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Oud L, Garza J. Association of multiple sclerosis with mortality in sepsis: a population-level analysis. J Intensive Care 2022; 10:36. [PMID: 35879778 PMCID: PMC9310428 DOI: 10.1186/s40560-022-00628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/17/2022] [Indexed: 11/21/2022] Open
Abstract
Background Multiple sclerosis (MS) is associated with increased risk of sepsis and higher sepsis-related mortality, compared to the general population. However, the evidence on the prognostic impact of MS in sepsis has been scarce. We aimed to evaluate the population-level association of MS with short-term mortality in sepsis. Methods We performed a retrospective population-based cohort study using a statewide data set to identify hospitalizations aged ≥ 18 years in Texas with sepsis, with and without MS during 2010–2017. Multilevel logistic models were fit to estimate the association of MS with short-term mortality among all sepsis hospitalizations, and for sensitivity analyses among hospitalizations with septic shock and those admitted to ICU. Results Among 283,025 sepsis hospitalizations, 1687 (0.6%) had MS. Compared to sepsis hospitalizations without MS, those with MS were younger (aged ≥ 65 years 35.0% vs 56.8%), less commonly racial/ethnic minority (36.2% vs 48.1%), and had lower mean Deyo comorbidity index (1.6 vs 2.7). The rates of septic shock and ICU admission were similar for sepsis hospitalizations with and without MS (58.7% vs 59.6% and 46.7% vs 46.0%, respectively). The unadjusted short-term mortality among sepsis hospitalizations with and without MS for the whole cohort, among those with septic shock, and among ICU admissions were 20.2% vs 31.3%, 25.6% vs 40.0%, and 24.0% vs 34.8%, respectively. On adjusted analyses, MS was associated with 17% lower odds of short-term mortality (adjusted odds ratio [aOR] 0.828 [95% CI 0.723–0.947]). Similar findings were observed on sensitivity analyses of patients with septic shock (aOR 0.764 [95% CI 0.651–0.896]), but MS was not associated with mortality among sepsis hospitalizations admitted to ICU (aOR 0.914 [95% CI 0.759–1.101]). Conclusions MS was associated with lower short-term mortality among septic patients, with findings consistent among the subset with septic shock. Among septic patients admitted to ICU, MS was not associated with mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00628-1.
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Oprea AD, Keshock MC, O'Glasser AY, Cummings KC, Edwards AF, Hunderfund AL, Urman RD, Mauck KF. Preoperative Management of Medications for Neurologic Diseases: Society for Perioperative Assessment and Quality Improvement Consensus Statement. Mayo Clin Proc 2022; 97:375-396. [PMID: 35120701 DOI: 10.1016/j.mayocp.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 10/14/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
Neurologic diseases are prevalent in patients undergoing invasive procedures; yet, no societal guidelines exist as to best practice in management of perioperative medications prescribed to treat these disorders. The Society for Perioperative Assessment and Quality Improvement tasked experts in internal medicine, anesthesiology, perioperative medicine, and neurology to provide evidence-based recommendations for preoperative management of these medications. The aim of this review is not only to provide consensus recommendations for preoperative management of patients on medications for neurologic disorders, but also to serve as an educational guide to perioperative clinicians. While, in general, medications for neurologic disorders should be continued preoperatively, an individualized approach may be needed in certain situations (eg, holding anticonvulsants on day of surgery if electroencephalographic mapping is planned during epilepsy surgery). Pertinent interactions with commonly used drugs in anesthesia practice, as well as considerations for targeted laboratory testing or perioperative drug substitutions, are addressed as well.
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Affiliation(s)
- Adriana D Oprea
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT.
| | - Maureen C Keshock
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Avital Y O'Glasser
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR
| | | | - Angela F Edwards
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | | | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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3
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Oud L, Garza J. The burden of sepsis in critically ill patients with multiple sclerosis: A population-based cohort study. J Crit Care 2022; 69:153985. [PMID: 35026610 DOI: 10.1016/j.jcrc.2022.153985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/28/2021] [Accepted: 01/04/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Multiple sclerosis (MS) is associated with increased risk of critical illness, sepsis, and sepsis-related death, compared to the general population. The epidemiology of sepsis and its impact on the outcomes of critically ill patients with MS are unknown. METHODS A statewide dataset was used to identify retrospectively ICU admissions in Texas aged ≥18 years with a diagnosis of MS during 2010-2017. The prevalence of sepsis and its impact on inpatient resource utilization and short-term mortality (a combination of in-hospital death or discharge to hospice) were examined. RESULTS Among 19,837 ICU admissions with MS, 6244 (31.5%) had sepsis. Compared to ICU admissions without sepsis, those with sepsis were older (aged ≥65 years 34.1% vs 24.1%), less commonly racial/ethnic minority (32.6% vs 35.2%), and had higher mean [SD] Deyo comorbidity index (1.7 [1.8] vs 1.2 [1.7]). On adjusted analyses, sepsis was associated with 42.7% longer hospital length of stay and 26.2% higher total hospital charges. Risk-adjusted short-term mortality among ICU admissions with and without sepsis was 13.4% vs 3.3%, respectively. CONCLUSIONS Sepsis was present in nearly 1 in 3 ICU admissions with MS, had substantial adverse impact on hospital resource utilization, and was associated with over 4-times higher short-term mortality.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th Street, Odessa, TX 79763, United States.
| | - John Garza
- Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th Street, Odessa, TX 79763, United States; Department of Mathematics, The University of Texas of the Permian Basin, 4901 E. University Blvd, Odessa, TX 79762, United States
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4
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Lymphocyte Counts and Multiple Sclerosis Therapeutics: Between Mechanisms of Action and Treatment-Limiting Side Effects. Cells 2021; 10:cells10113177. [PMID: 34831400 PMCID: PMC8625745 DOI: 10.3390/cells10113177] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 01/18/2023] Open
Abstract
Although the detailed pathogenesis of multiple sclerosis (MS) is not completely understood, a broad range of disease-modifying therapies (DMTs) are available. A common side effect of nearly every MS therapeutic agent is lymphopenia, which can be both beneficial and, in some cases, treatment-limiting. A sound knowledge of the underlying mechanism of action of the selected agent is required in order to understand treatment-associated changes in white blood cell counts, as well as monitoring consequences. This review is a comprehensive summary of the currently available DMTs with regard to their effects on lymphocyte count. In the first part, we describe important general information about the role of lymphocytes in the course of MS and the essentials of lymphopenic states. In the second part, we introduce the different DMTs according to their underlying mechanism of action, summarizing recommendations for lymphocyte monitoring and definitions of lymphocyte thresholds for different therapeutic regimens.
