1
|
Myeloid disorders after autoimmune disease. Best Pract Res Clin Haematol 2019; 32:74-88. [PMID: 30927978 DOI: 10.1016/j.beha.2019.02.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/02/2019] [Accepted: 02/06/2019] [Indexed: 12/14/2022]
Abstract
Autoimmune diseases (ADs) are associated with an increased risk not only of lymphoproliferative disorders but also of myeloid malignancies. The excess risk of myelodysplastic syndromes and/or acute myeloid leukemia is observed across several AD types, including systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disorders, multiple sclerosis, among others. The risk of developing myeloid neoplasms (MNs) is dependent on several variables, including the specific AD type, chronicity and severity of the AD, type and duration of exposure of disease modifying anti-rheumatic drugs or cytotoxics/immunosuppressives, and genetic predisposition risk. Putative triggering factors linking AD to elevated MN risk include AD-directed medications, shared genetic susceptibilities between the two disease entities, and chronic immune stimulation or bone marrow infiltration by the AD. Molecular mechanisms underpinning leukemogenesis remain largely speculative and warrant further investigation. Leukemias arising in patients with AD are not always 'therapy-related' in that MNs may develop in certain AD subtypes even among patients with no prior therapy exposure. Only a few studies have attempted to determine factors associated with MN development in AD but failed to demonstrate consistent characteristic clinical or paraclinical features. These reports have failed to demonstrate a clear correlation between individual agent exposure and subsequent leukemia development due to the low rates of therapy exposure compounded by the rarity of MN occurrence. Notwithstanding, the leukemogenic potential is best documented with agents such as azathioprine, cyclophosphamide, and mitoxantrone; this risk of MN development does not appear to be shared by biologic approaches such as anti-tumor necrosis factors-alpha inhibitors. In this article, we discuss plausible biologic mechanisms underlying MN pathogenesis in AD and review the data available on the development of MNs in patients with AD.
Collapse
|
2
|
Fernández Ó. Is there a change of paradigm towards more effective treatment early in the course of apparent high-risk MS? Mult Scler Relat Disord 2017; 17:75-83. [DOI: 10.1016/j.msard.2017.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 06/26/2017] [Accepted: 07/02/2017] [Indexed: 01/02/2023]
|
3
|
D’Amico E, Zanghì A, Patti F. Can new chemical therapies improve the management of multiple sclerosis in children? Expert Opin Pharmacother 2016; 18:45-55. [DOI: 10.1080/14656566.2016.1267139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Emanuele D’Amico
- Department of Neurosciences G.F. Ingrassia, University of Catania, Catania, Italy
| | - Aurora Zanghì
- Department of Neurosciences G.F. Ingrassia, University of Catania, Catania, Italy
| | - Francesco Patti
- Department of Neurosciences G.F. Ingrassia, University of Catania, Catania, Italy
| |
Collapse
|
4
|
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.
Collapse
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
| | | |
Collapse
|
5
|
Giri S, Pathak R, Martin MG, Bhatt VR. Survival of de novo and secondary acute promyelocytic leukemia: a propensity-matched analysis of the SEER database. Leuk Lymphoma 2015; 57:385-391. [PMID: 26084205 DOI: 10.3109/10428194.2015.1063142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Prior studies demonstrated that secondary acute promyelocytic leukemia (sAPL) and de novo APL may but not consistently have similar overall survival (OS). We used the Surveillance, Epidemiology, and End Results (SEER) 13 database to compare their OS. Patients with sAPL (n = 90), compared to de novo APL (n = 1600), were more likely to be older, White and diagnosed after year 2005. Mortality rate at 1 month (28.9% vs. 23.0%, p = 0.20) and 5-year OS (42% vs. 50%, p = 0.24) was similar between sAPL and de novo APL. In a multivariate analysis, sAPL was associated with similar OS as de novo APL (hazard ratio, HR 1.11; 95% confidence interval, CI 0.78-1.58; p = 0.546). This population-based study demonstrated no difference in OS or early mortality rate between sAPL and de novo APL. sAPL can be managed very similarly to de novo APL and does not need to be excluded from clinical trials of APL.
Collapse
Affiliation(s)
- Smith Giri
- a Department of Medicine , University of Tennessee Health Science Center , Memphis , TN , USA
| | - Ranjan Pathak
- b Department of Medicine , Reading Health System , Reading , PA , USA
| | - Mike G Martin
- a Department of Medicine , University of Tennessee Health Science Center , Memphis , TN , USA
| | - Vijaya Raj Bhatt
- c University of Nebraska Medical Center , Department of Internal Medicine, Division of Hematology-Oncology , Omaha, Nebraska , USA
| |
Collapse
|
6
|
Zhang L, Samad A, Pombo-de-Oliveira MS, Scelo G, Smith MT, Feusner J, Wiemels JL, Metayer C. Global characteristics of childhood acute promyelocytic leukemia. Blood Rev 2015; 29:101-25. [PMID: 25445717 PMCID: PMC4379131 DOI: 10.1016/j.blre.2014.09.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/21/2014] [Accepted: 09/23/2014] [Indexed: 12/29/2022]
Abstract
Acute promyelocytic leukemia (APL) comprises approximately 5-10% of childhood acute myeloid leukemia (AML) cases in the US. While variation in this percentage among other populations was noted previously, global patterns of childhood APL have not been thoroughly characterized. In this comprehensive review of childhood APL, we examined its geographic pattern and the potential contribution of environmental factors to observed variation. In 142 studies (spanning >60 countries) identified, variation was apparent-de novo APL represented from 2% (Switzerland) to >50% (Nicaragua) of childhood AML in different geographic regions. Because a limited number of previous studies addressed specific environmental exposures that potentially underlie childhood APL development, we gathered 28 childhood cases of therapy-related APL, which exemplified associations between prior exposures to chemotherapeutic drugs/radiation and APL diagnosis. Future population-based studies examining childhood APL patterns and the potential association with specific environmental exposures and other risk factors are needed.
