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Barboza A, Gaitán MI, Alonso R, Ysrraelit MC, Luetic G, Liwacki S, Patrucco L, Halfon MJ, Burgos M, Mainella C, Pierdabuena R, Recchia L, Steinberg J, Tkachuk VA, Zanga G, Carra A, Chertcoff A, Fernandez Liguori N, Lazaro L, Menichini ML, Miguez J, Orzuza G, Palavecino A, Pappolla A, Pigretti S, Pita C, Ruiz E, Silva B, Zentil G. Rebound activity after fingolimod cessation: A case - control study. Mult Scler Relat Disord 2022; 57:103329. [PMID: 35158443 DOI: 10.1016/j.msard.2021.103329] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 09/30/2021] [Accepted: 10/11/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND There has been an increase in the number of reports of multiple sclerosis (MS) rebound activity (RA), which is usually defined as a severe disease reactivation after natalizumab or fingolimod withdrawal that exceeds pre-treatment baseline inflammatory activity. The frequency and risk factors that could predict RA remain unknown. Fingolimod is currently the most frequently prescribed disease modifying therapy for MS in Argentina, so that there is a need to determine possible predictors of RA. OBJECTIVES To identify risk factors for developing RA after fingolimod cessation; to describe RA characteristics, management and evolution. METHODS The study was a multicenter, retrospective, case-control study of patients with MS who had discontinued fingolimod and were followed up to nine months after discontinuation. Demographic, clinical and paraclinical data was extracted, including age, gender, MS phenotype, reason for discontinuation, number of relapses during the year prior to suspension, time treated with fingolimod, EDSS before, during and after rebound, MRI findings. RESULTS 26 cases of RA were matched 1:1 with patients without RA. The median time elapsed to RA was 50 days. 68% showed worsening of the EDSS in the evaluation at 3 months of RA. When compared with the control group, no difference was found in terms of age, gender, phenotype, EDSS at the moment of suspension, reason for discontinuation, number of relapses in the previous year, and time on therapy. CONCLUSION In this case-controlled study, no risk factors could be identified to predict RA after fingolimod cessation. Further controlled, prospective, better powered studies are needed to confirm these findings.
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Affiliation(s)
- Andres Barboza
- Department of Neurology, Hospital Central de Mendoza, Mendoza, Argentina.
| | | | - Ricardo Alonso
- Centro Universitario de Esclerosis Multiple, Hospital Ramos Mejia, Buenos Aires, Argentina; Department of Neurology, Sanatorio Güemes, Buenos Aires, Argentina
| | | | | | - Susana Liwacki
- Department of Neurology, Hospital Cordoba, Cordoba, Argentina; Department of Neurology, Clinica Reina Fabiola. Cordoba, Argentina
| | - Liliana Patrucco
- Department of Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mario Javier Halfon
- Department of Neurology, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Marcos Burgos
- Department of Neurology, Hospital San Bernardo, Salta, Argentina
| | - Carolina Mainella
- Department of Neurology, Hospital Español de Rosario, Santa Fe, Argentina
| | - Raul Pierdabuena
- Department of Neurology, Clinica Reina Fabiola. Cordoba, Argentina
| | - Luciano Recchia
- Department of Neurology, Hospital Central de Mendoza, Mendoza, Argentina
| | - Judith Steinberg
- Department of Neurology, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | | | - Gisela Zanga
- Department of Neurology, ENERI, Buenos Aires, Argentina
| | - Adriana Carra
- Department of Neurology, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Aníbal Chertcoff
- Department of Neurology, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | | | - Luciana Lazaro
- Department of Neurology, Sanatorio Güemes, Buenos Aires, Argentina
| | | | - Jimena Miguez
- Department of Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gabriela Orzuza
- Department of Neurology, Hospital San Bernardo, Salta, Argentina
| | | | - Agustin Pappolla
- Department of Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Santiago Pigretti
- Department of Neurology, Hospital Central de Mendoza, Mendoza, Argentina
| | - Cacilia Pita
- Centro Universitario de Esclerosis Multiple, Hospital Ramos Mejia, Buenos Aires, Argentina
| | - Emiliano Ruiz
- Department of Neurology, Clinica Reina Fabiola. Cordoba, Argentina
| | - Berenice Silva
- Centro Universitario de Esclerosis Multiple, Hospital Ramos Mejia, Buenos Aires, Argentina
| | - Guillermo Zentil
- Department of Neurology, Hospital Central de Mendoza, Mendoza, Argentina
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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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3
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Cuascut FX, Alkabie S, Hutton GJ. Fingolimod-related cryptococcal meningoencephalitis and immune reconstitution inflammatory syndrome in a patient with multiple sclerosis. Mult Scler Relat Disord 2021; 53:103072. [PMID: 34139459 DOI: 10.1016/j.msard.2021.103072] [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: 11/24/2020] [Revised: 04/12/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022]
Abstract
Fingolimod is an oral medication for multiple sclerosis that sequesters certain subsets of lymphocytes in lymph nodes, reducing egress into blood and their subsequent CNS migration. The initial multi-site randomized Phase III controlled trials found rates of infection similar to those in control groups. However, post-marketing surveillance has revealed an association with several opportunistic infections, including cryptococcosis. We report a case of fingolimod-related cryptococcal meningoencephalitis and IRIS after drug discontinuation and suggest a surveillance and risk mitigation strategy.
