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Ciron J, Bourre B, Castelnovo G, Guennoc AM, De Sèze J, Ben-Amor AF, Savarin C, Vermersch P. Holistic, Long-Term Management of People with Relapsing Multiple Sclerosis with Cladribine Tablets: Expert Opinion from France. Neurol Ther 2024; 13:503-518. [PMID: 38488979 PMCID: PMC11136930 DOI: 10.1007/s40120-024-00589-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/09/2024] [Indexed: 03/17/2024] Open
Abstract
Cladribine tablets (CladT) has been available for therapeutic use in France since March 2021 for the management of highly active relapsing multiple sclerosis (RMS). This high-efficacy disease-modifying therapy (DMT) acts as an immune reconstitution therapy. In contrast to most high-efficacy DMTs, which act via continuous immunosuppression, two short courses of oral treatment with CladT at the beginning of years 1 and 2 of treatment provide long-term control of MS disease activity in responders to treatment, without the need for any further pharmacological treatment for several years. Although the labelling for CladT does not provide guidance beyond the initial treatment courses, real-world data on the therapeutic use of CladT from registries of previous clinical trial participants and patients treated in routine practice indicate that MS disease activity is controlled for a period of years beyond this time for a substantial proportion of patients. Moreover, this clinical experience has provided useful information on how to initiate and manage treatment with CladT. In this article we, a group of expert neurologists from France, provide recommendations on the initiation of CladT in DMT-naïve patients, how to switch from existing DMTs to CladT for patients with continuing MS disease activity, how to manage patients during the first 2 years of treatment and finally, how to manage patients with or without MS disease activity in years 3, 4 and beyond after initiating treatment with CladT. We believe that optimisation of the use of CladT beyond its initial courses of treatment will maximise the benefits of this treatment, especially early in the course of MS when suppression of focal inflammation in the CNS is a clinical priority to limit MS disease progression.
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Affiliation(s)
- Jonathan Ciron
- Department of Neurology, Centre de Ressources et de Compétences Sclérose en Plaques (CRC-SEP), Toulouse University Hospital, Hôpital Pierre-Paul Riquet, Toulouse, France
- INSERM UMR1291, CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse III, Toulouse, France
| | | | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | | | - Jérôme De Sèze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Ali Frederic Ben-Amor
- Knowlepsy Investment, Marseille Innovation, Technopôle de Château-Gombert, Marseille, France
| | - Carine Savarin
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France.
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2
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Hillert J, Bove R, Haddad LB, Hellwig K, Houtchens M, Magyari M, Merki-Feld GS, Montgomery S, Nappi RE, Stenager E, Thompson H, Tulek Z, Verdun Di Cantogno E, Simoni M. Expert opinion on the use of contraception in people with multiple sclerosis. Mult Scler 2024:13524585241228103. [PMID: 38456514 DOI: 10.1177/13524585241228103] [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: 03/09/2024]
Abstract
BACKGROUND Current guidance on the selection of appropriate contraception for people with multiple sclerosis (PwMS) is lacking. OBJECTIVE To address this gap, an expert-led consensus program developed recommendations to support clinicians in discussing family planning and contraception with women and men with multiple sclerosis (MS). METHODS A multidisciplinary steering committee (SC) of 13 international clinical experts led the program, supported by an extended faculty of 32 experts representing 18 countries. A modified Delphi methodology was used for decision-making and consensus-building. The SC drafted 15 clinical questions focused on patient-centered care, selection of contraception, and timing of stopping/starting contraception and disease-modifying therapies (DMTs). Statements addressing each question were drafted based on evaluation of published evidence and the experts' clinical experience. Consensus was reached if ⩾75% of respondents agreed (scoring 7-9 on a 9-point scale) with each recommendation. RESULTS Consensus was reached on 24 of 25 proposed recommendations, including how and when to discuss contraception, types and safety of contraceptives, and how to evaluate the most appropriate contraceptive options for specific patient groups, including those with significant disability or being treated with DMTs. CONCLUSION These expert recommendations provide the first practical, relevant, and comprehensive guidance for clinicians on the selection of contraception in PwMS.