Collapse
Affiliation(s)
- L Zhang
- School of Public Health, University of California, Berkeley, USA.
| | - A Samad
- School of Public Health, University of California, Berkeley, USA.
| | - M S Pombo-de-Oliveira
- Pediatric Hematology-Oncology Program, Research Center-National Institute of Cancer, Rio de Janeiro, Brazil.
| | - G Scelo
- International Agency for Research on Cancer (IARC), Lyon, France.
| | - M T Smith
- School of Public Health, University of California, Berkeley, USA.
| | - J Feusner
- Department of Hematology, Children's Hospital and Research Center Oakland, Oakland, USA.
| | - J L Wiemels
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA.
| | - C Metayer
- School of Public Health, University of California, Berkeley, USA.
| |
Collapse
|
7
|
Hsu JL, Liu SP, Lee CC, Hsu LC, Ho YF, Huang HS, Guh JH. A unique amidoanthraquinone derivative displays antiproliferative activity against human hormone-refractory metastatic prostate cancers through activation of LKB1-AMPK-mTOR signaling pathway. Naunyn Schmiedebergs Arch Pharmacol 2014; 387:979-90. [DOI: 10.1007/s00210-014-0998-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/22/2014] [Indexed: 12/21/2022]
|
8
|
Lin TH, Kim JH, Perez-Torres C, Chiang CW, Trinkaus K, Cross AH, Song SK. Axonal transport rate decreased at the onset of optic neuritis in EAE mice. Neuroimage 2014; 100:244-53. [PMID: 24936685 DOI: 10.1016/j.neuroimage.2014.06.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 05/30/2014] [Accepted: 06/03/2014] [Indexed: 12/21/2022] Open
Abstract
Optic neuritis is frequently the first symptom of multiple sclerosis (MS), an inflammatory demyelinating neurodegenerative disease. Impaired axonal transport has been considered as an early event of neurodegenerative diseases. However, few studies have assessed the integrity of axonal transport in MS or its animal models. We hypothesize that axonal transport impairment occurs at the onset of optic neuritis in experimental autoimmune encephalomyelitis (EAE) mice. In this study, we employed manganese-enhanced MRI (MEMRI) to assess axonal transport in optic nerves in EAE mice at the onset of optic neuritis. Axonal transport was assessed as (a) optic nerve Mn(2+) accumulation rate (in % signal change/h) by measuring the rate of increased total optic nerve signal enhancement, and (b) Mn(2+) transport rate (in mm/h) by measuring the rate of change in optic nerve length enhanced by Mn(2+). Compared to sham-treated healthy mice, Mn(2+) accumulation rate was significantly decreased by 19% and 38% for EAE mice with moderate and severe optic neuritis, respectively. The axonal transport rate of Mn(2+) was significantly decreased by 43% and 65% for EAE mice with moderate and severe optic neuritis, respectively. The degree of axonal transport deficit correlated with the extent of impaired visual function and diminished microtubule-associated tubulins, as well as the severity of inflammation, demyelination, and axonal injury at the onset of optic neuritis.
Collapse
Affiliation(s)
- Tsen-Hsuan Lin
- Department of Physics, Washington University, St. Louis, MO 63130, USA
| | - Joong Hee Kim
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Carlos Perez-Torres
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Chia-Wen Chiang
- Department of Chemistry, Washington University, St. Louis, MO 63130, USA
| | - Kathryn Trinkaus
- Divison of Biostatistics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Anne H Cross
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Sheng-Kwei Song
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO 63110, USA.
| |
Collapse
|
9
|
Salmen A, Gold R, Chan A. Management of disease-modifying treatments in neurological autoimmune diseases of the central nervous system. Clin Exp Immunol 2014; 176:135-48. [PMID: 24358961 PMCID: PMC3992026 DOI: 10.1111/cei.12258] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2013] [Indexed: 12/19/2022] Open
Abstract
The therapeutic armamentarium for autoimmune diseases of the central nervous system, specifically multiple sclerosis and neuromyelitis optica, is steadily increasing, with a large spectrum of immunomodulatory and immunosuppressive agents targeting different mechanisms of the immune system. However, increasingly efficacious treatment options also entail higher potential for severe adverse drug reactions. Especially in cases failing first-line treatment, thorough evaluation of the risk-benefit profile of treatment alternatives is necessary. This argues for the need of algorithms to identify patients more likely to benefit from a specific treatment. Moreover, paradigms to stratify the risk for severe adverse drug reactions need to be established. In addition to clinical/paraclinical measures, biomarkers may aid in individualized risk-benefit assessment. A recent example is the routine testing for anti-John Cunningham virus antibodies in natalizumab-treated multiple sclerosis patients to assess the risk for the development of progressive multi-focal leucoencephalopathy. Refined algorithms for individualized risk assessment may also facilitate early initiation of induction treatment schemes in patient groups with high disease activity rather than classical escalation concepts. In this review, we will discuss approaches for individiualized risk-benefit assessment both for newly introduced agents as well as medications with established side-effect profiles. In addition to clinical parameters, we will also focus on biomarkers that may assist in patient selection.
Collapse
Affiliation(s)
- A Salmen
- Department of Neurology, St Josef-Hospital, Ruhr-University, Bochum, Germany
| | | | | |
Collapse
|
10
|
Abstract
Therapy-related myelodysplastic syndrome (t-MDS) and therapy-related acute myeloid leukemia (t-AML) are late complications of cytotoxic therapies used to treat malignant, and increasingly, non-malignant conditions. Although distinct clinical, morphologic, and genetic features can be recognized, these disorders should be seen as part of a single disease spectrum recognized by the WHO in a singular classification, therapy-related myeloid neoplasms (t-MNs). Etiologic factors for t-MNs remain elusive, but ongoing research has characterized risk factors which vary between patient subgroups and exposures. Agents that damage DNA directly, interfere with DNA repair, and suppress the immune system's ability to detect malignant cells increase the risk of t-MNs. As in primary MDS and de novo AML, prognosis and treatment strategies rely on patient characteristics as well as cytogenetics. However, the overall outcome for patients with t-MNs remains poor. Here we review our current understanding of t-MNs as they are most often encountered by the practicing clinician.
