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Wandall-Holm MF, Holm RP, Heick A, Langkilde AR, Magyari M. Risk of T 2 lesions when discontinuing fingolimod: a nationwide predictive and comparative study. Brain Commun 2024; 6:fcad358. [PMID: 38214014 PMCID: PMC10783644 DOI: 10.1093/braincomms/fcad358] [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: 03/28/2023] [Revised: 10/25/2023] [Accepted: 01/01/2024] [Indexed: 01/13/2024] Open
Abstract
Fingolimod is a frequently used disease-modifying therapy in relapsing-remitting multiple sclerosis. However, case reports and small observational studies indicate a highly increased risk of disease reactivation after discontinuation. We aimed to investigate the risk of radiological disease reactivation in patients discontinuing fingolimod. We performed a nationwide cohort study in Denmark, including patients who discontinued fingolimod between January 2014 and January 2023. Eligibility was a diagnosis with relapsing-remitting multiple sclerosis and two MRIs performed respectively within 1 year before and after discontinuing fingolimod. The included patients were compared with those discontinuing dimethyl fumarate with the same eligibility criteria in an unadjusted and matched propensity score analysis. Matching was done on age, sex, Expanded Disability Status Scale, MRI data, cause for treatment discontinuation, treatment duration and relapse rate. The main outcome was the presence of new T2 lesions on the first MRI after treatment discontinuation. To identify high-risk patients among those discontinuing fingolimod, we made a predictive model assessing risk factors for obtaining new T2 lesions. Of 1324 patients discontinuing fingolimod in the study period, 752 were eligible for inclusion [mean age (standard deviation), years, 41 (10); 552 females (73%); median Expanded Disability Status Scale (Q1-Q3), 2.5 (2.0-3.5); mean disease duration (standard deviation), years, 12 (8)]. Of 2044 patients discontinuing dimethyl fumarate in the study period, 957 were eligible for inclusion, presenting similar baseline characteristics. Among patients discontinuing fingolimod, 127 (17%) had 1-2 new T2 lesions, and 124 (17%) had ≥3 new T2 lesions compared with 114 (12%) and 45 (5%), respectively, for those discontinuing dimethyl fumarate, corresponding to odds ratios (95% confidence interval) of 1.8 (1.3-2.3) and 4.4 (3.1-6.3). The predictive model, including 509 of the 752 patients discontinuing fingolimod, showed a highly increased risk of new T2 lesions among those with disease activity during fingolimod treatment and among females under 40 years. This nationwide study suggests that discontinuing fingolimod in some cases carries a risk of developing new T2 lesions, emphasizing the importance of clinical awareness. If feasible, clinicians should prioritize the prompt initiation of new disease-modifying therapies, particularly among young females.
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Affiliation(s)
- Malthe Faurschou Wandall-Holm
- Department of Neurology, Danish Multiple Sclerosis Registry, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
| | - Rolf Pringler Holm
- Department of Neurology, Danish Multiple Sclerosis Registry, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
| | - Alex Heick
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
| | - Annika Reynberg Langkilde
- Department of Radiology, Diagnostic Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen DK-2100, Denmark
| | - Melinda Magyari
- Department of Neurology, Danish Multiple Sclerosis Registry, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital—Rigshospitalet, Glostrup DK-2600, Denmark
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Cerdá-Fuertes N, Nagy S, Schaedelin S, Sinnecker T, Ruberte E, Papadopoulou A, Würfel J, Kuhle J, Yaldizli Ö, Kappos L, Derfuss T, Décard BF. Evaluation of frequency, severity, and independent risk factors for recurrence of disease activity after fingolimod discontinuation in a large real-world cohort of patients with multiple sclerosis. Ther Adv Neurol Disord 2023; 16:17562864221150312. [PMID: 36762317 PMCID: PMC9905031 DOI: 10.1177/17562864221150312] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/08/2022] [Indexed: 02/10/2023] Open
Abstract
Background Clinical and radiological signs of recurring disease activity (RDA) have been described in patients with multiple sclerosis (pwMS) after discontinuation of fingolimod (FGL). Objective To describe frequency, severity and potential risk factors for RDA after FGL discontinuation in a large real-world cohort of pwMS. Methods Post-FGL RDA was defined as evidence of clinical and/or radiological activity within 6 months after FGL discontinuation. Relapses with Expanded Disability Status Scale increase ⩾2 points and/or magnetic resonance imaging (MRI) activity with at least five cerebral gadolinium-enhancing lesions and/or ⩾6 cerebral new T2 lesions were defined as severe recurring disease activity (sRDA). Using a multivariate logistic model, we explored the influence of age, disease duration, sex, clinical, and MRI activity under FGL on the occurrence of RDA. Results We identified 110 pwMS who discontinued FGL. Thirty-seven (33.6%) developed post-FGL RDA and 13 (11.8%) also fulfilled criteria for sRDA. Younger age at diagnosis [odds ratio (OR) = 1.10, p < 0.01], shorter disease duration (OR = 1.17, p < 0.01), and MRI activity under FGL (OR = 2.92, p = 0.046) were independent risk factors for the occurrence of post-FGL RDA. Conclusion Individual risk assessment and optimal treatment sequencing can help to minimize the risk of post-FGL RDA. Early switch to highly effective disease-modifying therapy might reduce occurrence of post-FGL RDA.
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Affiliation(s)
- Nuria Cerdá-Fuertes
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Translational Imaging in Neurology (ThINK) Basel, Department of Medicine and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sara Nagy
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland,Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tim Sinnecker
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Medical Image Analysis Center (MIAC AG), Basel and qbig, Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Esther Ruberte
- Medical Image Analysis Center (MIAC AG), Basel and qbig, Department of Biomedical Engineering, University of Basel, Basel, Switzerland,Translational Imaging in Neurology (ThINK) Basel, Department of Medicine and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Athina Papadopoulou
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Translational Imaging in Neurology (ThINK) Basel, Department of Medicine and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jens Würfel
- Medical Image Analysis Center (MIAC AG), Basel and qbig, Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Jens Kuhle
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Özgür Yaldizli
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Translational Imaging in Neurology (ThINK) Basel, Department of Medicine and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ludwig Kappos
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tobias Derfuss
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
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Lescot L, Lefort M, Leguy S, Le Page E, Vukusic S, Edan G, Kerbrat A, Lebrun-Frenay C, De Sèze J, Laplaud DA, Wiertlewski S, Leray E, Michel L. Disease modifying therapies and disease activity during pregnancy and postpartum in a contemporary cohort of relapsing Multiple Sclerosis patients. Mult Scler Relat Disord 2022; 68:104122. [PMID: 36037756 DOI: 10.1016/j.msard.2022.104122] [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: 08/01/2022] [Accepted: 08/14/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND In Multiple Sclerosis (MS) women, therapeutic management for pregnancy planning and during pregnancy still represents a challenge regarding timing of disease-modifying therapies (DMT) stop, risk of disease reactivation and potential fetal toxicity. The objective of this study was to describe disease activity during pregnancy and postpartum depending on treatment status before conception in women with MS. METHODS 339 MS patients who have achieved a pregnancy between 2007 and 2017 were included. Women were classified according to their exposure to DMT in the 18 months period prior to pregnancy (untreated / first- / second/third-line treatment). RESULTS 122 women were not exposed to DMT prior to conception, whereas 147 were exposed to first-line DMT and 70 to second/third line DMT (73% to natalizumab and 23% to fingolimod) before conception. In the first-line group, the ARR decreased from 0.39 during the year before conception to 0.21 during pregnancy, whereas it increased in the second/third-line group from 0.59 to 0.78. 47.1% of the second/third-line group faced at least one relapse during pregnancy and the time from conception to first relapse was significantly shorter in this group (p < 10-4). The risk of relapse during pregnancy and postpartum was associated with occurrence of pre-conception relapses and second/third line DMT exposure before pregnancy. CONCLUSION Careful consideration should be given to natalizumab and fingolimod exposed patients before conception as they are at higher risk of reactivation of MS during pregnancy.
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Affiliation(s)
- Lucile Lescot
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Mathilde Lefort
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, University Rennes, Rennes F-35000, France
| | - Soizic Leguy
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Emmanuelle Le Page
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Sandra Vukusic
- Service de neurologie, Sclérose en plaques, Pathologies de la myéline et neuro-inflammation et centre de recherche, Ressources et compétences sur la sclérose en plaques, Hospices civils de Lyon, Bron 69677, France; Inserm 1028 et CNRS UMR 5292, Observatoire français de la sclérose en plaques, Centre de recherche en neurosciences de Lyon, Lyon 69003, France; Université de Lyon, Université Claude-Bernard Lyon 1, Lyon 69000, France; Eugène Devic EDMUS Foundation against multiple sclerosis, State-approved foundation, Bron 69677, France
| | - Gilles Edan
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Anne Kerbrat
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | | | - Jérome De Sèze
- Centre d'investigation clinique, INSERM U1434, Centre Hospitalier Universitaire de Strasbourg, 1 Place de l'Hôpital, Strasbourg 67000, France
| | - David Axel Laplaud
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Sandrine Wiertlewski
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Emmanuelle Leray
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, University Rennes, Rennes F-35000, France
| | - Laure Michel
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France; Microenvironment, Cell Differentiation, Immunology and Cancer unit, INSERM, Rennes I University, French Blood Agency, Rennes, France.
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Rowles WM, Hsu WY, McPolin K, Li A, Merrill S, Guo CY, Green AJ, Gelfand JM, Bove RM. Transitioning From S1P Receptor Modulators to B Cell-Depleting Therapies in Multiple Sclerosis: Clinical, Radiographic, and Laboratory Data. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:e1183. [PMID: 35581005 PMCID: PMC9128034 DOI: 10.1212/nxi.0000000000001183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 03/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with multiple sclerosis (MS) transition from oral sphingosine-1-receptor (S1P) modulators to anti-CD20 therapies for several circumstances. Optimal timing of this transition is uncertain, given competing concerns of rebound disease activity and ensuring immune reconstitution. The objective of this study was to evaluate the relationship between inflammatory activity and the transition period from fingolimod to anti-CD20 therapies in a real-world MS cohort. METHODS Medical records were reviewed for all patients at our center transitioning from fingolimod to rituximab or ocrelizumab between 2010 and October 2020. Time periods reviewed were the following: before fingolimod discontinuation, interval between fingolimod and anti-CD20 treatments, and after the first anti-CD20 infusion. The primary outcome was clinical relapses; MRI activity, time to absolute lymphocyte count (ALC) recovery, and infections were secondary. Clinical and demographic factors significant in univariable analyses were included in multivariable analyses. RESULTS Transition data were available for 108 patients (68.5% women, 68.5% relapsing-remitting MS, mean age 44.6 years). The median (interquartile range) interval between fingolimod and anti-CD20 therapy was 28 (1-115.2) days. Six of 51 patients (11.8%) with intervals >1 month and 0/57 patients with shorter intervals experienced a relapse (MRI confirmed) within 6 months of fingolimod discontinuation. In the year following anti-CD20 initiation, 4/108 patients (3.7%) experienced a relapse (median 214.5 days after infusion). An additional 7% of those undergoing contrast-enhanced MRIs developed Gd+ lesions. ALC normalized following treatment switch in 89/92; the interval between treatments was unrelated to ALC recovery or infection. DISCUSSION Delaying anti-CD20 start to monitor ALC after S1P modulator discontinuation may not be necessary and could increase rebound risk. ALC monitoring could instead occur after a rapid switch to anti-CD20 treatment.
