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Lapucci C, Frau J, Cocco E, Coghe G, Petracca M, Lanzillo R, Brescia Morra V, Nicoletti CG, Landi D, Marfia G, Vercellino M, Cavalla P, Bianco A, Mirabella M, Torri Clerici V, Tomas E, Ferrò MT, Grossi P, Nozzolillo A, Moiola L, Zaffaroni M, Ronzoni M, Pinardi F, Novi G, Cellerino M, Uccelli A, Inglese M. Ocrelizumab in MS patients with persistence of disease activity after alemtuzumab: A multi-center Italian study. Mult Scler 2024; 30:1151-1162. [PMID: 39143825 DOI: 10.1177/13524585241266509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
BACKGROUND The reason why some multiple sclerosis (MS) patients show disease activity after alemtuzumab (ALM) is still unclear, but ocrelizumab (OCR) could represent an interesting sequential therapeutic approach. OBJECTIVES To investigate safety and efficacy of OCR in MS patients with disease activity after two ALM courses. METHODS Observational retrospective multi-centers Italian cohort study. RESULTS Seventy-two subjects were included. Mean follow-up (FU) was 2.4 (±1) years. Forty-five patients (62.5%) experienced at least one adverse event (AE), with infections accounting for 96.7% of cases. A reduction in total lymphocytes was observed between OCR start and 6 months FU, driven by BCD19+ lymphocytes depletion (p < 0.001). Immunoglobulin M (IgM) levels decreased between OCR start and 6 months FU (p < 0.001). At 2-year FU, relapse, magnetic resonance imaging (MRI) activity and disability worsening-free survival were 92.1%, 90.8%, and 89.2%. The evidence of inflammatory activity between the two ALM courses was associated with higher risk of relapse, MRI activity, and NEDA-3 status loss in relapsing-remitting multiple sclerosis (RRMS; p = 0.02, p = 0.05, p = 0.01, respectively). CONCLUSIONS OCR after two ALM courses seemed to be safe and effective. Early IgM hypogammaglobulinemia occurred in a high proportion of patients. The evidence of inflammatory activity between ALM courses seemed to increase the risk of MS re-activation on OCR treatment.
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Affiliation(s)
| | - Jessica Frau
- Centro regionale per la diagnosi e la cura della Sclerosi Multipla, ASL Cagliari, Cagliari, Italy
| | - Eleonora Cocco
- Centro regionale per la diagnosi e la cura della Sclerosi Multipla, ASL Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public Health, Università degli studi di Cagliari, Cagliari, Italy
| | - Giancarlo Coghe
- Centro regionale per la diagnosi e la cura della Sclerosi Multipla, ASL Cagliari, Cagliari, Italy
| | - Maria Petracca
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Roberta Lanzillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Vincenzo Brescia Morra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | | | - Doriana Landi
- MS Center, Tor Vergata University of Rome, Rome, Italy
| | | | - Marco Vercellino
- Division of Neurology, Department of Neuroscience and Mental Health, City of Health and Science, University Hospital of Torino, Turin, Italy
| | - Paola Cavalla
- Division of Neurology, Department of Neuroscience and Mental Health, City of Health and Science, University Hospital of Torino, Turin, Italy
| | - Assunta Bianco
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Massimiliano Mirabella
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di Ricerca per la Sclerosi Multipla "Anna Paola Batocchi," Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valentina Torri Clerici
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Eugenia Tomas
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Maria Teresa Ferrò
- Neuroimmunology, Neurological Unit, Cerebrovascular Department, Center for Multiple Sclerosis, ASST Crema, Crema, Italy
| | - Paola Grossi
- Neuroimmunology, Neurological Unit, Cerebrovascular Department, Center for Multiple Sclerosis, ASST Crema, Crema, Italy
| | - Agostino Nozzolillo
- Multiple Sclerosis Center, Neurology Department, IRCCS San Raffaele Hospital, Milan, Italy
| | - Lucia Moiola
- Multiple Sclerosis Center, Neurology Department, IRCCS San Raffaele Hospital, Milan, Italy
| | - Mauro Zaffaroni
- Centro Sclerosi Multipla, Ospedale di Gallarate-ASST della Valle Olona, Gallarate, Italy
| | - Marco Ronzoni
- U.O. Neurologia, ASST Rhodense, Garbagnate Milanese, Italy
| | - Federica Pinardi
- IRCCS Istituto delle scienze neurologiche di Bologna, UOSI Riabilitazione Sclerosi Multipla Bologna, Bologna, Italy
| | - Giovanni Novi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maria Cellerino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Antonio Uccelli
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Matilde Inglese
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
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Bava CI, Valentino P, Malucchi S, Bottero R, Martire S, Sapio AD, Bertolotto A. Prevalence of elevated sNFL in a real-world setting: Results on 908 patients with different multiple sclerosis types and treatment conditions. Mult Scler Relat Disord 2024; 88:105748. [PMID: 38959590 DOI: 10.1016/j.msard.2024.105748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 06/18/2024] [Accepted: 06/23/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND In the field of research for new validated surrogate biomarkers of treatment efficacy, disease activity and progression in Multiple Sclerosis (MS), serum neurofilament light-chain (sNFL) are actually the best candidate for MS patient monitoring. However, before they can be implemented in clinical practice, their usefulness as additional red flag routine measure must be demonstrated. To tackle the problem, this real-life cross-sectional study at the Regional Referring Center for Multiple Sclerosis (CRESM) aims to characterize sNFL levels and prevalence of elevated sNFL, according to our age-dependent cut-off values, in a large group of patients with different types of MS and treatment conditions. METHODS 908 serum samples from as many MS patients being admitted at CRESM for diagnostic definition and/or during routinary treatment monitoring were consecutively collected between January 2019 and January 2020. sNFL levels were measured by single molecule array (Simoa™) technology on SR-X instrument using NF-light assays (Quanterix); results were interpreted using previously published cut-off values. RESULTS Primary and Secondary Progressive MS (PPMS, SPMS) forms demonstrate higher levels and prevalence of elevated sNFL (PPMS= 32 %, SPMS= 21 %) compared to the Relapse and Remitting one (RRMS = 12 %). Besides, naïve samples of RRMS and PPMS subtypes showed higher prevalence of elevated sNFL (RRMS naïve= 31 %, PPMS naïve=67 %) compared to samples from patients treated for more than 12 months (RRMS treat>12m= 9 %, PPMS treat>12m= 19 %); treated SPMS patients demonstrated higher sNFL levels and a prevalence (22 %) of elevated sNFL compared to RRMS treated patients. Focusing on RRMS, no statistical difference was found between groups of patients treated for whatever time (up to or more than 60 months) and with either DMT type (high or low-efficacy DMT). Finally, RRMS patients treated with all DMTs for more than 12 months, with the exception of teriflunomide and alemtuzumab showed a prevalence of elevated sNFL in the range of 5-10 %. CONCLUSION in a real-world setting comprising about 1000 MS patients, sNFL quantification was elevated in 5-to-67 % of patients, in different MS forms and treatment conditions. Elevated levels of sNFL must be considered a red-flag suggesting the need of a further clinical monitoring in any circumstance, as it can be indicative of new inflammation, ongoing degeneration or co-morbidities. This study supports the introduction of sNFL quantification in everyday patient management.