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Affiliation(s)
- Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Riley Bove
- UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Lisa B Haddad
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Kerstin Hellwig
- Katholisches Klinikum Bochum GmbH, Nordrhein-Westfalen, Bochum, Germany
| | - Maria Houtchens
- Brigham and Women's Hospital, Boston, MA, USA/ Harvard Medical School, Boston, MA, USA
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, University Hospital Boston, MA, USA/ Rigshospitalet, Copenhagen, Denmark
| | - Gabriele S Merki-Feld
- Clinic of Reproductive Endocrinology, University Hospital Zürich, Zürich, Switzerland
| | - Scott Montgomery
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
- Research Center of Reproductive Medicine, IRCCS San Matteo Foundation, Pavia, Italy
| | - Egon Stenager
- Department of Regional Research, University of Southern Denmark, Odense, Denmark
- MS-Clinic of Southern Jutland (Aabenraa, Esbjerg, Kolding), Sønderborg, Denmark
| | - Heidi Thompson
- Southern Health & Social Care Trust, Portadown, Northern Ireland
| | - Zeliha Tulek
- Istanbul University-Cerrahpasa, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Manuela Simoni
- Unit of Endocrinology, Department of Medical Specialties, University Hospital and Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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Deleu D, Garcia Canibano B, Elalamy O, Sayed Abdelmoneim M, Boshra A. Practical Guidance on the Use of Cladribine Tablets in the Management or Relapsing Multiple Sclerosis: Expert Opinion from Qatar. Degener Neurol Neuromuscul Dis 2023; 13:81-88. [PMID: 38105885 PMCID: PMC10725680 DOI: 10.2147/dnnd.s433459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
The increasing availability of high-efficacy disease-modifying therapies (DMT) for the management of relapsing multiple sclerosis (RMS) has increased the potential for individualised patient management but has added complexity to the design of treatment regimens. The long-term application of immune reconstitution therapy (IRT) is supported by an increasing database of real world studies that have added important information on the long-term safety and efficacy of this approach. Cladribine tablets (CladT) is an IRT given as two annual short courses of treatment, following which a majority of patients then demonstrate no significant MS disease activity over a period of years. Whether, and how, to treat patients beyond the first two years of treatment remains a matter for debate, as clinical evidence accumulates. We, a group of neurologists who manage people with RMS in Qatar, provide our expert consensus recommendations on the application and long-term management of CladT therapy based on our experience with treatment in the last 5 years. These include pragmatic recommendations for people with MS disease activity in years 3 and 4 (ie up to four years following first dose of CladT), and for people with or without MS disease activity in subsequent years. We believe our recommendations will help to ensure the optimal application of CladT-based IRT, with the potential benefit for the patient of achieving prolonged periods free of both MS disease symptoms and the burden of regular applications of immunosuppressive DMT.
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Affiliation(s)
- Dirk Deleu
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Osama Elalamy
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Amir Boshra
- Merck Serono Middle East FZ-Ltd., Dubai, UAE, an affiliate of Merck KGaA, Dubai, United Arab Emirates
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4
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Clavelou P, Castelnovo G, Pourcher V, De Sèze J, Vermersch P, Ben-Amor AF, Savarin C, Defer G. Expert Narrative Review of the Safety of Cladribine Tablets for the Management of Relapsing Multiple Sclerosis. Neurol Ther 2023; 12:1457-1476. [PMID: 37382841 PMCID: PMC10444734 DOI: 10.1007/s40120-023-00496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/11/2023] [Indexed: 06/30/2023] Open
Abstract
Cladribine tablets (CladT) is a highly active oral disease-modifying therapy (DMT) for the management of relapsing multiple sclerosis (RMS). CladT acts as an immune reconstitution therapy, in that two short courses of treatment 1 year apart have been shown to suppress disease activity for a prolonged period in most patients, without need for continued DMT. Each course of CladT induces a profound reduction in B lymphocytes that recovers over months, and serious lymphopenia (Grade 3-4) is uncommon. Smaller reductions in levels of T lymphocytes occur slightly later: on average, these remain within the normal range and repopulate progressively. A larger effect occurs on CD8 vs. CD4 cells. Reactivation of latent or opportunistic infections (e.g. varicella zoster, tuberculosis) is mostly associated with very low lymphocyte counts (< 200/mm3). Screening and managing pre-existing infections, vaccinating non-exposed patients and delaying the 2nd year of treatment with CladT to allow lymphocytes to recover to > 800/mm3 (if necessary) are important for avoiding infections and higher-grade lymphopenia. There was no demonstrable or apparent effect of CladT on the efficacy of vaccinations, including against Covid-19. Adverse events consistent with drug-induced liver injury (DILI) represent a rare but potentially serious complication of CladT therapy in spontaneous adverse event reporting; patients should be screened for liver dysfunction before starting treatment. Ongoing hepatic monitoring is not required, but CladT must be withdrawn if signs and symptoms of DILI develop. There was a numerical imbalance for malignancies when comparing cladribine to placebo in the clinical programme, particularly in short-term data, but recent evidence shows that the risk of malignancy with CladT is similar to the background rate in the general population and to that with other DMTs. Overall, CladT is well tolerated with a favorable safety profile appropriate for the management of RMS.
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Affiliation(s)
- Pierre Clavelou
- Department of Neurology, Clermont-Ferrand University Hospital, 58 Rue Montalembert, 63003, Clermont-Ferrand Cedex 1, France.