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Affiliation(s)
- William M. Rowles
- From the UCSF Weill Institute for Neurosciences (W.M.R., W.-Y.H., K.M., A.L., C.-Y.G., A.J.G., J.M.G., R.M.B.), Division of Neuroimmunology and Glial Biology, Department of Neurology, Department of Clinical Pharmacy (S.M.), and UCSF Department of Ophthalmology (A.J.G.), University of California, San Francisco
| | - Wan-Yu Hsu
- From the UCSF Weill Institute for Neurosciences (W.M.R., W.-Y.H., K.M., A.L., C.-Y.G., A.J.G., J.M.G., R.M.B.), Division of Neuroimmunology and Glial Biology, Department of Neurology, Department of Clinical Pharmacy (S.M.), and UCSF Department of Ophthalmology (A.J.G.), University of California, San Francisco
| | - Kira McPolin
- From the UCSF Weill Institute for Neurosciences (W.M.R., W.-Y.H., K.M., A.L., C.-Y.G., A.J.G., J.M.G., R.M.B.), Division of Neuroimmunology and Glial Biology, Department of Neurology, Department of Clinical Pharmacy (S.M.), and UCSF Department of Ophthalmology (A.J.G.), University of California, San Francisco
| | - Alyssa Li
- From the UCSF Weill Institute for Neurosciences (W.M.R., W.-Y.H., K.M., A.L., C.-Y.G., A.J.G., J.M.G., R.M.B.), Division of Neuroimmunology and Glial Biology, Department of Neurology, Department of Clinical Pharmacy (S.M.), and UCSF Department of Ophthalmology (A.J.G.), University of California, San Francisco
| | - Steven Merrill
- From the UCSF Weill Institute for Neurosciences (W.M.R., W.-Y.H., K.M., A.L., C.-Y.G., A.J.G., J.M.G., R.M.B.), Division of Neuroimmunology and Glial Biology, Department of Neurology, Department of Clinical Pharmacy (S.M.), and UCSF Department of Ophthalmology (A.J.G.), University of California, San Francisco
| | - Chu-Yueh Guo
- From the UCSF Weill Institute for Neurosciences (W.M.R., W.-Y.H., K.M., A.L., C.-Y.G., A.J.G., J.M.G., R.M.B.), Division of Neuroimmunology and Glial Biology, Department of Neurology, Department of Clinical Pharmacy (S.M.), and UCSF Department of Ophthalmology (A.J.G.), University of California, San Francisco
| | - Ari J. Green
- From the UCSF Weill Institute for Neurosciences (W.M.R., W.-Y.H., K.M., A.L., C.-Y.G., A.J.G., J.M.G., R.M.B.), Division of Neuroimmunology and Glial Biology, Department of Neurology, Department of Clinical Pharmacy (S.M.), and UCSF Department of Ophthalmology (A.J.G.), University of California, San Francisco
| | - Jeffrey Marc Gelfand
- From the UCSF Weill Institute for Neurosciences (W.M.R., W.-Y.H., K.M., A.L., C.-Y.G., A.J.G., J.M.G., R.M.B.), Division of Neuroimmunology and Glial Biology, Department of Neurology, Department of Clinical Pharmacy (S.M.), and UCSF Department of Ophthalmology (A.J.G.), University of California, San Francisco
| | - Riley M. Bove
- From the UCSF Weill Institute for Neurosciences (W.M.R., W.-Y.H., K.M., A.L., C.-Y.G., A.J.G., J.M.G., R.M.B.), Division of Neuroimmunology and Glial Biology, Department of Neurology, Department of Clinical Pharmacy (S.M.), and UCSF Department of Ophthalmology (A.J.G.), University of California, San Francisco
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Villaverde-González R. Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy. Degener Neurol Neuromuscul Dis 2022; 12:1-21. [PMID: 35023987 PMCID: PMC8743861 DOI: 10.2147/dnnd.s203406] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.
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Schoedel KA, Kolly C, Gardin A, Neelakantham S, Shakeri-Nejad K. Abuse and dependence potential of sphingosine-1-phosphate (S1P) receptor modulators used in the treatment of multiple sclerosis: a review of literature and public data. Psychopharmacology (Berl) 2022; 239:1-13. [PMID: 34773483 PMCID: PMC8770388 DOI: 10.1007/s00213-021-06011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 10/18/2021] [Indexed: 12/05/2022]
Abstract
Abuse and misuse of prescription drugs remains an ongoing concern in the USA and worldwide; thus, all centrally active new drugs must be assessed for abuse and dependence potential. Sphingosine-1-phosphate (S1P) receptor modulators are used primarily in the treatment of multiple sclerosis. Among the new S1P receptor modulators, siponimod, ozanimod, and ponesimod have recently been approved in the USA, European Union (EU), and other countries. This review of literature and other public data has been undertaken to assess the potential for abuse of S1P receptor modulators, including ozanimod, siponimod, ponesimod, and fingolimod, as well as several similar compounds in development. The S1P receptor modulators have not shown chemical or pharmacological similarity to known drugs of abuse; have not shown abuse or dependence potential in animal models for subjective effects, reinforcement, or physical dependence; and do not have adverse event profiles demonstrating effects of interest to individuals who abuse drugs (such as sedative, stimulant, mood-elevating, or hallucinogenic effects). In addition, no reports of actual abuse, misuse, or dependence were identified in the scientific literature for fingolimod, which has been on the market since 2010 (USA) and 2011 (EU). Overall, the data suggest that S1P receptor modulators are not associated with significant potential for abuse or dependence, consistent with their unscheduled status in the USA and internationally.
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Affiliation(s)
| | - Carine Kolly
- grid.419481.10000 0001 1515 9979Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Anne Gardin
- grid.419481.10000 0001 1515 9979Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Srikanth Neelakantham
- grid.464975.d0000 0004 0405 8189Novartis Institutes for Biomedical Research, Novartis Healthcare Pvt Ltd, Hyderabad, India
| | - Kasra Shakeri-Nejad
- grid.419481.10000 0001 1515 9979Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland
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Bianco A, Lucchini M, Totaro R, Fantozzi R, De Luca G, Di Lemme S, Presicce G, Evangelista L, Di Tommaso V, Pastorino R, De Fino C, De Arcangelis V, Centonze D, Mirabella M. Disease Reactivation after Fingolimod Discontinuation in Pregnant Multiple Sclerosis Patients. Neurotherapeutics 2021; 18:2598-2607. [PMID: 34494237 PMCID: PMC8803993 DOI: 10.1007/s13311-021-01106-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 12/01/2022] Open
Abstract
Recent studies estimated an incidence of 4-25% of disease rebound after withdrawal of fingolimod (FTY) for any reason, but specific data on disease reactivation after FTY withdrawal due to pregnancy are limited. The aim of the study was to evaluate the frequency and predictors of disease reactivation in patients who stopped FTY for pregnancy. A multicentre retrospective cohort study was conducted in four Italian MS centres in 2013-2019. Both planned and unplanned pregnancies were included. The annualized relapse rate (ARR) was calculated before FTY treatment, during FTY treatment, during pregnancy and during the year after delivery. In total, 27 patients (mean age 29 years) were included. The ARR 1 year before FTY treatment was 1.3. Patients were exposed to FTY for a median of 2.9 years. The ARR was 0.04 during the last year before conception (p < 0.001 compared with the ARR before FTY treatment). Eleven patients became pregnant after a mean of 88 days following FTY discontinuation, whereas 16 patients stopped FTY after pregnancy confirmation. Relapses were observed in 22% of patients during pregnancy and in 44% in the postpartum period. ARR increased both during pregnancy (0.49; p = 0.027) and in the first year after delivery (0.67; p < 0.001) compared to the last year before pregnancy. Compared with radiological assessment before pregnancy, more patients showed new or enlarging T2 lesions (63% vs 30%; p = 0.02) and gadolinium-enhancing lesions (44% vs 0; p = 0.0001) on brain Magnetic Resonance Imaging. Relapses during pregnancy were the only significant predictor for postpartum relapses (OR 1.9, 95% CI 1.11-3.1). One case of spontaneous abortion and no cases of abnormal foetal development were observed. Despite adequate and prolonged control of disease activity, women who discontinue FTY because of pregnancy are at risk for disease reactivation. In patients who relapsed during pregnancy, the initiation of high-efficacy disease modifying drugs (DMDs) soon after delivery is advisable to prevent postpartum relapses.
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Affiliation(s)
- Assunta Bianco
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Centro Di Ricerca Per La Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Matteo Lucchini
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Centro Di Ricerca Per La Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Rocco Totaro
- Demyelinating Disease Center, San Salvatore Hospital, L’Aquila, Italy
| | | | - Giovanna De Luca
- Multiple Sclerosis Centre, Unit of Neurology, SS Annunziata University Hospital, Chieti, Italy
| | | | - Giorgia Presicce
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Luana Evangelista
- Demyelinating Disease Center, San Salvatore Hospital, L’Aquila, Italy
| | - Valeria Di Tommaso
- Multiple Sclerosis Centre, Unit of Neurology, SS Annunziata University Hospital, Chieti, Italy
| | - Roberta Pastorino
- Department of Woman and Child Health and Public Health-Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara De Fino
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Valeria De Arcangelis
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Diego Centonze
- Neurology Unit, IRCCS Neuromed, Pozzilli, IS Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Massimiliano Mirabella
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Centro Di Ricerca Per La Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Proschmann U, Haase R, Inojosa H, Akgün K, Ziemssen T. Drug and Neurofilament Levels in Serum and Breastmilk of Women With Multiple Sclerosis Exposed to Natalizumab During Pregnancy and Lactation. Front Immunol 2021; 12:715195. [PMID: 34512637 PMCID: PMC8426350 DOI: 10.3389/fimmu.2021.715195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/05/2021] [Indexed: 12/28/2022] Open
Abstract
Objective To determine the transfer of the monoclonal antibody natalizumab into breastmilk and to evaluate drug and serum neurofilament light chain ((s)NfL) levels in natalizumab exposed pregnancies and lactation periods. Methods Eleven women with relapsing remitting multiple sclerosis treated with natalizumab during pregnancy and lactation were included in this study. Breastmilk samples were collected up to 302 days after delivery and analyzed for natalizumab concentration and NfL. Additionally, maternal drug levels and sNfL were determined preconceptually, in each trimester, at delivery and postpartum. Clinical and radiological disease activity was systemically assessed across pregnancy and postpartum period. Results The mean average natalizumab concentration in breast milk was low at 0.06 µg/ml [standard deviation (SD) 0.05] in the eight patients who provided serial breastmilk samples with an estimated mean absolute infant dose of 0.007 mg/kg/d (SD 0.005). The relative infant dose (RID), a metric comparing the infant with maternal drug exposure was low as well with a mean of 0.04% (SD=0.03). Most patients had a maximum concentration in breast milk at one to eight days after infusion. Pregnancy was associated with a non-significant decline of the median natalizumab serum concentration. All patients exposed to natalizumab prior (n=10) and during pregnancy (n=11) kept free of disease activity during gestation. While pregnancy was associated with low sNfL levels in patients treated with natalizumab prior and during pregnancy, the postpartum period was linked to a transient sNfL increase in some patients without any evidence of clinical or radiological disease activity. NfL was detectable in the majority of breastmilk samples with a median concentration of 1.7 pg/ml (range 0.004-18.1). Conclusion We determined transfer of natalizumab into breastmilk with an RID far below the threshold of concern of 10%. Studies including childhood development assessment are needed in order to gain safety data about natalizumab-exposed breastfeeding. SNfL assessment might be a useful adjunct to monitor silent disease activity and therapeutic response during pregnancy and postpartum period. However, further investigations regarding transient postpartum sNfL increases are required to determine its association to parturition per se or to a silent disease activity in people with multiple sclerosis.