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Affiliation(s)
- Cecilia Irene Bava
- NICO - Neuroscience Institute Cavalieri Ottolenghi, Orbassano, Italy; CRESM Biobank, University Hospital San Luigi Gonzaga, Orbassano, Italy; Department of Neurology and CRESM, University Hospital San Luigi Gonzaga, Orbassano, Italy.
| | - Paola Valentino
- NICO - Neuroscience Institute Cavalieri Ottolenghi, Orbassano, Italy
| | - Simona Malucchi
- Department of Neurology and CRESM, University Hospital San Luigi Gonzaga, Orbassano, Italy
| | - Rugiada Bottero
- Department of Neurology and CRESM, University Hospital San Luigi Gonzaga, Orbassano, Italy
| | - Serena Martire
- CRESM Biobank, University Hospital San Luigi Gonzaga, Orbassano, Italy; Department of Neuroscience "Rita Levi Montalcini", University of Turin, Italy
| | - Alessia Di Sapio
- CRESM Biobank, University Hospital San Luigi Gonzaga, Orbassano, Italy; Department of Neurology and CRESM, University Hospital San Luigi Gonzaga, Orbassano, Italy
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Bowen JD, Stulc J, Hunter SF, Chen H, Lewin JB, Scaramozza M, Bozin I, Then Bergh F. Diroximel Fumarate in Patients with Relapsing-Remitting Multiple Sclerosis: NEDA-3 After Re-Baselining in the Phase 3 EVOLVE-MS-1 Study. Adv Ther 2024; 41:3396-3406. [PMID: 38878121 PMCID: PMC11263382 DOI: 10.1007/s12325-024-02901-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/14/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION Diroximel fumarate (DRF) and dimethyl fumarate (DMF) are orally administered fumarate disease-modifying therapies (DMTs) for multiple sclerosis (MS). The safety, tolerability, and exploratory efficacy of DRF were evaluated in the phase 3 EVOLVE-MS-1 study. No Evidence of Disease Activity (NEDA-3) is a composite efficacy endpoint used in clinical trials for MS defined as no relapse, no 24-week confirmed disability progression (CDP), no new/newly enlarging T2 lesions, and no new gadolinium-enhancing lesions. As NEDA outcomes in studies may be confounded by initial disease activity, the objective of this analysis was to evaluate NEDA-3 in EVOLVE-MS-1 for newly enrolled patients and patients who were re-baselined after approximately 7 weeks. METHODS Patients entered EVOLVE-MS-1 as either newly enrolled or having completed the 5-week phase 3 EVOLVE-MS-2 study of DRF and DMF. Magnetic Resonance Imaging (MRI) was performed at baseline before each study (approx. 7 weeks apart) and at weeks 48 and 96 in EVOLVE-MS-1. Therefore, patients entering from EVOLVE-MS-2 were re-baselined after approximately 7 weeks. NEDA-3 outcomes on DRF are reported for prior DRF, prior DMF, and de novo patient groups. RESULTS Of 1057 patients in EVOLVE-MS-1, 239 (22.6%) had rolled over from receiving DRF in EVOLVE-MS-2 ("prior DRF"), 225 (21.3%) had rolled over from receiving DMF in EVOLVE-MS-2 ("prior DMF"), and 593 (56.1%) were newly enrolled ("de novo"). At week 48, Kaplan-Meier estimates of NEDA-3 were 72.3% (prior DRF), 72.1% (prior DMF), and 62.1% (de novo); at week 96, estimates were 50.2% (prior DRF), 48.2% (prior DMF), and 36.5% (de novo). CONCLUSIONS In EVOLVE-MS-1, after re-baselining at approximately 7 weeks, approximately half of DRF-treated patients achieved NEDA-3 at week 96, compared with 36.5% of patients who were not re-baselined. Re-baselining may be useful for assessing efficacy of DMTs by mitigating the influence of disease activity prior to the onset of efficacy. CLINICAL TRIAL REGISTRATIONS NCT03093324 (EVOLVE-MS-2); NCT02634307 (EVOLVE-MS-1).
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Affiliation(s)
| | - Jessica Stulc
- Minneapolis Clinic of Neurology, Golden Valley, MN, USA
| | | | | | | | | | - Ivan Bozin
- Biogen, Neuhofstrasse 30, 6340, Baar, Switzerland.
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Moser T, Foettinger F, Hitzl W, Novotna B, Berger T, Bsteh G, Di Pauli F, Hegen H, Kornek B, Langenscheidt D, Sellner J. Alemtuzumab treatment for multiple sclerosis in Austria: An observational long-term outcome study. Ann Clin Transl Neurol 2024; 11:1442-1455. [PMID: 38715245 PMCID: PMC11187963 DOI: 10.1002/acn3.52056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 02/29/2024] [Accepted: 03/19/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND/OBJECTIVE Observational real-world study to analyze the clinical effects of alemtuzumab (ALEM) and subsequent disease-modifying therapy (DMT) usage in multiple sclerosis (MS). METHODS Data retrieved from the Austrian MS treatment registry (AMSTR) included baseline (BL) characteristics (at ALEM start), annualized relapse rate (ARR), 6-month confirmed progression independent of relapse activity (PIRA; ≥ 0.5-point Expanded Disability Status Scale (EDSS) score increase), 6-month confirmed disability improvement (CDI; ≥ 0.5-point EDSS decrease), and safety outcomes until initiation of a subsequent DMT. The EDSS was re-baselined at 30 days from ALEM start (BL EDSS). RESULTS Eighty-seven ALEM-treated patients (median age: 32 years, 72% female, 14% treatment-naïve) were followed for a median of 55 (interquartile range 31-68) months. We found significant reductions in the ARR from 1.16 before ALEM to 0.15 throughout Years 1-9 (p < 0.001). Subsequent DMTs were initiated in 19 patients (22%, 74% anti-CD20 monoclonal antibodies). At Year 5 (n = 53), more patients achieved CDI (58%, 95% confidence interval (CI) 45%-71%) than had experienced PIRA (14%, CI 7.5%-24%), and 58% remained relapse-free. Shorter MS duration (p < 0.001, hazard ratio (HR) 0.86 (CI 0.80-0.93)) and no previous high-efficacy treatment (p < 0.001, HR 5.16 (CI 2.66-10.0)) were the best predictors of CDI, while PIRA was associated with a higher number of previous DMTs (p = 0.04, HR 3.06, CI 1.05-8.89). We found no new safety signals. INTERPRETATION ALEM had long-lasting beneficial effects on the ARR and disability improvement, especially when initiated early in the course of the disease. Only a subset of patients received subsequent DMTs.
