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Vakrakou AG, Brinia ME, Alexaki A, Koumasopoulos E, Stathopoulos P, Evangelopoulos ME, Stefanis L, Stadelmann-Nessler C, Kilidireas C. Multiple faces of multiple sclerosis in the era of highly efficient treatment modalities: Lymphopenia and switching treatment options challenges daily practice. Int Immunopharmacol 2023; 125:111192. [PMID: 37951198 DOI: 10.1016/j.intimp.2023.111192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 11/13/2023]
Abstract
The expanded treatment landscape in relapsing-remitting multiple sclerosis (MS) has resulted in highly effective treatment options and complexity in managing disease- or drug-related events during disease progression. Proper decision-making requires thorough knowledge of the immunobiology of MS itself and an understanding of the main principles behind the mechanisms that lead to secondary autoimmunity affecting organs other than the central nervous system as well as opportunistic infections. The immune system is highly adapted to both environmental and disease-modifying agents. Immune reconstitution following cell depletion or cell entrapment therapies eliminates pathogenic aspects of the disease but can also lead to distorted immune responses with harmful effects. Atypical relapses occur with second-line treatments or after their discontinuation and require appropriate clinical decisions. Lymphopenia is a result of the mechanism of action of many drugs used to treat MS. However, persistent lymphopenia and cell-specific lymphopenia could result in disease exacerbation, secondary autoimmunity, or the emergence of opportunistic infections. Clinicians treating patients with MS should be aware of the multiple faces of MS under novel, efficient treatment modalities and understand the intricate brain-immune cell interactions in the context of an altered immune system. MS relapses and disease progression still occur despite the current treatment modalities and are mediated either by failure to control effector mechanisms inherent to MS pathophysiology or by new drug-related mechanisms. The multiple faces of MS due to the highly adapted immune system of patients impose the need for appropriate switching therapies that safeguard disease remission and further clinical improvement.
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Affiliation(s)
- Aigli G Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neuropathology, University of Göttingen Medical Center, Göttingen, Germany.
| | - Maria-Evgenia Brinia
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Alexaki
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Koumasopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Stathopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Eleftheria Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
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Zhong M, van der Walt A, Monif M, Hodgkinson S, Eichau S, Kalincik T, Lechner-Scott J, Buzzard K, Skibina O, Van Pesch V, Butler E, Prevost J, Girard M, Oh J, Butzkueven H, Jokubaitis V. Prediction of relapse activity when switching to cladribine for multiple sclerosis. Mult Scler 2023; 29:119-129. [PMID: 35894247 DOI: 10.1177/13524585221111677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with relapsing-remitting multiple sclerosis commonly switch between disease-modifying therapies (DMTs). Identifying predictors of relapse when switching could improve outcomes. OBJECTIVE To determine predictors of relapse hazard when switching to cladribine. METHODS Data of patients who switched to cladribine, grouped by prior disease-modifying therapy (pDMT; interferon-β/glatiramer acetate, dimethyl fumarate, teriflunomide, fingolimod or natalizumab (NTZ)), were extracted from the MSBase Registry. Predictors of relapse hazard during the treatment gap and the first year of cladribine therapy were determined. RESULTS Of 513 patients, 22 relapsed during the treatment gap, and 38 within 1 year of starting cladribine. Relapse in the year before pDMT cessation predicted treatment gap relapse hazard (hazard ratio (HR) = 2.43, 95% confidence interval (CI) = 1.03-5.71). After multivariable adjustment, relapse hazard on cladribine was predicted by relapse before pDMT cessation (HR = 2.00, 95% CI = 1.01-4.02), treatment gap relapse (HR = 6.18, 95% confidence interval (CI) = 2.65-14.41), switch from NTZ (HR compared to injectable therapies 4.08, 95% CI = 1.35-12.33) and age at cladribine start (HR = 0.96, 95% CI = 0.91-0.99). CONCLUSION Relapse during or prior to the treatment gap, and younger age, are of prognostic relevance in the year after switching to cladribine. Switching from NTZ is also independently associated with greater relapse hazard.
