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Gonzalez-Lorenzo M, Ridley B, Minozzi S, Del Giovane C, Peryer G, Piggott T, Foschi M, Filippini G, Tramacere I, Baldin E, Nonino F. Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD011381. [PMID: 38174776 PMCID: PMC10765473 DOI: 10.1002/14651858.cd011381.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Different therapeutic strategies are available for the treatment of people with relapsing-remitting multiple sclerosis (RRMS), including immunomodulators, immunosuppressants and biological agents. Although each one of these therapies reduces relapse frequency and slows disability accumulation compared to no treatment, their relative benefit remains unclear. This is an update of a Cochrane review published in 2015. OBJECTIVES To compare the efficacy and safety, through network meta-analysis, of interferon beta-1b, interferon beta-1a, glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab, pegylated interferon beta-1a, daclizumab, laquinimod, azathioprine, immunoglobulins, cladribine, cyclophosphamide, diroximel fumarate, fludarabine, interferon beta 1-a and beta 1-b, leflunomide, methotrexate, minocycline, mycophenolate mofetil, ofatumumab, ozanimod, ponesimod, rituximab, siponimod and steroids for the treatment of people with RRMS. SEARCH METHODS CENTRAL, MEDLINE, Embase, and two trials registers were searched on 21 September 2021 together with reference checking, citation searching and contact with study authors to identify additional studies. A top-up search was conducted on 8 August 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) that studied one or more of the available immunomodulators and immunosuppressants as monotherapy in comparison to placebo or to another active agent, in adults with RRMS. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data. We considered both direct and indirect evidence and performed data synthesis by pairwise and network meta-analysis. Certainty of the evidence was assessed by the GRADE approach. MAIN RESULTS We included 50 studies involving 36,541 participants (68.6% female and 31.4% male). Median treatment duration was 24 months, and 25 (50%) studies were placebo-controlled. Considering the risk of bias, the most frequent concern was related to the role of the sponsor in the authorship of the study report or in data management and analysis, for which we judged 68% of the studies were at high risk of other bias. The other frequent concerns were performance bias (34% judged as having high risk) and attrition bias (32% judged as having high risk). Placebo was used as the common comparator for network analysis. Relapses over 12 months: data were provided in 18 studies (9310 participants). Natalizumab results in a large reduction of people with relapses at 12 months (RR 0.52, 95% CI 0.43 to 0.63; high-certainty evidence). Fingolimod (RR 0.48, 95% CI 0.39 to 0.57; moderate-certainty evidence), daclizumab (RR 0.55, 95% CI 0.42 to 0.73; moderate-certainty evidence), and immunoglobulins (RR 0.60, 95% CI 0.47 to 0.79; moderate-certainty evidence) probably result in a large reduction of people with relapses at 12 months. Relapses over 24 months: data were reported in 28 studies (19,869 participants). Cladribine (RR 0.53, 95% CI 0.44 to 0.64; high-certainty evidence), alemtuzumab (RR 0.57, 95% CI 0.47 to 0.68; high-certainty evidence) and natalizumab (RR 0.56, 95% CI 0.48 to 0.65; high-certainty evidence) result in a large decrease of people with relapses at 24 months. Fingolimod (RR 0.54, 95% CI 0.48 to 0.60; moderate-certainty evidence), dimethyl fumarate (RR 0.62, 95% CI 0.55 to 0.70; moderate-certainty evidence), and ponesimod (RR 0.58, 95% CI 0.48 to 0.70; moderate-certainty evidence) probably result in a large decrease of people with relapses at 24 months. Glatiramer acetate (RR 0.84, 95%, CI 0.76 to 0.93; moderate-certainty evidence) and interferon beta-1a (Avonex, Rebif) (RR 0.84, 95% CI 0.78 to 0.91; moderate-certainty evidence) probably moderately decrease people with relapses at 24 months. Relapses over 36 months findings were available from five studies (3087 participants). None of the treatments assessed showed moderate- or high-certainty evidence compared to placebo. Disability worsening over 24 months was assessed in 31 studies (24,303 participants). Natalizumab probably results in a large reduction of disability worsening (RR 0.59, 95% CI 0.46 to 0.75; moderate-certainty evidence) at 24 months. Disability worsening over 36 months was assessed in three studies (2684 participants) but none of the studies used placebo as the comparator. Treatment discontinuation due to adverse events data were available from 43 studies (35,410 participants). Alemtuzumab probably results in a slight reduction of treatment discontinuation due to adverse events (OR 0.39, 95% CI 0.19 to 0.79; moderate-certainty evidence). Daclizumab (OR 2.55, 95% CI 1.40 to 4.63; moderate-certainty evidence), fingolimod (OR 1.84, 95% CI 1.31 to 2.57; moderate-certainty evidence), teriflunomide (OR 1.82, 95% CI 1.19 to 2.79; moderate-certainty evidence), interferon beta-1a (OR 1.48, 95% CI 0.99 to 2.20; moderate-certainty evidence), laquinimod (OR 1.49, 95 % CI 1.00 to 2.15; moderate-certainty evidence), natalizumab (OR 1.57, 95% CI 0.81 to 3.05), and glatiramer acetate (OR 1.48, 95% CI 1.01 to 2.14; moderate-certainty evidence) probably result in a slight increase in the number of people who discontinue treatment due to adverse events. Serious adverse events (SAEs) were reported in 35 studies (33,998 participants). There was probably a trivial reduction in SAEs amongst people with RRMS treated with interferon beta-1b as compared to placebo (OR 0.92, 95% CI 0.55 to 1.54; moderate-certainty evidence). AUTHORS' CONCLUSIONS We are highly confident that, compared to placebo, two-year treatment with natalizumab, cladribine, or alemtuzumab decreases relapses more than with other DMTs. We are moderately confident that a two-year treatment with natalizumab may slow disability progression. Compared to those on placebo, people with RRMS treated with most of the assessed DMTs showed a higher frequency of treatment discontinuation due to AEs: we are moderately confident that this could happen with fingolimod, teriflunomide, interferon beta-1a, laquinimod, natalizumab and daclizumab, while our certainty with other DMTs is lower. We are also moderately certain that treatment with alemtuzumab is associated with fewer discontinuations due to adverse events than placebo, and moderately certain that interferon beta-1b probably results in a slight reduction in people who experience serious adverse events, but our certainty with regard to other DMTs is lower. Insufficient evidence is available to evaluate the efficacy and safety of DMTs in a longer term than two years, and this is a relevant issue for a chronic condition like MS that develops over decades. More than half of the included studies were sponsored by pharmaceutical companies and this may have influenced their results. Further studies should focus on direct comparison between active agents, with follow-up of at least three years, and assess other patient-relevant outcomes, such as quality of life and cognitive status, with particular focus on the impact of sex/gender on treatment effects.