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5
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Landtblom A, Berntsson SG, Boström I, Iacobaeus E. Multiple sclerosis and COVID-19: The Swedish experience. Acta Neurol Scand 2021; 144:229-235. [PMID: 34028810 PMCID: PMC8222873 DOI: 10.1111/ane.13453] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/16/2021] [Accepted: 04/22/2021] [Indexed: 12/13/2022]
Abstract
The COVID-19 pandemic has brought challenges for healthcare management of patients with multiple sclerosis (MS). Concerns regarding vulnerability to infections and disease-modifying therapies (DMTs) and their complications have been raised. Recent published guidelines on the use of DMTs in relation to COVID-19 in MS patients have been diverse between countries with lack of evidence-based facts. In Sweden, there exists a particular interest in anti-CD20 therapy as a possible risk factor for severe COVID-19 due to the large number of rituximab-treated patients off-label in the country. Rapid responses from the Swedish MS Association (SMSS) and the Swedish MS registry (SMSreg) have resulted in national guidelines on DMT use for MS patients and implementation of a COVID-19 module in the SMSreg. Recently updated guidelines also included recommendations on COVID-19 vaccination with regard to the different DMTs. Social distancing policies forced implementation of telemedicine consultation to replace in-person consultations as part of regular MS health care. Patient-reported outcome measures (PROMs) in SMSreg have been useful in this respect. This paper reports our experiences on the progress of national MS health care during the COVID-19 pandemic, in addition to offering an overview of the present scientific context.
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Affiliation(s)
- Anne‐Marie Landtblom
- Department of NeuroscienceUppsala UniversityUppsalaSweden
- Department of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden
| | | | - Inger Boström
- Department of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Ellen Iacobaeus
- Department of Clinical NeuroscienceDivision of NeurologyKarolinska Institute and Karolinska University HospitalStockholmSweden
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McDaniel C, Trankiem C. Necrotizing Fasciitis in a Patient on Long-Term Intramuscular Interferon-Beta for Multiple Sclerosis: A Case Report. JBJS Case Connect 2021; 10:e0288. [PMID: 32224665 DOI: 10.2106/jbjs.cc.19.00288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Immunomodulatory injections are becoming common long-term treatments for neuromuscular diseases such as multiple sclerosis (MS), although they carry a risk of local site infection. We describe a case of a 57-year-old man who developed necrotizing fasciitis of the anterior thigh secondary to intramuscular (IM) injections of interferon-beta-1A for MS, ultimately developing septic shock and requiring serial debridements for source control. CONCLUSIONS This is the first reported case of necrotizing fasciitis from chronic IM injections for MS and deserves particular attention because of the immunosuppressive nature of the injections. In patients with underlying predisposing factors for infection, such as decubitus ulcers, it may be prudent to reconsider the administration route. Patients in hypermetabolic states should be closely monitored for impaired response to infections.
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Affiliation(s)
- Claire McDaniel
- Department of Orthopaedic Surgery, Johns Hopkins University Hospital, Baltimore, Maryland
| | - Christine Trankiem
- Department of Critical Care and Trauma Surgery, Medstar Washington Hospital Center, Washington, DC
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7
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Eslami A, Dehbashi M, Ashja-Arvan M, Salehi H, Azimzadeh M, Ganjalikhani-Hakemi M. Assessment of ability of human adipose derived stem cells for long term overexpression of IL-11 and IL-13 as therapeutic cytokines. Cytotechnology 2020; 72:773-784. [PMID: 32935166 PMCID: PMC7547926 DOI: 10.1007/s10616-020-00421-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/02/2020] [Indexed: 02/05/2023] Open
Abstract
Adipose-derived stem cells (ADSCs) are a type of mesenchymal stem cells with the therapeutic effects that make them one of the best sources for cell therapy. In this study, we aimed to assess the ability of human ADSCs for constant expression of IL-11 and IL-13, simultaneously. In this study, the characterized hADSCs were transduced with a lentiviral vector (PCDH-513B) containing IL-11 and IL-13 genes, and the ability of long-term expression of the transgenes was evaluated by ELISA technique on days 15, 45 and 75 after transduction. Our results indicated a high rate of transduction (more than 90%) in the isolated hADSCs. Our data showed the highest rate of expression on days 75 after transduction which was 242.67 pg/ml for IL-11 and 303.6 pg/ml for IL-13 compared with 35.2 pg/ml and 35.6 pg/ml in untreated cells, respectively (p = 0.001). Besides, MTT assay showed transduction of hADSCs with lentiviral viruses containing IL-11 and IL-13 had no adverse effect on hADSCs proliferation (p-value = 0.89). Finally, we successfully constructed a hADSC population stably overexpressing IL-11 as the neurotrophic cytokine and IL-13 as the anti-inflammatory cytokine and this transduced cells can be used for further studies in EAE mice model.
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Affiliation(s)
- Asma Eslami
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Moein Dehbashi
- Division of Genetics, Department of Cell and Molecular Biology, Faculty of Biological Sciences and Technologies, University of Isfahan, 81746-73441 Isfahan, Iran
| | - Mehnoosh Ashja-Arvan
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Salehi
- Department of Anatomical Sciences, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Azimzadeh
- Department of Anatomical Sciences, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Hamdy SM, Abdel-Naseer M, Shehata HS, Hassan A, Elmazny A, Shalaby NM, Abokrysha NT, Kishk NA, Nada MAF, Ahmed SM, Hegazy MI, Mekkawy D, Mourad HS, Abdelalim A, Berger T. Managing Disease-Modifying Therapies and Breakthrough Activity in Multiple Sclerosis Patients During the COVID-19 Pandemic: Toward an Optimized Approach. Ther Clin Risk Manag 2020; 16:651-662. [PMID: 32801722 PMCID: PMC7398889 DOI: 10.2147/tcrm.s257714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022] Open
Abstract
The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has become a major public health challenge of global concern since December 2019, when the virus was recognized in Wuhan, the capital city of Hubei province in China and epicenter of the COVID-19 epidemic. Given the novelty of COVID-19 and the lack of specific anti-virus therapies, the current management is essentially supportive. There is an absence of consensus on guidelines or treatment strategies for complex disorders such as multiple sclerosis (MS), in which the risk of infections is higher than in the general population. This is due to the overall impairment of the immune system typical of autoimmune diseases, in addition to accumulation of disabilities, and the iatrogenic effect generated by corticosteroids and the recommended disease-modifying therapies (DMTs). DMTs have different modes of action, but all modulate and interfere with the patient's immune response, thereby raising concerns about adverse effects, such as an increased susceptibility to infections. In this review, we analyze the evidence for use of DMTs during the current critical period and ratify an algorithmic approach for management to optimize care between keeping DMTs, with their infection hazards, or coming off them, with the risk of disease activation. We also provide an algorithmic approach to the management of breakthrough activity during the COVID-19 pandemic.
