA. Lancet Neurol 2022; 21:579-581. [DOI: 10.1016/s1474-4422(22)00170-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 11/24/2022]
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Freeman L, Longbrake EE, Coyle PK, Hendin B, Vollmer T. High-Efficacy Therapies for Treatment-Naïve Individuals with Relapsing-Remitting Multiple Sclerosis. CNS Drugs 2022; 36:1285-1299. [PMID: 36350491 PMCID: PMC9645316 DOI: 10.1007/s40263-022-00965-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/11/2022]
Abstract
There are > 18 distinct disease-modifying therapy (DMT) options covering 10 mechanisms of action currently approved by the US Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis (RRMS). Given the multitude of available treatment options, and recent international consensus guidelines offering differing recommendations, there is broad heterogeneity in how the DMTs are used in clinical practice. Choosing a DMT for newly diagnosed patients with MS is currently a topic of significant debate in MS care. Historically, an escalation approach to DMT was used for newly diagnosed patients with RRMS. However, the evidence for clinical benefits of early treatment with high-efficacy therapies (HETs) in this population is emerging. In this review, we provide an overview of the DMT options and MS treatment strategies, and discuss the clinical benefits of HETs (including ofatumumab, ocrelizumab, natalizumab, alemtuzumab, and cladribine) in the early stages of MS, along with safety concerns associated with these DMTs. By minimizing the accumulation of neurological damage early in the disease course, early treatment with HETs may enhance long-term clinical outcomes over the lifetime of the patient.
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Affiliation(s)
- Léorah Freeman
- Department of Neurology, Dell Medical School, The University of Texas at Austin, 1601 Trinity St, Austin, TX, 78701, USA.
| | | | - Patricia K. Coyle
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Barry Hendin
- Banner, University Medicine Neurosciences Clinic, Phoenix, AZ USA
| | - Timothy Vollmer
- Department of Neurology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
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