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Affiliation(s)
- Undine Proschmann
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Rocco Haase
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Hernan Inojosa
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Katja Akgün
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Tjalf Ziemssen
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
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9
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Almouzain L, Stevenson F, Chard D, Rahman NA, Hamilton F. Switching treatments in clinically stable relapsing remitting multiple sclerosis patients planning for pregnancy. Mult Scler J Exp Transl Clin 2021; 7:20552173211001571. [PMID: 33796332 PMCID: PMC7985951 DOI: 10.1177/20552173211001571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/21/2021] [Indexed: 12/03/2022] Open
Abstract
Background The decision to have children can be complex, particularly for people with multiple sclerosis (MS). A key concern is the use of disease modifying drugs (DMDs) during pregnancy, and how continuing, stopping or switching them may affect the mother and child. In people with active MS, stopping medications puts the mother at risk of relapse and disease rebound. Objectives Review evidence on the effect of different switching strategies in people with stable relapsing remitting MS (RRMS). Methods We searched MEDLINE, EMBASE, EMCARE, CINAHL, SCOPUS, Cochrane Library up to March 2020. Only papers in English were included and no other limits were applied. Seven articles were included: four cohorts, two case reports and one randomized controlled trial (RCT). Results Two strategies were found: de-escalating, which was associated with an increased risk of relapses, and switching between first line injectables, with no change in relapse rate observed. Conclusion Evidence on the effect of switching strategy on disease course in stable RRMS patients planning for pregnancy is scarce, but when switching, current evidence suggests the risk of relapses mirrors known medication efficacy.
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Affiliation(s)
- Lubna Almouzain
- Research Department at Primary Care and Population Health, Institution of Epidemiology, University College of London, London, UK.,Clinical Pharmacy Department, King Saud University, Riyadh, Saudi Arabia
| | - Fiona Stevenson
- Research Department at Primary Care and Population Health, Institution of Epidemiology, University College of London, London, UK
| | - Declan Chard
- Department of Neuroinflammation, UCL Queen Square Institute of Neurology, London, UK
| | - Nur Abdul Rahman
- Research Department at Primary Care and Population Health, Institution of Epidemiology, University College of London, London, UK.,Department of Primary Care Medicine & Medical Education Unit, Universiti Sains Islam Malaysia, Nilai, Malaysia
| | - Fiona Hamilton
- Research Department at Primary Care and Population Health, Institution of Epidemiology, University College of London, London, UK
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10
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Alhomoud MA, Khan AS, Alhomoud I. The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis. Eur Neurol 2021; 84:71-84. [PMID: 33744881 DOI: 10.1159/000514432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/09/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an inflammatory demyelinating chronic neurological disease that affects the central nervous system of young adults and their quality of life. Several studies have investigated the effects of pregnancy and breastfeeding on MS. However, the evidence regarding the influence of pregnancy and breastfeeding on MS is still accumulating. This review aimed to summarize the current evidence regarding the effects of pregnancy and breastfeeding on MS. SUMMARY A systematic electronic literature search of the PubMed and Embase databases was conducted to determine relevant published articles. The eligible studies were summarized and evaluated in tables. Key Messages: The majority of the studies indicated that pregnancy appears to lower the rate of MS relapses, particularly in the third trimester. The evidence regarding the effect of breastfeeding on MS remains inconsistent. Despite reports of negative obstetric outcomes in some pregnant women with MS, pregnancies in women with MS should not be categorized as high-risk pregnancies.
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Affiliation(s)
- Mohsen Ali Alhomoud
- Department of Public Health, Ministry of Health, Eastern Province, Al Qatif, Saudi Arabia,
| | - Abdul Sattar Khan
- Family and Community Medicine Department, King Faisal University, Eastern Province, Al Ahsa, Saudi Arabia
| | - Iftetah Alhomoud
- Neurosciences Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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11
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Zhuravleva MV, Davydovskaya MV, Luchinina EV, Shelekhova TV, Kurguzova DO, Serebrova SY. [Comparison of the clinical benefits of second-line drugs modifying the course of multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:148-153. [PMID: 32929938 DOI: 10.17116/jnevro2020120081148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This review aims at describing clinical benefits and characteristics of the main highly effective disease modifying drugs (DMD) for multiple sclerosis (MS): alemtuzumab, cladribine tablets, ocrelizumab, natalizumab, fingolimod based on the efficacy and safety. The authors highlight that all MS DMDs have certain benefits and features that shall be considered in prescribing pharmacotherapy. Cladribine in tablets are comparable by the efficacy to other modern highly effective second-line drugs, have a high level of evidence and a favorable safety profile, as well as the most preferred benefit/risk ratio among other MS DMDs indicated for the treatment of highly active MS, which offers an advantage to the drug. The use of cladribine in tablets will contribute to further study of the efficacy and safety of this highly efficient drug for MS treatment.
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Affiliation(s)
- M V Zhuravleva
- Scientific Center for Examination of Medical Devices of the Ministry of Health of Russia, Moscow, Russia.,Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - M V Davydovskaya
- Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Moscow, Russia.,Scientific and Practical Center for Clinical and Economic Analysis, Krasnogorsk, Russia
| | - E V Luchinina
- Razumovsky Saratov State Medical University of the Ministry of Health of Russia, Saratov, Russia
| | - T V Shelekhova
- Razumovsky Saratov State Medical University of the Ministry of Health of Russia, Saratov, Russia
| | - D O Kurguzova
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia.,Center for the Clinical Study of Medicinal Products of the Institute of Translational Medicine and Biotechnology of the Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - S Yu Serebrova
- Scientific Center for Examination of Medical Devices of the Ministry of Health of Russia, Moscow, Russia.,Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
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12
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Canibaño B, Deleu D, Mesraoua B, Melikyan G, Ibrahim F, Hanssens Y. Pregnancy-related issues in women with multiple sclerosis: an evidence-based review with practical recommendations. J Drug Assess 2020; 9:20-36. [PMID: 32128285 PMCID: PMC7034025 DOI: 10.1080/21556660.2020.1721507] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 01/21/2020] [Indexed: 12/18/2022] Open
Abstract
Objective: To review the current evidence regarding pregnancy-related issues in multiple sclerosis (MS) and to provide recommendations specific for each of them. Research design and methods: A systematic review was performed based on a comprehensive literature search. Results: MS has no effect on fertility, pregnancy or fetal outcomes, and pregnancies do not affect the long-term disease course and accumulation of disability. There is a potential risk for relapse after use of gonadotropin-releasing hormone agonists during assisted reproduction techniques. At short-term, pregnancy leads to a reduction of relapses during the third trimester, followed by an increased risk of relapses during the first three months postpartum. Pregnancies in MS are not per se high risk pregnancies, and MS does not influence the mode of delivery or anesthesia unless in the presence of significant disability. MRI is not contraindicated during pregnancy; however, gadolinium contrast media should be avoided whenever possible. It is safe to use pulse dose methylprednisolone infusions to manage acute disabling relapses during pregnancy and breastfeeding. However, its use during the first trimester of pregnancy is still controversial. Women with MS should be encouraged to breastfeed with a possible favorable effect of exclusive breastfeeding. Disease-modifying drugs can be classified according to their potential for pregnancy-associated risk and impact on fetal outcome. Interferon beta (IFNβ) and glatiramer acetate (GA) may be continued until pregnancy is confirmed and, after consideration of the individual risk-benefit if continued, during pregnancy. The benefit of continuing natalizumab during the entire pregnancy may outweigh the risk of recurring disease activity, particularly in women with highly active MS. GA and IFNβ are considered safe during breastfeeding. The use of natalizumab during pregnancy or lactation requires monitoring of the newborn. Conclusions: This review provides current evidence and recommendations for counseling and management of women with MS preconception, during pregnancy and postpartum.
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Affiliation(s)
- Beatriz Canibaño
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Dirk Deleu
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Boulenouar Mesraoua
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Gayane Melikyan
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Faiza Ibrahim
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Yolande Hanssens
- Clinical Services Unit, Pharmacy, Hamad Medical Corporation, Doha, Qatar
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13
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Abstract
BACKGROUND Fingolimod is an effective therapy for multiple sclerosis (MS). Isolated reports of very aggressive MS rebound after discontinuation of fingolimod are drawing neurologists' attention to this potentially severe complication of the drug. OBJECTIVE Our objective was to collect literature data on cases of MS rebound following fingolimod withdrawal. In addition, we report six new cases of this adverse event in Brazil. METHODS We carried out a systematic review of published data on cases of MS rebound after fingolimod was discontinued. In addition, the study reports a retrospective data series of Brazilian patients presenting this rebound reaction. RESULTS Twenty papers have been published reporting on 52 patients with severe MS rebound after fingolimod withdrawal. Six new patients are included in the present paper, all of them with aggressive rebound and accumulated disability sequelae. CONCLUSION We recommend gradual discontinuation of fingolimod with replacement by other treatment. The washout period should not exceed 4 weeks.
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14
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Barry B, Erwin AA, Stevens J, Tornatore C. Fingolimod Rebound: A Review of the Clinical Experience and Management Considerations. Neurol Ther 2019; 8:241-250. [PMID: 31677060 PMCID: PMC6858914 DOI: 10.1007/s40120-019-00160-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Indexed: 12/15/2022] Open
Abstract
Because the treatment of multiple sclerosis (MS) may span decades, the need often arises to make changes to the treatment plan in order to accommodate changing circumstances. Switching drugs, or the discontinuation of immunomodulatory agents altogether, may leave patients vulnerable to relapse or disease progression. In some cases, severe MS disease activity is noted clinically and on MRI after treatment withdrawal. When this disease activity is disproportionate to the pattern observed prior to treatment initiation, patients are said to have experienced rebound. Of the US Food and Drug Administration (FDA)-approved agents to treat MS, the drugs most commonly implicated in rebound are natalizumab and fingolimod. In this review based on the reported cases and data from clinical trials, we characterize disease rebound after fingolimod cessation. We also outline fingolimod rebound management considerations, summarizing what evidence is available to help clinicians mitigate the risk of rebound, switch therapies, and treat rebound events when they occur. The commonly encountered situation of fingolimod discontinuation prior to pregnancy is also discussed.