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Valérie Pourcher
- Department of Infectious and Tropical Diseases, Pitié-Salpêtrière Hospital, APHP, Sorbonne Université, INSERM 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique Paris, Paris, France
| | - Jerome De Sèze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Ali-Frederic Ben-Amor
- Global Medical Affairs Neurology and Immunology, Ares Trading SA (An affiliate of Merck KGaA, Darmstadt, Germany), Eysins, Switzerland
| | - Carine Savarin
- Neurology Department, Medical Affairs (An affiliate of Merck KGaA, Darmstadt, Germany), Merck Santé, Lyon, France
| | - Gilles Defer
- Department of Neurology, Caen University Hospital, Caen, France
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5
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Oreja-Guevara C, Tintoré M, Meca V, Prieto JM, Meca J, Mendibe M, Rodríguez-Antigüedad A. Family Planning in Fertile-Age Patients With Multiple Sclerosis (MS) (ConPlanEM Study): Delphi Consensus Statements. Cureus 2023; 15:e44056. [PMID: 37746391 PMCID: PMC10517726 DOI: 10.7759/cureus.44056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/26/2023] Open
Abstract
Family planning is essential for establishing Multiple Sclerosis (MS) prognosis, treatment decision, and disease monitoring. We aimed to generate an expert consensus addressing recommendations for family planning in MS patients of childbearing age. Initially, a committee comprising seven neurologists, experts in the MS field, identified the topics to be addressed. Then, the committee elaborated on different evidence-based preliminary statements. Next, using the Delphi methodology, a panel of neurologists manifested their level of agreement on the different statements using a Likert-type scale. Consensus was reached when ⩾70% of respondents expressed an agreement or disagreement using a five-point scale. Consensus was achieved on 47 out of 63 recommendations after three rounds of evaluations. The panel considered it essential to address family planning in all patients of childbearing age. There was also consensus that treatment should not be delayed due to the patient's desire for pregnancy. Additionally, in highly active patients, planning the pregnancy in the medium to long term using depletory drugs such as cladribine or alemtuzumab might represent a useful strategy. However, risks of adverse effects on the fetus due to drug-associated secondary autoimmunity should be addressed when alemtuzumab is considered. Moreover, the maintenance of natalizumab during pregnancy in very active patients reached expert consensus. Also, the panel supported the use of certain disease-modifying treatment (DMT) during lactation in selected cases. Our results identified specific areas of pregnancy planning in MS patients, where different treatment strategies might be considered to facilitate a safe and successful pregnancy while maintaining clinical and radiological stability.
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Affiliation(s)
| | - Mar Tintoré
- Neurology, Multiple Sclerosis Center of Catalonia (Cemcat) Vall d'Hebrón University Hospital, Barcelona, ESP
| | - Virginia Meca
- Neurology, Princess University Hospital, Madrid, ESP
| | - José María Prieto
- Neurology, University Clinical Hospital of Santiago de Compostela, Madrid, ESP
| | - José Meca
- Neurology, Multiple Sclerosis CSUR and Clinical Neuroimmunology Unit, Virgen de la Arrixaca Clinical University Hospital, Cartagena, ESP
| | - Mar Mendibe
- Neurology, Neuroimmunology Group, Biocruces Bizkaia Research Institute, Cruces University Hospital, Bizkaia, ESP
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6
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Alonso R, Casas M, Lazaro L, Fernandez Liguori N, Pita C, Cohen L, Rojas JI, Pappolla A, Patrucco L, Cristiano E, Burgos M, Vrech C, Piedrabuena R, Pablo L, Deri N, Luetic G, Miguez J, Cabrera M, Martinez A, Zanga G, Tkachuk V, Tizio S, Carnero Contentti E, Knorre E, Leguizamon F, Mainella C, Nofal P, Liwacki S, Hryb J, Menichini M, Pestchanker C, Alonso M, Garcea O, Silva B. Achieving no evidence of disease activity-3 in highly active multiple sclerosis patients treated with cladribine and monoclonal antibodies. Mult Scler J Exp Transl Clin 2023; 9:20552173231154712. [PMID: 36846108 PMCID: PMC9950613 DOI: 10.1177/20552173231154712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/01/2023] [Indexed: 02/24/2023] Open
Abstract
Background We aimed to determine the proportion of highly active multiple sclerosis patients under high-efficacy therapies (HETs) achieve no evidence of disease activity-3 (NEDA-3) at 1 and 2 years, and to identify factors associated with failing to meet no evidence of disease activity 3 at 2 years. Methods This retrospective cohort study based on Argentina Multiple Sclerosis patient registry (RelevarEM), includes highly active multiple sclerosis patients who received HETs. Results In total, 254 (78.51%) achieved NEDA-3 at year 1 and 220 (68.12%) achieved NEDA-3 at year 2. Patients who achieved NEDA-3 at 2 years had a shorter duration of multiple sclerosis (p < 0.01) and a shorter time between first treatment and current treatment (p = 0.01). Early high-efficacy strategy patients reached NEDA-3 more frequently (p < 0.01). Being a naïve patient (odds ratio: 3.78, 95% confidence interval 1.50-9.86, p < 0.01) was an independent predictor to reach NEDA-3 at 2 years. No association was found between type of HETs and NEDA-3 at 2 years when adjusted for potential confounders (odds ratio: 1.73; 95% confidence interval 0.51-6.06, p 0.57). Conclusion We found a high proportion of patients who achieved NEDA-3 at 1 and 2 years. Early high-efficacy strategy patients had a higher probability of achieving NEDA-3 at 2 years.
