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Singer BA, Morgan D, Stamm JA, Williams AA. Patient and Physician Perspectives of Treatment Burden in Multiple Sclerosis. Neurol Ther 2024:10.1007/s40120-024-00654-1. [PMID: 39230830 DOI: 10.1007/s40120-024-00654-1] [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: 07/10/2024] [Accepted: 08/05/2024] [Indexed: 09/05/2024] Open
Abstract
The number of disease-modifying therapies (DMTs) approved for the treatment of multiple sclerosis (MS) has greatly increased in recent decades, leading to higher treatment complexity. DMTs can differ in mode and frequency of administration, benefit-risk profile, and associated costs. Patients with MS contend not only with the burden of their chronic disease but also with the treatment burden of their MS therapy. Adhering to dosing schedules and infusion appointments can be difficult for busy, working-age patients or those with limited access to transportation. Patients and healthcare professionals (HCPs) may have differing priorities, concerns, and preferences when selecting treatment, potentially affecting treatment satisfaction and, importantly, adherence. Additionally, patients face direct and indirect costs related to treatment. These factors can all contribute to a high treatment burden on patients, impacting their quality of life and potentially leading to worse patient outcomes. HCPs, patients, and caregivers must work together to alleviate treatment burden through effective communication, shared decision-making, appreciating each other's perspectives, and additional HCP support. Consideration of treatment burden into clinical guidelines is also warranted. In this review, we examine key factors impacting treatment burden for patients with MS, with a focus on the patient perspective as provided by our patient authors, and provide strategies to minimize treatment burden.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St. Louis, MO, 63131, USA.
| | - Dawn Morgan
- Patient Author: MS patient advocate, author, speaker, founder of Unquiet Minds Move Nonprofit, Washington, DC, USA
| | - Julie A Stamm
- Patient Author: MS patient advocate, author, educator, Denver, CO, USA
| | - Anita A Williams
- Patient Author: MS patient advocate, author, co-founder of MS Minority Research Engagement Partnership Network, RIDE Council steering committee member, Aurora, CO, USA
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Yang J, Sun Y, Zhou X, Zhang D, Xu Z, Cao J, Fan B. Risk of secondary autoimmune diseases with alemtuzumab treatment for multiple sclerosis: a systematic review and meta-analysis. Front Immunol 2024; 15:1343971. [PMID: 38690271 PMCID: PMC11058189 DOI: 10.3389/fimmu.2024.1343971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Abstract
Background and purpose The objective of this study is to evaluate the risk of secondary autoimmune diseases in multiple sclerosis (MS) patients treated with alemtuzumab (ALZ) through a meta-analysis. Methods PubMed, Web of Science, OVID, EMBASE, and Cochrane central register of controlled trials were searched. Information and data were screened and extracted by 2 researchers. The obtained data were analyzed using the R software meta package. Quality assessment was conducted using the Newcastle-Ottawa Scale (NOS). The causes of heterogeneity were analyzed using subgroup analysis and sensitivity analysis. Publication bias was evaluated using funnel plots and Egger's test. Results The search retrieved a total of 3530 papers from the databases. After screening, a total of 37 studies were included in the meta-analysis. The analysis results indicate that the pooled incidence rate of overall secondary autoimmune events (SAEs) in the included studies was 0.2824 [0.2348, 0.3300] (I²=94%, p<0.01). The overall incidence of autoimmune thyroid events (ATE) was 0.2257 [0.1810, 0.2703] (I²=94%, p<0.01). Among them, the rate of serious autoimmune thyroid events (SATE) was 0.0541 [0.0396, 0.0687] (I²=0%, p=0.44). The incidence rates of different thyroid events were as follows: Graves' disease (GD), 0.2266 [0.1632, 0.2900] (I²=83%, p<0.01); Hashimoto thyroiditis (HT), 0.0844 [0.0000, 0.2262] (I²=81%, p=0.02); Hashimoto thyroiditis with hypothyroidism (HTwH), 0.0499 [0.0058, 0.0940] (I²=37%, p=0.21); fluctuating thyroid dysfunction (FTD), 0.0219 [0.0015, 0.0424] (I²=0%, p=0.40); transient thyroiditis (TT), 0.0178 [0.0062, 0.0295] (I²=0%, p=0.94). The overall incidence of hematological events was 0.0431 [0.0274, 0.0621] (I²=70%, p<0.01). The incidence rates from high to low were as follows: lymphopenia, 0.0367 [0.0000, 0.0776] (I²=81%, p=0.02); Idiopathic thrombocytopenic purpura (ITP), 0.0258 [0.0199, 0.0323] (I²=25%, p=0.15); Hemolytic anemia (HA), 0.0177 [0.0081, 0.0391] (I²=29%, p=0.23); pancytopenia, 0.0136 [0.0000, 0.0314] (I²=0%, p=0.67); Neutropenia, 0.0081 [0.0000, 0.0183] (I²=0%, p=0.42). After excluding thyroid and hematological diseases, the combined incidence of other related SAEs was 0.0061 [0.0014, 0.0109] (I²=50%, p=0.02). The incidence of each disease ranked from highest to lowest as: skin psoriasis (SP), 0.0430 [0.0000, 0.0929] (I²=0%, p=0.57); alopecia areata (AA), 0.0159 [0.0024, 0.0372] (I²=19%, p=0.29); vitiligo, 0.0134 [0.0044, 0.0223] (I²=0%, p=0.81); inflammatory atrichia (IA), 0.0103 [0.0000, 0.0232] (I²=0%, p=0.43); chronic urticaria (CU), 0.0107 [0.0000, 0.0233] (I²=0%, p=0.60); and nephropathy, 0.0051 [0.0000, 0.0263] (I²=62%, p=0.02). Conclusion The occurrence of secondary autoimmune diseases in patients with MS treated with ALZ is noteworthy, particularly in the form of thyroid events and hematological events. Clinicians should monitor the overall condition of patients promptly for early management and avoid delayed diagnosis and treatment. Systematic review registration inplasy.com/inplasy-2024-4-0048/, identifier INPLASY202440048.
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Affiliation(s)
- Jianguo Yang
- The First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Yuying Sun
- The First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Xinpeng Zhou
- Rheumatology and Immunology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Di Zhang
- Rheumatology and Immunology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Ziqi Xu
- Rheumatology and Immunology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Jiaojiao Cao
- The First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Bing Fan
- Rheumatology and Immunology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
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Rodríguez de Vera Gómez P, Méndez Muros M, Torres Cuadro A, Toyos Sáenz de Miera FJ, López Ruiz R, Guerrero Vázquez R, García González JJ, Garrido Hermosilla AM, Martín Hernández T. Alemtuzumab induces severe orbitopathy in relapsing-remitting multiple sclerosis. J Neurol 2024; 271:486-496. [PMID: 37773417 DOI: 10.1007/s00415-023-11995-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/05/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023]
Abstract
CONTEXT Treatment with Alemtuzumab (ALZ) in patients with Relapsing-Remitting Multiple Sclerosis (RRMS) is associated with the development of ALZ-induced Graves' disease (GD-ALZ). Some cases may develop associated Graves´ Orbitopathy (GO-ALZ), with possible visual compromise. AIM The aim of this study was to describe the main clinical and biochemical characteristics of GD-ALZ, as well as the clinical course of a case series of GO-ALZ METHODS: This study is a retrospective observational study, carried out in a reference hospital for the care of patients with RRMS in Spain. Cases treated with ALZ in the period 2014-2022 were included. GO-ALZ cases were identified among those with clinical symptoms compatible with thyroid eye disease after initiating ALZ treatment. RESULTS A total of 135 cases, with a mean follow-up of 69.6 months after the first ALZ cycle, were included. The incidence of GD-ALZ was 32.6% (44/135), with a predominance of women (77.3%) and mean age of 41.9 years. The presence of first-degree relatives with hypothyroidism was identified as risk factor for the development of GD-ALZ (adjusted P-value: 0.02). GO-ALZ was diagnosed in 6 cases (incidence: 13.6%), of which 3 had severe clinical forms of GO, requiring anti-IL-6 treatment. A favorable response was reported in all of them, with a significant decrease in disease activity and improvement in proptosis. CONCLUSIONS We report one of the largest cohorts of GD-ALZ and GO-ALZ cases. The diagnosis of these entities should be taken into account in patients treated with Alemtuzumab, given the risk of developing severe clinical forms. In moderate-severe forms of GO-ALZ, drugs with anti-IL-6 activity are a safe and effective option.
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Affiliation(s)
- Pablo Rodríguez de Vera Gómez
- Endocrinology and Nutrition Department, University Hospital Virgen de la Macarena, Avenida Dr Fedriani 3, 41009, Seville, Spain.
| | - Mariola Méndez Muros
- Endocrinology and Nutrition Department, University Hospital Virgen de la Macarena, Avenida Dr Fedriani 3, 41009, Seville, Spain.