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Affiliation(s)
- Marien Gonzalez-Lorenzo
- Laboratorio di Metodologia delle revisioni sistematiche e produzione di Linee Guida, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ben Ridley
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Cochrane Italy, Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Guy Peryer
- School of Health Sciences, University of East Anglia (UEA), Norwich, UK
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, Queens University, Kingston, Ontario, Canada
| | - Matteo Foschi
- Department of Neuroscience, Multiple Sclerosis Center - Neurology Unit, S.Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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Hellwig K, Tokic M, Thiel S, Hemat S, Timmesfeld N, Ciplea AI, Gold R, Langer-Gould AM. Multiple Sclerosis Disease Activity and Disability Following Cessation of Fingolimod for Pregnancy. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/4/e200110. [PMID: 37217309 DOI: 10.1212/nxi.0000000000200110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/08/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Discontinuation of fingolimod ≥2 months before pregnancy is recommended to minimize potential teratogenicity. The magnitude of MS pregnancy relapse risk, particularly severe relapses, after fingolimod cessation is unclear, as is whether this risk is reduced by pregnancy or modifiable factors. METHODS Pregnancies who stopped fingolimod treatment within 1 year before or during pregnancy were identified from the German MS and Pregnancy Registry. Data were collected through structured telephone-administered questionnaires and neurologists' notes. Severe relapses were defined as a ≥2.0 increase in Expanded Disability Status Scale (EDSS) or new or worsening relapse-related ambulatory impairment. Women who continued to meet this definition 1 year postpartum were classified as reaching the Severe Relapse Disability Composite Score (SRDCS). Multivariable models accounting for measures of disease severity and repeated events were used. RESULTS Of the 213 pregnancies among 201 women (mean age at pregnancy onset 32 years) identified, 56.81% (n = 121) discontinued fingolimod after conception. Relapses during pregnancy (31.46%) and the postpartum year (44.60%) were common. Nine pregnancies had a severe relapse during pregnancy and additional 3 during the postpartum year. One year postpartum, 11 of these (6.32% of n = 174 with complete EDSS information) reached the SRDCS. Adjusted relapse rates during pregnancy were slightly higher compared with the year before pregnancy (relapse rate ratio = 1.24, 95% CI 0.91-1.68). Neither exclusive breastfeeding nor resuming fingolimod within 4 weeks of delivery were associated with a reduced risk of postpartum relapses. Most pregnancies relapsed during the first 3 months postpartum (n = 55/204, 26.96%). DISCUSSION Relapses during pregnancy after fingolimod cessation are common. Approximately 6% of women will retain clinically meaningful disability from these pregnancy-related, fingolimod cessation relapses 1 year postpartum. This information should be shared with women on fingolimod desiring pregnancy, and optimizing MS treatment with nonteratogenic approaches should be discussed.
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Affiliation(s)
- Kerstin Hellwig
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group.
| | - Marianne Tokic
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Sandra Thiel
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Spalmai Hemat
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Nina Timmesfeld
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Andrea I Ciplea
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Ralf Gold
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Annette M Langer-Gould
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
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Cerdá-Fuertes N, Nagy S, Schaedelin S, Sinnecker T, Ruberte E, Papadopoulou A, Würfel J, Kuhle J, Yaldizli Ö, Kappos L, Derfuss T, Décard BF. Evaluation of frequency, severity, and independent risk factors for recurrence of disease activity after fingolimod discontinuation in a large real-world cohort of patients with multiple sclerosis. Ther Adv Neurol Disord 2023; 16:17562864221150312. [PMID: 36762317 PMCID: PMC9905031 DOI: 10.1177/17562864221150312] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/08/2022] [Indexed: 02/10/2023] Open
Abstract
Background Clinical and radiological signs of recurring disease activity (RDA) have been described in patients with multiple sclerosis (pwMS) after discontinuation of fingolimod (FGL). Objective To describe frequency, severity and potential risk factors for RDA after FGL discontinuation in a large real-world cohort of pwMS. Methods Post-FGL RDA was defined as evidence of clinical and/or radiological activity within 6 months after FGL discontinuation. Relapses with Expanded Disability Status Scale increase ⩾2 points and/or magnetic resonance imaging (MRI) activity with at least five cerebral gadolinium-enhancing lesions and/or ⩾6 cerebral new T2 lesions were defined as severe recurring disease activity (sRDA). Using a multivariate logistic model, we explored the influence of age, disease duration, sex, clinical, and MRI activity under FGL on the occurrence of RDA. Results We identified 110 pwMS who discontinued FGL. Thirty-seven (33.6%) developed post-FGL RDA and 13 (11.8%) also fulfilled criteria for sRDA. Younger age at diagnosis [odds ratio (OR) = 1.10, p < 0.01], shorter disease duration (OR = 1.17, p < 0.01), and MRI activity under FGL (OR = 2.92, p = 0.046) were independent risk factors for the occurrence of post-FGL RDA. Conclusion Individual risk assessment and optimal treatment sequencing can help to minimize the risk of post-FGL RDA. Early switch to highly effective disease-modifying therapy might reduce occurrence of post-FGL RDA.