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Affiliation(s)
- Tobias Moser
- Department of Neurology, Christian Doppler Medical CenterParacelsus Medical UniversitySalzburgAustria
| | - Fabian Foettinger
- Department of Neurology, Christian Doppler Medical CenterParacelsus Medical UniversitySalzburgAustria
| | - Wolfgang Hitzl
- Department of Ophthalmology and OptometryParacelsus Medical University/Salzburger Landeskliniken (SALK)SalzburgAustria
- Research Program Experimental Ophthalmology and Glaucoma ResearchParacelsus Medical UniversitySalzburgAustria
- Department of Research and Innovation, Team Biostatistics and Publication of Clinical TrialsParacelsus Medical UniversitySalzburgAustria
| | - Bianka Novotna
- Department of NeurologyLandesklinikum Mistelbach‐GänserndorfMistelbachAustria
| | - Thomas Berger
- Department of Neurology and Comprehensive Center for Clinical Neurosciences and Mental Healthboth Medical University of ViennaViennaAustria
| | - Gabriel Bsteh
- Department of Neurology and Comprehensive Center for Clinical Neurosciences and Mental Healthboth Medical University of ViennaViennaAustria
| | | | - Harald Hegen
- Department of NeurologyMedical University of InnsbruckInnsbruckAustria
| | - Barbara Kornek
- Department of Neurology and Comprehensive Center for Clinical Neurosciences and Mental Healthboth Medical University of ViennaViennaAustria
| | | | - Johann Sellner
- Department of Neurology, Christian Doppler Medical CenterParacelsus Medical UniversitySalzburgAustria
- Department of NeurologyLandesklinikum Mistelbach‐GänserndorfMistelbachAustria
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Yang J, Sun Y, Zhou X, Zhang D, Xu Z, Cao J, Fan B. Risk of secondary autoimmune diseases with alemtuzumab treatment for multiple sclerosis: a systematic review and meta-analysis. Front Immunol 2024; 15:1343971. [PMID: 38690271 PMCID: PMC11058189 DOI: 10.3389/fimmu.2024.1343971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Abstract
Background and purpose The objective of this study is to evaluate the risk of secondary autoimmune diseases in multiple sclerosis (MS) patients treated with alemtuzumab (ALZ) through a meta-analysis. Methods PubMed, Web of Science, OVID, EMBASE, and Cochrane central register of controlled trials were searched. Information and data were screened and extracted by 2 researchers. The obtained data were analyzed using the R software meta package. Quality assessment was conducted using the Newcastle-Ottawa Scale (NOS). The causes of heterogeneity were analyzed using subgroup analysis and sensitivity analysis. Publication bias was evaluated using funnel plots and Egger's test. Results The search retrieved a total of 3530 papers from the databases. After screening, a total of 37 studies were included in the meta-analysis. The analysis results indicate that the pooled incidence rate of overall secondary autoimmune events (SAEs) in the included studies was 0.2824 [0.2348, 0.3300] (I²=94%, p<0.01). The overall incidence of autoimmune thyroid events (ATE) was 0.2257 [0.1810, 0.2703] (I²=94%, p<0.01). Among them, the rate of serious autoimmune thyroid events (SATE) was 0.0541 [0.0396, 0.0687] (I²=0%, p=0.44). The incidence rates of different thyroid events were as follows: Graves' disease (GD), 0.2266 [0.1632, 0.2900] (I²=83%, p<0.01); Hashimoto thyroiditis (HT), 0.0844 [0.0000, 0.2262] (I²=81%, p=0.02); Hashimoto thyroiditis with hypothyroidism (HTwH), 0.0499 [0.0058, 0.0940] (I²=37%, p=0.21); fluctuating thyroid dysfunction (FTD), 0.0219 [0.0015, 0.0424] (I²=0%, p=0.40); transient thyroiditis (TT), 0.0178 [0.0062, 0.0295] (I²=0%, p=0.94). The overall incidence of hematological events was 0.0431 [0.0274, 0.0621] (I²=70%, p<0.01). The incidence rates from high to low were as follows: lymphopenia, 0.0367 [0.0000, 0.0776] (I²=81%, p=0.02); Idiopathic thrombocytopenic purpura (ITP), 0.0258 [0.0199, 0.0323] (I²=25%, p=0.15); Hemolytic anemia (HA), 0.0177 [0.0081, 0.0391] (I²=29%, p=0.23); pancytopenia, 0.0136 [0.0000, 0.0314] (I²=0%, p=0.67); Neutropenia, 0.0081 [0.0000, 0.0183] (I²=0%, p=0.42). After excluding thyroid and hematological diseases, the combined incidence of other related SAEs was 0.0061 [0.0014, 0.0109] (I²=50%, p=0.02). The incidence of each disease ranked from highest to lowest as: skin psoriasis (SP), 0.0430 [0.0000, 0.0929] (I²=0%, p=0.57); alopecia areata (AA), 0.0159 [0.0024, 0.0372] (I²=19%, p=0.29); vitiligo, 0.0134 [0.0044, 0.0223] (I²=0%, p=0.81); inflammatory atrichia (IA), 0.0103 [0.0000, 0.0232] (I²=0%, p=0.43); chronic urticaria (CU), 0.0107 [0.0000, 0.0233] (I²=0%, p=0.60); and nephropathy, 0.0051 [0.0000, 0.0263] (I²=62%, p=0.02). Conclusion The occurrence of secondary autoimmune diseases in patients with MS treated with ALZ is noteworthy, particularly in the form of thyroid events and hematological events. Clinicians should monitor the overall condition of patients promptly for early management and avoid delayed diagnosis and treatment. Systematic review registration inplasy.com/inplasy-2024-4-0048/, identifier INPLASY202440048.
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Affiliation(s)
- Jianguo Yang
- The First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Yuying Sun
- The First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Xinpeng Zhou
- Rheumatology and Immunology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Di Zhang
- Rheumatology and Immunology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Ziqi Xu
- Rheumatology and Immunology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Jiaojiao Cao
- The First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Bing Fan
- Rheumatology and Immunology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
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van Pesch V, Hanganu AR, Sankari SE. Long-term follow up of alemtuzumab-treated patients: a retrospective study in a Belgian tertiary care center. Acta Neurol Belg 2024:10.1007/s13760-024-02542-9. [PMID: 38619747 DOI: 10.1007/s13760-024-02542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/23/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Pivotal studies have reported a significant proportion of patients achieving no evidence of disease activity (NEDA) after 2 cycles of treatment with alemtuzumab (ATZ), that can be maintained for several years. Long-term real-world evidence regarding ATZ as well as subsequent treatment trajectories is still scarce. OBJECTIVE To analyze the effectiveness and safety of ATZ-treated patients in a tertiary care Belgian center. METHODS A retrospective cohort study including 32 patients treated with ATZ between 2015 and 2021 was performed. RESULTS 32 patients received 2 ATZ courses with a mean follow-up (FU) duration of 5.6 years (range: 2.25-8.2). 21.75% patients were treatment naïve. 40.5% were previously treated with natalizumab or fingolimod. NEDA-3 was achieved in 61.3-85% of patients, with failure mostly attributed to recurrence of radiological disease activity. During FU, annualized relapse rates remained very low (0.06-0.14), disability improvement occurred in up to 40.5%, whereas disability worsening occurred in up to 13.5%. Retreatment risk was associated with younger age (< 45 years old, Odds Ratio 8.0, p = 0.02) and a higher number of previous DMTs (Hazard ratio 2.7, 95%CI 1.3-7.4, p = 0.02). Safety in our cohort was consistent with the known profile of ATZ. At the end of FU, 65.6% patients remained untreated after 2 or 3 courses of ATZ, while the remaining switched to anti-CD20 therapy or cladribine. CONCLUSION ATZ is a high efficacy therapy for active MS, providing long-term remission in a significant proportion of patients. Retreatment was more frequent in younger patients or patients having failed a higher number of previous DMTs.