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Affiliation(s)
- Fernando X Cuascut
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Department of Neurology, Baylor College of Medicine, Houston, Texas, United States.
| | - Samir Alkabie
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Department of Neurology, Baylor College of Medicine, Houston, Texas, United States
| | - George J Hutton
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Department of Neurology, Baylor College of Medicine, Houston, Texas, United States
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Double Filtration Plasmapheresis Treatment of Refractory Multiple Sclerosis Relapsed on Fingolimod: A Case Report. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10217404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Double filtration plasmapheresis (DFPP) is an emerging semi-selective apheretic method for treating immuno-mediated neurological diseases. Here we report the first case of steroid-refractory relapsed multiple sclerosis (MS) on Fingolimod (FTY), treated effectively by this technique, in a 37-year-old woman. This condition is thought to be caused by soluble inflammatory species, but its demyelinating pattern is unknown; moreover, despite megadoses of intravenous 6-methyl prednisolone, it induces severe neurological deterioration, but dramatically responded to DFPP in our patient. The clinical improvement was driven by a strong DFPP-induced anti-inflammatory effect, with significant reduction of C3/C4 components, total gamma globulin concentrations (IgG), and gamma-fibrinogen (FGG), resulting in a brain pseudoatrophy phenomenon. Our findings are: first, the steroid-refractory relapsed MS on FTY, however serious, can be treated with DFPP; second, given the good clinical improvement due to the DFPP-induced neuroinflammatory components removal, this clinical condition can be associated with a Lucchinetti pattern II of demyelination.
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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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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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7
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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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Sánchez P, Meca-Lallana V, Vivancos J. Tumefactive multiple sclerosis lesions associated with fingolimod treatment: Report of 5 cases. Mult Scler Relat Disord 2018; 25:95-98. [PMID: 30056362 DOI: 10.1016/j.msard.2018.07.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/17/2018] [Accepted: 07/01/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Fingolimod is a sphingosine 1-phosphate receptor modulator, which sequesters lymphocytes in lymph nodes and prevents them from entering the central nervous system. There have been increasing reports of severe rebounds with tumefactive demyelinatinglesions (TDLs) in patients with multiple sclerosis under fingolimod treatment, as well as following therapy discontinuation. Our objective is to review the clinico-radiological characteristics of patients with TDLs associated with fingolimod. METHODS Retrospective review of medical records of MS patients from our center, who were treated with fingolimod and developed TDLs. We review the literature. RESULTS We found 5 cases: 4 developed TDLs as rebounds after treatment cessation and 1 under treatment. The 4 rebound cases were women, with a mean age of 34.7 years (SD = 3.6) and a mean disease duration of 10.2 years (SD = 4.1). The mean duration of fingolimod treatment before discontinuation was 36.2 months (SD = 22.4) and the mean time lapse between treatment withdrawal and rebound was 9.75 weeks (SD = 7.4). The total pre-rebound lymphocyte count (cells/mm3) was 482.5 (SD = 325.7) and1017.5 (SD = 364.8) during rebound. The TDL patient under fingolimod was a 36-year-old man who had been on fingolimod for 32 months after switching from glatiramer acetate. TDLs were multiple in 2 cases and solitary in 3. Acute treatment for rebound included high dose steroids (5/5), plasma exchange (3/5) and rituximab (2/5). Treatment after fingolimod included rituximab (2/5), alemtuzumab (2/5) and glatiramer acetate (1/5). CONCLUSIONS Our study, along with similar reports in literature, highlights the need for close monitoring in patients who plan to switch from fingolimod to other treatments because of the risk of severe rebound. The etiopathogenic association between fingolimod and TDLs is not clear, but given the increasing reports of cases it should be taken into account for treatment selection in patients with this type of lesions.