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Affiliation(s)
- Sherif M Hamdy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maged Abdel-Naseer
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hatem S Shehata
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hassan
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Elmazny
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nevin M Shalaby
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Noha T Abokrysha
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nirmeen A Kishk
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona A F Nada
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sandra M Ahmed
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed I Hegazy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Doaa Mekkawy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Husam S Mourad
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Abdelalim
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Thomas Berger
- Neurology Department, Medical University of Vienna, Vienna, Austria
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9
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Halasan C, Isache C, Sands M. A case of Disseminated Herpes Zoster in a patient with Multiple Sclerosis on Glatiramer acetate. IDCases 2020; 21:e00873. [PMID: 32637319 PMCID: PMC7330603 DOI: 10.1016/j.idcr.2020.e00873] [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: 06/08/2020] [Accepted: 06/14/2020] [Indexed: 11/23/2022] Open
Abstract
We present a case of Disseminated Herpes Zoster in a 73 year old man who had been taking Glatiramer acetate for 8 years as treatment for Multiple Sclerosis. He presented to the emergency room with complaints of a painful skin lesions on his buttocks and was found to have a generalized papulo-pustular rash. He was treated with IV Acyclovir and concurrent Piperacillin-Tazobactam plus Vancomycin for disseminated herpes zoster with a necrotic bacterial superinfection on his buttocks. Multiple Sclerosis is a chronic immune mediated disease of the CNS and is treated with immunomodulators and immunosuppressive medications. With more than 2 decades of Glatiramer acetate use, it is regarded as the safest immunomodulator without any associated reported infections. This is the first case of Disseminated Herpes Zoster associated with Glatiramer.
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Affiliation(s)
- C. Halasan
- Department of Infectious Diseases, University of Florida-Jacksonville, United States
| | - C. Isache
- Department of Infectious Diseases, University of Florida-Jacksonville, United States
| | - M. Sands
- Department of Infectious Diseases, University of Florida-Jacksonville, United States
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10
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Persson R, Lee S, Ulcickas Yood M, Wagner Usn Mc CM, Minton N, Niemcryk S, Lindholm A, Evans AM, Jick SS. Infections in patients diagnosed with multiple sclerosis: A multi-database study. Mult Scler Relat Disord 2020; 41:101982. [PMID: 32070858 DOI: 10.1016/j.msard.2020.101982] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/23/2019] [Accepted: 02/03/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent data on the rates of infections among patients with multiple sclerosis (MS) are sparse. The objective of this study was to quantify incidence of infections in patients with MS compared with a matched sample of patients without MS (non-MS). METHODS This study was conducted in two separate electronic medical databases: the United States Department of Defense (US-DOD) military health care system and the United Kingdom's Clinical Practice Research Datalink GOLD (UK-CPRD). We identified patients with a first recorded diagnosis of MS between 2001 and 2016 (UK-CPRD) or 2004 and 2017 (US-DOD) and matched non-MS patients. We identified infections recorded after the MS diagnosis date (or the matched date in non-MS patients) and calculated incidence rates (IRs) and incidence rate ratios (IRRs) with 95% confidence intervals (CIs) by infection site and type. RESULTS Relative to non-MS patients, MS patients had higher rates of any infection (US-DOD IRR 1.76; 95% CI 1.72-1.80 and UK-CPRD IRR 1.25; 95% CI 1.21-1.29) and a two-fold higher rate of hospitalized infections (US-DOD IRR 2.43; 95% CI 2.23-2.63 and UK-CPRD IRR 2.00; 95% CI 1.84-2.17). IRs of any infection were higher in females compared with males in both MS and non-MS patients, while IRs of hospitalized infections were similar between sexes in both MS and non-MS patients. The IR of first urinary tract or kidney infection was nearly two-fold higher in MS compared with non-MS patients (US-DOD IRR 1.88; 95% CI 1.81-1.95 and UK-CPRD IRR 1.97; 95% CI 1.86-2.09) with higher rates in females compared with males. IRs for any opportunistic infection, candidiasis and any herpes virus were increased between 20 and 52% among MS patients compared with non-MS patients. IRs of meningitis, tuberculosis, hepatitis B and C were all low. CONCLUSION MS patients have an increased risk of infection, notably infections of the renal tract, and a two-fold increased risk of hospitalized infections compared with non-MS patients.
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Affiliation(s)
- R Persson
- Boston Collaborative Drug Surveillance Program, Lexington, MA, USA
| | - S Lee
- Bristol-Myers Squibb, Summit, NJ, USA
| | - M Ulcickas Yood
- EpiSource, LLC, Newton, MA, USA; Boston University School of Public Health, Boston, MA, USA
| | | | - N Minton
- Bristol-Myers Squibb, Summit, NJ, USA
| | | | | | - A M Evans
- Health ResearchTx, LLC, Trevose, PA, USA
| | - S S Jick
- Boston Collaborative Drug Surveillance Program, Lexington, MA, USA; Boston University School of Public Health, Boston, MA, USA.
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11
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Zheng C, Kar I, Chen CK, Sau C, Woodson S, Serra A, Abboud H. Multiple Sclerosis Disease-Modifying Therapy and the COVID-19 Pandemic: Implications on the Risk of Infection and Future Vaccination. CNS Drugs 2020; 34:879-896. [PMID: 32780300 PMCID: PMC7417850 DOI: 10.1007/s40263-020-00756-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The coronavirus 2019 (COVID-19) pandemic is expected to linger. Decisions regarding initiation or continuation of disease-modifying therapy for multiple sclerosis have to consider the potential relevance to the pandemic. Understanding the mechanism of action and the possible idiosyncratic effects of each therapeutic agent on the immune system is imperative during this special time. The infectious side-effect profile as well as the route and frequency of administration of each therapeutic agent should be carefully considered when selecting a new treatment or deciding on risk mitigation strategies for existing therapy. More importantly, the impact of each agent on the future severe acute respiratory syndrome coronavirus type-2 (SARS-CoV-2) vaccine should be carefully considered in treatment decisions. Moreover, some multiple sclerosis therapies may have beneficial antiviral effects against SARS-CoV-2 while others may have beneficial immune-modulating effects against the cytokine storm and hyperinflammatory phase of the disease. Conventional injectables have a favorable immune profile without an increased exposure risk and therefore may be suitable for mild multiple sclerosis during the pandemic. However, moderate and highly active multiple sclerosis will continue to require treatment with oral or intravenous high-potency agents but a number of risk mitigation strategies may have to be implemented. Immune-modulating therapies such as the fumerates, sphinogosine-1P modulators, and natalizumab may be anecdotally preferred over cell-depleting immunosuppressants during the pandemic from the immune profile standpoint. Within the cell-depleting agents, selective (ocrelizumab) or preferential (cladribine) depletion of B cells may be relatively safer than non-selective depletion of lymphocytes and innate immune cells (alemtuzumab). Patients who develop severe iatrogenic or idiosyncratic lymphopenia should be advised to maintain social distancing even in areas where lockdown has been removed or ameliorated. Patients with iatrogenic hypogammaglobulinemia may require prophylactic intravenous immunoglobulin therapy in certain situations. When the future SARS-CoV-2 vaccine becomes available, patients with multiple sclerosis should be advised that certain therapies may interfere with mounting a protective immune response to the vaccine and that serological confirmation of a response may be required after vaccination. They should also be aware that most multiple sclerosis therapies are incompatible with live vaccines if a live SARS-CoV-2 vaccine is developed. In this article, we review and compare disease-modifying therapies in terms of their effect on the immune system, published infection rates, potential impact on SARS-CoV-2 susceptibility, and vaccine-related implications. We propose risk mitigation strategies and practical approaches to disease-modifying therapy during the COVID-19 pandemic.