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Affiliation(s)
- Vincent van Pesch
- Department of Neurology, Cliniques Universitaires Saint-Luc (Neurology), UCLouvain, Brussels, Belgium.
| | - Andreea-Raluca Hanganu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, Fundeni Clinical Institute, Bucharest, Romania
| | - Souraya El Sankari
- Department of Neurology, Cliniques Universitaires Saint-Luc (Neurology), UCLouvain, Brussels, Belgium
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Costa-Frossard França L, Meca Lallana V, Labiano-Fontcuberta A, Blasco R, Monreal E, Martínez Ginés ML, Aguirre C, Sabin Muñoz J, Sainz de la Maza S, Cuello JP, Díaz-Pérez C, Chico García JL, Lozano Ros A, Rodríguez Jorge F, Martínez Martínez S, García Domínguez JM. Real-World Retrospective Analysis of Alemtuzumab Outcomes in Relapsing-Remitting Multiple Sclerosis: The LEMCAM Study. CNS Drugs 2024; 38:231-238. [PMID: 38418770 PMCID: PMC10920415 DOI: 10.1007/s40263-024-01066-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Alemtuzumab is a high-efficacy treatment approved for relapsing-remitting multiple sclerosis (RRMS). Although clinical trials and observational studies are consistent in showing its efficacy and manageable safety profile, further studies under clinical practice conditions are needed to further support its clinical use. OBJECTIVE The aim of this observational retrospective study was to evaluate the effectiveness and safety of alemtuzumab to add to the current real-world evidence on the drug. METHODS A cohort of 115 adult patients with RRMS treated with alemtuzumab between 2014 and 2020 was retrospectively followed up in five centers in Spain. Analysis included annualized relapse rate (ARR), 6-month confirmed disability worsening (CDW), 6-month confirmed disability improvement (CDI), radiological activity, no evidence of disease activity (NEDA-3), and safety signals. Given the different follow-up periods among participants, ARR was calculated using the person-years method. CDI was defined as a ≥ 1.0-point decrease in Expanded Disability Status Scale (EDSS) score assessed in patients with a baseline EDSS score ≥ 2.0 confirmed 6 months apart. CDW was defined as a ≥ 1.0-point increase in EDSS score assessed in patients with a baseline EDSS score ≥ 1.0 (≥ 1.5 if baseline EDSS = 0), confirmed 6 months apart. RESULTS ARR decreased from 1.9 (95% confidence interval 1.60-2.33) in the year prior to alemtuzumab initiation to 0.28 (0.17-0.37) after 1 year of treatment (87% reduction), and to 0.22 (0.13-0.35) after the second year. Over the entire follow-up period, ARR was 0.24 (0.18-0.30). At year 1, 75% of patients showed no signs of magnetic resonance imaging (MRI) activity and 70% at year 5. One percent of patients experienced 6-month CDW at year 1, 2.6% at year 2, 7.4% at year 3, and no patients over years 4 and 5. A total of 7.7% of patients achieved 6-month CDI in year 1, 3.6% in year 2, and maintained it at years 3 and 4. Most patients achieved annual NEDA-3: year 1, 72%; year 2, 79%; year 3, 80%; year 4, 89%; year 5, 75%. Infusion-related reactions were observed in 95% of patients and infections in 74%. Thyroid disorders occurred in 30% of patients, and only three patients developed immune thrombocytopenia. No cases of progressive multifocal leukoencephalopathy were reported. CONCLUSIONS This study shows that alemtuzumab reduced the relapse rate and disability worsening in real-world clinical practice, with many patients achieving and sustaining NEDA-3 over time. The safety profile of alemtuzumab was consistent with previous findings, and no new or unexpected safety signals were observed. As this was an observational and retrospective study, the main limitation of not having all variables comprehensively available for all patients should be considered when interpreting results.
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Affiliation(s)
| | - Virginia Meca Lallana
- Demyelinating Diseases Unit, Neurology Service, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Rosario Blasco
- Neuroimmunology Unit, Neurology Service, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Enric Monreal
- Department of Neurology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- IRYCIS (Ramón y Cajal Institute for Health Research), Madrid, Spain
- REEM (Spanish Network of Multiple Sclerosis), Universidad de Alcalá, Madrid, Spain
| | | | - Clara Aguirre
- Demyelinating Diseases Unit, Neurology Service, Hospital Universitario La Princesa, Madrid, Spain
| | - Julia Sabin Muñoz
- Neuroimmunology Unit, Neurology Service, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Susana Sainz de la Maza
- Department of Neurology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- IRYCIS (Ramón y Cajal Institute for Health Research), Madrid, Spain
- REEM (Spanish Network of Multiple Sclerosis), Universidad de Alcalá, Madrid, Spain
| | - Juan Pablo Cuello
- Department of Neurology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Carolina Díaz-Pérez
- Demyelinating Diseases Unit, Neurology Service, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Alberto Lozano Ros
- Department of Neurology, Hospital Universitario Gregorio Marañón, Madrid, Spain
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8
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Deleu D, Garcia Canibano B, Elalamy O, Sayed Abdelmoneim M, Boshra A. Practical Guidance on the Use of Cladribine Tablets in the Management or Relapsing Multiple Sclerosis: Expert Opinion from Qatar. Degener Neurol Neuromuscul Dis 2023; 13:81-88. [PMID: 38105885 PMCID: PMC10725680 DOI: 10.2147/dnnd.s433459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
The increasing availability of high-efficacy disease-modifying therapies (DMT) for the management of relapsing multiple sclerosis (RMS) has increased the potential for individualised patient management but has added complexity to the design of treatment regimens. The long-term application of immune reconstitution therapy (IRT) is supported by an increasing database of real world studies that have added important information on the long-term safety and efficacy of this approach. Cladribine tablets (CladT) is an IRT given as two annual short courses of treatment, following which a majority of patients then demonstrate no significant MS disease activity over a period of years. Whether, and how, to treat patients beyond the first two years of treatment remains a matter for debate, as clinical evidence accumulates. We, a group of neurologists who manage people with RMS in Qatar, provide our expert consensus recommendations on the application and long-term management of CladT therapy based on our experience with treatment in the last 5 years. These include pragmatic recommendations for people with MS disease activity in years 3 and 4 (ie up to four years following first dose of CladT), and for people with or without MS disease activity in subsequent years. We believe our recommendations will help to ensure the optimal application of CladT-based IRT, with the potential benefit for the patient of achieving prolonged periods free of both MS disease symptoms and the burden of regular applications of immunosuppressive DMT.