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Affiliation(s)
- Nuria Cerdá-Fuertes
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Translational Imaging in Neurology (ThINK) Basel, Department of Medicine and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sara Nagy
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland,Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tim Sinnecker
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Medical Image Analysis Center (MIAC AG), Basel and qbig, Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Esther Ruberte
- Medical Image Analysis Center (MIAC AG), Basel and qbig, Department of Biomedical Engineering, University of Basel, Basel, Switzerland,Translational Imaging in Neurology (ThINK) Basel, Department of Medicine and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Athina Papadopoulou
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Translational Imaging in Neurology (ThINK) Basel, Department of Medicine and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jens Würfel
- Medical Image Analysis Center (MIAC AG), Basel and qbig, Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Jens Kuhle
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Özgür Yaldizli
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Translational Imaging in Neurology (ThINK) Basel, Department of Medicine and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ludwig Kappos
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tobias Derfuss
- Neurology Clinic and Policlinic, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
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Constantinescu V, Akgün K, Ziemssen T. Current status and new developments in sphingosine-1-phosphate receptor antagonism: fingolimod and more. Expert Opin Drug Metab Toxicol 2022; 18:675-693. [PMID: 36260948 DOI: 10.1080/17425255.2022.2138330] [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: 11/04/2022]
Abstract
INTRODUCTION Fingolimod was the first oral disease-modifying treatment approved for relapsing-remitting multiple sclerosis (MS) that serves as a sphingosine-1-phosphate receptor (S1PR) agonist. The efficacy is primarily mediated by S1PR subtype 1 activation, leading to agonist-induced down-modulation of receptor expression and further functional antagonism, blocking the egression of auto-aggressive lymphocytes from the lymph nodes in the peripheral compartment. The role of S1P signaling in the regulation of other pathways in human organisms through different S1PR subtypes has received much attention due to its immune-modulatory function and its significance for the regeneration of the central nervous system (CNS). The more selective second-generation S1PR modulators have improved safety and tolerability profiles. AREAS COVERED This review has been carried out based on current data on S1PR modulators, emphasizing the benefits of recent advances in this emergent class of immunomodulatory treatment for MS. EXPERT OPINION Ongoing clinical research suggests that S1PR modulators represent an alternative to first-line therapies in selected cases of MS. A better understanding of the relevance of selective S1PR pathways and the ambition to optimize selective modulation has improved the safety and tolerability of S1PR modulators in MS therapy and opened new perspectives for the treatment of other diseases.
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Affiliation(s)
- Victor Constantinescu
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Katja Akgün
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
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Clickable Biomaterials for Modulating Neuroinflammation. Int J Mol Sci 2022; 23:ijms23158496. [PMID: 35955631 PMCID: PMC9369181 DOI: 10.3390/ijms23158496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 02/04/2023] Open
Abstract
Crosstalk between the nervous and immune systems in the context of trauma or disease can lead to a state of neuroinflammation or excessive recruitment and activation of peripheral and central immune cells. Neuroinflammation is an underlying and contributing factor to myriad neuropathologies including neurodegenerative diseases like Alzheimer’s disease and Parkinson’s disease; autoimmune diseases like multiple sclerosis; peripheral and central nervous system infections; and ischemic and traumatic neural injuries. Therapeutic modulation of immune cell function is an emerging strategy to quell neuroinflammation and promote tissue homeostasis and/or repair. One such branch of ‘immunomodulation’ leverages the versatility of biomaterials to regulate immune cell phenotypes through direct cell-material interactions or targeted release of therapeutic payloads. In this regard, a growing trend in biomaterial science is the functionalization of materials using chemistries that do not interfere with biological processes, so-called ‘click’ or bioorthogonal reactions. Bioorthogonal chemistries such as Michael-type additions, thiol-ene reactions, and Diels-Alder reactions are highly specific and can be used in the presence of live cells for material crosslinking, decoration, protein or cell targeting, and spatiotemporal modification. Hence, click-based biomaterials can be highly bioactive and instruct a variety of cellular functions, even within the context of neuroinflammation. This manuscript will review recent advances in the application of click-based biomaterials for treating neuroinflammation and promoting neural tissue repair.