Collapse
MESH Headings
- DNA Damage
- DNA Repair/drug effects
- Humans
- Immunosuppressive Agents/adverse effects
- Immunosuppressive Agents/therapeutic use
- Leukemia, Myeloid, Acute/chemically induced
- Leukemia, Myeloid, Acute/classification
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Myelodysplastic Syndromes/chemically induced
- Myelodysplastic Syndromes/mortality
- Myelodysplastic Syndromes/pathology
- Myelodysplastic Syndromes/therapy
- Neoplasms, Second Primary/mortality
- Neoplasms, Second Primary/pathology
- Neoplasms, Second Primary/therapy
Collapse
Affiliation(s)
- Jane E Churpek
- Section of Hematology Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA; Center for Clinical Cancer Genetics, The University of Chicago, Chicago, IL, USA.
| | - Richard A Larson
- Section of Hematology Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA; Comprehensive Cancer Center, The University of Chicago, Chicago, IL, USA.
| |
Collapse
|
11
|
Rivera VM, Jeffery DR, Weinstock-Guttman B, Bock D, Dangond F. Results from the 5-year, phase IV RENEW (Registry to Evaluate Novantrone Effects in Worsening Multiple Sclerosis) study. BMC Neurol 2013; 13:80. [PMID: 23841877 PMCID: PMC3710498 DOI: 10.1186/1471-2377-13-80] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 07/01/2013] [Indexed: 12/22/2022] Open
Abstract
Background Registry to Evaluate Novantrone Effects in Worsening Multiple Sclerosis (RENEW) was a 5-year, phase IV study in which the safety of Mitoxantrone was monitored in a patient cohort from the United States (US). The objective of the study was to evaluate the long-term safety profile of Mitoxantrone in patients with secondary progressive multiple sclerosis (SPMS), progressive relapsing multiple sclerosis (PRMS), and worsening relapsing-remitting multiple sclerosis (RRMS). Methods Overall, 509 patients (395 SPMS, 81 worsening RRMS, 33 PRMS) were enrolled and treated at 46 multiple sclerosis (MS) treatment centers located in the US. Patients received Mitoxantrone in accordance with the package insert every 3 months. During the treatment phase, patients received laboratory workups and cardiac monitoring every 3 months and then annually for a total of 5 years. Results Five hundred and nine subjects were enrolled in this trial and received at least one infusion of Mitoxantrone. Overall, 172 (33.8%) completed the 5-year trial (i.e., participated for 5 years ± 3 months [treatment + follow-up]); 337 (66.2%) did not complete the 5-year trial. Annual follow-up data were available for 250 of 509 enrolled patients. Left ventricular ejection fraction reduction under 50% was reported in 27 (5.3%) patients during the treatment phase (n = 509) and 14 (5.6%) patients during the annual follow-up phase (n = 250). Signs and symptoms of congestive heart failure were observed in 10 (2.0%) patients (six during treatment phase and four during the annual follow-up phase). Post-hoc analyses of the risk for cardiotoxicity outcomes revealed that cumulative dose exposure is the primary risk factor associated with the risk of cardiac toxicity with Mitoxantrone. Therapy-related leukemia was reported in three (0.6%) patients who received total cumulative Mitoxantrone doses of 73.5 mg/m2, 107.3 mg/m2, and 97.1 mg/m2 respectively. During the treatment phase, persistent amenorrhea developed in 22% (28/128) of women with regular menses and 51% (25/49) of women with irregular menses at baseline. During the annual follow-up phase, persistent amenorrhea developed in 5% (4/73) of women with regular menses at baseline. Conclusion RENEW results are consistent with the known safety profile of Mitoxantrone, and provide additional long-term safety data for Mitoxantrone in MS patients.
Collapse
|
12
|
Lugaresi A, di Ioia M, Travaglini D, Pietrolongo E, Pucci E, Onofrj M. Risk-benefit considerations in the treatment of relapsing-remitting multiple sclerosis. Neuropsychiatr Dis Treat 2013; 9:893-914. [PMID: 23836975 PMCID: PMC3699254 DOI: 10.2147/ndt.s45144] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system and mainly affects young adults. Its natural history has changed in recent years with the advent of disease-modifying drugs, which have been available since the early 1990s. The increasing number of first-line and second-line treatment options, together with the variable course of the disease and patient lifestyles and expectations, makes the therapeutic decision a real challenge. The aim of this review is to give a comprehensive overview of the main present and some future drugs for relapsing-remitting MS, including risk-benefit considerations, to enable readers to draw their own conclusions regarding the risk-benefit assessment of personalized treatment strategies, taking into account not only treatment-related but also disease-related risks. We performed a Medline literature search to identify studies on the treatment of MS with risk stratification and risk-benefit considerations. We focused our attention on studies of disease-modifying, immunomodulating, and immunosuppressive drugs, including monoclonal antibodies. Here we offer personal considerations, stemming from long-term experience in the treatment of MS and thorough discussions with other neurologists closely involved in the care of patients with the disease. MS specialists need to know not only the specific risks and benefits of single drugs, but also about drug interactions, either in simultaneous or serial combination therapy, and patient comorbidities, preferences, and fears. This has to be put into perspective, considering also the risks of untreated disease in patients with different clinical and radiological characteristics. There is no single best treatment strategy, but therapy has to be tailored to the patient. This is a time-consuming task, rich in complexity, and influenced by the attitude towards risk on the parts of both the patient and the clinical team. The broader the MS drug market becomes, the harder it will be for the clinician to help the patient decide which therapeutic strategy to opt for.
Collapse
Affiliation(s)
- Alessandra Lugaresi
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Maria di Ioia
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Daniela Travaglini
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Erika Pietrolongo
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Eugenio Pucci
- Operative Unit Neurologia ASUR Marche Area Vasta 3, Macerata, Italy
| | - Marco Onofrj
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| |
Collapse
|
13
|
Rashidi A, Fisher SI. Therapy-related acute promyelocytic leukemia: a systematic review. Med Oncol 2013; 30:625. [DOI: 10.1007/s12032-013-0625-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 06/03/2013] [Indexed: 12/20/2022]
|
14
|
Abstract
Prevention of disability through disease-modifying therapies has been a source of significant attention among clinicians treating children and adolescents with multiple sclerosis (MS). In this article, we will review currently available literature on therapies and the management of pediatric-onset multiple sclerosis, with specific discussion of therapies for acute exacerbations and disease-modifying therapies that may prevent relapses and slow disease progression, and will include a brief discussion of future directions in symptomatic interventions for cognitive decline, fatigue, and depression in children and adolescents with multiple sclerosis. Our article will focus specifically on children and adolescents with relapsing-remitting multiple sclerosis, as 99% of cases of pediatric-onset multiple sclerosis are relapsing-remitting multiple sclerosis.