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Affiliation(s)
- Ricardo Alonso
- Ricardo Alonso, Centro Universitario
Esclerosis Múltiple CUEM, Hospital Ramos Mejía, Urquiza 609, CP (1221) Ciudad de
Buenos Aires, Argentina; Facultad de Medicina, Universidad de Buenos Aires,
Ciudad de Buenos Aires, Argentina.
| | | | - Luciana Lazaro
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos
Mejía, Buenos Aires, Argentina
| | - Nora Fernandez Liguori
- Servicio de Neurología, Sanatorio Güemes, Buenos Aires, Argentina,Servicio de Neurología, Hospital Tornú, Buenos
Aires, Argentina
| | | | - Leila Cohen
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos
Mejía, Buenos Aires, Argentina
| | - Juan Ignacio Rojas
- Centro de esclerosis Múltiple Buenos Aires,
Buenos Aires, Argentina,Servicio de Neurología, CEMIC, Buenos Aires,
Argentina
| | | | | | | | - Marcos Burgos
- Servicio de Neurología, Hospital San Bernardo,
Salta, Argentina
| | - Carlos Vrech
- Servicio de Neurología, Sanatorio Allende,
Córdoba, Spain
| | - Raul Piedrabuena
- Servicio de Neurología, Clínica Universitaria
Reina Fabiola, Córdoba, Spain
| | - Lopez Pablo
- Sección de nueroinmunología, Hospital Alemán,
Buenos Aires, Argentina
| | | | | | - Jimena Miguez
- Servicio de neurología, Hospital Italiano,
Buenos Aires, Argentina
| | - Mariela Cabrera
- Servicio de neurología, Hospital Militar,
Campo de Mayo, Buenos Aires, Argentina
| | | | - Gisela Zanga
- Servicio de neurología, Hospital Cesar
Milstein, Buenos Aires, Argentina
| | - Verónica Tkachuk
- Servicio de neurología, Hospital de Clínica José de San
Martín, Buenos Aires, Argentina
| | - Santiago Tizio
- Servicio de neurología, Hospital Español, La Plata, Argentina
| | | | | | | | | | - Pedro Nofal
- Servicio de neurología, Hospital Nuestra
Señora del Carmen, Tucumán, Argentina
| | - Susana Liwacki
- Servicio de neurología, Hospital Córdoba,
Córdoba, Spain
| | - Javier Hryb
- Servicio de neurología, Hospital Durand,
Buenos Aires, Argentina
| | | | | | | | - Orlando Garcea
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos
Mejía, Buenos Aires, Argentina
| | - Berenice Silva
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos
Mejía, Buenos Aires, Argentina,Servicio de neurología, Hospital Italiano,
Buenos Aires, Argentina
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7
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The Place of Immune Reconstitution Therapy in the Management of Relapsing Multiple Sclerosis in France: An Expert Consensus. Neurol Ther 2022; 12:351-369. [PMID: 36564664 PMCID: PMC10043116 DOI: 10.1007/s40120-022-00430-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/29/2022] [Indexed: 12/25/2022] Open
Abstract
The treatment strategy in relapsing multiple sclerosis (RMS) is a complex decision requiring individualization of treatment sequences to maximize clinical outcomes. Current local and international guidelines do not provide specific recommendation on the use of immune reconstitution therapy (IRT) as alternative to continuous immunosuppression in the management of RMS. The objective of the program was to provide consensus-based expert opinion on the optimal use of IRT in the management of RMS. A Delphi method was performed from May 2022 to July 2022. Nineteen clinical assertions were developed by a scientific committee and sent to 14 French clinical experts in MS alongside published literature. Two consecutive reproducible anonymous votes were conducted. Consensus on recommendations was achieved when more than 75% of the respondents agreed or disagreed with the clinical assertions. After the second round, consensus was achieved amongst 16 out of 19 propositions: 13 clinical assertions had a 100% consensus, 3 clinical assertions a consensus above 75% and 3 without consensus. Expert-agreed consensus is provided on topics related to the benefit of the early use of IRT from immunological and clinical perspectives, profiles of patients who may benefit most from the IRT strategy (e.g. patients with family planning, patient preference and lifestyle requirements). These French expert consensuses provide up-to-date relevant guidance on the use of IRT in clinical practice. The current program reflects status of knowledge in 2022 and should be updated in timely manner when further clinical data in IRT become available.