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Affiliation(s)
- Pedro Sánchez
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Madrid. Instituto de Investigación Sanitaria La Princesa, Spain.
| | - Virginia Meca-Lallana
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Madrid. Instituto de Investigación Sanitaria La Princesa, Spain
| | - José Vivancos
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Madrid. Instituto de Investigación Sanitaria La Princesa, Spain
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The Shifting Landscape of Disease-Modifying Therapies for Relapsing Multiple Sclerosis. J Neuroophthalmol 2018; 38:210-216. [PMID: 29750735 DOI: 10.1097/wno.0000000000000659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is the most common nontraumatic neurological disorder of young adults, and roughly 85% of patients present with the relapsing form of the disease. Over the past 2 decades, the treatment arsenal for relapsing MS has expanded and evolved from mildly effective and relatively benign injectable agents to potent cell-depleting monoclonal agents. The latter have the potential to achieve disease remission coupled with risk of moderate to severe adverse events with which all MS care providers will need to acquaint themselves. METHODS This review is based on a detailed assessment of MS pivotal trials, extension studies, and expert reviews of the agents discussed. RESULTS/CONCLUSIONS The following review should aid those practitioners directly and indirectly involved in the care of MS patients in understanding the benefits and risks associated with the medications they prescribe.
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10
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Ghadiri M, Fitz-Gerald L, Rezk A, Li R, Nyirenda M, Haegert D, Giacomini PS, Bar-Or A, Antel J. Reconstitution of the peripheral immune repertoire following withdrawal of fingolimod. Mult Scler 2018; 23:1225-1232. [PMID: 28749311 DOI: 10.1177/1352458517713147] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Following fingolimod cessation, immune reconstitution or lack thereof may have consequences for disease rebound or safety of commencing alternative therapies. OBJECTIVE To examine the degree and profile of peripheral blood lymphocyte reconstitution following fingolimod withdrawal. METHODS Total lymphocyte counts (TLC) and CD4+/CD8+ T-cell counts were measured in 18 multiple sclerosis (MS) patients pre-treatment, on fingolimod, and up to 8-9 months post-cessation. T-cell subsets were analyzed using flow cytometry. RESULTS At 2-week post-fingolimod cessation, TLC reconstitution was variable and not correlated with age, treatment duration, pre-, or on-treatment TLC. Despite normalization of TLC and CD4+:CD8+ ratios over months, naive subsets remained lower and effector memory subsets higher in frequency compared with pre-treatment. Drug-induced increases in ratios of regulatory to pathogenic Th17-containing central memory populations appeared to rapidly return to baseline. CONCLUSION Early peripheral lymphocyte reconstitution after fingolimod withdrawal remains partial and heterogeneous. Relative frequencies of circulating naive and memory T-cell subsets may not recover for many months, even when clinical laboratory tests have normalized. Analyzing specific components of the peripheral immune repertoire helps define the overall immune status of patients. To be determined is whether assessment of such immune measures will have implications for the timing and safety of commencing alternative therapies.