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Affiliation(s)
- Dirk Deleu
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Osama Elalamy
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Amir Boshra
- Merck Serono Middle East FZ-Ltd., Dubai, UAE, an affiliate of Merck KGaA, Dubai, United Arab Emirates
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9
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Vaisvilas M, Kaubrys G, Kizlaitiene R, Taluntiene V, Giedraitiene N. Autologous hematopoietic stem cell transplantation is superior to alemtuzumab in patients with highly active relapsing multiple sclerosis and severe disability. Mult Scler Relat Disord 2023; 80:105096. [PMID: 37949024 DOI: 10.1016/j.msard.2023.105096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/30/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To assess the differences of treatment outcomes regarding disease activity in patients with highly active relapsing multiple sclerosis (RMS), treated with autologous hematopoietic stem cell transplantation (HSCT) or alemtuzumab (ATZ). METHODS Open-label prospective single-center observational cohort study, enrolling patients with highly active RMS for treatment with ATZ or HSCT between 2014 and 2021. RESULTS A total of 50 patients (31/50 (62 %) in HSCT vs 19/50 (38 %) in ATZ group) were included. There were no significant differences in relapse rate, MRI activity or disability worsening between the two study groups during the first two years after treatment onset. However, at 3 to 5 years follow-up, HSCT was superior to ATZ in all the aforementioned aspects. Kaplan-Meier analysis at 5 years post treatment revealed superiority of HSCT in relapse rate (69.6 % vs 95.7 %, p = 0.027), MRI activity (54.5 % vs 75.1 %, p = 0.038) and disability worsening (57.1 % vs 90.9 %, p = 0.031). CONCLUSIONS ATZ may halt disability progression early in the course of highly active RMS, but the disability starts accumulating later, while in HSCT patients disability improvement is consistent both 3 and 5 years after treatment onset.
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Affiliation(s)
- Mantas Vaisvilas
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Gintaras Kaubrys
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Rasa Kizlaitiene
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Vera Taluntiene
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Natasa Giedraitiene
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
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10
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Puthenparampil M, Gaggiola M, Miscioscia A, Mauceri VA, De Napoli F, Zanotelli G, Anglani M, Nosadini M, Sartori S, Perini P, Rinaldi F, Gallo P. Alemtuzumab following natalizumab is more effective in adult-onset than paediatric-onset multiple sclerosis. Ther Adv Neurol Disord 2023; 16:17562864231177196. [PMID: 37808246 PMCID: PMC10559704 DOI: 10.1177/17562864231177196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Paediatric-onset multiple sclerosis (POMS) therapeutic approach derives from of adult-onset multiple sclerosis (AOMS) tailored algorithms. Objectives To evaluate in a common clinical scenario the efficacy and safety of alemtuzumab (ALZ) in POMS and AOMS. Methods All patients switching from natalizumab (NTZ) to ALZ for safety concerns (high anti-John Cunningham Virus Antibody Index value, anti-JCV Index) were enrolled in this single-centre, retrospective, case-control open-label study. Results Ten POMS and 27 AOMS were followed up for 51.3 months. After month 12, we found a lower risk of clinical or radiological relapses among AOMS patients and among patients with older age at ALZ (both p < 0.05). Survival analysis revealed an increased risk of relapse in POMS compared with AOMS (logrank p = 0.00498) and patients starting ALZ before age 22.75 years than the elder ones (logrank p = 0.0018). Survival analysis did not disclose any difference between AOMS and POMS (logrank p = 0.27) in terms of progression independent of any relapse activity (PIRA). In addition, no evidence of relapse-associated worsening was observed. Autoimmune events were reported by 5 AOMS and no POMS (29.4% versus 0.0%, p = 0.057), and survival analysis was not significant (logrank p = 0.0786). Conclusion ALZ seems more effective in AOMS than in POMS following NTZ. These findings underrate ALZ effectiveness when shifting from NTZ in POMS.
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Affiliation(s)
- Marco Puthenparampil
- Multiple Sclerosis Centre, Clinica Neurologica, Dipartimento di Neuroscienze, Università degli Studi di Padova, Via Giustiniani 5, 35128 Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Marta Gaggiola
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Alessandro Miscioscia
- Department of Neurosciences, University of Padua, Padova, Italy
- Padua Neuroscience Centre, University of Padua, Padova, Italy
| | - Valentina Annamaria Mauceri
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Federica De Napoli
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Giovanni Zanotelli
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | | | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute ‘Città della Speranza’, Padova, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute ‘Città della Speranza’, Padova, Italy
| | - Paola Perini
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Francesca Rinaldi
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Paolo Gallo
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
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11
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Clavelou P, Castelnovo G, Pourcher V, De Sèze J, Vermersch P, Ben-Amor AF, Savarin C, Defer G. Expert Narrative Review of the Safety of Cladribine Tablets for the Management of Relapsing Multiple Sclerosis. Neurol Ther 2023; 12:1457-1476. [PMID: 37382841 PMCID: PMC10444734 DOI: 10.1007/s40120-023-00496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/11/2023] [Indexed: 06/30/2023] Open
Abstract
Cladribine tablets (CladT) is a highly active oral disease-modifying therapy (DMT) for the management of relapsing multiple sclerosis (RMS). CladT acts as an immune reconstitution therapy, in that two short courses of treatment 1 year apart have been shown to suppress disease activity for a prolonged period in most patients, without need for continued DMT. Each course of CladT induces a profound reduction in B lymphocytes that recovers over months, and serious lymphopenia (Grade 3-4) is uncommon. Smaller reductions in levels of T lymphocytes occur slightly later: on average, these remain within the normal range and repopulate progressively. A larger effect occurs on CD8 vs. CD4 cells. Reactivation of latent or opportunistic infections (e.g. varicella zoster, tuberculosis) is mostly associated with very low lymphocyte counts (< 200/mm3). Screening and managing pre-existing infections, vaccinating non-exposed patients and delaying the 2nd year of treatment with CladT to allow lymphocytes to recover to > 800/mm3 (if necessary) are important for avoiding infections and higher-grade lymphopenia. There was no demonstrable or apparent effect of CladT on the efficacy of vaccinations, including against Covid-19. Adverse events consistent with drug-induced liver injury (DILI) represent a rare but potentially serious complication of CladT therapy in spontaneous adverse event reporting; patients should be screened for liver dysfunction before starting treatment. Ongoing hepatic monitoring is not required, but CladT must be withdrawn if signs and symptoms of DILI develop. There was a numerical imbalance for malignancies when comparing cladribine to placebo in the clinical programme, particularly in short-term data, but recent evidence shows that the risk of malignancy with CladT is similar to the background rate in the general population and to that with other DMTs. Overall, CladT is well tolerated with a favorable safety profile appropriate for the management of RMS.