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Treatment with Cladribine Tablets Beyond Year 4: A Position Statement by Southeast European Multiple Sclerosis Centers. Neurol Ther 2022; 12:25-37. [PMID: 36394714 PMCID: PMC9672547 DOI: 10.1007/s40120-022-00422-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022] Open
Abstract
Based on the results of the pivotal CLARITY study, cladribine tablets were approved for use in the European Union in 2017 as a high-efficacy therapy for highly active relapsing-remitting multiple sclerosis (MS). Cladribine tablets are used as an induction therapy: half of the total dose is given in year 1 and the other half in year 2. In the CLARITY Extension trials, repeating the dose routinely in years 3 and 4, was not associated with significantly improved disease control. However, there is very limited evidence on how to manage people with MS (pwMS) beyond year 4, which is increasingly important because more and more patients are now ≥ 4 years after cladribine treatment. Overall, postapproval data show that treatment with two cladribine cycles effectively controls disease activity in the long term. However, there is general agreement that some pwMS with suboptimal response could benefit from retreatment. This study reviews the practical aspects of using cladribine tablets, summarizes the evidence from clinical trials and real-world studies on the safety and efficacy of cladribine, and proposes a treatment algorithm developed by expert consensus for pwMS previously treated with cladribine. In brief, we propose that additional courses of cladribine tablets should be considered in patients with minimal (no relapses, 1-2 new lesions) or moderate (1 relapse, 3-4 new lesions) disease activity, while significant disease activity (> 1 relapse, > 3 new lesions) or progression should warrant a switch to another high-efficacy treatment (HET). More evidence is needed to improve the treatment guidelines for pwMS who previously received cladribine.
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9
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Meca-Lallana V, García Domínguez JM, López Ruiz R, Martín-Martínez J, Arés Luque A, Hernández Pérez MA, Prieto González JM, Landete Pascual L, Sastre-Garriga J. Expert-Agreed Practical Recommendations on the Use of Cladribine. Neurol Ther 2022; 11:1475-1488. [PMID: 36068429 PMCID: PMC9447968 DOI: 10.1007/s40120-022-00394-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/03/2022] [Indexed: 12/13/2022] Open
Abstract
Cladribine is a disease-modifying selective immune reconstitution oral therapy for adult patients with highly active relapsing multiple sclerosis (RMS). It was approved in the USA in 2019 and in Europe in 2017, thus there are still gaps in existing guidelines for using cladribine tablets in clinical practice. Nine experts with extensive experience in managing patients with multiple sclerosis in Spain identified some of the unanswered questions related to the real-life use of cladribine tablets. They reviewed the available clinical trial data and real-world evidence, including their own experiences of using cladribine, over the course of three virtual meetings held between November 2020 and January 2021. This article gathers their practical recommendations to aid treatment decision-making and optimise the use of cladribine tablets in patients with RMS. The consensus recommendations cover the following areas: candidate patient profiles, switching strategies (to and from cladribine), managing response to cladribine and safety considerations.
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Affiliation(s)
- Virginia Meca-Lallana
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario "La Princesa", Madrid, Spain.
| | | | - Rocío López Ruiz
- Multiple Sclerosis Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | | | - Adrián Arés Luque
- Neurology Department, Complejo Asistencial Universitario de León, León, Spain
| | | | | | | | - Jaume Sastre-Garriga
- Neurology Department, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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10
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Abstract
Neuroimmunological diseases and their treatment compromise the immune system, thereby increasing the risk of infections and serious illness. Consequently, vaccinations to protect against infections are an important part of the clinical management of these diseases. However, the wide variety of immunotherapies that are currently used to treat neuroimmunological disease — particularly multiple sclerosis and neuromyelitis optica spectrum disorders — can also impair immunological responses to vaccinations. In this Review, we discuss what is known about the effects of various immunotherapies on immunological responses to vaccines and what these effects mean for the safe and effective use of vaccines in patients with a neuroimmunological disease. The success of vaccination in patients receiving immunotherapy largely depends on the specific mode of action of the immunotherapy. To minimize the risk of infection when using immunotherapy, assessment of immune status and exclusion of underlying chronic infections before initiation of therapy are essential. Selection of the required vaccinations and leaving appropriate time intervals between vaccination and administration of immunotherapy can help to safeguard patients. We also discuss the rapidly evolving knowledge of how immunotherapies affect responses to SARS-CoV-2 vaccines and how these effects should influence the management of patients on these therapies during the COVID-19 pandemic. In this Review, the authors discuss how various immunotherapies for neuroimmunological diseases interact with vaccination responses, including responses to SARS-CoV-2 vaccinations, and the implications for the safe and effective use of vaccines in patients with these diseases. Vaccination against infection is an essential part of the management of neuroimmunological diseases. All indicated vaccinations should be administered before initiation of immunotherapy whenever possible; appropriate intervals between vaccination and treatment vary with treatment and vaccination. Inactivated vaccines are considered safe in neuroimmunological diseases but live vaccines are generally contraindicated during immunotherapy. Vaccination responses during immunotherapy can be diminished or abrogated, depending on the treatment and vaccination; antibody titre testing to monitor responses can be considered where appropriate. Vaccinations must be avoided during relapses or exacerbations of neuroimmunological diseases. Vaccination against SARS-CoV-2 is recommended for patients with neuroimmunological disease but some immunotherapies limit the immune response; therefore, timing should be considered carefully.