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Affiliation(s)
- Brian Barry
- Georgetown University Medical Center, Washington, DC, USA
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15
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Sepúlveda M, Montejo C, Llufriu S, Sola-Valls N, Reyes D, Martinez-Lapiscina EH, Zubizarreta I, Pulido-Valdeolivas I, Martinez-Hernandez E, Ariño H, Baños N, Saiz A, Blanco Y. Rebound of multiple sclerosis activity after fingolimod withdrawal due to planning pregnancy: Analysis of predisposing factors. Mult Scler Relat Disord 2019; 38:101483. [PMID: 31734621 DOI: 10.1016/j.msard.2019.101483] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/03/2019] [Accepted: 10/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Rebound of multiple sclerosis (MS) activity has been described after the withdrawal of high-efficacy drugs, but its impact during pregnancy is less known. We describe a series of cases of rebound syndrome after the cessation of fingolimod due to pregnancy planning. METHODS The clinical and radiological data of 7 MS patients who discontinued fingolimod therapy between May 2012 and March 2018 to plan a pregnancy was analysed. RESULTS Three (42.8%) of the 7 patients experienced a rebound effect, all of whom became pregnant. During pregnancy, the 3 patients had a mean (SD) of 5.3 (1.3) relapses, and 13 of the 15 relapses were treated with intravenous steroids and/or immunoglobulin. These patients experienced a median increase of 3 points in the Expanded Disability Status Scale (range, 2-4), as well as a median increase of 27 new gadolinium-enhancing lesions (range, 9-40) and 38 new T2 lesions in a post-partum MRI (range, 21-70). The 3 pregnancies resulted in the delivery of healthy babies. A strong correlation was found between the lymphocyte count at fingolimod onset and the annual relapse rate in the period without therapy (r= -0.84, p = 0.005). The time to first relapse was shorter in patients who had <300/μl lymphocytes at fingolimod onset (median time 46 vs 426 days, p = 0.010). CONCLUSION Rebound activity after fingolimod suspension represents a severe long-lasting inflammatory syndrome that may affect up to 40% of female MS patient who discontinue therapy due to pregnancy planning. Lymphopenia (<300/μl) in the first 3 months of fingolimod onset may predispose patients to suffer earlier and higher disease activity upon cessation.
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Affiliation(s)
- Maria Sepúlveda
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Carmen Montejo
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Sara Llufriu
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Nuria Sola-Valls
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - David Reyes
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Elena H Martinez-Lapiscina
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Irati Zubizarreta
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Irene Pulido-Valdeolivas
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Eugenia Martinez-Hernandez
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Helena Ariño
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Nuria Baños
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Universitat de Barcelona, Spain
| | - Albert Saiz
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Yolanda Blanco
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain.
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16
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Yamout B, Sahraian M, Bohlega S, Al-Jumah M, Goueider R, Dahdaleh M, Inshasi J, Hashem S, Alsharoqi I, Khoury S, Alkhawajah M, Koussa S, Al Khaburi J, Almahdawi A, Alsaadi T, Slassi E, Daodi S, Zakaria M, Alroughani R. Consensus recommendations for the diagnosis and treatment of multiple sclerosis: 2019 revisions to the MENACTRIMS guidelines. Mult Scler Relat Disord 2019; 37:101459. [PMID: 31670208 DOI: 10.1016/j.msard.2019.101459] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 12/19/2022]
Abstract
With evolving diagnostic criteria and the advent of new oral and parenteral therapies for 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 in 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 multiple sclerosis (MS) therapies is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, and progressive MS. 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
- Nehme and Therese Tohme MS Center, American University of Beirut Medical Center, Beirut, Lebanon.
| | - M Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - S Bohlega
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Al-Jumah
- King Fahad Medical Cit, MOH, Riyadh, Saudi Arabia
| | - R Goueider
- Service de Neurologie, Hôpital Razi, Manouba, Tunis
| | | | - J Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - S Hashem
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - I Alsharoqi
- Dept of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain
| | - S Khoury
- Nehme and Therese Tohme MS Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Alkhawajah
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - S Koussa
- MS Center- Geitaoui Lebanese University Hospital, Beirut, Lebanon
| | - J Al Khaburi
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - A Almahdawi
- Consultant neurologist, neurology unit, Baghdad Teaching Hospital, Medical City Complex, Iraq
| | - T Alsaadi
- American Center for Psychiatry & Neurology- UAE
| | - E Slassi
- Hôpital Cheikh Khalifa Ibn Zaid, Casablanca- Morocco
| | - S Daodi
- Hospital Center Nedir Mohamed, Faculty of Medicine University Mouloud Mammeri Tizi-ouzou Algeria
| | | | - R Alroughani
- Amiri Hospital, Arabian Gulf Street, Sharq, Kuwait
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17
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Berenguer-Ruiz L, Gimenez-Martinez J, Palazón-Bru A, Sempere AP. Relapses and obstetric outcomes in women with multiple sclerosis planning pregnancy. J Neurol 2019; 266:2512-2517. [PMID: 31256279 DOI: 10.1007/s00415-019-09450-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the effect of discontinuation of different disease-modifying therapies (DMTs) before pregnancy with respect to the occurrence of relapses and pregnancy outcomes. METHODS Women with multiple sclerosis who desire to bear children were followed prospectively. Demographic data, clinical characteristics, and the information on the use of DMTs were collected. A multivariate analysis was used to assess the relationship between relapses and the prior use of different DMTs. RESULTS The present study assessed 75 consecutive pregnancy plans (66 women), 65 of which resulted in pregnancy. The mean age of the participants was 32.1 ± 4.2 years, and the mean disease duration was 6.1 ± 4.2 years. No relapses before pregnancy were reported in the group of women who maintained their DMT until pregnancy confirmation, while 14 relapses were reported in 12/42 women (29%) who discontinued DMT before pregnancy. During pregnancy, patients on natalizumab or fingolimod before pregnancy had a higher rate of relapses. Most women restarted their previous DMT after delivery within the first trimester. The relapse rate in postpartum was 0.07. CONCLUSIONS Disease-modifying therapies received influences the risk of relapse and disease progression from women who are planning pregnancy. The risk of relapse during pregnancy was significantly higher in the group of women treated with natalizumab or fingolimod compared to the group of women treated with interferon beta or glatiramer acetate. The postpartum risk of relapses was lower than that found in previous reports.
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Affiliation(s)
| | | | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, Sant Joan d'Alacant, Spain
| | - Angel Perez Sempere
- Neurology Service, Hospital General Universitario de Alicante, 03010, Alicante, Spain. .,Department of Clinical Medicine, Miguel Hernández University, Sant Joan d'Alacant, Spain.
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18
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Alroughani R, Akhtar S, Zeineddine M, El Kouzi Y, El Ayoubi NK, Ahmed SF, Behbehani R, Khoury SJ, Al-Hashel JY, Yamout BI. Risk of relapses during pregnancy among multiple sclerosis patients. Mult Scler Relat Disord 2019; 34:9-13. [PMID: 31202959 DOI: 10.1016/j.msard.2019.06.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/15/2019] [Accepted: 06/07/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Relapse rate in women with Multiple Sclerosis (MS) is reduced during pregnancy especially in the third trimester according to the previous studies. OBJECTIVES To measure the annual relapse rate (ARR) in women with MS during pregnancy. METHODS A retrospective study was conducted using prospectively collected data from two MS registries in Kuwait and Lebanon. Demographics, clinical characteristics including relapses, disease modifying therapies (DMTs) and their washout periods were extracted. The annual relapse rates pre and post pregnancies were compared and the relationship between relapses and prior use of different DMTs was assessed. RESULTS Data of 164 pregnancies (132 MS patients) was reviewed. Mean age and disease duration at the time of pregnancy confirmation were 32.4 ± 5.3 and 7.8 ± 4.7 years respectively. Most patients (91.7%; n = 121) were on DMTs in the year prior to pregnancy. The pre-pregnancy ARR was 0.10 (95% CI: 0.04 - 0.13), which increased to 0.20 (95% CI: 0.13- 0.29) during pregnancy. Most relapses occurred either during the 1st (ARR = 0.24; 95% CI: 0.12 - 0.44) or 3rd (ARR = 0.32; 95%CI: 0.17 - 0.53) trimesters. Fingolimod (31.8%) and natalizumab (22.7%) were the most commonly prescribed DMTs in patients who sustained relapses during pregnancy. The mean washout period was significantly longer among subjects with relapses (9.3 ± 6.6 vs. 2.5 ± 3.9; p < 0.001) than those of without relapses. CONCLUSIONS Relapse rate during pregnancy was higher than previous studies conducted in patients on platform therapies or untreated. Longer washout period prior to conception was associated with increased relapses especially in fingolimod and natalizumab treated patients.
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Affiliation(s)
- Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Arabian Gulf Street, Sharq 11013, Kuwait.
| | - Saeed Akhtar
- Department of Community Medicine and Behavioural Sciences, Faculty of Medicine, Kuwait University, Jabriya, Kuwait
| | - Maya Zeineddine
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut, Beirut, Lebanon
| | - Yehya El Kouzi
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut, Beirut, Lebanon
| | - Nabil K El Ayoubi
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut, Beirut, Lebanon
| | - Samar F Ahmed
- Department of Neurology, Ibn Sina Hospital, Sabah Medical Area, Kuwait; Department of Neurology and Psychiatry, Minia University, Minia, Egypt
| | - Raed Behbehani
- Department of Neuro-Ophthalmology, Al-Bahar Eye Center, Sabah Medical Area, Kuwait
| | - Samia J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut, Beirut, Lebanon
| | - Jasem Y Al-Hashel
- Department of Neurology, Ibn Sina Hospital, Sabah Medical Area, Kuwait; Department of Medicine, Faculty of Medicine, Kuwait University, Jabriya, Kuwait
| | - Bassem I Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut, Beirut, Lebanon
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19
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Alroughani R, Inshasi JS, Deleu D, Al-Hashel J, Shakra M, Elalamy OR, Shatila AO, Al-Asmi A, Al Sharoqi I, Canibano BG, Boshra A. An Overview of High-Efficacy Drugs for Multiple Sclerosis: Gulf Region Expert Opinion. Neurol Ther 2019; 8:13-23. [PMID: 30875021 PMCID: PMC6534637 DOI: 10.1007/s40120-019-0129-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Indexed: 01/29/2023] Open
Abstract
This article discusses the opinions of the multiple sclerosis (MS) experts in the Gulf region on the use of high-efficacy disease-modifying drugs (DMDs; natalizumab, fingolimod, alemtuzumab, cladribine tablets, and ocrelizumab) in clinical practice. The experts reviewed the current literature including pivotal clinical trials and meta-analyses for high-efficacy DMDs, supplemented by the expert opinions on the usage of these DMDs in clinical practice. Several criteria were discussed by the panel based on different efficacy, safety, and convenience attributes. The panel concluded that all the DMDs available for the treatment of MS have benefits and risks, which should be considered while discussing the treatment plan with the patient. It is important to have a personalized approach based on the risk-benefit assessment for each case. Common considerations while choosing treatments include effectiveness, side effects/safety, and convenience/route of administration. Funding: Merck Serono Middle East FZ LTD.