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Affiliation(s)
- Crystal Zheng
- Raabe College of Pharmacy, Ohio Northern University, Ada, OH USA
| | - Indrani Kar
- System Pharmacy Services, University Hospitals of Cleveland, Cleveland, OH USA
| | - Claire Kaori Chen
- Specialty Pharmacy, University Hospitals of Cleveland, Cleveland, OH USA
| | - Crystal Sau
- Specialty Pharmacy, University Hospitals of Cleveland, Cleveland, OH USA ,Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Bolwell, 5th Floor, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Sophia Woodson
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Bolwell, 5th Floor, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Alessandro Serra
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Bolwell, 5th Floor, 11100 Euclid Avenue, Cleveland, OH 44106 USA ,VA Multiple Sclerosis Center of Excellence, Cleveland VA Medical Center, Cleveland, OH USA
| | - Hesham Abboud
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Bolwell, 5th Floor, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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12
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Sahin E, Hamamcı M, Kantekin Y. Measurement of mucociliary clearance in the patients with multiple sclerosis. Eur Arch Otorhinolaryngol 2019; 277:469-473. [PMID: 31707467 DOI: 10.1007/s00405-019-05717-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/30/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of the present study was to measure nasal mucociliary clearance (NMC) time in the patients with MS and to compare the findings with healthy population. METHODS Totally 97 individuals including 47 patients with relapsing-remitting multiple sclerosis and 50 healthy volunteers were enrolled into the study. Saccharin clearance test was performed on both groups and NMC time was measured. Data analysis was performed by SPSS version 24.0 statistics program (SPSS Inc., Chicago, Illinois, USA). Statistical tests were interpreted at p < 0.05 significance level. RESULTS The NMC time averages in MS patients and healthy control group were 12.43 ± 4.05 min and 8.14 ± 2.87 min, respectively; the difference between the groups was significant (p < 0.001). There was a statistically strong association between NMC time values and Expanded Disability Status Scale (EDSS) values in MS patients (r = 0.817, p < 0.001). CONCLUSION We found nasal mucociliary transport time longer in MS patients than healthy population in the present study. To the best of our knowledge, there is not any study conducted about this topic in the literature. We believe that our findings would shed a light on further studies.
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Affiliation(s)
- Ender Sahin
- Department of Otolaryngology, Faculty of Medicine, Bozok University, Atatürk Yolu 7. Km, 66100, Yozgat, Turkey.
| | - Mehmet Hamamcı
- Department of Neurology, Faculty of Medicine, Bozok University, Yozgat, Turkey
| | - Yunus Kantekin
- Department of Otolaryngology, Faculty of Medicine, Bozok University, Atatürk Yolu 7. Km, 66100, Yozgat, Turkey
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13
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Adjuvants as Delivery Systems in Antigen-Specific Immunotherapies. J Pharm Sci 2019; 108:3831-3841. [PMID: 31526814 DOI: 10.1016/j.xphs.2019.09.011] [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: 03/29/2019] [Revised: 07/23/2019] [Accepted: 09/11/2019] [Indexed: 11/24/2022]
Abstract
Combining autoantigens with immune-modulating drugs has emerged as an attractive approach to selectively reinstate tolerance in autoimmune diseases. The disparate properties of autoantigens and small-molecule immunosuppressants commonly used to treat autoimmune diseases can confound efforts to co-deliver these therapies. However, both components may be co-delivered with adjuvants which have been successful in delivering antigens to immune cells. We evaluated several common adjuvants as vehicles to co-deliver a model antigen and immunosuppressant, ovalbumin (OVA) and dexamethasone (DEX), respectively. Formulations were developed, and the release of DEX from adjuvants was investigated. Next, the effect of adjuvant, DEX, and OVA was tested in vitro using a DC line. A MF59-analog (MF59a) formulation was advanced to more sophisticated co-culture studies using OVA-primed bone marrow-derived dendritic cells and splenocytes or T-cells from OT-II mice. Most of these studies indicated MF59a-based antigen-specific immunotherapies could diminish the markers of inflammation associated with OVA recognition. We rationalized MF59a co-delivery of antigen and drug could reduce the risk of side effects typically associated with these drugs and reinstate immune tolerance, thus prompting continued investigation of emulsion adjuvants as delivery vehicles for antigen-specific immunotherapy of autoimmune diseases.
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Fox EJ, Buckle GJ, Singer B, Singh V, Boster A. Lymphopenia and DMTs for relapsing forms of MS: Considerations for the treating neurologist. Neurol Clin Pract 2019; 9:53-63. [PMID: 30859008 PMCID: PMC6382377 DOI: 10.1212/cpj.0000000000000567] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose of review To provide neurologists with an update on the proposed mechanisms of action (MOAs) of disease-modifying therapies (DMTs) for the treatment of relapsing MS, and their effect on peripheral blood leukocytes, in order to inform treatment decisions. Recent findings DMTs have vastly differing MOAs, including effects on peripheral blood leukocyte counts, particularly lymphocytes. The clinical implications of changes in lymphocyte counts need to be understood in the context of the underlying MOAs of each respective DMT, with treatment tailored to individual patient needs. Summary DMTs can alter lymphocyte counts, subsets, activation, and distribution, and thus can influence immune surveillance. Serial monitoring of total leukocytes and absolute lymphocyte counts (ALCs) is advisable in patients receiving DMTs. ALCs should be interpreted regarding expected immunologic changes and individual patient characteristics. Any decision to switch DMTs should consider these factors, along with drug efficacy, safety, and effect on quality of life.