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Rieckmann P, Centonze D, Giovannoni G, Hua LH, Oreja-Guevara C, Selchen D, Sørensen PS, Vermersch P, Wiendl H, Salloukh H, Yamout B. Expert opinion on COVID-19 vaccination and the use of cladribine tablets in clinical practice. Ther Adv Neurol Disord 2021; 14:17562864211058298. [PMID: 34899987 PMCID: PMC8655448 DOI: 10.1177/17562864211058298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/19/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Gaps in current evidence and guidance leave clinicians with unanswered questions on the use of cladribine tablets for the treatment of multiple sclerosis (MS) in the era of the COVID-19 pandemic, in particular relating to COVID-19 vaccination. OBJECTIVE We describe a consensus-based program led by international MS experts with the aim of supplementing current guidelines and treatment labels by providing timely recommendations relating to COVID-19 vaccination and the use of cladribine tablets in clinical practice. METHODS A steering committee (SC) of 10 international MS experts identified 7 clinical questions to answer concerning the use of cladribine tablets and COVID-19 vaccination, which addressed issues relating to patient selection, timing and efficacy, and safety. Clinical recommendations to address each question were drafted using available evidence combined with expert opinion from the SC. An extended faculty of 28 MS experts, representing 19 countries, in addition to the 10 SC members, voted on the recommendations. Consensus on recommendations was achieved when ⩾75% of respondents expressed an agreement score of 7-9, on a 9-point scale. RESULTS Consensus was achieved on all 13 recommendations. Clinical recommendations are provided on whether all patients with MS receiving cladribine tablets should be vaccinated against COVID-19, and whether they should be prioritized; the timing of vaccination around dosing of cladribine tablets (i.e. before and after a treatment course); and the safety of COVID-19 vaccination for these patients. CONCLUSION These expert recommendations provide timely guidance on COVID-19 vaccination in patients receiving cladribine tablets, which is relevant to everyday clinical practice.
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Affiliation(s)
- Peter Rieckmann
- Center for Clinical Neuroplasticity, Medical Park Loipl, Bischofswiesen, Germany
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Diego Centonze
- Unit of Neurology and Neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Le H. Hua
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Celia Oreja-Guevara
- Neurology, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Daniel Selchen
- Division of Neurology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, University of Copenhagen and Rigshospitalet, Copenhagen, Denmark
| | - Patrick Vermersch
- Université de Lille, INSERM-U1172, Centre Hospitalier Universitaire de Lille, Fédératif Hospitalo-Universitaire Precise, Lille, France
| | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Hashem Salloukh
- Ares Trading SA, Eysins, Switzerland (an affiliate of Merck KGaA)
| | - Bassem Yamout
- Neurology Institute, Harley Street Medical Center, Abu Dhabi, UAE
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut, 1107 2020 Beirut, Lebanon
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12
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Espinoza MA, Rojas R, Zaupa A, Balmaceda C. A Model-Based Economic Evaluation of Cladribine Versus Alemtuzumab, Ocrelizumab and Natalizumab for the Treatment of Relapsing-Remitting Multiple Sclerosis with High Disease Activity in Chile. PHARMACOECONOMICS - OPEN 2021; 5:635-647. [PMID: 34224114 PMCID: PMC8611154 DOI: 10.1007/s41669-021-00282-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE The aim of this study was to evaluate the cost effectiveness of cladribine compared with alemtuzumab, natalizumab, and ocrelizumab for the treatment of highly active multiple sclerosis (HAD-MS) from the perspective of the Chilean health care public sector. MATERIALS AND METHODS A Markov model was used to compare costs and quality-adjusted life-years (QALYs) over a 45-year time horizon using a 3% discount rate for costs and outcomes. Natural history of the disease was modeled in terms of progression of disability according to the Expanded Disability Status Scale (EDSS). A network meta-analysis was used as a source of comparative effectiveness for disability progression and annual relapse rates. Differences in costs and outcomes were modeled for only 10 years due to high temporal uncertainty. Ocrelizumab was assumed to have the same efficacy as cladribine due to lack of data. Direct costs were taken from national tariffs and expressed in 2019 US dollars. Utilities for EDSS health states were obtained from the literature. Second-order uncertainty was characterized through deterministic and probabilistic sensitivity analysis. FINDINGS Compared with natalizumab (the current strategy covered in Chile), cladribine is associated with incremental costs and QALYs of US$70,989 and 1.875, respectively (incremental cost-effectiveness ratio [ICER] $37,861). Ocrelizumab was extendedly dominated by cladribine and natalizumab, and alemtuzumab was dominated by cladribine. A scenario analysis of a 10% discount did not modify the results substantially, but showed a decrease in the ICER of cladribine versus natalizumab (ICER $29,833/QALY). IMPLICATIONS Cladribine is a new oral alternative to treat patients with HAD-MS that is expected to produce higher QALYs than all evaluated alternatives. In the context of a conservative analysis, cladribine cannot be considered cost effective for the Chilean health care public sector using a 1 GDP per capita threshold. However, under reasonable discount scenarios, cladribine becomes an attractive alternative for the health system.