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Affiliation(s)
- Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait.
| | | | - Dirk Deleu
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar
| | - Jasem Al-Hashel
- Department of Neurology, Ibn Sina Hospital, Kuwait City, Kuwait
| | - Mustafa Shakra
- Department of Neurology, Sheikh Khalifa Medical City, Abu Dhabi, UAE
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20
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Portaccio E, Amato MP. Breastfeeding and post-partum relapses in multiple sclerosis patients. Mult Scler 2019; 25:1211-1216. [PMID: 30793658 DOI: 10.1177/1352458519830588] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
While it is acknowledged that exclusive breastfeeding has well-established benefits for both infant/child and mother health, evidence on the relationships between breastfeeding and disease course in women with multiple sclerosis (MS) is still controversial. On one hand, in the post-partum period, a disease worsening is possible, particularly in women with more active MS. On the other hand, the use of disease modifying drugs is currently contraindicated during lactation. In this topical review, we describe available evidence on the relationship between breastfeeding and disease activity in MS. In some studies, a possible protective role for exclusive breastfeeding against the risk of post-partum relapse has been suggested, while, in others, its impact was neutral. Waiting for definitive evidence on this topic, we propose a pragmatic approach to breastfeeding choice, on a case-by-case basis, considering the disease characteristics before and during pregnancy and the patient therapeutic history.
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Affiliation(s)
- Emilio Portaccio
- SOC Neurologia - Firenze, Azienda USL Toscana Centro, Florence, Italy
| | - Maria Pia Amato
- Section of Neurosciences, Department of NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
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21
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Fragoso YD, Adoni T, Brooks JBB, Finkelsztejn A, da Gama PD, Grzesiuk AK, Marques VD, Parolin MFK, Sato HK, Varela DL, Vasconcelos CCF. Practical Evidence-Based Recommendations for Patients with Multiple Sclerosis Who Want to Have Children. Neurol Ther 2018; 7:207-232. [PMID: 30167914 PMCID: PMC6283793 DOI: 10.1007/s40120-018-0110-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Indexed: 12/14/2022] Open
Abstract
Multiple sclerosis (MS) management presently aims to reach a state of no (or minimal) evidence of disease activity. The development and commercialization of new drugs has led to a renewed interest in family planning, since patients with MS may face a future with reduced (or no) disease-related neurological disability. The advice of neurologists is often sought by patients who want to have children and need to know more about disease control at conception and during pregnancy and the puerperium. When MS is well controlled, the simple withdrawal of drugs for patients who intend to conceive is not an option. On the other hand, not all treatments presently recommended for MS are considered safe during conception, pregnancy and/or breastfeeding. The objective of the present study was to summarize the practical and evidence-based recommendations for family planning when our patients (women and men) have MS.Funding TEVA Pharmaceutical Brazil.
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Affiliation(s)
| | - Tarso Adoni
- Hospital Sirio-Libanes de Sao Paulo, São Paulo, SP, Brazil
| | | | | | | | | | | | | | - Henry K Sato
- Instituto de Neurologia de Curitiba, Curitiba, PR, Brazil
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22
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Comi G, Hartung HP, Bakshi R, Williams IM, Wiendl H. Benefit-Risk Profile of Sphingosine-1-Phosphate Receptor Modulators in Relapsing and Secondary Progressive Multiple Sclerosis. Drugs 2018; 77:1755-1768. [PMID: 28905255 PMCID: PMC5661009 DOI: 10.1007/s40265-017-0814-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since the approval of fingolimod, several selective sphingosine-1-phosphate receptor modulators have entered clinical development for multiple sclerosis. However, side effects can occur with sphingosine-1-phosphate receptor modulators. By considering short-term data across the drug class and longer term fingolimod data, we aim to highlight the potential of sphingosine-1-phosphate receptor modulators in multiple sclerosis, while offering reassurance that their benefit–risk profiles are suitable for long-term therapy. Short-term fingolimod studies demonstrated the efficacy of this drug class, showed that cardiac events upon first-dose administration are transient and manageable, and showed that serious adverse events are rare. Early-phase studies of selective sphingosine-1-phosphate receptor modulators also show efficacy with a similar or improved safety profile, and treatment initiation effects were reduced with dose titration. Longer term fingolimod studies demonstrated sustained efficacy and raised no new safety concerns, with no increases in macular edema, infection, or malignancy rates. Switch studies identified no safety concerns and greater patient satisfaction and persistence with fingolimod when switching from injectable therapies with no washout period. Better outcomes were seen with short than with long washouts when switching from natalizumab. The specific immunomodulatory effects of sphingosine-1-phosphate receptor modulators are consistent with the low observed rates of long-term, drug-related adverse effects with fingolimod. Short-term data for selective sphingosine-1-phosphate receptor modulators support their potential effectiveness in multiple sclerosis, and improved side-effect profiles may widen patient access to this drug class. The long-term safety, tolerability, and persistence profiles of fingolimod should reassure clinicians that sphingosine-1-phosphate receptor modulators are likely to be suitable for the long-term treatment of multiple sclerosis.
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Affiliation(s)
- Giancarlo Comi
- Department of Neurology and INSPE, Scientific Institute Hospital San Raffaele, Vita-Salute San Raffaele University, Milan, Italy.
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.,Center for Neuropsychiatry, LVR Klinikum, Düsseldorf, Germany
| | | | | | - Heinz Wiendl
- Department of Neurology, University Hospital Münster, Münster, Germany
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23
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Giovannoni G, Hawkes C, Waubant E, Lublin F. The 'Field Hypothesis': rebound activity after stopping disease-modifying therapies. Mult Scler Relat Disord 2018. [PMID: 28641776 DOI: 10.1016/j.msard.2017.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Queen Mary University London, Barts and The London School of Medicine and Dentistry, 4 Newark Street, London E1 2AT, UK.
| | - Chris Hawkes
- Blizard Institute, Queen Mary University London, Barts and The London School of Medicine and Dentistry, 4 Newark Street, London E1 2AT, UK.
| | - Emmanuelle Waubant
- Department of Neurology, UCSF School of Medicine, 675 Nelson Rising Lane, San Francisco CA 94158, USA.
| | - Fred Lublin
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA.
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24
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Sato K, Niino M, Kawashima A, Yamada M, Miyazaki Y, Fukazawa T. Disease Exacerbation after the Cessation of Fingolimod Treatment in Japanese Patients with Multiple Sclerosis. Intern Med 2018; 57:2647-2655. [PMID: 29709955 PMCID: PMC6191590 DOI: 10.2169/internalmedicine.0793-18] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective In Japan, following the launch of dimethyl fumarate (DMF) after fingolimod as a disease-modifying drug in multiple sclerosis (MS), some patients switched from fingolimod to DMF. The aim of this study was to determine the follow-up status of MS patients who switched to DMF after fingolimod cessation. Methods Clinical and magnetic resonance imaging (MRI) data in 19 patients with MS who switched to DMF were collected for at least for 6 months after fingolimod cessation. Results Ten patients (52.6%) experienced clinical or MRI exacerbation after fingolimod cessation. The peripheral blood lymphocyte counts at the time of fingolimod cessation in those with disease exacerbation were significantly lower than in those without exacerbation. The patients with disease exacerbation were further classified into three groups based on MRI findings: those with some new T2-weighted lesions with or without gadolinium (Gd) enhancement (group I), those with more new and/or enlarged T2-weighted lesions with Gd enhancement compared to pre-fingolimod induction (group II), and those with multifocal tumefactive demyelinating lesions. In group II, the clinical disease activity, which was similar to that at fingolimod initiation in group I, was higher than the clinical disease activity observed before fingolimod initiation. Conversely, group III exhibited unexpected new MRI findings that were not evident before fingolimod initiation. Conclusion Cessation of fingolimod might precipitate rebound or reactivation of clinical disease in patients with MS, and careful follow-up is necessary for patients who discontinue fingolimod.
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Affiliation(s)
| | - Masaaki Niino
- Department of Clinical Research, Hokkaido Medical Center, Japan
| | | | | | - Yusei Miyazaki
- Department of Clinical Research, Hokkaido Medical Center, Japan
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25
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Factors Predictive of Severe Multiple Sclerosis Disease Reactivation After Fingolimod Cessation. Neurologist 2018; 23:12-16. [PMID: 29266038 DOI: 10.1097/nrl.0000000000000154] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fingolimod withdrawal may trigger the return of pretreatment disease activity. It is difficult to identify patients at risk of disease reactivation. We compared the demographic and clinical features of patients experiencing severe disease reactivation (SDR) after fingolimod cessation with those of patients who did not. METHODS All patients who commenced fingolimod and who continued therapy for at least 6 months were included. The demographic and clinical features of the 2 groups (SDR vs. no SDR) were assessed. RESULTS Forty-four of 303 patients discontinued fingolimod for various reasons. Among these, 31 fulfilled our inclusion criteria and 8 (25.8%) exhibited SDR after drug cessation. The mean time for SDR was 2.6 months (range, 2 to 3 mo). The annualized relapse rate before fingolimod therapy was higher in the SDR than in the non-SDR group (1.59 vs. 0.81) (P=0.018). Although statistical significance was not attained, the mean Expanded Disability Status Scale score at the time of fingolimod cessation was higher in the non-SDR than in the SDR group (2.5 vs. 1.12) (P=0.074). CONCLUSIONS SDR may develop within the first 3 months after cessation of fingolimod. Patients with higher annualized relapse rates and lower Expanded Disability Status Scale scores before commencing fingolimod treatment were more likely to exhibit SDR.