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Affiliation(s)
- Michael Zhong
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Anneke van der Walt
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Mastura Monif
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia/MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Tomas Kalincik
- MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia/Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, NSW, Australia
| | - Katherine Buzzard
- MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia
| | - Olga Skibina
- Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia/Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia
| | | | | | | | - Marc Girard
- CHUM and Universite de Montreal, Montreal, QC, Canada
| | - Jiwon Oh
- Division of Neurology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Helmut Butzkueven
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Vilija Jokubaitis
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
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Vainio SK, Dickens AM, Matilainen M, López-Picón FR, Aarnio R, Eskola O, Solin O, Anthony DC, Rinne JO, Airas L, Haaparanta-Solin M. Dimethyl fumarate decreases short-term but not long-term inflammation in a focal EAE model of neuroinflammation. EJNMMI Res 2022; 12:6. [PMID: 35107664 PMCID: PMC8811048 DOI: 10.1186/s13550-022-00878-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background Dimethyl fumarate (DMF) is an oral immunomodulatory drug used in the treatment of autoimmune diseases. Here, we sought to study whether the effect of DMF can be detected using positron emission tomography (PET) targeting the 18-kDa translocator protein (TSPO) in the focal delayed-type hypersensitivity rat model of multiple sclerosis (fDTH-EAE). The rats were treated orally twice daily from lesion activation (day 0) with either vehicle (tap water with 0.08% Methocel, 200 µL; control group n = 4 (3 after week four)) or 15 mg/kg DMF (n = 4) in 0.08% aqueous Methocel (200 µL) for 8 weeks. The animals were imaged by PET using the TSPO tracer [18F]GE-180 in weeks 0, 1, 2, 4, 8, and 18 following lesion activation, and the non-displaceable binding potential (BPND) was calculated. Immunohistochemical staining for Iba1, CD4, and CD8 was performed in week 18, and in separate cohorts of animals, following 2 or 4 weeks of treatment. Results Using the fDTH-EAE model, DMF reduced the [18F]GE-180 BPND in the DMF-treated animals compared to control animals after 1 week of treatment (two-tailed unpaired t test, p = 0.031), but not in weeks 2, 4, 8, or 18 when imaged in vivo by PET. Immunostaining for Iba1 showed that DMF had no effect on the perilesional volume or the core lesion volume after 2 or 4 weeks of treatment, or at 18 weeks. However, the optical density (OD) measurements of CD4+ staining showed reduced OD in the lesions of the treated rats. Conclusions DMF reduced the microglial activation in the fDTH-EAE model after 1 week of treatment, as detected by PET imaging of the TSPO ligand [18F]GE-180. However, over an extended time course, reduced microglial activation was not observed using [18F]GE-180 or by immunohistochemistry for Iba1+ microglia/macrophages. Additionally, DMF did affect the infiltration of CD4+ and CD8+ T-lymphocytes at the fDTH-EAE lesion. Supplementary Information The online version contains supplementary material available at 10.1186/s13550-022-00878-y. In a focal rat DTH-EAE model of neuroinflammation, dimethyl fumarate decreases the uptake of TSPO PET tracer [18F]GE-180 in the short term. Long-term [18F]GE-180 follow-up did not indicate a treatment effect. Decreased neuroinflammation, CD4+ T cell infiltration, and CD8+ T cell infiltration were detected using immunohistochemistry.
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Affiliation(s)
- S K Vainio
- Turku PET Centre, Preclinical PET Imaging, Preclinical Imaging Laboratory, University of Turku, Tykistökatu 6 A, 20520, Turku, Finland. .,MediCity Research Laboratory, University of Turku, Turku, Finland.
| | - A M Dickens
- Department of Chemistry, University of Turku, Turku, Finland.,Turku Bioscience, Turku, Finland
| | - M Matilainen
- Faculty of Science and Engineering, Åbo Akademi University, Turku, Finland.,Turku PET Centre, University of Turku, Turku, Finland
| | - F R López-Picón
- Turku PET Centre, Preclinical PET Imaging, Preclinical Imaging Laboratory, University of Turku, Tykistökatu 6 A, 20520, Turku, Finland.,MediCity Research Laboratory, University of Turku, Turku, Finland
| | - R Aarnio
- MediCity Research Laboratory, University of Turku, Turku, Finland.,Turku PET Centre, University of Turku, Turku, Finland
| | - O Eskola
- Turku PET Centre, Radiopharmaceutical Chemistry Laboratory, University of Turku, Turku, Finland
| | - O Solin
- Accelerator Laboratory, Åbo Akademi University, Turku, Finland.,Turku PET Centre, Radiopharmaceutical Chemistry Laboratory, University of Turku, Turku, Finland
| | - D C Anthony
- Department of Pharmacology, University of Oxford, Oxford, UK
| | - J O Rinne
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland.,Turku PET Centre, University of Turku, Turku, Finland
| | - L Airas
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland.,Department of Clinical Medicine, University of Turku, Turku, Finland
| | - M Haaparanta-Solin
- Turku PET Centre, Preclinical PET Imaging, Preclinical Imaging Laboratory, University of Turku, Tykistökatu 6 A, 20520, Turku, Finland.,MediCity Research Laboratory, University of Turku, Turku, Finland
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Challenges of switching towards anti-CD20 monoclonal antibodies in RR-MS: A monocentric study. Mult Scler Relat Disord 2021; 52:102981. [PMID: 34004434 DOI: 10.1016/j.msard.2021.102981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/22/2021] [Accepted: 04/22/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Anti-CD20 monoclonal antibodies (mAb) have demonstrated their drastic efficacy in the treatment of active relapsing-remitting multiple sclerosis (RR-MS). This study investigates the management of their initiation after another disease modifying therapy (DMT). The objective of this study was to assess the frequency and the risk factors of relapses during the wash-out period (WP) between cessation of last DMT and initiation of anti-CD20 mAb in RR-MS. METHODS All non-naive RR-MS patients who initiated a treatment with Rituximab or Ocrelizumab between 2016 and 2019 have been included in this retrospective monocentric study. Univariate and multivariate analysis were conducted to evaluate risk factors of relapses during the WP. RESULTS 73 patients (mean age 35.3 years, standard deviation (SD): 8.7 years) were included, with a mean number of 3.1 (SD: 1.3) previous DMTs. The DMT most frequently received before the switch was Fingolimod (Fg, 31 patients, 42.5%). 20 patients (27.4%) experienced relapses during the WP. Risk factors were previous treatment by Fg (p = 0.001) and WP duration (p = 0.032). Among patients switching from Fg, the probability of experiencing a relapse was 35% after 1 month of wash-out. CONCLUSION This study suggests to shorten the WP duration when switching towards anti-CD20 mAb, especially after Fg, to avoid relapses.