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Affiliation(s)
- Manuel Antonio Espinoza
- Unidad de Evaluación de Tecnologías en Salud, Centro de Investigación Clínica, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Piso 2, Santiago, Chile
- Departamento de Salud Pública, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Piso 2, Santiago, Chile
| | | | - Alessandro Zaupa
- Departamento de Salud Pública, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Piso 2, Santiago, Chile
| | - Carlos Balmaceda
- Unidad de Evaluación de Tecnologías en Salud, Centro de Investigación Clínica, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Piso 2, Santiago, Chile.
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13
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Long-Term Safety and Efficacy of Subcutaneous Cladribine Used in Increased Dosage in Patients with Relapsing Multiple Sclerosis: 20-Year Observational Study. J Clin Med 2021; 10:jcm10215207. [PMID: 34768726 PMCID: PMC8584572 DOI: 10.3390/jcm10215207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/17/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Abstract
Cladribine is currently registered as a 10-milligram tablet formulation with a fixed cumulative dosage of 3.5 mg/kg over 2 years. It is important to investigate if an increased dosage may lead to further clinical stability with preserved safety. This study used an off-label subcutaneous (s.c.) formulation of cladribine and compared outcomes (Expanded Disability Status Scale (EDSS) scores and disease progression) between 52 relapsing multiple sclerosis (RMS) patients receiving different s.c. dosing regimens with up to 20 years of follow-up. The study group received induction therapy with s.c. cladribine (1.8 mg/kg cumulative dose; consistent with 3.5 mg/kg of cladribine tablets). Patients were subsequently offered maintenance therapy (repeated courses of 0.3 mg/kg s.c. cladribine during 5–20-year follow-up). Forty-one patients received an increased cumulative dose (higher than the induction dose of 1.8 mg/kg); 11 received the standard induction dose. Risk of progression on the EDSS correlated with lower cumulative dose (p < 0.05) and more advanced disability at treatment initiation (p < 0.05) as assessed by EDSS change between year 1 and years 5 and 10 as the last follow-up. Maintenance treatment was safe and well-tolerated, based on limited source data. Subcutaneous cladribine with increased cumulative maintenance dosage was associated with disease stability and favorable safety over a prolonged period of follow-up (up to 20 years) in RMS patients.
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14
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Rammohan K, Coyle PK, Sylvester E, Galazka A, Dangond F, Grosso M, Leist TP. The Development of Cladribine Tablets for the Treatment of Multiple Sclerosis: A Comprehensive Review. Drugs 2021; 80:1901-1928. [PMID: 33247831 PMCID: PMC7708385 DOI: 10.1007/s40265-020-01422-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cladribine is a purine nucleoside analog initially developed in the 1970s as a treatment for various blood cancers. Due to the molecule’s ability to preferentially reduce T and B lymphocytes, it has been developed into an oral formulation for the treatment of multiple sclerosis (MS). The unique proposed mechanism of action of cladribine allows for the therapy to be delivered orally over two treatment-week cycles per year, one cycle at the beginning of the first month and one cycle at the beginning of the second month of years 1 and 2, with the potential for no further cladribine treatment required in years 3 and 4. This review summarizes the clinical development program for cladribine tablets in patients with MS, including the efficacy endpoints and results from the 2-year phase III CLARITY study in patients with relapsing–remitting MS (RRMS), the 2-year CLARITY EXTENSION study, and the phase III ORACLE-MS study in patients with a first clinical demyelinating event at risk for developing MS. Efficacy results from the phase II ONWARD study, in which cladribine tablets were administered as an add-on to interferon-β therapy in patients with RRMS, are also summarized. A review of all safety data, including lymphopenia, infections, and malignancies, is provided based on data from all trials in patients with MS, including the initial parenteral formulation studies. Based on these data, cladribine tablets administered at 3.5 mg/kg over 2 years have been approved across the globe for various forms of relapsing MS. The development of cladribine tablets for the treatment of multiple sclerosis: a comprehensive review (MP4 279143 kb)
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Affiliation(s)
- Kottil Rammohan
- Multiple Sclerosis Center, University of Miami, Miami, FL, USA.