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Affiliation(s)
- Edward J Fox
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
| | - Guy J Buckle
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
| | - Barry Singer
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
| | - Vibhuti Singh
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
| | - Aaron Boster
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
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Reginald McDaniel H, LaGanke C, Bloom L, Goldberg S, Lages LC, Lantigua LA, Atlas SE, Woolger JM, Lewis JE. The Effect of a Polysaccharide-Based Multinutrient Dietary Supplementation Regimen on Infections and Immune Functioning in Multiple Sclerosis. J Diet Suppl 2018; 17:184-199. [PMID: 30285512 DOI: 10.1080/19390211.2018.1495675] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Multiple sclerosis (MS) is a progressive neurodegenerative disease associated with increased infection rates, chronic inflammation, and premature death. Optimization of nutritional status via dietary supplementation may improve immune function in people suffering from MS and lead to decreased rates of infection. Fifteen individuals with a diagnosis of relapsing-remitting MS for an average of 12.4 years (SD =7.4; R = 2, 25) were enrolled in a one-year open-label clinical trial. Participants consumed a broad-spectrum dietary supplement regimen containing polysaccharides, phytochemicals, antioxidants, vitamins, and minerals three times per day. The occurrence of infections and a panel of cytokines, growth factors, and T- and B-cell subsets were assessed at baseline and 12 months. Seven female and 8 male participants with an average age of 51.3 years (SD =7.2; R = 38, 65) completed the study. At the end of the intervention, participants had fewer total infections (M = 7.9, SD =8.1 at baseline and M = 2.5, SD =4.3 at 12-month follow-up). At 12 months, IL-2, TNF-α, EGF, and CD95 + CD34+ significantly increased, while IL-1β significantly decreased. No major adverse effects were reported; only mild gastrointestinal intolerance was reported in four cases. A decreased occurrence of infection was observed in MS patients treated with 12 months of a polysaccharide-based multinutrient dietary supplement. Significant changes were also noted in several key biomarkers that would be physiologically favorable to the MS population. Thus, the results of this study suggest an immunomodulatory effect of the dietary supplement regimen studied.
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Affiliation(s)
| | | | - Laura Bloom
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Lucas C Lages
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Laura A Lantigua
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Steven E Atlas
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Judi M Woolger
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - John E Lewis
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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16
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Hincapie AL, Penm J, Burns CF. Factors Associated with Patient Preferences for Disease-Modifying Therapies in Multiple Sclerosis. J Manag Care Spec Pharm 2018; 23:822-830. [PMID: 28737987 PMCID: PMC10398239 DOI: 10.18553/jmcp.2017.23.8.822] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Treatment adherence in patients with multiple sclerosis (MS) is essential to reduce the rate of acute neurological attacks, severity of relapses, and hospitalizations and to slow its progression. Adherence rates in MS patients have been shown to be affected by multiple factors, including physical or cognitive difficulties, perceived lack of treatment efficacy, treatment-related adverse events, injection anxiety, and frequency of administration. OBJECTIVE To elicit the preferences of MS patients for noneconomic and economic attributes of current disease-modifying therapies (DMTs). METHODS We used conjoint analysis to estimate preferences from a convenience sample through a web-based online survey. Patients were invited to participate in the study using web portals and newsletters for MS patients. The conjoint survey included the following 6 attributes: (1) overall efficacy based on autoimmune disease progression stabilization; (2) acute increase in disease activity (flare-up); (3) rate of respiratory tract infections; (4) rate of serious respiratory tract infections (leading to hospitalization); (5) medication use; and (6) patient monthly out-of-pocket medication costs. Using a fractional factorial design, 24 product profiles were created. Each respondent reviewed a random selection of 8 profiles. With each profile, subjects were asked to indicate their likelihood to try the hypothetical products on a scale from 0 to 100. Random effects linear regression was used to elicit preferences. RESULTS After exclusion of respondents with incomplete information, data from 129 subjects were included in the analysis. The overall relative importance of each attribute for the ranges presented were (1) 38.4% for monthly out-of-pocket cost; (2) 21.5% for route and frequency of administration; (3) 15.9% for risk of hospitalization by infection; (4) 11.9% for risk of respiratory tract infection; (5) 7.4% for risk of flare-ups; and (6) 5.0% for disease progression stabilization. Preference weights indicated that subjects favored subcutaneous (beta coefficient [β] = -2.26, 95% CI = -4.22 to -0.22) and oral administration (β = 7.93, 95% CI = 5.95 to 10.2) over intramuscular (β = -5.67, 95% CI = -8.67 to -3.56), but no significant differences were found between subcutaneous over intramuscular administration. Monthly out-of-pocket cost was the most influential attribute, with an overall relative importance of 38%. The most preferred level was $75 (β = 12.85, 95% CI = 10.64 to 15.06) followed by $150 (β = 3.41, 95% CI = 0.98 to 5.84) when compared between $75, $150, $300, and $450 a month. CONCLUSIONS Conjoint analysis proved to be a convenient tool to quantify respondents' relative preferences for DMT characteristics. Respondents gave higher weight to DMT monthly out-of-pocket costs and mode of administration than to adverse effects or efficacy. These findings may assist in the development of DMT cost-sharing strategies and shared decision making at the point of care. DISCLOSURES No outside funding supported this study. The authors declare no potential conflicts of interest. Study concept and design were contributed by Hincapie and Burns. Data were collected by Hincapie and Burns, and interpreted by all the authors. The manuscript was written by Hincapie, Penm, and Burns and revised by Penm, Hincapie, and Burns. At the time of data collection, Burns was a PhD candidate at The University of Oklahoma, College of Pharmacy.
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Affiliation(s)
- Ana L Hincapie
- 1 James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio
| | - Jonathan Penm
- 1 James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio
| | - Craig F Burns
- 2 College of Pharmacy, University of Oklahoma, Tulsa
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17
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Navas C, Torres-Duque CA, Munoz-Ceron J, Álvarez C, García JR, Zarco L, Vélez LA, Awad C, Castro CA. Diagnosis and treatment of latent tuberculosis in patients with multiple sclerosis, expert consensus. On behalf of the Colombian Association of Neurology, Committee of Multiple Sclerosis. Mult Scler J Exp Transl Clin 2018; 4:2055217317752202. [PMID: 29372069 PMCID: PMC5774739 DOI: 10.1177/2055217317752202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/06/2017] [Indexed: 11/28/2022] Open
Abstract
Background Multiple sclerosis is an inflammatory and neurodegenerative demyelinating disease. Current treatment of multiple sclerosis focuses on the use of immunomodulatory, immunosuppressant, and selective immunosuppressant agents. Some of these medications may result in high risk of opportunistic infections including tuberculosis. Objective The purpose of this study was to obtain consensus from a panel of neurologists, pulmonologists, infectious disease specialists, and epidemiology experts regarding the diagnosis, treatment, and monitoring of latent tuberculosis in patients with multiple sclerosis. Methods A panel of experts in multiple sclerosis and tuberculosis was established. The methodological process was performed in three phases: definition of questions, answer using Delphi methodology, and the discussion of questions not agreed. Results Tuberculosis screening is suggested when multiple sclerosis drugs are prescribed. The recommended tests for latent tuberculosis are tuberculin and interferon gamma release test. When an anti-tuberculosis treatment is indicated, monitoring should be performed to determine liver enzyme values with consideration of age as well as comorbid conditions such as a history of alcoholism, age, obesity, concomitant hepatotoxic drugs, and history of liver disease. Conclusion Latent tuberculosis should be considered in patients with multiple sclerosis who are going to be treated with immunomodulatory and immunosuppressant medications. Transaminase level monitoring is required on a periodic basis depending on clinical and laboratory characteristics. In addition to the liver impairment, other side effects should be considered when Isoniazid is prescribed.