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Affiliation(s)
- Mahtab Ghadiri
- Montreal Neurologic Institute, McGill University, Montreal, QC, Canada/Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
| | | | - Ayman Rezk
- Montreal Neurologic Institute, McGill University, Montreal, QC, Canada
| | - Rui Li
- Montreal Neurologic Institute, McGill University, Montreal, QC, Canada
| | - Mukanthu Nyirenda
- Montreal Neurologic Institute, McGill University, Montreal, QC, Canada
| | - David Haegert
- Department of Pathology, McGill University, Montreal, QC, Canada
| | | | - Amit Bar-Or
- Montreal Neurologic Institute, McGill University, Montreal, QC, Canada/Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Antel
- Montreal Neurologic Institute, McGill University, Montreal, QC, Canada
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11
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Multiple sclerosis treatment with fingolimod: profile of non-cardiologic adverse events. Acta Neurol Belg 2017; 117:821-827. [PMID: 28528469 DOI: 10.1007/s13760-017-0794-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 05/15/2017] [Indexed: 01/25/2023]
Abstract
Fingolimod was the first oral medication approved for management of multiple sclerosis and is currently used by tens of thousands patients worldwide. Fingolimod acts via the sphingosine 1-phosphate (S1P) receptor, maintaining peripheral lymphocytes entrapped in the lymph nodes. In consequence, there is a reduction in the infiltration of aggressive lymphocytes into the central nervous system. The drug is safe and effective, and its first hours of use are associated with related to S1P receptors in the heart. This side effect is well known by all doctors prescribing fingolimod. However, the drug has other potential adverse events that, although relatively rare, require awareness from the neurologist. Among these there are infections (herpes simplex, herpes zoster, Cryptococcus, Epstein-Barr virus, hepatitis, Molluscum Contagiosum, and leishmaniosis), lung and thyroid complications, refractory headaches, encephalopathy, vasculopathy, tumefactive lesions in magnetic resonance imaging and ophthalmological disorders. The present review lists the non-cardiologic adverse events that all neurologists prescribing fingolimod should be aware of.
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12
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Pardo G, Jones DE. The sequence of disease-modifying therapies in relapsing multiple sclerosis: safety and immunologic considerations. J Neurol 2017; 264:2351-2374. [PMID: 28879412 PMCID: PMC5688209 DOI: 10.1007/s00415-017-8594-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/11/2017] [Accepted: 08/12/2017] [Indexed: 12/18/2022]
Abstract
The treatment landscape for relapsing forms of multiple sclerosis (RMS) has expanded considerably over the last 10 years with the approval of multiple new disease-modifying therapies (DMTs), and others in late-stage clinical development. All DMTs for RMS are believed to reduce central nervous system immune-mediated inflammatory processes, which translate into demonstrable improvement in clinical and radiologic outcomes. However, some DMTs are associated with long-lasting effects on the immune system and/or serious adverse events, both of which may complicate the use of subsequent therapies. When customizing a treatment program, a benefit–risk assessment must consider multiple factors, including the efficacy of the DMT to reduce disease activity, the short- and long-term safety and immunologic profiles of each DMT, the criteria used to define switching treatment, and the risk tolerance of each patient. A comprehensive benefit–risk assessment can only be achieved by evaluating the immunologic, safety, and efficacy data for DMTs in the controlled clinical trial environment and the postmarketing clinical practice setting. This review is intended to help neurologists make informed decisions when treating RMS by summarizing the known data for each DMT and raising awareness of the multiple considerations involved in treating people with RMS throughout the entire course of their disease.
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Affiliation(s)
- Gabriel Pardo
- OMRF Multiple Sclerosis Center of Excellence, Oklahoma Medical Research Foundation, 820 NE 15th Street, Oklahoma City, OK, 73104, USA.
| | - David E Jones
- Department of Neurology, University of Virginia School of Medicine, PO Box 800394, Charlottesville, VA, 22908, USA
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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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14
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Belova AN, Rasteryaeva MV, Zhulina NI, Belova EM, Boyko AN. [Immune reconstitution inflammatory syndrome and rebound syndrome in multiple sclerosis patients who stopped disease modification therapy: current understanding and a case report]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:74-84. [PMID: 28617365 DOI: 10.17116/jnevro20171172274-84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
More and more multiple sclerosis patients have been receiving treatment with new immunomodulatory drugs. Its discontinuation because of side-effects, lack of efficacy or pregnancy has been increasing as well. This paper reviews such severe complications of natalizumab and fingolimod cessation as immune reconstitution inflammatory syndrome (IRIS) and rebound. The short history, immunopathogenesis and diagnostic criteria of IRIS in individuals with human immunodeficiency virus infection are covered. Clinical and radiological presentations as well as possible pathogenic mechanisms of IRIS in patients treated with natalizumab and fingolimod are discussed. The authors also report the case of a woman with multiple sclerosis treated with fingolimod, who experienced a severe relapse when she stopped treatment. Diagnostic criteria and prognostic factors for IRIS and rebound are needed in patients with multiple sclerosis who discontinue the new disease modification therapy.