| | - Patricia K Coyle
- Multiple Sclerosis Comprehensive Care Center, Stony Brook University, Stony Brook, NY, USA
| | | | | | - Fernando Dangond
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Megan Grosso
- EMD Serono, Inc., Rockland, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Thomas P Leist
- Comprehensive MS Center, Jefferson University, Philadelphia, PA, USA
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15
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Rejdak K, Papuć E. Cladribine suppresses disease activity in neuromyelitis optica spectrum disorder: a 2-year follow-up study. Eur J Neurol 2021; 28:3167-3172. [PMID: 34233064 DOI: 10.1111/ene.15012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 05/24/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Neuromyelitis optica spectrum disorder (NMOSD) is a difficult condition to treat. Cladribine selectively and transiently depletes B and T lymphocytes, leading to long-lasting immune reconstitution. This report describes observations from 24 months of follow-up after cladribine in NMOSD patients. METHODS This is a retrospective analysis of a case series including 12 seropositive patients with NMOSD. Patients were given cladribine by subcutaneous injections in a series of several 2-day cycles of 20 mg administered at intervals of 4-6 weeks. Thus, the full treatment course delivered a cumulative bioavailable dose similar to that approved for treatment of multiple sclerosis. Annualized relapse rate (ARR), disability (Expanded Disability Status Scale [EDSS] score) and safety in the 24 months preceding and the 24 months following the initiation of cladribine treatment were assessed. RESULTS The mean ARR in the 24 months preceding cladribine treatment was 1.04 (95% confidence interval [CI] 0.67-1.62). The mean ARR in the 24 months following initiation of cladribine treatment was 0.21 (95% CI 0.08-0.56). The ratio in the rate of events post versus prior cladribine initiation was 0.20 (95% CI 0.07-0.59) and highly significant (p = 0.0073). The EDSS score did not change over the follow-up period (2.5 ± 1.7; mean ± SD) compared to baseline (2.5 ± 1.5; mean ± SD). No serious adverse events considered to be linked to cladribine were observed during follow-up. CONCLUSIONS Cladribine was safe in NMOSD patients over a 2-year observation period. Cladribine treatment was associated with clinical stabilization, as evidenced by significantly decreased ARR and no progression of EDSS score.
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Affiliation(s)
- Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Ewa Papuć
- Department of Neurology, Medical University of Lublin, Lublin, Poland
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16
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Miravalle AA, Katz J, Robertson D, Hayward B, Harlow DE, Lebson LA, Sloane JA, Bass AD, Fox EJ. CLICK-MS and MASTER-2 Phase IV trial design: cladribine tablets in suboptimally controlled relapsing multiple sclerosis. Neurodegener Dis Manag 2021; 11:99-111. [PMID: 33517769 DOI: 10.2217/nmt-2020-0059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Cladribine tablets 10 mg (3.5 mg/kg cumulative dose over 2 years) are approved for the treatment of relapsing forms of multiple sclerosis (MS), including relapsing-remitting MS and active secondary progressive MS. However, real-world data on cladribine tablets are limited. CLICK-MS and MASTER-2 are single arm, observational, 30-month, Phase IV studies in the US evaluating the effectiveness and safety of cladribine tablets 3.5 mg/kg in patients with relapsing-remitting MS or active secondary progressive MS who had suboptimal response to prior injectable (CLICK-MS), or infusion/oral (MASTER-2) disease-modifying therapy. The primary end point is 24-month annualized relapse rate. Key secondary end points include patient-reported outcomes on quality of life measures, treatment adherence and adverse events. Studies began in 2019 and are expected to be completed in 2023. Trial registration number • CLICK-MS: NCT03933215 (ClinicalTrials.gov) Full title; CLadribine tablets: observational evaluation of effectIveness and patient-reported outcomes in suboptimally Controlled patients previously taKing injectable disease-modifying drugs for relapsing forms of Multiple Sclerosis • MASTER-2: NCT03933202 (ClinicalTrials.gov) Full title; Cladribine tablets: observational evaluation of effectiveness and patient-reported outcomes in suboptiMAlly controlled patientS previously Taking oral or infusion disEase-modifying dRugs for relapsing forms of multiple sclerosis.
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Affiliation(s)
- Augusto A Miravalle
- Advanced Neurology of Colorado, University of Colorado, Fort Collins, CO 80528, USA
| | - Joshua Katz
- Elliot Lewis Center for Multiple Sclerosis Care, Wellesley, MA 02481, USA
| | - Derrick Robertson
- Department of Neurology, Multiple Sclerosis Division, University of South Florida, Tampa, FL 33612, USA
| | - Brooke Hayward
- EMD Serono, Inc., Rockland, MA 02370, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Danielle E Harlow
- EMD Serono, Inc., Rockland, MA 02370, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Lori A Lebson
- EMD Serono, Inc., Rockland, MA 02370, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Jacob A Sloane
- BIDMC Department of Neurology, Harvard Medical School, Boston, MA 02115, USA
| | - Ann D Bass
- Neurology Center of San Antonio, San Antonio, TX 78258, USA
| | - Edward J Fox
- Central Texas Neurology Consultants, Round Rock, TX 78681, USA
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