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Affiliation(s)
- Carlos Navas
- Department of Neurology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Carlos A Torres-Duque
- Fundación Neumológica Colombiana, Colombia.,Universidad de la Sabana, Bogotá, Colombia.,Universidad del Rosario, Bogotá, Colombia
| | - Joe Munoz-Ceron
- Clínica Universitaria Colombia - Hospital MEDERI Bogotá, Colombia
| | - Carlos Álvarez
- Department of infectology, Clinica Universitaria Colombia, Bogotá, Colombia
| | - Juan R García
- Departamento de Neurología, Clínica de Marly, Bogota Colombia
| | - Luis Zarco
- Department of Neurology, Hospital de San Ignacio, Universidad Javeriana, Bogotá, Colombia
| | - Lázaro A Vélez
- Department of Internal Medicine, Faculty of Medicine, University of Antioquia, Medellin, Colombia
| | - Carlos Awad
- Deparmet of pulmonology, Hospital Santa Clara, Bogotá, Colombia
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18
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Celius EG. Infections in patients with multiple sclerosis: Implications for disease-modifying therapy. Acta Neurol Scand 2017; 136 Suppl 201:34-36. [PMID: 29068490 DOI: 10.1111/ane.12835] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2017] [Indexed: 12/27/2022]
Abstract
Patients with multiple sclerosis have an increased risk of infections compared to the general population. The increased risk has been described for decades and is not alone attributed to the use of disease-modifying drugs, but secondary to the disability. The introduction of more potent immunomodulatory drugs may cause an additional challenge, and depending on the mechanism of action, a treatment-induced increased risk of bacterial, viral, fungal or parasitic infections is observed. The choice of treatment in the individual patient with infections and multiple sclerosis must be guided by the drugs' specific mechanism of action, the drug-specific risk of infection and comorbidities. Increased monitoring and follow-up through treatment registries is warranted to increase our understanding and thereby improve management.
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Affiliation(s)
- E. G. Celius
- Department of Neurology; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; Institute of Health and Society; University of Oslo; Oslo Norway
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19
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Kuo R, Saito E, Miller SD, Shea LD. Peptide-Conjugated Nanoparticles Reduce Positive Co-stimulatory Expression and T Cell Activity to Induce Tolerance. Mol Ther 2017; 25:1676-1685. [PMID: 28408181 PMCID: PMC5498812 DOI: 10.1016/j.ymthe.2017.03.032] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 03/21/2017] [Accepted: 03/22/2017] [Indexed: 12/11/2022] Open
Abstract
Targeted approaches to treat autoimmune diseases would improve upon current therapies that broadly suppress the immune system and lead to detrimental side effects. Antigen-specific tolerance was induced using poly(lactide-co-glycolide) nanoparticles conjugated with disease-relevant antigen to treat a model of multiple sclerosis. Increasing the nanoparticle dose and amount of conjugated antigen both resulted in more durable immune tolerance. To identify active tolerance mechanisms, we investigated downstream cellular and molecular events following nanoparticle internalization by antigen-presenting cells. The initial cell response to nanoparticles indicated suppression of inflammatory signaling pathways. Direct and functional measurement of surface MHC-restricted antigen showed positive correlation with both increasing particle dose from 1 to 100 μg/mL and increasing peptide conjugation by 2-fold. Co-stimulatory analysis of cells expressing MHC-restricted antigen revealed most significant decreases in positive co-stimulatory molecules (CD86, CD80, and CD40) following high doses of nanoparticles with higher peptide conjugation, whereas expression of a negative co-stimulatory molecule (PD-L1) remained high. T cells isolated from mice immunized against myelin proteolipid protein (PLP139-151) were co-cultured with antigen-presenting cells administered PLP139-151-conjugated nanoparticles, which resulted in reduced T cell proliferation, increased T cell apoptosis, and a stronger anti-inflammatory response. These findings indicate several potential mechanisms used by peptide-conjugated nanoparticles to induce antigen-specific tolerance.
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MESH Headings
- Animals
- Antigen-Presenting Cells/drug effects
- Antigen-Presenting Cells/immunology
- Antigen-Presenting Cells/pathology
- Antigens/chemistry
- Antigens/immunology
- Antigens/pharmacology
- B7-1 Antigen/genetics
- B7-1 Antigen/immunology
- B7-2 Antigen/genetics
- B7-2 Antigen/immunology
- CD40 Antigens/genetics
- CD40 Antigens/immunology
- Delayed-Action Preparations/administration & dosage
- Delayed-Action Preparations/chemistry
- Encephalomyelitis, Autoimmune, Experimental/genetics
- Encephalomyelitis, Autoimmune, Experimental/immunology
- Encephalomyelitis, Autoimmune, Experimental/pathology
- Encephalomyelitis, Autoimmune, Experimental/therapy
- Female
- Gene Expression
- Immune Tolerance/drug effects
- Immunoconjugates/chemistry
- Immunoconjugates/metabolism
- Immunoconjugates/pharmacology
- Mice
- Mice, Inbred C57BL
- Myelin Proteolipid Protein/chemistry
- Myelin Proteolipid Protein/immunology
- Myelin Proteolipid Protein/pharmacology
- Nanoparticles/administration & dosage
- Nanoparticles/chemistry
- Ovalbumin/chemistry
- Ovalbumin/immunology
- Ovalbumin/pharmacology
- Particle Size
- Polyglactin 910/chemistry
- Polyglactin 910/metabolism
- Primary Cell Culture
- Spleen/drug effects
- Spleen/immunology
- Spleen/pathology
- T-Lymphocytes, Regulatory/drug effects
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/pathology
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Affiliation(s)
- Robert Kuo
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Eiji Saito
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Stephen D Miller
- Department of Microbiology-Immunology, Northwestern University, Chicago, IL 60611, USA
| | - Lonnie D Shea
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI 48109, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA.
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20
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[Infection risks in multiple sclerosis therapy by infusion of disease modifying drugs]. DER NERVENARZT 2016; 86:971-7. [PMID: 26187545 DOI: 10.1007/s00115-015-4388-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The increased risk of developing infections when using disease-modifying drugs for treatment of multiple sclerosis (MS) is a major challenge in the daily clinical routine. In the growing field of treatment options specific knowledge of treatment-related risks of infections and appropriate preventive and countermeasures is mandatory. Current clinical experience shows that an individual risk stratification is necessary when choosing treatment options and while monitoring during and after treatment administration. The determination of the individual risk of infection in the context of serial use of disease-modifying drugs remains a challenging issue. In addition to the mechanisms of action, the warning notices and current recommendations on infection prophylaxis when using intravenous disease-modifying drugs, such as alemtuzumab, natalizumab and mitoxantron, are presented in detail.