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Affiliation(s)
- Pierre Clavelou
- Department of Neurology, Clermont-Ferrand University Hospital, 58 Rue Montalembert, 63003, Clermont-Ferrand Cedex 1, France.
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Valérie Pourcher
- Department of Infectious and Tropical Diseases, Pitié-Salpêtrière Hospital, APHP, Sorbonne Université, INSERM 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique Paris, Paris, France
| | - Jerome De Sèze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Ali-Frederic Ben-Amor
- Global Medical Affairs Neurology and Immunology, Ares Trading SA (An affiliate of Merck KGaA, Darmstadt, Germany), Eysins, Switzerland
| | - Carine Savarin
- Neurology Department, Medical Affairs (An affiliate of Merck KGaA, Darmstadt, Germany), Merck Santé, Lyon, France
| | - Gilles Defer
- Department of Neurology, Caen University Hospital, Caen, France
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12
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Coles AJ, Achiron A, Traboulsee A, Singer BA, Pozzilli C, Oreja-Guevara C, Giovannoni G, Comi G, Freedman MS, Ziemssen T, Shiota D, Rawlings AM, Wong AT, Chirieac M, Montalban X. Safety and efficacy with alemtuzumab over 13 years in relapsing-remitting multiple sclerosis: final results from the open-label TOPAZ study. Ther Adv Neurol Disord 2023; 16:17562864231194823. [PMID: 37745914 PMCID: PMC10515516 DOI: 10.1177/17562864231194823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/29/2023] [Indexed: 09/26/2023] Open
Abstract
Background and objectives Alemtuzumab demonstrated superior efficacy versus subcutaneous interferon (IFN) beta-1a in participants with relapsing-remitting multiple sclerosis in the 2-year CARE-MS I and II trials. Efficacy was maintained in the 4-year CARE-MS extension, during which alemtuzumab-treated participants ('alemtuzumab-only') could receive additional courses upon disease activity, and IFN-treated participants switched to alemtuzumab ('IFN-alemtuzumab'). Participants who completed the CARE-MS extension could enroll in the open-label TOPAZ study which assessed safety and efficacy for 5-7 years (11-13 years after alemtuzumab/IFN initiation). Methods Participants received additional alemtuzumab courses as needed. Assessments included adverse events (AEs; primary outcome), annualized relapse rate (ARR), 6-month confirmed disability worsening [CDW; ⩾1.0-point Expanded Disability Status Scale (EDSS) score increase or ⩾1.5 if baseline EDSS = 0], and 6-month confirmed disease improvement [CDI; >1.0-point EDSS decrease (baseline score ⩾2.0)]. Results 43.5% of alemtuzumab-only participants from CARE-MS II and 54.2% from CARE-MS I received no additional alemtuzumab courses; 30.0% and 20.9%, respectively, received one additional course (the median). Incidences of AEs, including thyroid AEs and infections, declined over time. The safety profile of alemtuzumab was similar for participants who received zero, one, or two additional courses. For CARE-MS II participants, who had inadequate response to previous treatment, ARR remained low during Years 3-13 for the alemtuzumab-only [0.17; 95% confidence interval (CI) 0.15-0.20] and IFN-alemtuzumab (0.14; 0.11-0.17) groups. At Year 11, the proportions of participants who were either free from CDW or who had CDI were higher in the alemtuzumab-only group (58% and 49%, respectively) than in the IFN-alemtuzumab group (51% and 37%). For CARE-MS I participants, who were previously treatment-naïve, clinical outcomes remained improved, and no between-group differences were apparent. Conclusion Safety risks associated with alemtuzumab treatment declined over time. Clinical benefits were maintained up to 11-13 years, and most participants did not require more than one additional course. Clinicaltrialsgov identifiers NCT00530348; NCT00548405; NCT00930553; NCT02255656.
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Affiliation(s)
- Alasdair J. Coles
- Department of Clinical Neurosciences, University of Cambridge, Box 165, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
| | - Anat Achiron
- Multiple Sclerosis Center, Sheba Medical Center, Tel HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Israel
| | - Anthony Traboulsee
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Barry A. Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St. Louis, MO, USA
| | - Carlo Pozzilli
- Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clinico San Carlos, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM) and IdISSC, Madrid, Spain
| | | | - Giancarlo Comi
- Casa di Cura del Policlinico, Università Vita Salute San Raffaele, Milan, Italy
| | - Mark S. Freedman
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Neurological Clinic, Carl Gustav Carus University Hospital, Dresden, Germany
| | | | | | | | | | - Xavier Montalban
- Department of Neurology-Neuroimmunology and Multiple Sclerosis Centre of Catalonia, Vall d’Hebron University Hospital, Barcelona, Spain
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13
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Altunan B, Ünal A, Efendi H, Köseoğlu M, Terzi M, Kotan D, Tamam Y, Boz C, Güler S, Turan ÖF, Altunrende B, Balcı FB, Turgut N, Akçalı A, Yildirim KA, Günal Dİ, Sunter G, Bingöl A. Use of follow-on fingolimod for multiple sclerosis: Analysis of effectiveness and patient reported outcomes in a real-world clinical setting. Mult Scler Relat Disord 2023; 77:104880. [PMID: 37459716 DOI: 10.1016/j.msard.2023.104880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/19/2023] [Accepted: 07/09/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Follow-on disease modifying therapies (FO-DMTs) do not always require Phase III studies. There are concerns that cheaper FO-DMTs are only used to reduce healthcare costs. However, the well-being of people with MS (pwMS) should be a priority. We aimed to evaluate the efficacy, safety and treatment satisfaction of one of the FO- Fingolimod (FTY) used in Turkey with the approval of Turkish Ministry of Health. METHODS PwMS under FTY were recruited from 13 centers and real-world data and answers of satisfaction and adherence statements of pwMS on FTY treatment were analyzed. RESULTS Data of 239 pwMS were obtained. The duration of FTY treatment was 2.5 ± 0.8 (1-4) years in pwMS who were included in the study and whose treatment continued for at least one year. Significant decreases in annual relapse rate (p < 0.001), Expanded Disability Status Scale (p < 0.001) and neuroimaging findings (p < 0.001) were observed. While 64% of the patients were satisfied and 71.5% were found to adherent with this FO-FTY. CONCLUSION This multicenter retrospective study found that the efficacy, safety and treatment adherence of a prescribed FO-FTY were consistent with the results of real-world studies. Studies including real-world data may provide guidance to address issues related to FO-FTY use.