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Affiliation(s)
- A N Belova
- Privolzskyi Federal Medical Research Center, Nizhny Novgorod, Russia
| | - M V Rasteryaeva
- Privolzskyi Federal Medical Research Center, Nizhny Novgorod, Russia
| | - N I Zhulina
- Nizhny Novgorod State Medical Academy, Nizhny Novgorod, Russia
| | - E M Belova
- Nizhny Novgorod State Medical Academy, Nizhny Novgorod, Russia
| | - A N Boyko
- Pirogov National Russian Scientific Medical University, Moscow, Russia ,Center for demyelination diseases 'Neuroclinic', Moscow, Russia
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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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Grigoriadis N, Linnebank M, Alexandri N, Muehl S, Hofbauer GFL. Considerations on long-term immuno-intervention in the treatment of multiple sclerosis: an expert opinion. Expert Opin Pharmacother 2016; 17:2085-95. [PMID: 27594523 DOI: 10.1080/14656566.2016.1232712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION As management of multiple sclerosis (MS) requires life-long treatment with disease-modifying agents, any risks associated with long-term use should be considered when evaluating therapeutic options. AREAS COVERED Immune cells of the innate and adaptive immune systems play various roles in the pathogenesis of MS. MS therapies affect the immune system, each with a unique mode of action, and consequently possess different long-term safety profiles. Rare, but serious safety concerns, including an increased risk of infection and cancer, have been associated with immunosuppressant use. The risks associated with newer immunosuppressive agents, which target specific elements of MS disease pathophysiology, are not yet fully established as the duration of clinical trials is relatively short and post-marketing experience is limited. Non-immunosuppressants used to treat MS have well-defined safety profiles established over a large number of patient-years demonstrating them to be well-tolerated long-term treatment options. When considering the long-term use of disease-modifying agents for treating MS, classification as immunosuppressants or non-immunosuppressants can be useful when evaluating potential risks associated with chronic use. EXPERT OPINION A successful therapeutic strategy for any serious, chronic disease such as MS should weigh effectiveness versus long-term safety of available treatments.
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Affiliation(s)
- Nikolaos Grigoriadis
- a B' Department of Neurology, Laboratory of Experimental Neurology and Neuroimmunology , AHEPA University Hospital, Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Michael Linnebank
- b Klinik für Neurologie Universitätsspital Zürich , Zürich , Switzerland.,c Department of Neurology , Helios-Klinik, Hagen-Ambrock , Hagen , Germany
| | | | - Sarah Muehl
- e Merck (Schweiz) AG, Zug, Switzerland, a subsidiary of Merck KGaA Darmstadt , Germany
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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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Dramatic recovery of steroid-refractory relapsed multiple sclerosis following Fingolimod discontinuation using selective immune adsorption. BMC Neurol 2015; 15:125. [PMID: 26227815 PMCID: PMC4521477 DOI: 10.1186/s12883-015-0377-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 07/10/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Selective immune adsorption (SIA) is an emerging method for treating immune-mediated neurological diseases, given its superior safety profile compared to plasma exchange (PEX). However, the available literature concerning Multiple Sclerosis includes no cases of SIA applied to steroid-refractory rebound after Fingolimod discontinuation. CASE PRESENTATION Here we report the case of a 32-year-old woman suffering from multiple sclerosis treated with Fingolimod and admitted to a Multiple Sclerosis Centre after drug discontinuation due to the occurrence of lymphopenia. During the few weeks preceding admission, the patient experienced progressive and severe neurological deterioration that did not respond to an initial cycle of pulsed high doses of intravenous 6-methyl prednisolone (IVMP). Given the ineffectiveness of a second cycle of IVMP, the patient was treated with plasma immunoadsorption, leading to dramatic functional recovery. The patient then started a neuro-rehabilitation program. About one month after the final SIA procedure the patient started Natalizumab-based therapy, while maintaining a stable neurological condition. We noted significant modification of C3/C4 complement components and total gamma globulin concentrations (IgG) during SIA. CONCLUSIONS Our observations show that however serious, steroid-refractory neurological deterioration occurring after Fingolimod discontinuation in multiple sclerosis can be treated with selective immune-adsorption therapy which thus represents a good alternative in these cases. It could be speculated that this clinical condition was associated with pattern II of demyelination, given the good response to a form of treatment that acts on autoantibodies. Thus, SIA represented an effective therapeutic strategy for this case of relapsed MS as steroid-resistent rebound post Fingolimod cessation.
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