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Nelson RE, Xie Y, DuVall SL, Butler J, Kamauu AWC, Knippenberg K, Schuerch M, Foskett N, LaFleur J. Multiple Sclerosis and Risk of Infection-Related Hospitalization and Death in US Veterans. Int J MS Care 2015; 17:221-30. [PMID: 26472943 DOI: 10.7224/1537-2073.2014-035] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study estimated the risk of infection-related hospitalizations and death in patients with and without multiple sclerosis (MS). METHODS We identified adults with MS in the US Department of Veterans Affairs (VA) system between 1999 and 2010. Each veteran with MS was matched, on age and sex, with up to four veterans without MS. Multivariable Cox proportional hazards regression models were performed to assess the influence of MS on the development of serious and fatal infections. RESULTS The cohort included 7743 veterans with MS and 30,972 veterans without MS. Mean (SD) age was 53.8 (13.3) years, and 80.8% were male. The incidence per 1000 person-years of overall serious infections was 19.2 (95% confidence interval [CI], 17.6-20.8) for those with MS and 10.3 (95% CI, 9.8-10.9) for those without MS. Fatal infection incidence rates were 1.2 (95% CI, 0.8-1.7) for patients with MS and 0.5 (95% CI, 0.3-0.6) for patients without MS. Regression models showed that veterans with MS were at greater risk for overall serious (hazard ratio [HR] = 1.52, P < .01) and fatal (HR = 1.85, P = .03) infections and serious respiratory (HR = 1.31, P = .01), urinary tract (HR = 4.44, P < .01), and sepsis-related infections (HR = 2.56, P < .01). CONCLUSIONS This study provides evidence that VA patients with MS are more likely than those without MS to be hospitalized and die of infection.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Yan Xie
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Scott L DuVall
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Jorie Butler
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Aaron W C Kamauu
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Kristin Knippenberg
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Markus Schuerch
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Nadia Foskett
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Joanne LaFleur
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
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22
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Winkelmann A, Löbermann M, Reisinger EC, Hartung HP, Zettl UK. [Immunotherapy and infectious issues in multiple sclerosis. Self-injectable and oral drugs for immunotherapy]. DER NERVENARZT 2015; 86:960-970. [PMID: 26187544 DOI: 10.1007/s00115-015-4369-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Immunotherapy is generally associated with an increased risk for the development of infections. Due to the continuously expanding spectrum of new and potent immunotherapy treatment options for multiple sclerosis (MS), this article describes the currently known risks for treatment-related infections and the current recommendations for prevention of corresponding problems with drugs used in treatment strategies for MS and their mechanisms of action. The new treatment options in particular are linked to specific and severe infections; therefore, intensive and long-lasting monitoring is required before, during and after treatment and multidisciplinary surveillance of patients is needed. This article gives a detailed review of drug-specific red flags and current recommendations for the prophylaxis of infections associated with treatment of relapsing-remitting MS and when using self-injectable and oral disease-modifying immunotherapeutic drugs.
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Affiliation(s)
- A Winkelmann
- Klinik und Poliklinik für Neurologie, Universitätsmedizin Rostock, Gehlsheimer Str. 20, 18147, Rostock, Deutschland,
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23
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Abstract
The interface of multiple sclerosis (MS) and infection occurs on several levels. First, infectious disease has been postulated as a potential trigger, if not cause, of MS. Second, exacerbation of MS has been well-documented as a consequence of infection, and, lastly, infectious diseases have been recognized as a complication of the therapies currently employed in the treatment of MS. MS is a disease in which immune dysregulation is a key component. Examination of central nervous system (CNS) tissue of people affected by MS demonstrates immune cell infiltration, activation and inflammation. Therapies that alter the immune response have demonstrated efficacy in reducing relapse rates and evidence of brain inflammation on magnetic resonance imaging (MRI). Despite the altered immune response in MS, there is a lack of evidence that these patients are at increased risk of infectious disease in the absence of treatment or debility. Links between infections and disease-modifying therapies (DMTs) used in MS will be discussed in this review, as well as estimates of occurrence and ways to potentially minimize these risks. We address infection in MS in a comprehensive fashion, including (1) the impact of infections on relapse rates in patients with MS; (2) a review of available infection data from pivotal trials and postmarketing studies for the approved and experimental DMTs, including frequency, types and severity of infections; and (3) relevant risk minimization strategies, particularly as they pertain to progressive multifocal leukoencephalopathy (PML).
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24
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Fragoso YD, Adoni T, Anacleto A, Brooks JBB, Carvalho MDJ, Claudino R, Damasceno A, Ferreira MLB, Gama PDD, Goncalves MVM, Grzesiuk AK, Matta APDC, Parolin MFK. How do we manage and treat a patient with multiple sclerosis at risk of tuberculosis? Expert Rev Neurother 2014; 14:1251-60. [PMID: 25242167 DOI: 10.1586/14737175.2014.962517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Tuberculosis continues to be a serious health problem worldwide. The disease continues to be underdiagnosed and not properly treated. In conditions that affect the immune system, such as multiple sclerosis (MS), latent tuberculosis may thrive and reactivate during the use of immunomodulatory and immunosuppressive drugs. Among the best treatment options for patients with latent or active tuberculosis who have MS are IFN-β, glatiramer acetate and mitoxantrone. Drugs leading to a reduced number and/or function of lymphocytes should be avoided or used with caution. Tuberculosis must always be investigated in patients with MS and treated with rigor.
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Affiliation(s)
- Yara Dadalti Fragoso
- Department of Neurology and MS Reference Center, Universidade Metropolitana de Santos, SP, Brazil
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25
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Stüve O, Zettl U. Neuroinflammation of the central and peripheral nervous system: an update. Clin Exp Immunol 2014; 175:333-5. [PMID: 24384012 DOI: 10.1111/cei.12260] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2013] [Indexed: 12/20/2022] Open
Abstract
Inflammatory disorders of the peripheral nervous system (PNS) and central nervous system (CNS) are common, and contribute substantially to physical and emotional disability of affected individuals. Often, the afflicted are young and in their active years. In the past, physicians and scientists often had very little to offer in terms of diagnostic precision and therapeutic effectiveness. During the past two decades, both of these relative shortcomings have clearly improved. Some of the recent developments in clinical neuroimmunology are illustrated in this special edition of Clinical and Experimental Immunology.