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26
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Das G, Damotte V, Gelfand JM, Bevan C, Cree BAC, Do L, Green AJ, Hauser SL, Bove R. Rituximab before and during pregnancy: A systematic review, and a case series in MS and NMOSD. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e453. [PMID: 29564373 PMCID: PMC5858951 DOI: 10.1212/nxi.0000000000000453] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/09/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the safety of rituximab treatment before and during pregnancy in women with MS and neuromyelitis optica spectrum disorders (NMOSDs) who may be at risk of relapses by performing a systematic literature review combined with a retrospective single-center case series. METHODS Studies were systematically identified in the PubMed, Google Scholar, and EMBASE using the key terms "pregnancy" and "rituximab"; 22 articles were included for review (>17,000 screened). Then, patients with MS and NMOSD from 1 center (University of California, San Francisco) exposed to rituximab before conception were identified through medical record review. RESULTS Systematic review: We identified 102 pregnancies with rituximab use within 6 months of conception: 78 resulted in live births and 12 in spontaneous abortions. Of 54 live births with reported gestational age, 31 occurred at term (37 weeks+) and 2 before 32 weeks. When checked, B-cell counts were low in 39% of newborns and normalized within 6 months. Case series: we identified 11 pregnancies (1 ongoing) in 10 women (7 MS and 3 NMOSD) treated with rituximab within 6 months of conception. All completed pregnancies resulted in term live births of healthy newborns (1 lost to follow-up at term). No maternal relapses occurred before/during pregnancy; 1 occurred postpartum (NMOSD). CONCLUSION No major safety signal was observed with rituximab use within 6 months of conception. Beyond the need for monitoring neonatal B cells, these observations support prospectively monitoring a larger patient cohort to determine whether rituximab may safely protect women with MS and NMOSD who are planning a pregnancy against relapses.
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Affiliation(s)
- Gitanjali Das
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Vincent Damotte
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Jeffrey M Gelfand
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Carolyn Bevan
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Bruce A C Cree
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Lynn Do
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Ari J Green
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Stephen L Hauser
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Riley Bove
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
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27
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Alroughani R, Alowayesh MS, Ahmed SF, Behbehani R, Al-Hashel J. Relapse occurrence in women with multiple sclerosis during pregnancy in the new treatment era. Neurology 2018; 90:e840-e846. [PMID: 29429970 DOI: 10.1212/wnl.0000000000005065] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 12/04/2017] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To determine the rate of relapse occurrence during pregnancy and postpartum. METHODS In a cross-sectional study using the national multiple sclerosis (MS) registry, pregnant women with relapsing MS were identified. Data on demographics, clinical characteristics, and disease-modifying therapies (DMTs), including washout periods, were collected. Timings and durations of relapses were extracted. A multivariate logistic regression was used to assess the relationship between relapses and prior use of different DMTs. RESULTS Completed data were available for 99 pregnancies (87 patients). Mean age and mean age at onset were 31.8 ± 5 and 24.4 ± 5.6 years, respectively, while the mean disease duration was 7.4 ± 4.6 years. Most pregnancies (89.9%) occurred in patients who were on DMTs in the year preceding pregnancy with a mean treatment duration of 63.4 ± 29 months. The rates of occurrence of relapses during pregnancy and postpartum were 17.2% and 13.7%, respectively. Most of the relapses occurred during the first (n = 6) and third (n = 7) trimesters. Rate of relapse was highest among patients receiving natalizumab and fingolimod before pregnancy. A longer washout period was significantly associated with relapse occurrence. CONCLUSION The relapse occurrence during pregnancy is higher than the previously published rates. The use of high-efficacy therapies with long washout periods before conception was associated with an increased risk of relapses during pregnancy. Postpartum relapse occurrence was similar to that in previous reports.
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Affiliation(s)
- Raed Alroughani
- From the Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq; Department of Pharmacy Practice (M.S.A.), School of Pharmacy, Kuwait University, Jabriya; Department of Neurology (S.F.A., J.A.-H.), Ibn Sina Hospital, Sabah Medical Area, Kuwait; Department of Neurology and Psychiatry (S.F.A.), Minia University, Egypt; Department of Ophthalmology (R.B.), Al-Bahar Eye Center, Sabah Medical Area; and Department of Medicine (J.A.-H.), Faculty of Medicine, Kuwait University, Jabriya.
| | - Maryam S Alowayesh
- From the Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq; Department of Pharmacy Practice (M.S.A.), School of Pharmacy, Kuwait University, Jabriya; Department of Neurology (S.F.A., J.A.-H.), Ibn Sina Hospital, Sabah Medical Area, Kuwait; Department of Neurology and Psychiatry (S.F.A.), Minia University, Egypt; Department of Ophthalmology (R.B.), Al-Bahar Eye Center, Sabah Medical Area; and Department of Medicine (J.A.-H.), Faculty of Medicine, Kuwait University, Jabriya
| | - Samar F Ahmed
- From the Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq; Department of Pharmacy Practice (M.S.A.), School of Pharmacy, Kuwait University, Jabriya; Department of Neurology (S.F.A., J.A.-H.), Ibn Sina Hospital, Sabah Medical Area, Kuwait; Department of Neurology and Psychiatry (S.F.A.), Minia University, Egypt; Department of Ophthalmology (R.B.), Al-Bahar Eye Center, Sabah Medical Area; and Department of Medicine (J.A.-H.), Faculty of Medicine, Kuwait University, Jabriya
| | - Raed Behbehani
- From the Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq; Department of Pharmacy Practice (M.S.A.), School of Pharmacy, Kuwait University, Jabriya; Department of Neurology (S.F.A., J.A.-H.), Ibn Sina Hospital, Sabah Medical Area, Kuwait; Department of Neurology and Psychiatry (S.F.A.), Minia University, Egypt; Department of Ophthalmology (R.B.), Al-Bahar Eye Center, Sabah Medical Area; and Department of Medicine (J.A.-H.), Faculty of Medicine, Kuwait University, Jabriya
| | - Jasem Al-Hashel
- From the Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq; Department of Pharmacy Practice (M.S.A.), School of Pharmacy, Kuwait University, Jabriya; Department of Neurology (S.F.A., J.A.-H.), Ibn Sina Hospital, Sabah Medical Area, Kuwait; Department of Neurology and Psychiatry (S.F.A.), Minia University, Egypt; Department of Ophthalmology (R.B.), Al-Bahar Eye Center, Sabah Medical Area; and Department of Medicine (J.A.-H.), Faculty of Medicine, Kuwait University, Jabriya
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28
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Vermersch P, Radue EW, Putzki N, Ritter S, Merschhemke M, Freedman MS. A comparison of multiple sclerosis disease activity after discontinuation of fingolimod and placebo. Mult Scler J Exp Transl Clin 2017; 3:2055217317730096. [PMID: 28989795 PMCID: PMC5624444 DOI: 10.1177/2055217317730096] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 07/19/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cases of higher-than-expected disease activity have been reported following fingolimod discontinuation. OBJECTIVE The objective of this paper is to assess the risk of substantially higher-than-expected disease activity post-study drug discontinuation (SDD) at the individual patient level using data from the Phase III, placebo-controlled FREEDOMS and FREEDOMS II trials. METHODS Baseline gadolinium-enhancing T1-lesion volumes were used to statistically model the expected level of MRI disease activity post-SDD. Patients exceeding this level were classed as "MRI outliers." Patients with an unusually high increase in Expanded Disability Status Scale score, hospitalization for relapse, severe relapse, or relapse with incomplete recovery post-SDD were classed as "clinical outliers." RESULTS In FREEDOMS, the number of MRI outliers post-SDD was 2/69 (2.9%), 1/65 (1.5%) and 7/83 (8.4%) for the placebo, fingolimod 0.5 mg, and fingolimod 1.25 mg groups, respectively. In FREEDOMS II, the corresponding numbers were 4/72 (5.6%), 6/79 (7.6%) and 3/73 (4.1%). The number of clinical outliers across both trials was low. No consistent evidence of placebo vs fingolimod, dose-related or inter-trial patterns was discernable. CONCLUSION The low number of clinical and MRI outliers and lack of any discernible pattern within and between trials, including between placebo and fingolimod, argues against a systematic risk of higher-than-expected recurrence of disease activity following discontinuation of fingolimod.
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Affiliation(s)
- Patrick Vermersch
- University of Lille, CHU Lille, LIRIC - INSERM U995, FHU Imminent, France
| | | | | | | | | | - Mark S Freedman
- University of Ottawa, The Ottawa Hospital Research Institute, Canada
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29
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Meinl I, Havla J, Hohlfeld R, Kümpfel T. Recurrence of disease activity during pregnancy after cessation of fingolimod in multiple sclerosis. Mult Scler 2017; 24:991-994. [PMID: 28920764 DOI: 10.1177/1352458517731913] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Fingolimod is an effective treatment for active relapsing-remitting multiple sclerosis (MS). Discontinuation of therapy may be followed by recurrence of disease activity. Thus, female MS patients may be at risk of relapse during pregnancy after stopping fingolimod. OBJECTIVES AND METHODS To report the disease course during pregnancy of five women who interrupted therapy with fingolimod for pregnancy. RESULTS All patients experienced relapses during pregnancy and/or postpartum after stopping fingolimod. CONCLUSION The risk of recurrence of disease activity during pregnancy after stopping fingolimod may be substantial. This should be considered and discussed with MS patients who are planning to become pregnant.
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Affiliation(s)
- Ingrid Meinl
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany/The Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
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30
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Novi G, Ghezzi A, Pizzorno M, Lapucci C, Bandini F, Annovazzi P, Mancardi GL, Uccelli A. Dramatic rebounds of MS during pregnancy following fingolimod withdrawal. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e377. [PMID: 28804745 PMCID: PMC5532747 DOI: 10.1212/nxi.0000000000000377] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/11/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Giovanni Novi
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) (N.G., C.L., G.L.M., A.U.), University of Genoa, Italy; Multiple Sclerosis Study Center (A.G., P.A.), Hospital of Gallarate, Italy; San Paolo Hospital (M.P., F.B.), Savona, Italy; and IRCCS AUO San Martino-IST (G.L.M., A.U.), Genoa, Italy
| | - Angelo Ghezzi
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) (N.G., C.L., G.L.M., A.U.), University of Genoa, Italy; Multiple Sclerosis Study Center (A.G., P.A.), Hospital of Gallarate, Italy; San Paolo Hospital (M.P., F.B.), Savona, Italy; and IRCCS AUO San Martino-IST (G.L.M., A.U.), Genoa, Italy
| | - Matteo Pizzorno
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) (N.G., C.L., G.L.M., A.U.), University of Genoa, Italy; Multiple Sclerosis Study Center (A.G., P.A.), Hospital of Gallarate, Italy; San Paolo Hospital (M.P., F.B.), Savona, Italy; and IRCCS AUO San Martino-IST (G.L.M., A.U.), Genoa, Italy
| | - Caterina Lapucci
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) (N.G., C.L., G.L.M., A.U.), University of Genoa, Italy; Multiple Sclerosis Study Center (A.G., P.A.), Hospital of Gallarate, Italy; San Paolo Hospital (M.P., F.B.), Savona, Italy; and IRCCS AUO San Martino-IST (G.L.M., A.U.), Genoa, Italy
| | - Fabio Bandini
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) (N.G., C.L., G.L.M., A.U.), University of Genoa, Italy; Multiple Sclerosis Study Center (A.G., P.A.), Hospital of Gallarate, Italy; San Paolo Hospital (M.P., F.B.), Savona, Italy; and IRCCS AUO San Martino-IST (G.L.M., A.U.), Genoa, Italy
| | - Pietro Annovazzi
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) (N.G., C.L., G.L.M., A.U.), University of Genoa, Italy; Multiple Sclerosis Study Center (A.G., P.A.), Hospital of Gallarate, Italy; San Paolo Hospital (M.P., F.B.), Savona, Italy; and IRCCS AUO San Martino-IST (G.L.M., A.U.), Genoa, Italy
| | - Giovanni L Mancardi
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) (N.G., C.L., G.L.M., A.U.), University of Genoa, Italy; Multiple Sclerosis Study Center (A.G., P.A.), Hospital of Gallarate, Italy; San Paolo Hospital (M.P., F.B.), Savona, Italy; and IRCCS AUO San Martino-IST (G.L.M., A.U.), Genoa, Italy
| | - Antonio Uccelli
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) (N.G., C.L., G.L.M., A.U.), University of Genoa, Italy; Multiple Sclerosis Study Center (A.G., P.A.), Hospital of Gallarate, Italy; San Paolo Hospital (M.P., F.B.), Savona, Italy; and IRCCS AUO San Martino-IST (G.L.M., A.U.), Genoa, Italy
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Yoshii F, Moriya Y, Ohnuki T, Ryo M, Takahashi W. Neurological safety of fingolimod: An updated review. ACTA ACUST UNITED AC 2017; 8:233-243. [PMID: 28932291 PMCID: PMC5575715 DOI: 10.1111/cen3.12397] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/23/2017] [Accepted: 05/08/2017] [Indexed: 12/16/2022]
Abstract
Fingolimod (FTY) is the first oral medication approved for treatment of relapsing–remitting multiple sclerosis (RRMS). Its effectiveness and safety were confirmed in several phase III clinical trials, but proper evaluation of safety in the real patient population requires long‐term post‐marketing monitoring. Since the approval of FTY for RRMS in Japan in 2011, it has been administered to approximately 5000 MS patients, and there have been side‐effect reports from 1750 patients. Major events included infectious diseases, hepatobiliary disorders, nervous system disorders and cardiac disorders. In the present review, we focus especially on central nervous system adverse events. The topics covered are: (i) clinical utility of FTY; (ii) safety profile; (iii) post‐marketing adverse events in Japan; (iv) white matter (tumefactive) lesions; (v) rebound after FTY withdrawal; (vi) relationship between FTY and progressive multifocal leukoencephalopathy; (vii) FTY and progressive multifocal leukoencephalopathy‐related immune reconstitution inflammatory syndrome; and (viii) neuromyelitis optica and leukoencephalopathy.