Collapse
Affiliation(s)
- E Ann Yeh
- Demyelinating Disorders Program, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
| | | |
Collapse
|
15
|
Hofmann A, Stellmann JP, Kasper J, Ufer F, Elias WG, Pauly I, Repenthin J, Rosenkranz T, Weber T, Köpke S, Heesen C. Long-term treatment risks in multiple sclerosis: risk knowledge and risk perception in a large cohort of mitoxantrone-treated patients. Mult Scler 2012; 19:920-5. [DOI: 10.1177/1352458512461967] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Balancing treatment benefits and risks is part of a shared decision-making process before initiating any treatment in multiple sclerosis (MS). Patients understand, appreciate and profit from evidence-based patient information (EBPI). While these processes are well known, long-term risk awareness and risk processing of patients has not been studied. Mitoxantrone treatment in MS is associated with long-term major potential harms – leukaemia (LK) and cardiotoxicity (CT). The risk knowledge and perception among patients currently or previously treated with mitoxantrone is unknown. Objectives: The objective of this article is to conduct a retrospective cohort study in greater Hamburg, Germany, to estimate risk awareness and perception in MS patients treated with mitoxantrone. Methods: MS patients with at least one dose of mitoxantrone between 1991 and 2010 from six major MS centres in greater Hamburg received a questionnaire assessing risk awareness and perception as well as a written EBPI about mitoxantrone-associated LK and CT. Results: Fifty-one per cent in the cohort of n = 575 patients returned the questionnaire. Forty per cent correctly estimated the risk of LK (CT 16%); 56% underestimated the risk (CT 82%). Reading the information increased the accuracy of LK risk estimation, and patients did not report an increase of worries. The EBPI was appreciated and recommended by 85%. Conclusion: Risk awareness of mitoxantrone-treated patients is insufficient, but can be increased by EBPI without increasing worries. Continued patient information during and after treatment should be implemented in management algorithms.
Collapse
Affiliation(s)
- A Hofmann
- Institute for Neuroimmunology and Clinical MS Research (INIMS) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - JP Stellmann
- Institute for Neuroimmunology and Clinical MS Research (INIMS) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - J Kasper
- Institute for Neuroimmunology and Clinical MS Research (INIMS) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
- Department of Primary Medical Care, University Medical Center Hamburg, Germany
- Unit of Health Science and Education, University of Hamburg, Germany
| | - F Ufer
- Institute for Neuroimmunology and Clinical MS Research (INIMS) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | | | - I Pauly
- Department of Neurology, Asklepios Klinik Nord, Germany
| | - J Repenthin
- Department of Neurology, Asklepios Klinik Barmbek, Germany
| | - T Rosenkranz
- Department of Neurology, Asklepios Klinik St. Georg, Germany
| | - T Weber
- Department of Neurology, Marienkrankenhaus, Germany
| | - S Köpke
- Institute for Neuroimmunology and Clinical MS Research (INIMS) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
- Nursing Research Group, Institute for Social Medicine, University of Lübeck, Germany
| | - C Heesen
- Institute for Neuroimmunology and Clinical MS Research (INIMS) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | | |
Collapse
|
16
|
Mitoxantrone induces natural killer cell maturation in patients with secondary progressive multiple sclerosis. PLoS One 2012; 7:e39625. [PMID: 22768101 PMCID: PMC3387260 DOI: 10.1371/journal.pone.0039625] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 05/29/2012] [Indexed: 12/01/2022] Open
Abstract
Mitoxantrone is one of the few drugs approved for the treatment of progressive multiple sclerosis (MS). However, the prolonged use of this potent immunosuppressive agent is limited by the appearance of severe side effects. Apart from its general cytotoxic effect, the mode of action of mitoxantrone on the immune system is poorly understood. Thus, to develop safe therapeutic approaches for patients with progressive MS, it is essential to elucidate how mitoxantrone exerts it benefits. Accordingly, we initiated a prospective single-arm open-label study with 19 secondary progressive MS patients. We investigated long-term effects of mitoxantrone on patient peripheral immune subsets using flow cytometry. While we corroborate that mitoxantrone persistently suppresses B cells in vivo, we show for the first time that treatment led to an enrichment of neutrophils and immunomodulatory CD8low T cells. Moreover, sustained mitoxantrone applications promoted not only persistent NK cell enrichment but also NK cell maturation. Importantly, this mitoxantrone-induced NK cell maturation was seen only in patients that showed a clinical response to treatment. Our data emphasize the complex immunomodulatory role of mitoxantrone, which may account for its benefit in MS. In particular, these results highlight the contribution of NK cells to mitoxantrone efficacy in progressive MS.
Collapse
|
17
|
Tur C, Tintoré M, Aguilera C. [Disease modifying drugs in multiple sclerosis and pregnancy]. Med Clin (Barc) 2012; 139:316-8. [PMID: 22743277 DOI: 10.1016/j.medcli.2012.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/17/2012] [Accepted: 04/19/2012] [Indexed: 11/17/2022]
Affiliation(s)
- Carmen Tur
- Centre d'Esclerosi Múltiple de Catalunya (CEM-Cat), Unitat de Neuroimmunologia Clínica, Servei de Neurologia, Hospital Vall d'Hebron, Barcelona, España.