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Affiliation(s)
- Bengü Altunan
- Department of Neurology, Faculty of Medicine, Tekirdag Namık Kemal University, Kampus street,.Süleymanpasa, Tekirdag 59100, Turkey
| | - Aysun Ünal
- Department of Neurology, Faculty of Medicine, Tekirdag Namık Kemal University, Kampus street,.Süleymanpasa, Tekirdag 59100, Turkey.
| | - Hüsnü Efendi
- Department of Neurology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | | | - Murat Terzi
- Department of Neurology, Ondokuz Mayıs University, Samsun, Turkey
| | - Dilcan Kotan
- Department of Neurology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Yusuf Tamam
- Department of Neurology, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
| | - Cavit Boz
- Department of Neurology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Sibel Güler
- Department of Neurology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Ömer Faruk Turan
- Department of Neurology, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Burcu Altunrende
- Bilim University, Florence Nightingale Hospital, Istanbul, Turkey
| | | | - Nilda Turgut
- Department of Neurology, Faculty of Medicine, Tekirdag Namık Kemal University, Kampus street,.Süleymanpasa, Tekirdag 59100, Turkey
| | - Aylin Akçalı
- Department of Neurology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | | | - Dilek İnce Günal
- Department of Neurology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Gulin Sunter
- Department of Neurology, Faculty of Medicine, Marmara University, Istanbul, Turkey
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14
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López-Real AM, Gonzalez I, Solar DM, Oterino A, Costa E, Pato A, Llaneza MA, García-Estévez DA, Rodriguez-Regal A, Rodriguez M, Peña J. Alemtuzumab treatment in real clinical practice: Experience in a multicenter cohort. Mult Scler Relat Disord 2023; 75:104762. [PMID: 37229800 DOI: 10.1016/j.msard.2023.104762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Alemtuzumab is a highly effective treatment for relapsing remitting multiple sclerosis (RRMS), but in recent years safety-related concerns had emerged due to description of novel serious side effects not registered in CARE-MS I and CARE-MS II phase 3 studies, nor in TOPAZ extension study. Data about alemtuzumab use in real clinical practice are limited and based mainly on retrospective studies with small sample sizes. Therefore, more information about effectiveness and safety of alemtuzumab in this context is needed. METHODS A multicenter observational prospective study to investigate effectivity and safety of alemtuzumab in a real-world setting was performed. Primary endpoints were the change in annualized relapse rate (ARR), and in disability measured by EDSS score. Secondary endpoints were the cumulative probability of confirmed 6-month disability improvement and worsening. Disability worsening and disability improvement were considered when the EDSS score was increased or decreased, respectively, in 1 point if baseline EDSS score was <5.0, or in 0.5 point if baseline EDSS score was ≥5.5, confirmed over 6 months. Other secondary endpoint was the proportion of patients who achieved NEDA-3 status (absence of clinical relapses, disability EDSS progression, and MRI disease activity as depicted by new/enlarging T2 lesions or Gadolinium enhancing T1 lesions). Adverse events also were recorded. RESULTS A total of 195 RRMS patients (70% female) who started alemtuzumab treatment were included. Mean of follow-up was 2.38 years. Alemtuzumab significantly reduced the annualized relapse rate from baseline with risk reductions of 86%, 83.5%, and 84%, at 12, 24, and 36 months of follow-up respectively (Friedman test, p-value < 0.05 for all comparisons). Alemtuzumab also significantly reduced EDSS score over one and two years after starting alemtuzumab treatment (Friedman test, p-value<0.001 for both comparisons). A high proportion of patients presented confirmed 6-month stability or disability improvement (92%, 82%, and 79%, over 1, 2 and 3 years of follow-up respectively). The proportion of patients who retained NEDA-3 status at 12, 24 and 36 months were 61%, 49%, and 42%, respectively. Baseline characteristics associated with a lower probability of achieving NEDA-3 were younger age, sex female, high ARR, elevated number of previous treatments, and switch from a second line therapy. Infusion related reactions were the most frequent adverse event observed. The most common infections were urinary tract infections (50%), and upper respiratory tract infections (19%) over the 3 years of follow- up. Secondary thyroid autoimmunity was developed in 18.5% of patients. CONCLUSION Alemtuzumab has demonstrated in real clinical practice high effectiveness in controlling multiple sclerosis activity, and no unexpected adverse events were observed.
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Affiliation(s)
| | - I Gonzalez
- Complejo Hospitalario Universitario de Vigo, Spain
| | - D M Solar
- Hospital Universitario Cabueñes, Spain
| | - A Oterino
- Hospital Universitario Marqués de Valdecilla, Spain
| | - E Costa
- Complejo Hospitalario Universitario de Santiago de Compostela, Spain
| | - A Pato
- Hospital Rivera Povisa. Vigo, Spain
| | - M A Llaneza
- Complejo Hospitalario Universitario de Ferrol, Spain
| | | | | | - M Rodriguez
- Hospital Universitario Lucus Augusti. Lugo, Spain
| | - J Peña
- Hospital Universitario San Agustín. Avilés, Spain
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15
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Alroughani R, AlMojel M, Al-Hashel J, Ahmed SF. A real-life study of alemtuzumab in persons with multiple sclerosis: Kuwait's experience. Mult Scler Relat Disord 2023; 74:104712. [PMID: 37054581 DOI: 10.1016/j.msard.2023.104712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/25/2023] [Accepted: 04/08/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Alemtuzumab, a humanized anti-CD52 monoclonal antibody, has been approved as a treatment in persons with active relapsing-remitting multiple sclerosis (RRMS). Real-world data in middle east is very limited. We aimed to evaluate the effectiveness and safety of alemtuzumab in a real-world clinical setting. METHODS This observational, registry based study assessed persons with multiple sclerosis (PwMS) who were treated with alemtuzumab and completed at least follow up one year after second course. Baseline clinical and radiological characteristics within one year prior to alemtuzumab initiation were collected. The relapse rate, disability measures, radiological activity and adverse events at last follow-up visits were assessed. RESULTS Data of seventy-three persons with multiple sclerosis (MS) was analyzed, of which 53 (72.6%) were females. Mean age and mean disease duration were 34.25 ± 7.62 and 9.23 ± 6.20 years respectively. Alemtuzumab was started in 32 (43.8%) naïve patients due to highly active disease and in 25 (34.2%) (PwMS) who were on prior therapies and in 16 (22%) patients due to adverse events on prior medications. Mean follow-up period was 4 ± 1.67 years. In the last follow-up visits, most of our cohort was relapse free (79.5% vs. 17.8%; p < 0.001) compared to baseline before alemtuzumab treatment while mean EDSS score was reduced (2.21 ± 2.15 vs. 2.41 ± 1.85; p < 0.059). The proportion of PwMS who had MRI activity (new T2/ Gd-enhancing) lesions were significantly reduced compared to baseline (15.1% vs. 82.2%; p < 0.001). NEDA-3 was achieved in 57.5% of (PwMS). NEDA-3 was significantly better in naïve patients (78% versus. 41.5%; p < 0.002) and in patients with disease duration < 5 years, (82.6% v 43.2%; p < 0.002). Several adverse events such as infusion reactions (75.3%), autoimmune thyroiditis (16.4%) and glomerulonephritis (2.7%) were reported. CONCLUSION The effectiveness and safety profile of alemtuzumab in this cohort were consistent with data of clinical trials. Early initiation of Alemtuzumab is associated with favorable outcome.