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Affiliation(s)
- O Stüve
- Neurology Section, VA North Texas Health Care System, Dallas VA Medical Center, Dallas, TX, USA; Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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26
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Rommer PS, Dudesek A, Stüve O, Zettl UK. Monoclonal antibodies in treatment of multiple sclerosis. Clin Exp Immunol 2014; 175:373-84. [PMID: 24001305 DOI: 10.1111/cei.12197] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2013] [Indexed: 01/14/2023] Open
Abstract
Monoclonal antibodies (mAbs) are used as therapeutics in a number of disciplines in medicine, such as oncology, rheumatology, gastroenterology, dermatology and transplant rejection prevention. Since the introduction and reintroduction of the anti-alpha4-integrin mAb natalizumab in 2004 and 2006, mAbs have gained relevance in the treatment of multiple sclerosis (MS). At present, numerous mAbs have been tested in clinical trials in relapsing-remitting MS, and in progressive forms of MS. One of the agents that might soon be approved for very active forms of relapsing-remitting MS is alemtuzumab, a humanized mAb against CD52. This review provides insights into clinical studies with the mAbs natalizumab, alemtuzumab, daclizumab, rituximab, ocrelizumab and ofatumumab.
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Affiliation(s)
- P S Rommer
- Clinic and Policlinic of Neurology, University of Rostock, Rostock, Germany; Department of Neurology, Medical University of Vienna, Vienna, Austria
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27
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Rommer PS, Zettl UK, Kieseier B, Hartung HP, Menge T, Frohman E, Greenberg BM, Hemmer B, Stüve O. Requirement for safety monitoring for approved multiple sclerosis therapies: an overview. Clin Exp Immunol 2014; 175:397-407. [PMID: 24102425 DOI: 10.1111/cei.12206] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2013] [Indexed: 12/12/2022] Open
Abstract
During the last two decades, treatment options for patients with multiple sclerosis (MS) have broadened tremendously. All agents that are currently approved for clinical use have potential side effects, and a careful risk-benefit evaluation is part of a decision algorithm to identify the optimal treatment choice for an individual patient. Whereas glatiramer acetate and interferon beta preparations have been used in MS for decades and have a proven safety record, more recently approved drugs appear to be more effective, but potential risks might be more severe. The potential complications of some novel therapies might not even have been identified to their full extent. This review is aimed at the clinical neurologist in that it offers insights into potential adverse events of each of the approved MS therapeutics: interferon beta, glatiramer acetate, mitoxantrone, natalizumab, fingolimod and teriflunomide, as well as recently approved therapeutics such as dimethyl fumarate and alemtuzumab. It also provides recommendations for monitoring the different drugs during therapy in order to avoid common side effects.
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Affiliation(s)
- P S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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28
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Melzer N, Meuth SG. Disease-modifying therapy in multiple sclerosis and chronic inflammatory demyelinating polyradiculoneuropathy: common and divergent current and future strategies. Clin Exp Immunol 2014; 175:359-72. [PMID: 24032475 DOI: 10.1111/cei.12195] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2013] [Indexed: 01/15/2023] Open
Abstract
Multiple sclerosis (MS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) represent chronic, autoimmune demyelinating disorders of the central and peripheral nervous system. Although both disorders share some fundamental pathogenic elements, treatments do not provide uniform effects across both disorders. We aim at providing an overview of current and future disease-modifying strategies in these disorders to demonstrate communalities and distinctions. Intravenous immunoglobulins (IVIG) have demonstrated short- and long-term beneficial effects in CIDP but are not effective in MS. Dimethyl fumarate (BG-12), teriflunomide and laquinimod are orally administered immunomodulatory drugs that are already approved or likely to be approved in the near future for the basic therapy of patients with relapsing-remitting MS (RRMS) due to positive results in Phase III clinical trials. However, clinical trials with these drugs in CIDP have not (yet) been initiated. Natalizumab and fingolimod are approved for the treatment of RRMS, and trials to evaluate their safety and efficacy in CIDP are now planned. Alemtuzumab, ocrelizumab and daclizumab respresent monoclonal antibodies in advanced stages of clinical development for their use in RRMS patients. Attempts to study the safety and efficacy of alemtuzumab and B cell-depleting anti-CD20 antibodies, i.e. rituximab, ocrelizumab or ofatumumab, in CIDP patients are currently under way. We provide an overview of the mechanism of action and clinical data available on disease-modifying immunotherapy options for MS and CIDP. Enhanced understanding of the relative effects of therapies in these two disorders may aid rational treatment selection and the development of innovative treatment approaches in the future.
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Affiliation(s)
- N Melzer
- Department of Neurology, University of Münster, Münster, Germany
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29
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de la Pena I, Pabon M, Acosta S, Sanberg PR, Tajiri N, Kaneko Y, Borlongan CV. Oligodendrocytes engineered with migratory proteins as effective graft source for cell transplantation in multiple sclerosis. CELL MEDICINE 2014; 6:123-127. [PMID: 24999443 DOI: 10.3727/215517913x674144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Multiple sclerosis (MS) is characterized by widespread immunomodulatory demyelination of the CNS resulting in nerve cell dysfunction. Accordingly, treatment strategies have been centered on immunodulation and remyelination, with the former primarily focused on reducing the pathology rather than enhancing myelin repair which the latter targets. While conceding to the emerging view of heterogeneity in the pathology of MS, which precludes variations in degree of immune response (i.e., inflammation) and demyelination, the concept of enhancing myelin repair is appealing since it is likely to provide both disease-reducing and disease-inhibiting therapeutic approach to MS. In this regard, we and several others, have proposed that cell replacement therapy is an effective strategy to repair the myelin in MS. Here, we hypothesize that transplantation of mouse bone marrow-derived oligodendrocytes (BMDOs) and BMDOs transfected with Ephrin proteins (BMDO+Ephrin), which are known to enhance cell and axonal migratory capacity, may produce therapeutic benefits in animal models of MS.
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Affiliation(s)
- Ike de la Pena
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair. University of South Florida, Morsani College of Medicine 12901 Bruce B. Downs Blvd., Tampa, FL 33612
| | - Mibel Pabon
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair. University of South Florida, Morsani College of Medicine 12901 Bruce B. Downs Blvd., Tampa, FL 33612
| | - Sandra Acosta
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair. University of South Florida, Morsani College of Medicine 12901 Bruce B. Downs Blvd., Tampa, FL 33612
| | - Paul R Sanberg
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair. University of South Florida, Morsani College of Medicine 12901 Bruce B. Downs Blvd., Tampa, FL 33612
| | - Naoki Tajiri
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair. University of South Florida, Morsani College of Medicine 12901 Bruce B. Downs Blvd., Tampa, FL 33612
| | - Yuji Kaneko
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair. University of South Florida, Morsani College of Medicine 12901 Bruce B. Downs Blvd., Tampa, FL 33612
| | - Cesar V Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair. University of South Florida, Morsani College of Medicine 12901 Bruce B. Downs Blvd., Tampa, FL 33612
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