| | | | | |
Collapse
|
18
|
Abstract
Pediatric onset multiple sclerosis (MS) may be seen in 2-5% of patients with MS. It is characterized by high disease burden. As such, early treatment with preventative therapies should be considered. Although randomized controlled trials have not been conducted on therapies for pediatric MS, there is a growing body of literature suggesting safety of first-line agents approved for use in adult MS, including interferons and glatiramer acetate. The use of second-line therapies, such as natalizumab, cyclophosphamide, and mitoxantrone has been described in a small number of pediatric MS cases. These case series suggest benefit of these agents after limited follow-up. Little information on long-term effects of therapies such as cyclophosphamide, mitoxantrone, or natalizumab is available for this population, although concerns of increased risk for opportunistic infections (progressive multifocal leukoencephalopathy with natalizumab) and secondary hematologic cancers (with mitoxantrone) exist. Finally, although fatigue, motor, cognitive, and psychosocial difficulties are common in this population, no trials have been conducted on pharmacologic or non-pharmacologic interventions for the management of these problems. Therapies for spasticity, including baclofen (including the baclofen pump), diazepam, and botulinum toxin have been evaluated in children with cerebral palsy and may be used safely in children. Psychiatric intervention is often necessary for affective disorders. Interventions for fatigue have not been studied, although evidence in the adult MS literature suggests possible benefit of exercise and modafinil. This article provides a practical guide to the diagnosis and treatment of multiple sclerosis in pediatric patients.
Collapse
Affiliation(s)
- E Ann Yeh
- Department of Pediatrics (Neurology), University of Toronto, ON, Canada.
| |
Collapse
|
19
|
Stroet A, Hemmelmann C, Starck M, Zettl U, Dörr J, Friedemann P, Paul F, Flachenecker P, Fleischer V, Zipp F, Nückel H, Kieseier BC, Ziegler A, Gold R, Chan A. Incidence of therapy-related acute leukaemia in mitoxantrone-treated multiple sclerosis patients in Germany. Ther Adv Neurol Disord 2012; 5:75-9. [PMID: 22435072 PMCID: PMC3302202 DOI: 10.1177/1756285611433318] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The incidence of therapy-related acute leukaemia (TRAL) in mitoxantrone treatment in multiple sclerosis (MS) is controversially discussed. METHODS AND RESULTS In a retrospective meta-analysis from six centres, we observed six cases of acute myeloid leukaemia (AML) (incidence 0.41% for patients with mean follow up after end of treatment of 3.6 years, n = 1.156; incidence 0.25% for all patients, n = 2.261). Potential influencing factors such as myelotoxic or glucocorticosteroid pretreatment/cotreatment were present in all but one case of TRAL. Between 1990 and 2010, 11 cases of TRAL were reported to the Drug Commission of the German Medical Association (estimated risk of 0.09-0.13%). CONCLUSIONS Regional differences in reported TRAL incidence may point to confounding cofactors such as administration protocols and cotreatments.
Collapse
|
20
|
Duffield AS, Aoki J, Levis M, Cowan K, Gocke CD, Burns KH, Borowitz MJ, Vuica-Ross M. Clinical and pathologic features of secondary acute promyelocytic leukemia. Am J Clin Pathol 2012; 137:395-402. [PMID: 22338051 DOI: 10.1309/ajcpe0mv0ytwluue] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is a relatively common form of acute myeloid leukemia (AML) that has an excellent prognosis. In contrast, secondary acute myeloid leukemias, including therapy-related AML and AML with myelodysplasia-related changes, have a relatively poor prognosis. We identified 9 cases of APL at our institution in which there was a history of chemotherapy, radiotherapy, chronic immunosuppression, or antecedent myelodysplastic syndrome. The clinical and pathologic findings in these cases of secondary APL were compared with the clinical and pathologic findings in cases of de novo APL. We found that secondary and de novo APL had abnormal promyelocytes with similar morphologic and immunophenotypic features, comparable cytogenetic findings, comparable rates of FMS-like tyrosine kinase mutations, and similar rates of recurrent disease and death. These data suggest that secondary APL is similar to de novo APL and, thus, should be considered distinct from other secondary acute myeloid neoplasms.
Collapse
|
21
|
Colovic N, Suvajdzic N, Kraguljac Kurtovic N, Djordjevic V, Dencic Fekete M, Drulovic J, Vidovic A, Tomin D. Therapy-related acute leukemia in two patients with multiple sclerosis treated with Mitoxantrone. Biomed Pharmacother 2011; 66:173-4. [PMID: 22440894 DOI: 10.1016/j.biopha.2011.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 10/31/2011] [Indexed: 11/19/2022] Open
Abstract
Two cases of therapy-related acute leukemia (TRAL) after the use of Mitoxantrone for the treatment of secondary progressive multiple sclerosis (MS) are reported. They were extracted from the group of 42 consecutive patients with TRAL diagnosed and treated in single centre between 2000-2010. They were the only two with MS and the only two treated with Mitoxantrone. The first patient was a 43-year-old male with a previous history of MS of 15-year-duration, who developed acute promyelocytic leukemia 9 months following Mitoxantrone therapy (cumulative dose 120 mg). The second patient was a 55-year-old female suffering from MS for 16 years, who developed acute mixed-phenotype leukemia, T/myeloid type, with 46,XX,del(7)(p13)[12]/47,XX,idem,+3/[6]/46,XX[2], 15 months after completion of Mitoxantrone therapy (cumulative dose 100mg). Acute mixed-phenotype leukemia, T/myeloid type is for the first time described in the context of prior Mitoxantrone therapy. Although the incidence of TRAL in relation to Mitoxantrone pretreatment is rare, we should be vigilant for the prompt identification of this adverse event.