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Affiliation(s)
- Fumihito Yoshii
- Department of Neurology Saiseikai Hiratsuka Hospital Hiratsuka Japan.,Department of Neurology Tokai University Oiso Hospital Oiso Japan
| | - Yusuke Moriya
- Department of Neurology Tokai University Oiso Hospital Oiso Japan
| | - Tomohide Ohnuki
- Department of Neurology Tokai University Oiso Hospital Oiso Japan
| | - Masafuchi Ryo
- Department of Neurology Tokai University Oiso Hospital Oiso Japan
| | - Wakoh Takahashi
- Department of Neurology Tokai University Oiso Hospital Oiso Japan
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Severe disease exacerbations in patients with multiple sclerosis after discontinuing fingolimod. Neurol Neurochir Pol 2017; 51:156-162. [PMID: 28209440 DOI: 10.1016/j.pjnns.2017.01.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/21/2017] [Indexed: 11/20/2022]
Abstract
Discontinuation of fingolimod in patients with multiple sclerosis (MS) can lead to disease reactivation. In this review, we describe cases of severe exacerbations in patients with MS following discontinuation of fingolimod, including three cases from our center. We consider potential mechanisms of disease reactivation after cessation of fingolimod, and the evidence supporting this rebound effect. We conclude that discontinuation of fingolimod results in the return of disease activity, which then leads to severe exacerbations (i.e., rebounds) in a clinically significant proportion of patients. Lastly, we consider disease-modifying treatment options for patients who discontinue fingolimod.
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Pregnancy and the Use of Disease-Modifying Therapies in Patients with Multiple Sclerosis: Benefits versus Risks. Mult Scler Int 2016; 2016:1034912. [PMID: 28078140 PMCID: PMC5203912 DOI: 10.1155/2016/1034912] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/14/2016] [Indexed: 12/02/2022] Open
Abstract
The burden of multiple sclerosis (MS) in women of childbearing potential is increasing, with peak incidence around the age of 30 years, increasing incidence and prevalence, and growing female : male ratio. Guidelines recommend early use of disease-modifying therapies (DMTs), which are contraindicated or recommended with considerable caution, during pregnancy/breastfeeding. Many physicians are reluctant to prescribe them for a woman who is/is planning to be pregnant. Interferons are not absolutely contraindicated during pregnancy, since interferon-β appears to lack serious adverse effects in pregnancy, despite a warning in its labelling concerning risk of spontaneous abortion. Glatiramer acetate, natalizumab, and alemtuzumab also may not induce adverse pregnancy outcomes, although natalizumab may induce haematologic abnormalities in newborns. An accelerated elimination procedure is needed for teriflunomide if pregnancy occurs on treatment or if pregnancy is planned. Current evidence supports the contraindication for fingolimod during pregnancy; data on other DMTs remains limited. Increased relapse rates following withdrawal of some DMTs in pregnancy are concerning and require further research. The postpartum period brings increased risk of disease reactivation that needs to be carefully addressed through effective communication between treating physicians and mothers intending to breastfeed. We address the potential for use of the first- and second-line DMTs in pregnancy and lactation.
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Teixeira MZ. Biological therapies (immunomodulatory drugs), worsening of psoriasis and rebound effect: new evidence of similitude. HOMEOPATHY 2016; 105:344-355. [PMID: 27914574 DOI: 10.1016/j.homp.2016.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 04/25/2016] [Accepted: 09/14/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Employing the secondary action or adaptative reaction of the organism as therapeutic response, homeopathy uses the treatment by similitude (similia similibus curentur) administering to sick individuals the medicines that caused similar symptoms in healthy individuals. Such homeostatic or paradoxical reaction of the organism is scientifically explained through the rebound effect of drugs, which cause worsening of symptoms after withdrawal of several palliative treatments. Despite promoting an improvement in psoriasis at the beginning of the treatment, modern biological therapies provoke worsening of the psoriasis (rebound psoriasis) after discontinuation of drugs. METHOD Exploratory qualitative review of the literature on the occurrence of the rebound effect with the use of immunomodulatory drugs [T-cell modulating agents and tumor necrosis factor (TNF) inhibitors drugs] in the treatment of psoriasis. RESULTS Several researches indicate the rebound effect as the mechanism of worsening of psoriasis with the use of efalizumab causing the suspension of its marketing authorization in 2009, in view of some severe cases. Other studies also have demonstrated the occurrence of rebound psoriasis with the use of alefacept, etanercept and infliximab. CONCLUSION As well as studied in other classes of drugs, the rebound effect of biologic agents supports the principle of similitude (primary action of the drugs followed by secondary action and opposite of the organism).
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Affiliation(s)
- Marcus Zulian Teixeira
- Department of Internal Medicine, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.
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Gündüz T, Kürtüncü M, Eraksoy M. Severe rebound after withdrawal of fingolimod treatment in patients with multiple sclerosis. Mult Scler Relat Disord 2016; 11:1-3. [PMID: 28104247 DOI: 10.1016/j.msard.2016.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Tuncay Gündüz
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Murat Kürtüncü
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Mefkure Eraksoy
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey
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Hassoun L, Eisele J, Thomas K, Ziemssen T. Hands on Alemtuzumab-experience from clinical practice: whom and how to treat. ACTA ACUST UNITED AC 2016. [DOI: 10.1186/s40893-016-0011-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Thomé R, de Carvalho AC, Alves da Costa T, Ishikawa LLW, Fraga-Silva TFDC, Sartori A, de Oliveira ALR, Verinaud L. Artesunate Ameliorates Experimental Autoimmune Encephalomyelitis by Inhibiting Leukocyte Migration to the Central Nervous System. CNS Neurosci Ther 2016; 22:707-14. [PMID: 27165523 DOI: 10.1111/cns.12561] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/14/2016] [Accepted: 04/17/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND AIMS Experimental autoimmune encephalomyelitis (EAE) is T-cell-dependent disease of the central nervous system (CNS) of mice. This model resembles multiple sclerosis (MS) in many aspects. Therapies that focus in the modulation of the immune response and cellular infiltration in the CNS present best effects in the clinics. Artesunate (Art) is a semi-synthetic sesquiterpene derivative from artemisinin and has been shown to reduce the clinical signs of autoimmune disease models through mechanisms not yet understood. In this study, we aimed to evaluate whether administration of Art would ameliorate EAE. METHODS AND RESULTS C57BL6 mice were immunized with MOG35-55 peptide to induce EAE. At the same time, Art treatment started (3 mg/kg/day via i.p.) for five consecutive days. We found that Art treatment reduced the clinical signs of EAE and that correlated with a reduced infiltration of cells in the CNS. Disease amelioration did not correlate with immunomodulation as recall responses, leukocyte subpopulations, and gene expression analysis were similar among treated and untreated mice. Ultimately, further analysis provided data indicating that a possible mechanism of action for Art is dependent on the cellular migration to the CNS. CONCLUSIONS Artesunate reduces the severity of EAE by inhibiting migration of pathogenic T cells to the CNS.
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Affiliation(s)
- Rodolfo Thomé
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
| | - Ana Carolina de Carvalho
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
| | - Thiago Alves da Costa
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
| | - Larissa Lumi Watanabe Ishikawa
- Department of Immunology and Microbiology, Institute of Biosciences of Botucatu, São Paulo State University, Botucatu, Brazil
| | | | - Alexandrina Sartori
- Department of Immunology and Microbiology, Institute of Biosciences of Botucatu, São Paulo State University, Botucatu, Brazil
| | | | - Liana Verinaud
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
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Giovannoni G, Marta M, Davis A, Turner B, Gnanapavan S, Schmierer K. Switching patients at high risk of PML from natalizumab to another disease-modifying therapy. Pract Neurol 2016; 16:389-93. [PMID: 27114560 DOI: 10.1136/practneurol-2015-001355] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2016] [Indexed: 12/25/2022]
Abstract
There are several options for switching people with multiple sclerosis (MS) who are at high risk of developing progressive multifocal leukoencephalopathy (PML) from natalizumab to alemtuzumab. However, some of these have risks that need to be managed, for example, the risks of carrying over asymptomatic PML from natalizumab on to the new therapy, and the risk of rebound disease activity associated with a prolonged washout after starting natalizumab. We propose a pragmatic bridging strategy, using another disease-modifying therapy (DMT), to reduce the risk of switching from natalizumab to alemtuzumab. We also discuss the caveats and subtleties associated with sequencing DMTs in MS and the complex decision making involved.