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Tur C, Dubessy AL, Otero-Romero S, Amato MP, Derfuss T, Di Pauli F, Iacobaeus E, Mycko M, Abboud H, Achiron A, Bellinvia A, Boyko A, Casanova JL, Clifford D, Dobson R, Farez MF, Filippi M, Fitzgerald KC, Fonderico M, Gouider R, Hacohen Y, Hellwig K, Hemmer B, Kappos L, Ladeira F, Lebrun-Frénay C, Louapre C, Magyari M, Mehling M, Oreja-Guevara C, Pandit L, Papeix C, Piehl F, Portaccio E, Ruiz-Camps I, Selmaj K, Simpson-Yap S, Siva A, Sorensen PS, Sormani MP, Trojano M, Vaknin-Dembinsky A, Vukusic S, Weinshenker B, Wiendl H, Winkelmann A, Zuluaga Rodas MI, Tintoré M, Stankoff B. The risk of infections for multiple sclerosis and neuromyelitis optica spectrum disorder disease-modifying treatments: Eighth European Committee for Treatment and Research in Multiple Sclerosis Focused Workshop Review. April 2021. Mult Scler 2022; 28:1424-1456. [PMID: 35196927 DOI: 10.1177/13524585211069068] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the recent years, the treatment of multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) has evolved very rapidly and a large number of disease-modifying treatments (DMTs) are now available. However, most DMTs are associated with adverse events, the most frequent of which being infections. Consideration of all DMT-associated risks facilitates development of risk mitigation strategies. An international focused workshop with expert-led discussions was sponsored by the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) and was held in April 2021 to review our current knowledge about the risk of infections associated with the use of DMTs for people with MS and NMOSD and corresponding risk mitigation strategies. The workshop addressed DMT-associated infections in specific populations, such as children and pregnant women with MS, or people with MS who have other comorbidities or live in regions with an exceptionally high infection burden. Finally, we reviewed the topic of DMT-associated infectious risks in the context of the current SARS-CoV-2 pandemic. Herein, we summarize available evidence and identify gaps in knowledge which justify further research.
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Affiliation(s)
- Carmen Tur
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Anne-Laure Dubessy
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/ Department of Neurology, Saint Antoine Hospital, AP-HP, Paris, France
| | - Susana Otero-Romero
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Maria Pia Amato
- Department of NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Tobias Derfuss
- Neurology Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedicine and Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Franziska Di Pauli
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ellen Iacobaeus
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Marcin Mycko
- Department of Neurology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Hesham Abboud
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Cleveland, OH, USA
| | - Anat Achiron
- Sheba Medical Center at Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Angelo Bellinvia
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Alexey Boyko
- Department of Neurology, Neurosurgery and Medical Genetics, Pirogov Russian National Research Medical University, Moscow, Russia/Institute of Clinical Neurology and Department of Neuroimmunology, Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - Jean-Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA
| | - David Clifford
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK/Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Mauricio F Farez
- Center for Research on Neuroimmunological Diseases, FLENI, Buenos Aires, Argentina
| | - Massimo Filippi
- Neurology Unit, Neurorehabilitation Unit and Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy/Vita-Salute San Raffaele University, Milan, Italy
| | - Kathryn C Fitzgerald
- Department of Neurology and Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Mattia Fonderico
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Riadh Gouider
- Department of Neurology, Razi Hospital, Tunis, Tunisia
| | - Yael Hacohen
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Filipa Ladeira
- Neurology Department, Hospital Santo António dos Capuchos, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Christine Lebrun-Frénay
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, UR2CA-URRIS, Université Nice Côte d'Azur, Nice, France
| | - Céline Louapre
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/Sorbonne University, Paris Brain Institute-ICM, Assistance Publique Hôpitaux de Paris, Inserm, CNRS, Hôpital de la Pitié Salpêtrière, CIC Neurosciences, Paris, France
| | - Melinda Magyari
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matthias Mehling
- Neurology Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedicine and Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, Idissc, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Lekha Pandit
- Center for Advanced Neurological Research, KS Hegde Medical Academy, Nitte (Deemed to be University), Mangalore, India
| | - Caroline Papeix
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/Sorbonne University, Paris Brain Institute-ICM, Assistance Publique Hôpitaux de Paris, Inserm, CNRS, Hôpital de la Pitié Salpêtrière, CIC Neurosciences, Paris, France
| | - Fredrik Piehl
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Emilio Portaccio
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Isabel Ruiz-Camps
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Krzysztof Selmaj
- Collegium Medicum, Department of Neurology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland/Center of Neurology, Lodz, Poland
| | - Steve Simpson-Yap
- Clinical Outcomes Research Unit, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Aksel Siva
- Department of Neurology, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Per Soelberg Sorensen
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - Adi Vaknin-Dembinsky
- Hadassah-Hebrew University Medical Center, Department of Neurology, The Agnes-Ginges Center for Neurogenetics Jerusalem, Jerusalem, Israel
| | - Sandra Vukusic
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France/Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR5292, Lyon, France/Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
| | | | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Münster, Germany
| | | | | | - Mar Tintoré
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Bruno Stankoff
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/ Department of Neurology, Saint Antoine Hospital, AP-HP, Paris, France
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7
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Schoedel KA, Kolly C, Gardin A, Neelakantham S, Shakeri-Nejad K. Abuse and dependence potential of sphingosine-1-phosphate (S1P) receptor modulators used in the treatment of multiple sclerosis: a review of literature and public data. Psychopharmacology (Berl) 2022; 239:1-13. [PMID: 34773483 PMCID: PMC8770388 DOI: 10.1007/s00213-021-06011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 10/18/2021] [Indexed: 12/05/2022]
Abstract
Abuse and misuse of prescription drugs remains an ongoing concern in the USA and worldwide; thus, all centrally active new drugs must be assessed for abuse and dependence potential. Sphingosine-1-phosphate (S1P) receptor modulators are used primarily in the treatment of multiple sclerosis. Among the new S1P receptor modulators, siponimod, ozanimod, and ponesimod have recently been approved in the USA, European Union (EU), and other countries. This review of literature and other public data has been undertaken to assess the potential for abuse of S1P receptor modulators, including ozanimod, siponimod, ponesimod, and fingolimod, as well as several similar compounds in development. The S1P receptor modulators have not shown chemical or pharmacological similarity to known drugs of abuse; have not shown abuse or dependence potential in animal models for subjective effects, reinforcement, or physical dependence; and do not have adverse event profiles demonstrating effects of interest to individuals who abuse drugs (such as sedative, stimulant, mood-elevating, or hallucinogenic effects). In addition, no reports of actual abuse, misuse, or dependence were identified in the scientific literature for fingolimod, which has been on the market since 2010 (USA) and 2011 (EU). Overall, the data suggest that S1P receptor modulators are not associated with significant potential for abuse or dependence, consistent with their unscheduled status in the USA and internationally.