Collapse
Affiliation(s)
- Natasa Colovic
- Faculty of Medicine, University of Belgrade, Dr Subotića 8, Belgrade, Serbia
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Ramadan SM, Fouad TM, Summa V, Hasan SK, Lo-Coco F. Acute myeloid leukemia developing in patients with autoimmune diseases. Haematologica 2011; 97:805-17. [PMID: 22180424 DOI: 10.3324/haematol.2011.056283] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Therapy-related acute myeloid leukemia is an unfortunate complication of cancer treatment, particularly for patients with highly curable primary malignancies and favorable life expectancy. The risk of developing therapy-related acute myeloid leukemia also applies to patients with non-malignant conditions, such as autoimmune diseases treated with cytotoxic and/or immunosuppressive agents. There is considerable evidence to suggest that there is an increased occurrence of hematologic malignancies in patients with autoimmune diseases compared to the general population, with a further increase in risk after exposure to cytotoxic therapies. Unfortunately, studies have failed to reveal a clear correlation between leukemia development and exposure to individual agents used for the treatment of autoimmune diseases. Given the dismal outcome of secondary acute myeloid leukemia and the wide range of available agents for treatment of autoimmune diseases, an increased awareness of this risk and further investigation into the pathogenetic mechanisms of acute leukemia in autoimmune disease patients are warranted. This article will review the data available on the development of acute myeloid leukemia in patients with autoimmune diseases. Possible leukemogeneic mechanisms in these patients, as well as evidence supporting the association of their primary immunosuppressive status and their exposure to specific therapies, will also be reviewed. This review also supports the idea that it may be misleading to label leukemias that develop in patients with autoimmune diseases who are exposed to cytotoxic agents as 'therapy-related leukemias'. A better understanding of the molecular defects in autoimmune disease patients who develop acute leukemia will lead to a better understanding of the association between these two diseases entities.
Collapse
Affiliation(s)
- Safaa M Ramadan
- Department of Medical Oncology, NCI-Cairo University, 11796 Cairo, Egypt.
| | | | | | | | | |
Collapse
|
23
|
Kiraly A, Koffman B, Hacker M, Gunning W, Rasche S, Quinn A. A novel aza-anthrapyrazole blocks the progression of experimental autoimmune encephalomyelitis after the priming of autoimmunity. Clin Immunol 2011; 141:304-16. [DOI: 10.1016/j.clim.2011.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Revised: 08/17/2011] [Accepted: 08/18/2011] [Indexed: 11/16/2022]
|
24
|
Abstract
OPINION STATEMENT Therapies for relapsing-remitting pediatric multiple sclerosis (MS) are aimed at preventing relapses (disease modifying therapies), treating acute attacks, and managing disabling cognitive and physical symptoms. Initial disease modifying therapy to prevent relapses should use one of four first-line injectable therapies that are approved for adult relapsing-remitting MS: interferon beta 1a IM, interferon beta 1a SC, interferon beta 1b SC, or glatiramer acetate. If breakthrough disease occurs or the medication is poorly tolerated, the next step should be to try one of the other first-line therapies. If the first-line therapies have been exhausted, second-line therapies such as natalizumab, cyclophosphamide, or mitoxantrone may be considered. One must use caution when choosing these potent therapies, as secondary effects may include serious infection or malignancy. Phase III studies in adult MS have been published on two oral agents, fingolimod and cladribine, and fingolimod has received FDA approval for use in relapsing-remitting MS in adults. These drugs have not been evaluated in the pediatric MS population, nor have any of three other oral agents now in phase III development: laquinimod, BG-12, and teriflunomide. Acute relapses can be treated with pulse methylprednisolone at a dosage of 20 to 30 mg/kg per day (maximum 1 g per day) for 3 to 5 days. If this is ineffective, intravenous immunoglobulin (2 g/kg divided over 2-5 days) or plasmapheresis may be considered. Neuropsychological, physical therapy, and occupational therapy screening should be performed on patients with pediatric MS. Interventions focusing on visual motor integration may be particularly useful in this group Spasticity may be treated with symptomatic therapies, but one must be aware of potential adverse effects of agents such as baclofen and diazepam. Headache, fatigue, anxiety, and depression are frequently seen, and patients may need a psychiatry consultation and counseling.
Collapse
|
25
|
Motlló C, Manuel Sancho J, García O, Granada I, Millá F, Ribera JM. Leucemias agudas secundarias a tratamiento con quimioterapia y/o radioterapia: estudio de 23 pacientes. Med Clin (Barc) 2011; 137:449-52. [DOI: 10.1016/j.medcli.2010.09.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 09/10/2010] [Accepted: 09/14/2010] [Indexed: 10/18/2022]
|
26
|
Hartung HP, Montalban X, Sorensen PS, Vermersch P, Olsson T. Principles of a new treatment algorithm in multiple sclerosis. Expert Rev Neurother 2011; 11:351-62. [PMID: 21375441 DOI: 10.1586/ern.11.15] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We are entering a new era in the management of patients with multiple sclerosis (MS). The first oral treatment (fingolimod) has now gained US FDA approval, addressing an unmet need for patients with MS who wish to avoid parenteral administration. A second agent (cladribine) is currently being considered for approval. With the arrival of these oral agents, a key question is where they may fit into the existing MS treatment algorithm. This article aims to help answer this question by analyzing the trial data for the new oral therapies, as well as for existing MS treatments, by applying practical clinical experience, and through consideration of our increased understanding of how to define treatment success in MS. This article also provides a speculative look at what the treatment algorithm may look like in 5 years, with the availability of new data, greater experience and, potentially, other novel agents.
Collapse
Affiliation(s)
- Hans-Peter Hartung
- Department of Neurology, Heinrich-Heine-University Medical School, Düsseldorf, Germany.
| | | | | | | | | |
Collapse
|
27
|
Krieger S. Multiple Sclerosis Therapeutic Pipeline: Opportunities and Challenges. ACTA ACUST UNITED AC 2011; 78:192-206. [DOI: 10.1002/msj.20241] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
28
|
Patti F, Lo Fermo S. Lights and shadows of cyclophosphamide in the treatment of multiple sclerosis. Autoimmune Dis 2011; 2011:961702. [PMID: 21547093 PMCID: PMC3087413 DOI: 10.4061/2011/961702] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 12/29/2010] [Accepted: 01/19/2011] [Indexed: 11/20/2022] Open
Abstract
Cyclophosphamide (cy) is an alkylating agent used to treat malignancies and immune-mediated inflammatory nonmalignant processes. It has been used as a treatment in cases of worsening multiple sclerosis (MS). Cy is currently used for patients whose disease is not controlled by beta-interferon or glatiramer acetate as well as those with rapidly worsening MS. The most commonly used regimens involve outpatient IV pulse therapy given with or without corticosteroids every 4 to 8 weeks. Side effects include nausea, headache, alopecia, pain, male and women infertility, bladder toxicity, and risk of malignancy. Previous studies suggest that cy is effective in patients in the earlier stages of disease, where inflammation predominates over degenerative processes. Given that early inflammatory events appear to correlate with later disability, a major question is whether strong anti-inflammatory drugs, such as cy, will have an impact on later degenerative changes if given early in the disease to halt inflammation.