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Affiliation(s)
- Gavin Giovannoni
- Department of Neurosciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Monica Marta
- Department of Neurosciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Angharad Davis
- Department of Neurosciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Benjamin Turner
- Department of Neurosciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Sharmilee Gnanapavan
- Department of Neurosciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Klaus Schmierer
- Department of Neurosciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
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Ayzenberg I, Hoepner R, Kleiter I. Fingolimod for multiple sclerosis and emerging indications: appropriate patient selection, safety precautions, and special considerations. Ther Clin Risk Manag 2016; 12:261-72. [PMID: 26929636 PMCID: PMC4767105 DOI: 10.2147/tcrm.s65558] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Fingolimod (FTY720), an immunotherapeutic drug targeting the sphingosine-1-phosphate receptor, is a widely used medication for relapsing-remitting multiple sclerosis (MS). Apart from the pivotal Phase III trials demonstrating efficacy against placebo and interferon-β-1a once weekly, sufficient clinical data are now available to assess its real-world efficacy and safety profile. Approved indications of fingolimod differ between countries. This discrepancy, to some extent, reflects the intermediate position of fingolimod in the expanding lineup of MS medications. With individualization of therapy, appropriate patient selection gets more important. We discuss various scenarios for fingolimod use in relapsing-remitting MS and their pitfalls: as first-line therapy, as escalation therapy after failure of previous immunotherapies, and as de-escalation therapy following highly potent immunotherapies. Potential side effects such as bradycardia, infections, macular edema, teratogenicity, and progressive multifocal leukoencephalopathy as well as appropriate safety precautions are outlined. Disease reactivation has been described upon fingolimod cessation; therefore, patients should be closely monitored for MS activity for several months after stopping fingolimod. Finally, we discuss preclinical and clinical data indicating neuroprotective effects of fingolimod, which might open the way to future indications such as stroke, Alzheimer’s disease, and other neurodegenerative disorders.
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Affiliation(s)
- Ilya Ayzenberg
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Robert Hoepner
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Ingo Kleiter
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Gajofatto A, Turatti M, Monaco S, Benedetti MD. Clinical efficacy, safety, and tolerability of fingolimod for the treatment of relapsing-remitting multiple sclerosis. DRUG HEALTHCARE AND PATIENT SAFETY 2015; 7:157-67. [PMID: 26715860 PMCID: PMC4686225 DOI: 10.2147/dhps.s69640] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Fingolimod is a selective immunosuppressive agent approved worldwide for the treatment of relapsing-remitting multiple sclerosis (MS), a chronic and potentially disabling neurological condition. Randomized double-blind clinical trials have shown that fingolimod significantly reduces relapse rate and ameliorates a number of brain MRI measures, including cerebral atrophy, compared to both placebo and intramuscular interferon-β1a. The effect on disability progression remains controversial, since one Phase III trial showed a significant benefit of treatment while two others did not. Although fingolimod has a very convenient daily oral dosing, the possibility of serious cardiac, ocular, infectious, and other rare adverse events justified the decision of the European Medicines Agency to approve the drug as a second-line treatment for MS patients not responsive to first-line therapy, or those with rapidly evolving course. In the United States, fingolimod is instead authorized as a first-line treatment. The aim of this review is to describe and discuss the characteristics of fingolimod concerning its efficacy, safety, and tolerability in the clinical context of multiple sclerosis management.
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Affiliation(s)
- Alberto Gajofatto
- Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy ; Division of Neurology B, Verona University Hospital, Verona, Italy
| | - Marco Turatti
- Division of Neurology B, Verona University Hospital, Verona, Italy
| | - Salvatore Monaco
- Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy ; Division of Neurology B, Verona University Hospital, Verona, Italy
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Cavone L, Felici R, Lapucci A, Buonvicino D, Pratesi S, Muzzi M, Hakiki B, Maggi L, Peruzzi B, Caporale R, Annunziato F, Amato MP, Chiarugi A. Dysregulation of sphingosine 1 phosphate receptor-1 (S1P1) signaling and regulatory lymphocyte-dependent immunosuppression in a model of post-fingolimod MS rebound. Brain Behav Immun 2015; 50:78-86. [PMID: 26130058 DOI: 10.1016/j.bbi.2015.06.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/22/2015] [Accepted: 06/24/2015] [Indexed: 10/24/2022] Open
Abstract
Fingolimod affords protection from MS by sequestering lymphocytes in secondary lymphoid organs via down regulation of their sphingosine 1 phosphate receptor (S1P1). Unexpectedly, accumulating evidence indicates that patients who discontinue fingolimod treatment may be at risk of rehearsal of magnetic resonance (MR) and clinical disease activity, sometimes featuring dramatic rebound. We therefore developed in vivo and in vitro models of post-fingolimod MS rebound to unravel its cellular and molecular mechanisms. The impact of fingolimod withdrawal on T regulatory lymphocytes was also investigated by means of cytofluorimetric analysis and antigen-specific lymphocyte proliferation assays. We show that mice with relapsing-remitting experimental autoimmune encephalomyelitis (EAE) undergo extremely severe, chronic disease rebound upon discontinuation of fingolimod. Remarkably, rebound is preceded by a burst of S1P1 overexpression in lymph node-entrapped lymphocytes that correlates with subsequent massive lymphocyte egress and widespread CNS immune infiltration. Also, consistent with the ability of S1P1 to counteract polarization and function of T regulatory lymphocytes their number and suppression of effector T cells is reduced by fingolimod suspension. Data disclose the first pathogenic mechanisms of post-fingolimod rebound that may be targeted for therapeutic intervention.
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Affiliation(s)
- Leonardo Cavone
- Headache Center and Clinical Pharmacology Unit, Department of Health Sciences, Careggi University Hospital, Italy; Pharmacology and Oncology Unit, Department of Health Sciences, University of Florence, Italy.
| | - Roberta Felici
- Pharmacology and Oncology Unit, Department of Health Sciences, University of Florence, Italy
| | - Andrea Lapucci
- Pharmacology and Oncology Unit, Department of Health Sciences, University of Florence, Italy
| | - Daniela Buonvicino
- Pharmacology and Oncology Unit, Department of Health Sciences, University of Florence, Italy
| | - Sara Pratesi
- Department of Experimental and Clinical Medicine and DENOTHE Center, University of Florence, Florence 50134, Italy; Regenerative Medicine Unit of Azienda Ospedaliera Careggi, Italy
| | - Mirko Muzzi
- Pharmacology and Oncology Unit, Department of Health Sciences, University of Florence, Italy
| | - Bahia Hakiki
- Department NEUROFARBA, Section Neurosciences, University of Florence, Italy
| | - Laura Maggi
- Department of Experimental and Clinical Medicine and DENOTHE Center, University of Florence, Florence 50134, Italy; Regenerative Medicine Unit of Azienda Ospedaliera Careggi, Italy
| | - Benedetta Peruzzi
- General Laboratory Unit (Microscopy and Clinical Cytometry Unit), Careggi University Hospital, Italy
| | - Roberto Caporale
- General Laboratory Unit (Microscopy and Clinical Cytometry Unit), Careggi University Hospital, Italy
| | - Francesco Annunziato
- Department of Experimental and Clinical Medicine and DENOTHE Center, University of Florence, Florence 50134, Italy; Regenerative Medicine Unit of Azienda Ospedaliera Careggi, Italy
| | - Maria Pia Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Italy
| | - Alberto Chiarugi
- Headache Center and Clinical Pharmacology Unit, Department of Health Sciences, Careggi University Hospital, Italy; Pharmacology and Oncology Unit, Department of Health Sciences, University of Florence, Italy
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Berger B, Baumgartner A, Rauer S, Mader I, Luetzen N, Farenkopf U, Stich O. Severe disease reactivation in four patients with relapsing–remitting multiple sclerosis after fingolimod cessation. J Neuroimmunol 2015; 282:118-22. [DOI: 10.1016/j.jneuroim.2015.03.022] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/17/2015] [Accepted: 03/20/2015] [Indexed: 11/28/2022]
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Ward MD, Jones DE, Goldman MD. Overview and safety of fingolimod hydrochloride use in patients with multiple sclerosis. Expert Opin Drug Saf 2015; 13:989-98. [PMID: 24935480 DOI: 10.1517/14740338.2014.920820] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Fingolimod (Gilenya®, FTY720) is an oral sphingosine-1-phosphate analogue that was approved by the FDA in 2010 for the treatment of relapsing forms of multiple sclerosis (MS). Fingolimod's mechanism of action is primarily related to lymphocyte sequestration in primary and secondary lymphoid tissues. Phase III trials demonstrated a reduction in annualized relapse rate and MRI progression in fingolimod-treated subjects compared with both placebo and IFN-β-treated subjects. Frequent adverse effects include fatigue, gastrointestinal disturbance, headache and upper respiratory tract infection. More serious, but rare, adverse events associated with fingolimod include atrioventricular block, symptomatic bradycardia, herpetic viral infections and macular edema. AREAS COVERED We discuss the mechanism of action, pharmacokinetics, clinical efficacy and safety profile of fingolimod in patients with relapsing MS. EXPERT OPINION Fingolimod is an effective treatment for relapsing MS and its oral route of administration may be preferred by some. Fingolimod is generally well tolerated but requires diligence in patient selection and monitoring. Additional information is needed regarding risk of infection, malignancy and rebound disease with long-term use of fingolimod.
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Affiliation(s)
- Melanie D Ward
- University of Virginia, Department of Neurology , PO Box 800394, Charlottesville, VA 22908 , USA
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Management of multiple sclerosis during pregnancy and the reproductive years: a systematic review. Obstet Gynecol 2015; 124:1157-1168. [PMID: 25415167 DOI: 10.1097/aog.0000000000000541] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To examine the evidence guiding management of multiple sclerosis (MS) in reproductive-aged women. DATA SOURCES We conducted an electronic literature search using PubMed, ClinicalTrials.gov, and other available resources. The following keywords were used: "multiple sclerosis" and "pregnancy." We manually searched the reference lists of identified studies. METHODS OF STUDY SELECTION Two reviewers categorized all studies identified in the search by management topic, including effect of pregnancy on MS course, fetal risks associated with disease-modifying treatments during pregnancy, and management of patients off disease-modifying treatment. We categorized studies by strength of evidence and included prior meta-analyses and systematic studies. These studies were then summarized and discussed by an expert multidisciplinary team. TABULATION, INTEGRATION, AND RESULTS The risk of MS relapses is decreased during pregnancy and increased postpartum. Data are lacking regarding the risks of disease-modifying treatments during pregnancy. There may be an increased risk of MS relapses after use of assisted reproductive techniques. There does not appear to be a major increase in adverse outcomes in newborns of mothers with MS. CONCLUSION Although there are many unmet research needs, the reviewed data support the conclusion that in the majority of cases, women with MS can safely choose to become pregnant, give birth, and breastfeed children. Clinical management should be individualized to optimize both the mother's reproductive outcomes and MS course.
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46
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Multiple sclerosis rebound after fingolimod discontinuation for lymphopenia. Neurol Sci 2014; 35:1485-6. [DOI: 10.1007/s10072-014-1800-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 04/10/2014] [Indexed: 10/25/2022]
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Affiliation(s)
- Giancarlo Comi
- Department of Neurology; University Vita-Salute San Raffaele; San Raffaele Scientific Institute; Milan Italy
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