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Affiliation(s)
| | - Carine Kolly
- grid.419481.10000 0001 1515 9979Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Anne Gardin
- grid.419481.10000 0001 1515 9979Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Srikanth Neelakantham
- grid.464975.d0000 0004 0405 8189Novartis Institutes for Biomedical Research, Novartis Healthcare Pvt Ltd, Hyderabad, India
| | - Kasra Shakeri-Nejad
- grid.419481.10000 0001 1515 9979Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland
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8
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Koska V, Förster M, Brouzou K, Arat E, Albrecht P, Aktas O, Küry P, Meuth SG, Kremer D. Case Report: Persisting Lymphopenia During Neuropsychiatric Tumefactive Multiple Sclerosis Rebound Upon Fingolimod Withdrawal. Front Neurol 2021; 12:785180. [PMID: 34777236 PMCID: PMC8585856 DOI: 10.3389/fneur.2021.785180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Fingolimod (FTY) is a disease modifying therapy for relapsing remitting multiple sclerosis (RRMS) which can lead to severe lymphopenia requiring therapy discontinuation in order to avoid adverse events. However, this can result in severe disease reactivation occasionally presenting with tumefactive demyelinating lesions (TDLs). TDLs, which are thought to originate from a massive re-entry of activated lymphocytes into the central nervous system, are larger than 2 cm in diameter and may feature mass effect, perifocal edema, and gadolinium enhancement. In these cases, it can be challenging to exclude important differential diagnoses for TDLs such as progressive multifocal leukoencephalopathy (PML) or other opportunistic infections. Here, we present the case of a 26-year-old female patient who suffered a massive rebound with TDLs following FTY discontinuation with primarily neuropsychiatric symptoms despite persisting lymphopenia. Two cycles of seven plasmaphereses each were necessary to achieve remission and ocrelizumab was used for long-term stabilization.
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Affiliation(s)
- Valeria Koska
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Moritz Förster
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Katja Brouzou
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Ercan Arat
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Philipp Albrecht
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Patrick Küry
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - David Kremer
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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9
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Bianco A, Lucchini M, Totaro R, Fantozzi R, De Luca G, Di Lemme S, Presicce G, Evangelista L, Di Tommaso V, Pastorino R, De Fino C, De Arcangelis V, Centonze D, Mirabella M. Disease Reactivation after Fingolimod Discontinuation in Pregnant Multiple Sclerosis Patients. Neurotherapeutics 2021; 18:2598-2607. [PMID: 34494237 PMCID: PMC8803993 DOI: 10.1007/s13311-021-01106-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 12/01/2022] Open
Abstract
Recent studies estimated an incidence of 4-25% of disease rebound after withdrawal of fingolimod (FTY) for any reason, but specific data on disease reactivation after FTY withdrawal due to pregnancy are limited. The aim of the study was to evaluate the frequency and predictors of disease reactivation in patients who stopped FTY for pregnancy. A multicentre retrospective cohort study was conducted in four Italian MS centres in 2013-2019. Both planned and unplanned pregnancies were included. The annualized relapse rate (ARR) was calculated before FTY treatment, during FTY treatment, during pregnancy and during the year after delivery. In total, 27 patients (mean age 29 years) were included. The ARR 1 year before FTY treatment was 1.3. Patients were exposed to FTY for a median of 2.9 years. The ARR was 0.04 during the last year before conception (p < 0.001 compared with the ARR before FTY treatment). Eleven patients became pregnant after a mean of 88 days following FTY discontinuation, whereas 16 patients stopped FTY after pregnancy confirmation. Relapses were observed in 22% of patients during pregnancy and in 44% in the postpartum period. ARR increased both during pregnancy (0.49; p = 0.027) and in the first year after delivery (0.67; p < 0.001) compared to the last year before pregnancy. Compared with radiological assessment before pregnancy, more patients showed new or enlarging T2 lesions (63% vs 30%; p = 0.02) and gadolinium-enhancing lesions (44% vs 0; p = 0.0001) on brain Magnetic Resonance Imaging. Relapses during pregnancy were the only significant predictor for postpartum relapses (OR 1.9, 95% CI 1.11-3.1). One case of spontaneous abortion and no cases of abnormal foetal development were observed. Despite adequate and prolonged control of disease activity, women who discontinue FTY because of pregnancy are at risk for disease reactivation. In patients who relapsed during pregnancy, the initiation of high-efficacy disease modifying drugs (DMDs) soon after delivery is advisable to prevent postpartum relapses.