Collapse
Affiliation(s)
- Francesco Patti
- Department of Neuroscience, University of Catania, Catania, Italy
| | | |
Collapse
|
29
|
Fernández O. Tratamiento oral con laquinimod en la esclerosis múltiple. Neurologia 2011; 26:111-7. [DOI: 10.1016/j.nrl.2010.07.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Accepted: 07/26/2010] [Indexed: 11/26/2022] Open
|
30
|
Banwell B, Bar-Or A, Giovannoni G, Dale RC, Tardieu M. Therapies for multiple sclerosis: considerations in the pediatric patient. Nat Rev Neurol 2011; 7:109-22. [PMID: 21224883 DOI: 10.1038/nrneurol.2010.198] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Current and emerging therapies for multiple sclerosis (MS) offer promise for improved disease control and long-term clinical outcome. To date, these therapies have been evaluated solely in the context of adult MS. However, onset of MS in children is being increasingly recognized, and recent studies have identified a significant impact of MS onset during childhood on cognitive and physical functioning. Optimization of pediatric MS care requires that promising new therapies be made available to children and adolescents, but also that safety and tolerability and potential influence of therapies on the developing immune and neural networks of pediatric patients be closely considered. We propose care algorithms illustrating models for therapy that detail careful monitoring of pediatric patients with MS, provide definitions for inadequate treatment response and treatment escalation, and foster multinational collaboration in future therapeutic trials.
Collapse
Affiliation(s)
- Brenda Banwell
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, ON, Canada.
| | | | | | | | | |
Collapse
|
31
|
Wipfler P, Harrer A, Pilz G, Oppermann K, Trinka E, Kraus J. Recent developments in approved and oral multiple sclerosis treatment and an update on future treatment options. Drug Discov Today 2011; 16:8-21. [DOI: 10.1016/j.drudis.2010.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 10/12/2010] [Accepted: 10/25/2010] [Indexed: 12/23/2022]
|
32
|
Fernández O. Oral laquinimod treatment in multiple sclerosis. NEUROLOGÍA (ENGLISH EDITION) 2011. [DOI: 10.1016/s2173-5808(11)70022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
|
33
|
Ammatuna E, Montesinos P, Hasan SK, Ramadan SM, Esteve J, Hubmann M, Pagoni M, Grimwade D, Sanz MA, Lo-Coco F. Presenting features and treatment outcome of acute promyelocytic leukemia arising after multiple sclerosis. Haematologica 2010; 96:621-5. [PMID: 21193421 DOI: 10.3324/haematol.2010.036657] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
We report the clinical features and treatment outcome of 33 patients with multiple sclerosis who developed acute promyelocytic leukemia. Thirty patients were previously exposed to mitoxantrone. The median latency period between treatment initiation and acute promyelocytic leukemia diagnosis was 32 months. The PML-RARA bcr1 iso-form was identified in 87% of cases. Twenty-nine (90%) patients achieved hematologic remission after all-trans retinoic acid and chemotherapy (n = 31) or arsenic trioxide and all-trans retinoic acid. Consolidation included modified chemotherapy or arsenic trioxide. At a median follow up of 26 months, 23 patients are in complete remission, 4 relapsed and one developed secondary leukemia. The 5-year cumulative incidence of relapse and overall survival were 23% and 68%, respectively. Although treatment heterogeneity and suboptimal post-remission therapy must be taken into account, overall results and development of secondary leukemia in one patient suggest that effective and less toxic agents like arsenic trioxide warrants further investigation in this context.
Collapse
|
34
|
Mitoxantrone for worsening multiple sclerosis: Tolerability, toxicity, adherence and efficacy in the clinical setting. Clin Neurol Neurosurg 2010; 112:876-82. [DOI: 10.1016/j.clineuro.2010.07.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2009] [Revised: 06/28/2010] [Accepted: 07/19/2010] [Indexed: 11/21/2022]
|
35
|
Meyer C, Ansorge N, Siglienti I, Salmen S, Stroet A, Nückel H, Dührsen U, Ritter PR, Schmidt WE, Gold R, Chan A. [Mitoxantrone-related acute leukemia by multiple sclerosis. Case report and practical approach by unclear cytopenia]. DER NERVENARZT 2010; 81:1483-9. [PMID: 21079910 DOI: 10.1007/s00115-010-3041-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Mitoxantrone is highly efficacious in the treatment of severe multiple sclerosis (MS). Mitoxantrone therapy-related acute leukemia (TRAL) has recently become the focus of interest. METHODS A case report of fatal TRAL following mitoxantrone therapy is presented with a discussion on the differential diagnosis and risk factors. The interdisciplinary development of diagnostic and therapeutic algorithms is presented from a haematological and neurological point of view. RESULTS We describe the case of a 34-year-old MS patient who developed TRAL following mitoxantrone therapy (cumulative dose 45 mg/m(2) body surface). The patient died from endocarditis. TRAL is a rare but potentially fatal complication of mitoxantrone therapy with a wide variation of reported incidence. Thus far, no specific risk factors relating for example to preceding therapy and treatment regimens have been identified. Frequent laboratory controls and early bone marrow aspiration are mandatory for suspected TRAL as the condition is potentially curable. CONCLUSIONS TRAL needs to be considered in the risk-benefit assessment of mitoxantrone therapy, however, the exact incidence and risk factors (e.g. dosage, treatment regimen) are still unclear. The risks are controllable under close surveillance and early diagnosis is important for prognosis. Future investigations need to concentrate on identification of potential risk factors.