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Affiliation(s)
- Raed Alroughani
- Division of Neurology, Amiri Hospital, Arabian Gulf Street, Sharq 13041, Kuwait; MS Clinic, Ibn Sina Hospital, P.O. Box 25427, Safat 13115, Kuwait
| | - Malak AlMojel
- Department of Medicine, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait
| | - Jasem Al-Hashel
- Department of Medicine, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait; Department of Neurology, Ibn Sina Hospital, P.O. Box 25427, Safat 13115, Kuwait
| | - Samar Farouk Ahmed
- Department of Medicine, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait; Department of Neurology and Psychiatry, Minia University, P.O. Box 61519, Minia 61111, Egypt.
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Muñoz-Vendrell A, Arroyo-Pereiro P, León I, Bau L, Matas E, Martínez-Yélamos A, Martínez-Yélamos S, Romero-Pinel L. Natalizumab continuation versus switching to ocrelizumab after PML risk stratification in RRMS patients: a natural experiment. J Neurol 2023; 270:2559-2566. [PMID: 36913038 PMCID: PMC10129953 DOI: 10.1007/s00415-023-11645-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Natalizumab (NTZ) and ocrelizumab (OCR) can be used for the treatment of relapsing-remitting multiple sclerosis (RRMS). In patients treated with NTZ, screening for JC virus (JCV) is mandatory, and a positive serology usually requires a change in treatment after 2 years. In this study, JCV serology was used as a natural experiment to pseudo-randomize patients into NTZ continuation or OCR. METHODS An observational analysis of patients who had received NTZ for at least 2 years and were either changed to OCR or maintained on NTZ, depending on JCV serology status, was performed. A stratification moment (STRm) was established when patients were pseudo-randomized to either arm (NTZ continuation if JCV negativity, or change to OCR if JCV positivity). Primary endpoints include time to first relapse and presence of relapses after STRm and OCR initiation. Secondary endpoints include clinical and radiological outcomes after 1 year. RESULTS Of the 67 patients included, 40 continued on NTZ (60%) and 27 were changed to OCR (40%). Baseline characteristics were similar. Time to first relapse was not significantly different. Ten patients in the JCV + OCR arm presented a relapse after STRm (37%), four during the washout period, and 13 patients in the JCV-NTZ arm (32.5%, p = 0.701). No differences in secondary endpoints were detected in the first year after STRm. CONCLUSIONS The JCV status can be used as a natural experiment to compare treatment arms with a low selection bias. In our study, switching to OCR versus NTZ continuation led to similar disease activity outcomes.
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Affiliation(s)
- Albert Muñoz-Vendrell
- Neurology Department, Multiple Sclerosis Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Carrer de la Feixa Llarga S/N, 08907, Barcelona, Spain
| | - Pablo Arroyo-Pereiro
- Neurology Department, Multiple Sclerosis Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Carrer de la Feixa Llarga S/N, 08907, Barcelona, Spain.
| | - Isabel León
- Neurology Department, Multiple Sclerosis Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Carrer de la Feixa Llarga S/N, 08907, Barcelona, Spain
| | - Laura Bau
- Neurology Department, Multiple Sclerosis Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Carrer de la Feixa Llarga S/N, 08907, Barcelona, Spain
| | - Elisabet Matas
- Neurology Department, Multiple Sclerosis Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Carrer de la Feixa Llarga S/N, 08907, Barcelona, Spain
| | - Antonio Martínez-Yélamos
- Neurology Department, Multiple Sclerosis Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Carrer de la Feixa Llarga S/N, 08907, Barcelona, Spain
| | - Sergio Martínez-Yélamos
- Neurology Department, Multiple Sclerosis Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Carrer de la Feixa Llarga S/N, 08907, Barcelona, Spain
| | - Lucía Romero-Pinel
- Neurology Department, Multiple Sclerosis Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Carrer de la Feixa Llarga S/N, 08907, Barcelona, Spain
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Alemtuzumab-Related Lymphocyte Subset Dynamics and Disease Activity or Autoimmune Adverse Events: Real-World Evidence. J Clin Med 2023; 12:jcm12051768. [PMID: 36902555 PMCID: PMC10002781 DOI: 10.3390/jcm12051768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES alemtuzumab is a monoclonal anti-CD52 antibody acting on B and T cells in highly active multiple sclerosis (MS). We analyzed changes in lymphocyte subsets after alemtuzumab administration in relation to disease activity and autoimmune adverse events. METHODS lymphocyte subset counts were assessed longitudinally using linear mixed models. Subset counts at baseline and during follow-up were correlated with relapse rate, adverse events, or magnetic resonance (MRI) activity. RESULTS we recruited 150 patients followed for a median of 2.7 years (IQR: 1.9-3.7). Total lymphocytes, CD4, CD8, and CD20 significantly decreased in all patients over 2 years (p < 0.001). Previous treatment with fingolimod increased the risk of disease activity and adverse events (p = 0.029). We found a higher probability of disease reactivation in males and in patients with over three active lesions at baseline. Higher EDSS scores at baseline and longer disease duration predicted the switch to other treatments after alemtuzumab. DISCUSSION AND CONCLUSIONS Our real-world study supports data from clinical trials in which lymphocyte subsets were not useful for predicting disease activity or autoimmune disease during treatment. The early use of an induction therapy such as alemtuzumab in patients with a lower EDSS score and short history of disease could mitigate the risk of treatment failure.
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The Place of Immune Reconstitution Therapy in the Management of Relapsing Multiple Sclerosis in France: An Expert Consensus. Neurol Ther 2022; 12:351-369. [PMID: 36564664 PMCID: PMC10043116 DOI: 10.1007/s40120-022-00430-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/29/2022] [Indexed: 12/25/2022] Open
Abstract
The treatment strategy in relapsing multiple sclerosis (RMS) is a complex decision requiring individualization of treatment sequences to maximize clinical outcomes. Current local and international guidelines do not provide specific recommendation on the use of immune reconstitution therapy (IRT) as alternative to continuous immunosuppression in the management of RMS. The objective of the program was to provide consensus-based expert opinion on the optimal use of IRT in the management of RMS. A Delphi method was performed from May 2022 to July 2022. Nineteen clinical assertions were developed by a scientific committee and sent to 14 French clinical experts in MS alongside published literature. Two consecutive reproducible anonymous votes were conducted. Consensus on recommendations was achieved when more than 75% of the respondents agreed or disagreed with the clinical assertions. After the second round, consensus was achieved amongst 16 out of 19 propositions: 13 clinical assertions had a 100% consensus, 3 clinical assertions a consensus above 75% and 3 without consensus. Expert-agreed consensus is provided on topics related to the benefit of the early use of IRT from immunological and clinical perspectives, profiles of patients who may benefit most from the IRT strategy (e.g. patients with family planning, patient preference and lifestyle requirements). These French expert consensuses provide up-to-date relevant guidance on the use of IRT in clinical practice. The current program reflects status of knowledge in 2022 and should be updated in timely manner when further clinical data in IRT become available.
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