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Rebound after discontinuation of teriflunomide in patients with multiple sclerosis: 2 case reports. Mult Scler Relat Disord 2020; 41:102017. [PMID: 32120027 DOI: 10.1016/j.msard.2020.102017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/11/2020] [Accepted: 02/21/2020] [Indexed: 11/23/2022]
Abstract
Teriflunomide is an oral first-line disease modifying treatment (DMT) for patients with relapsing-remitting multiple sclerosis (RRMS). It can take up to two years to achieve systemic clearance of teriflunomide to an acceptable level, but this washout period may be accelerated by administration of cholestyramine. Relapse of multiple sclerosis (MS) during washout of teriflunomide or other first-line DMT is not as common. We report two patients with RRMS who experienced a relapse after the accelerated elimination period (AEP) of teriflunomide and confirmation of negative plasmatic levels (<0.02 µg/ml). In cases of risk of MS activity, we should not wait for teriflunomide negative plasmatic levels confirmation before starting the next DMT to reduce the risk of relapse.
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Hou X, Xu H, Chen W, Zhang N, Zhao Z, Fang X, Zhang X, Chen H, Xu Y. Neuroprotective effect of dimethyl fumarate on cognitive impairment induced by ischemic stroke. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:375. [PMID: 32355819 PMCID: PMC7186746 DOI: 10.21037/atm.2020.02.10] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Oxidative damage may contribute to post-stroke cognitive impairment (PSCI), but the underlying mechanisms are not fully elucidated. Dimethyl fumarate (DMF) has been used as an antioxidant in multiple sclerosis and psoriasis patients. We hypothesized that redox state was associated with PSCI, and DMF might exert neuroprotective effect against PSCI via anti-oxidative actions. Methods To confirm this hypothesis, we first conducted a clinical study (NCT03519828) that enrolled patients diagnosed with acute ischemic stroke within 48 hours. Data were analyzed based on demographic characteristics, disease history, clinical data and redox state. Logistic regression was used to identify the factors associated with PSCI. Next, a middle cerebral artery occlusion (MCAO) rat model was used to explore the antioxidant capacity and neuroprotective effect of DMF. Furthermore, behavioural experiments, histology and immunostaining, and transmission electron microscopy were also performed. Results Higher baseline NIHSS score, lower GSH/GSSG and T-AOC levels were found in the PSCI patients. Better performance in Morris water maze and shuttle box testing, more regular arranged neurons and Nissl bodies, less TUNEL-positive cells and autophagosomes, lower expression of 4-HNE, and higher expression of GCLM and NQO1 were found in the (DMF + MCAO) rats compared with the MCAO rats. Conclusions These findings suggest that DMF may alleviate PSCI via neuroprotective actions, providing a new therapeutic strategy for PSCI.
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Affiliation(s)
- Xiaowen Hou
- School of Public Health, China Medical University, Shenyang 110122, China.,Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Haibin Xu
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Wanli Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Nannan Zhang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Ziai Zhao
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Xin Fang
- School of Public Health, China Medical University, Shenyang 110122, China
| | - Xing Zhang
- School of Public Health, China Medical University, Shenyang 110122, China
| | - Huisheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Yuanyuan Xu
- School of Public Health, China Medical University, Shenyang 110122, China
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Affiliation(s)
- Paul S Giacomini
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University Health Centre, Montreal, QC, Canada
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