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Affiliation(s)
- Assunta Bianco
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Centro Di Ricerca Per La Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Matteo Lucchini
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Centro Di Ricerca Per La Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Rocco Totaro
- Demyelinating Disease Center, San Salvatore Hospital, L’Aquila, Italy
| | | | - Giovanna De Luca
- Multiple Sclerosis Centre, Unit of Neurology, SS Annunziata University Hospital, Chieti, Italy
| | | | - Giorgia Presicce
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Luana Evangelista
- Demyelinating Disease Center, San Salvatore Hospital, L’Aquila, Italy
| | - Valeria Di Tommaso
- Multiple Sclerosis Centre, Unit of Neurology, SS Annunziata University Hospital, Chieti, Italy
| | - Roberta Pastorino
- Department of Woman and Child Health and Public Health-Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara De Fino
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Valeria De Arcangelis
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Diego Centonze
- Neurology Unit, IRCCS Neuromed, Pozzilli, IS Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Massimiliano Mirabella
- Multiple Sclerosis Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Centro Di Ricerca Per La Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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10
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Landi D, Signori A, Cellerino M, Fenu G, Nicoletti CG, Ponzano M, Mancuso E, Fronza M, Ricchiuto ME, Boffa G, Inglese M, Marfia GA, Cocco E, Frau J. What happens after fingolimod discontinuation? A multicentre real-life experience. J Neurol 2021; 269:796-804. [PMID: 34136943 DOI: 10.1007/s00415-021-10658-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/05/2021] [Accepted: 06/09/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To analyse the course of multiple sclerosis (MS) after fingolimod withdrawal in a multicentre cohort. METHODS Patients who discontinued fingolimod were included. Relapses, Expanded Disability Status Scale (EDSS), and new/gadolinium-enhancing lesions on magnetic resonance imaging (MRI) were assessed during the last year on fingolimod, and in the year after discontinuation. Wilcoxon test was used to analyse the difference in EDSS and relapses between the two periods, and to compare lymphocyte counts at discontinuation and 3 months later. Demographic and clinical variables were evaluated using univariable and multivariable logistic regression analyses. RESULTS Patients were 230 (females 66.1%; mean age 38 years; median EDSS 3). Fingolimod was discontinued due to inefficacy in 57%, and 87.4% started another treatment. Relapse was observed in 33% of the patients in the year after discontinuation. Severe reactivation was observed in 15%. During the first 6 months after discontinuation, new/enhancing lesions were seen in 62/116 patients. Higher age at the fingolimod discontinuation was found to be associated with a lower probability of inflammatory activity (p = 0.001) and severe reactivation (p = 0.007) during the year after discontinuation. Lower lymphocyte count was a risk factor for clinical, radiological, and severe activity (p = 0.02, p = 0.002, p = 0.01, respectively). CONCLUSIONS The main reason for the discontinuation of fingolimod was inefficacy. One-third of the patients had a relapse during the year after discontinuation, 15% experienced a severe reactivation, and approximately 50% of patients with available MRI scan had new/enhancing lesions. The risk factors for disease activity after discontinuation were low lymphocyte count and younger age.
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Affiliation(s)
- Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Alessio Signori
- Department of Health Sciences, University of Genova, Genoa, Italy
| | - Maria Cellerino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Giuseppe Fenu
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna, University of Cagliari, Via Is Guadazzonis, 2, 09126, Cagliari, Italy
| | - Carolina Gabri Nicoletti
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Marta Ponzano
- Department of Health Sciences, University of Genova, Genoa, Italy
| | - Elisabetta Mancuso
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Marzia Fronza
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna, University of Cagliari, Via Is Guadazzonis, 2, 09126, Cagliari, Italy
| | - Maria Elena Ricchiuto
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giacomo Boffa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Unit of Neurology, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, IS, Italy
| | - Eleonora Cocco
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna, University of Cagliari, Via Is Guadazzonis, 2, 09126, Cagliari, Italy
| | - Jessica Frau
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna, University of Cagliari, Via Is Guadazzonis, 2, 09126, Cagliari, Italy.
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11
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Abstract
BACKGROUND Fingolimod is an effective therapy for multiple sclerosis (MS). Isolated reports of very aggressive MS rebound after discontinuation of fingolimod are drawing neurologists' attention to this potentially severe complication of the drug. OBJECTIVE Our objective was to collect literature data on cases of MS rebound following fingolimod withdrawal. In addition, we report six new cases of this adverse event in Brazil. METHODS We carried out a systematic review of published data on cases of MS rebound after fingolimod was discontinued. In addition, the study reports a retrospective data series of Brazilian patients presenting this rebound reaction. RESULTS Twenty papers have been published reporting on 52 patients with severe MS rebound after fingolimod withdrawal. Six new patients are included in the present paper, all of them with aggressive rebound and accumulated disability sequelae. CONCLUSION We recommend gradual discontinuation of fingolimod with replacement by other treatment. The washout period should not exceed 4 weeks.
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12
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Barry B, Erwin AA, Stevens J, Tornatore C. Fingolimod Rebound: A Review of the Clinical Experience and Management Considerations. Neurol Ther 2019; 8:241-250. [PMID: 31677060 PMCID: PMC6858914 DOI: 10.1007/s40120-019-00160-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Indexed: 12/15/2022] Open
Abstract
Because the treatment of multiple sclerosis (MS) may span decades, the need often arises to make changes to the treatment plan in order to accommodate changing circumstances. Switching drugs, or the discontinuation of immunomodulatory agents altogether, may leave patients vulnerable to relapse or disease progression. In some cases, severe MS disease activity is noted clinically and on MRI after treatment withdrawal. When this disease activity is disproportionate to the pattern observed prior to treatment initiation, patients are said to have experienced rebound. Of the US Food and Drug Administration (FDA)-approved agents to treat MS, the drugs most commonly implicated in rebound are natalizumab and fingolimod. In this review based on the reported cases and data from clinical trials, we characterize disease rebound after fingolimod cessation. We also outline fingolimod rebound management considerations, summarizing what evidence is available to help clinicians mitigate the risk of rebound, switch therapies, and treat rebound events when they occur. The commonly encountered situation of fingolimod discontinuation prior to pregnancy is also discussed.