Collapse
Affiliation(s)
- C Meyer
- Neurologische Klinik, St.-Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Esposito F, Radaelli M, Martinelli V, Sormani MP, Martinelli Boneschi F, Moiola L, Rocca MA, Rodegher M, Comi G. Comparative study of mitoxantrone efficacy profile in patients with relapsing—remitting and secondary progressive multiple sclerosis. Mult Scler 2010; 16:1490-9. [DOI: 10.1177/1352458510379613] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Mitoxantrone (MTX) is an immunosuppressive drug approved for multiple sclerosis (MS) treatment. Objective: The aim of this study is to evaluate and to compare the clinical and neuroradiological responses to MTX in relapsing—remitting (RR) and secondary progressive (SP) MS patients. Methods: We conducted a retrospective, non-randomized, open-label, observational study to evaluate the clinical and neuroradiological response to the drug in 79 patients with RR MS and 210 patients with SP MS. Results: A statistically significant reduction ( p < 0.001) in the number of relapses was observed during MTX treatment and in the year after in both RR and SP MS patients. On the contrary, an opposite behavior in terms of disease progression was found in RR compared with SP MS patients, resulting in a statistically significant improvement of the Expanded Disability Status Scale score during the MTX treatment ( p < 0.001) and in the year after ( p < 0.001) for RR MS patients compared with a continuous, although mild, worsening of the disability in SP MS patients ( p < 0.001). Finally, a significant reduction ( p < 0.001) of new Gd-enhanced lesions in both RR and SP MS patients was observed in a subgroup of 224 individuals who underwent a brain MRI evaluation before and after MTX treatment. Conclusions: MTX should be considered as an effective therapeutic option in RR MS patients with evidence of relevant disease activity, but the potential life-threatening adverse events and the overall benefit—risk ratio must be carefully evaluated at individual patient level.
Collapse
Affiliation(s)
- Federica Esposito
- Department of Neurology, Division of Neuroscience, Scientific Institute San Raffaele, Milan, Italy/Institute of Experimental Neurology, Scientific Institute San Raffaele, Milan, Italy,
| | - Marta Radaelli
- Department of Neurology, Division of Neuroscience, Scientific Institute San Raffaele, Milan, Italy/Institute of Experimental Neurology, Scientific Institute San Raffaele, Milan, Italy
| | - Vittorio Martinelli
- Department of Neurology, Division of Neuroscience, Scientific Institute San Raffaele, Milan, Italy/Institute of Experimental Neurology, Scientific Institute San Raffaele, Milan, Italy
| | - Maria Pia Sormani
- Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Filippo Martinelli Boneschi
- Department of Neurology, Division of Neuroscience, Scientific Institute San Raffaele, Milan, Italy/Institute of Experimental Neurology, Scientific Institute San Raffaele, Milan, Italy
| | - Lucia Moiola
- Department of Neurology, Division of Neuroscience, Scientific Institute San Raffaele, Milan, Italy/Institute of Experimental Neurology, Scientific Institute San Raffaele, Milan, Italy
| | - Maria Assunta Rocca
- Institute of Experimental Neurology, Scientific Institute San Raffaele, Milan, Italy/Neuroimaging Research Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Mariaemma Rodegher
- Department of Neurology, Division of Neuroscience, Scientific Institute San Raffaele, Milan, Italy/Institute of Experimental Neurology, Scientific Institute San Raffaele, Milan, Italy
| | - Giancarlo Comi
- Department of Neurology, Division of Neuroscience, Scientific Institute San Raffaele, Milan, Italy/Institute of Experimental Neurology, Scientific Institute San Raffaele, Milan, Italy
| |
Collapse
|
37
|
Yeh EA. Diagnosis and treatment of multiple sclerosis in pediatric and adolescent patients: current status and future therapies. Adolesc Health Med Ther 2010; 1:61-71. [PMID: 24600262 PMCID: PMC3916074 DOI: 10.2147/ahmt.s8130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric-onset multiple sclerosis (MS) comprises approximately 3%-5% of cases of MS in North America. Recent years have seen significant advances in the diagnosis and treatment of this condition, including the introduction of proposed diagnostic criteria for pediatric demyelinating disorders, and a growing body of knowledge regarding treatment options. This article reviews current approaches to the diagnosis and management of pediatric MS.
Collapse
Affiliation(s)
- E Ann Yeh
- Department of Neurology, Pediatric MS Center of the JNI, SUNY Buffalo, Buffalo, NY, USA
| |
Collapse
|
38
|
Tenembaum SN. Therapy of multiple sclerosis in children and adolescents. Clin Neurol Neurosurg 2010; 112:633-40. [PMID: 20471159 DOI: 10.1016/j.clineuro.2010.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Accepted: 04/17/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Paediatric multiple sclerosis accounts for up to 10% of all MS cases. The initial course of the disease is relapsing-remitting in most children, with a relapse rate generally higher than that observed in adult patients. There is published experience on the use of first-line disease modifying therapies in children with MS. However, about 1/3 of paediatric MS cases do not respond to IFN-beta or glatiramer acetate and continue to develop relapses and disease progression. These patients could be proposed to a second-line treatment. METHODS A comprehensive review of the published literature related to pharmacologic treatment of MS in adults and paediatric patients was performed. The recent literature has been extracted for new evidence from controlled trials in adult patients, and open treatment studies and reported expert opinion in paediatric patients. RESULTS No disease modifying drug has been approved for the treatment of children and adolescents with MS, although the currently available first-line therapies for adults seem to be safe and well tolerated in this population. Further studies are required to assess the safety and efficacy of second-line treatments in children with MS. CONCLUSION The present article constitutes an update of the existing publications regarding treatment of acute events of CNS demyelination in children and adolescents as well as considerations for the use of immunomodulatory therapies.
Collapse
Affiliation(s)
- Silvia N Tenembaum
- Referral Center for Paediatric MS and Related Disorders, Department of Neurology, National Paediatric Hospital Dr. J.P. Garrahan, Combate de los Pozos 1881, Buenos Aires, Argentina.
| |
Collapse
|
39
|
|
40
|
Kuntz NL, Chabas D, Weinstock-Guttman B, Chitnis T, Yeh EA, Krupp L, Ness J, Rodriguez M, Waubant E. Treatment of multiple sclerosis in children and adolescents. Expert Opin Pharmacother 2010; 11:505-20. [DOI: 10.1517/14656560903527218] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|