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Affiliation(s)
- Brian Barry
- Georgetown University Medical Center, Washington, DC, USA
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13
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Outcomes after fingolimod to alemtuzumab treatment shift in relapsing-remitting MS patients: a multicentre cohort study. J Neurol 2019; 266:2440-2446. [PMID: 31209573 DOI: 10.1007/s00415-019-09424-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/04/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND A high reactivation of multiple sclerosis (MS) was reported in patients treated with alemtuzumab after fingolimod. We aimed to understand whether this shift enhanced the risk for reactivation in a real-life cohort. METHODS Subjects with relapsing MS, shifting from fingolimod to alemtuzumab were enrolled. We collected the following data: age, sex, disease duration, relapses after fingolimod withdrawal, new T2/gadolinium (Gd)-enhancing lesions in the last magnetic resonance imaging (MRI) during fingolimod and in the first, while on alemtuzumab, lymphocyte counts at alemtuzumab start, and Expanded Disability Status Scale (EDSS) before and after alemtuzumab. RESULTS We enrolled 77 patients (women 61 (79%); mean age 36.2 years (SD 9.6), and disease duration 12.3 years (SD 6.8) at fingolimod discontinuation; median washout 1.8 months). The annualised relapse rate was 0.89 during fingolimod, 1.32 during washout, and 0.15 after alemtuzumab (p = 0.001). The EDSS changed from a median of 3 (IQR 2-4) at the end of fingolimod to 2.5 after alemtuzumab (IQR 1.5-4) (p = 0.013). The washout length and the lymphocyte count before alemtuzumab were not associated with EDSS change after alemtuzumab (p = 0.59 and p = 0.33, respectively). MRI activity decreased after alemtuzumab compared to that during fingolimod (p = 0.001). At alemtuzumab start, lymphocyte counts were < 0.8 × 103/mL in 21 patients. CONCLUSIONS In our cohort, alemtuzumab reduced relapse, new T2/Gd-enhancing lesions, and EDSS score, as compared to the previous periods (fingolimod/washout). These results were not related to washout length or lymphocyte counts. Therefore, a rapid initiation of alemtuzumab after fingolimod does not seem to be a risk factor for MS reactivation.
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14
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Schmidt S, Schulten T. Severe rebound after cessation of fingolimod treated with ocrelizumab with coincidental transient aggravation: report of two cases. Ther Adv Neurol Disord 2019; 12:1756286419846818. [PMID: 31105771 PMCID: PMC6503590 DOI: 10.1177/1756286419846818] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/11/2019] [Indexed: 11/16/2022] Open
Abstract
Background Fingolimod (FTY), an oral treatment for patients with relapsing-remitting multiple sclerosis (RRMS), has been associated with a significant rebound of disease activity after cessation of therapy. Methods We present the clinical and radiological findings of two patients with severe rebound after FTY withdrawal, which was further aggravated by the initiation of treatment with the B cell-depleting monoclonal antibody, ocrelizumab. Results Both patients exhibited significant Expanded Disability Status Scale progression after administration of ocrelizumab despite immune reconstitution more than 3 months after FTY withdrawal. Conclusions Although the observed effect may be coincidental, ocrelizumab may complicate recovery of rebound after cessation of FTY. Further studies are warranted to better understand and predict the clinical and immunological consequences of sequential immunosuppressive and immunomodulatory treatments in patients with highly active RRMS.
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Affiliation(s)
- Stephan Schmidt
- Neurologische Gemeinschaftspraxis Bonn, Gesundheitszentrum St. Johannes, Kölnstr. 54, 53111 Bonn, Germany
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15
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Lapucci C, Baroncini D, Cellerino M, Boffa G, Callegari I, Pardini M, Novi G, Sormani MP, Mancardi GL, Ghezzi A, Zaffaroni M, Uccelli A, Inglese M, Roccatagliata L. Different MRI patterns in MS worsening after stopping fingolimod. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e566. [PMID: 31086807 PMCID: PMC6481223 DOI: 10.1212/nxi.0000000000000566] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/05/2019] [Indexed: 11/15/2022]
Abstract
Objective To analyze MRI images in patients with MS who experienced worsening of neurologic status (WNS) after stopping fingolimod (FTY). Methods In this retrospective study, demographic, clinical, and radiologic data of patients with MS who experienced WNS after stopping FTY were retrospectively collected. We introduced the "δExpanded Disability Status Scale (EDSS)-ratio" to identify patients who, after FTY withdrawal, showed an inflammatory flare-up exceeding the highest lifetime disease activity level. Patients with δEDSS-ratio > 1 were enrolled in the study. Results Eight patients were identified. The mean (SD) age of the 8 (7 female) patients was 35.3 (4.9) years. The mean FTY treatment duration was 3.1 (0.8) years. The mean FTY discontinuation-WNS interval was 4 (0.9) months. The 4 patients with δEDSS-ratio ≥ 2 developed severe monophasic WNS (EDSS score above 8.5), characterized by clinical features and MRI findings not typical of MS, which we classified as "tumefactive demyelination pattern" (TDL) and "Punctuated pattern" (PL). Conversely, patients whose δEDSS-ratio was between 1 and 2 had clinical features and brain MRI compatible with a more typical, even if aggressive, MS relapse. In patients with TDL and PL, the flare-up of inflammatory activity led to severe tissue damage resulting in T2 but also T1 lesion volume increase at 6-month follow-up. Conclusions Peculiar MRI features (TDL and PL), different from a typical MS flare-up, might occur in some patients who experienced WNS after stopping FTY. Further studies, also involving immunologic biomarkers, are necessary to investigate TDL or PL pathophysiology.
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Affiliation(s)
- Caterina Lapucci
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Damiano Baroncini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Maria Cellerino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Giacomo Boffa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Ilaria Callegari
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Matteo Pardini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Giovanni Novi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Maria Pia Sormani
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Giovanni Luigi Mancardi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Angelo Ghezzi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Mauro Zaffaroni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Antonio Uccelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Luca Roccatagliata
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics (C.L., M.C., G.B., M.P., G.N., G.L.M., A.U., M.I.), Maternal and Child Health (DiNOGMI), University of Genoa; Multiple Sclerosis Centre (D.B., A.G., M.Z.), Gallarate Hospital, ASST of Valle Olona, Gallarate; Department of Neurology (M.C., G.B., M.P., G.L.M., A.U.), Ospedale Policlinico San Martino-Sistema Sanitario Regione; Liguria -Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia; IRCCS Foundation C. Mondino National Neurological Institute (I.C.), Pavia; Department of Health Sciences (DISSAL) (M.P.S., L. R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy; Department of Radiology and Neuroscience (M.I.), Icahn School of Medicine at Mount Sinai, New York; and Department of Neuroradiology (L.R.), Ospedale Policlinico San Martino IRCCS, Genoa, Italy
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16
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Extensive Multiple Sclerosis Reactivation after Switching from Fingolimod to Rituximab. Case Rep Neurol Med 2018; 2018:5190794. [PMID: 30112230 PMCID: PMC6077610 DOI: 10.1155/2018/5190794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/16/2018] [Indexed: 01/09/2023] Open
Abstract
During treatment with fingolimod, B cells are redistributed from blood to secondary lymphoid organs, where they are protected from the effect of anti-CD20 and other cell-depleting therapies. We describe a multiple sclerosis patient who had almost complete depletion of B cells in blood during and shortly after treatment with fingolimod. He developed severe disease activity resembling immune reconstitution syndrome after switching from fingolimod to rituximab, with first dose being six weeks after fingolimod cessation. Following recommendations from the Swedish MS Association, rituximab treatment was started as one single dose of 1000 mg. In patients treated with fingolimod, pathogenic B cells may still be sequestered in secondary lymph nodes if this dose is given early. To deplete such B cells as they egress from the lymph nodes, we propose that a second dose of rituximab a few weeks after the first dose should be considered.
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17
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Frau J, Sormani MP, Signori A, Realmuto S, Baroncini D, Annovazzi P, Signoriello E, Maniscalco GT, La Gioia S, Cordioli C, Frigeni B, Rasia S, Fenu G, Grasso R, Sartori A, Lanzillo R, Stromillo ML, Rossi S, Forci B, Cocco E. Clinical activity after fingolimod cessation: disease reactivation or rebound? Eur J Neurol 2018; 25:1270-1275. [DOI: 10.1111/ene.13694] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Affiliation(s)
- J. Frau
- Department of Medical Sciences and Public Health University of Cagliari CagliariItaly
| | - M. P. Sormani
- Department of Health Sciences Section of Biostatistics University of Genova GenovaItaly
| | - A. Signori
- Department of Health Sciences Section of Biostatistics University of Genova GenovaItaly
| | - S. Realmuto
- Department of Experimental Biomedicine and Clinical Neurosciences University of Palermo PalermoItaly
| | - D. Baroncini
- Multiple Sclerosis Study Centre AO s. Antonio Abate GallarateItaly
| | - P. Annovazzi
- Multiple Sclerosis Study Centre AO s. Antonio Abate GallarateItaly
| | - E. Signoriello
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences Second University of Naples NaplesItaly
| | - G. T. Maniscalco
- Neurological Clinic and Multiple Sclerosis Centre of ‘AORN A.Cardarelli’ NaplesItaly
| | - S. La Gioia
- USC Neurologia ASST Papa Giovanni XXIII BergamoItaly
| | - C. Cordioli
- Multiple Sclerosis Center Spedali Civili of Brescia Presidio di Montichiari BresciaItaly
| | - B. Frigeni
- USC Neurologia ASST Papa Giovanni XXIII BergamoItaly
| | - S. Rasia
- Multiple Sclerosis Center Spedali Civili of Brescia Presidio di Montichiari BresciaItaly
| | - G. Fenu
- Department of Medical Sciences and Public Health University of Cagliari CagliariItaly
| | - R. Grasso
- Neurologia Universitaria OORR FoggiaItaly
| | - A. Sartori
- Clinica Neurologica Azienda Ospedaliero‐Universitaria Ospedali Riuniti di Trieste TriesteItaly
| | - R. Lanzillo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology Multiple Sclerosis Centre Federico II University NaplesItaly
| | - M. L. Stromillo
- Department of Medicine, Surgery and Neuroscience University of Siena SienaItaly
| | - S. Rossi
- Neuroimmunology and Neuromuscular Diseases Unit IRCCS Fondazione Istituto Neurologico Carlo Besta MilanoItaly
| | - B. Forci
- Dipartimento di Neuroscienze Azienda Ospedaliero‐Universitaria Careggi Area del farmaco e Salute del bambino (NEUROFARBA) Florence Italy
| | - E. Cocco
- Department of Medical Sciences and Public Health University of Cagliari CagliariItaly
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