- Andalusian Reference Unit for Graves' Orbitopathy (UPRA) Endocrinology, Seville, Spain.
| | - Alberto Torres Cuadro
- Endocrinology and Nutrition Department, University Hospital Virgen de la Macarena, Avenida Dr Fedriani 3, 41009, Seville, Spain
| | | | - Rocío López Ruiz
- Neurology Department, University Hospital Virgen de la Macarena, Seville, Spain
| | - Raquel Guerrero Vázquez
- Endocrinology and Nutrition Department, University Hospital Virgen de la Macarena, Avenida Dr Fedriani 3, 41009, Seville, Spain
| | | | - Antonio Manuel Garrido Hermosilla
- Ophthalmology Department, University Hospital Virgen de la Macarena, Seville, Spain
- Andalusian Reference Unit for Graves' Orbitopathy (UPRA) Endocrinology, Seville, Spain
| | - Tomás Martín Hernández
- Endocrinology and Nutrition Department, University Hospital Virgen de la Macarena, Avenida Dr Fedriani 3, 41009, Seville, Spain
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Kazakou P, Tzanetakos D, Vakrakou AG, Tzartos JS, Evangelopoulos ΜE, Anagnostouli M, Stathopoulos P, Kassi GN, Stefanis L, Kilidireas C, Zapanti E. Thyroid autoimmunity following alemtuzumab treatment in multiple sclerosis patients: a prospective study. Clin Exp Med 2023; 23:2885-2894. [PMID: 36641771 PMCID: PMC10543528 DOI: 10.1007/s10238-022-00981-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/20/2022] [Indexed: 01/16/2023]
Abstract
Autoimmune thyroid disease (AITD) is the most common adverse effect in alemtuzumab (ALZ) treated relapsing-remitting (RR) multiple sclerosis (MS) patients. The objective of this prospective study was to analyze the occurrence, timing of onset, clinical course, and laboratory characteristics of AITD post-ALZ. We evaluated 35 RRMS patients treated with ALZ at a single academic MS center; clinical and laboratory data were collected before ALZ initiation and thereafter quarterly on follow-up with a median of 43.5 months. Seventeen out of 31 patients (54.8%) with no prior history of thyroid dysfunction developed AITD with a mean onset of 19.4 months ± 10.2 (SD) after the first ALZ cycle; Graves' disease (GD) (n = 9); hypothyroidism with positive stimulating thyrotropin receptor antibodies (TRAb) (n = 1); Hashimoto thyroiditis (HT) (n = 6); HT with hypothyroidism (n = 1). Interestingly, seven of nine (77.7%) GD patients showed a fluctuating course. Three out of four patients with preexisting thyroid disease remained stable, whereas one with prior HT and hypothyroidism developed fluctuating GD. All patients with GD commenced antithyroid drugs (ATDs); five continued on "block and replace" treatment; one required radioactive iodine, and one total thyroidectomy. Our analysis showed earlier onset of ALZ-induced AITD in comparison to most other ALZ cohorts; overall, these patients required complex therapeutic approaches of the AITD. We observed a higher rate of fluctuating GD, with earlier onset and lower remission rate than previously reported, which in the majority of patients required prolonged "block and replace" therapy in the minimum dose of each therapeutic agent or more definitive interventions.
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Affiliation(s)
- Paraskevi Kazakou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Dimitrios Tzanetakos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece.
| | - Aigli G Vakrakou
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - John S Tzartos
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Μaria-Eleptheria Evangelopoulos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Anagnostouli
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Stathopoulos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgia N Kassi
- Department of Endocrinology, Alexandra Hospital, Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Rodríguez de Vera Gómez P, García-González JJ, Ravé-García R, López Ruiz R, Torres-Cuadro A, Eichau-Madueño S, García-García C, Martín-Hernández T. Graves' disease induced by Alemtuzumab in relapsing-remitting multiple sclerosis patients: an observational study in a reference center. J Endocrinol Invest 2022; 45:1977-1990. [PMID: 35718853 DOI: 10.1007/s40618-022-01832-4] [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] [Received: 02/12/2022] [Accepted: 05/30/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Graves' disease induced by Alemtuzumab (GD-IA) is one of the most frequently observed adverse events in patients with multiple sclerosis (MS) treated with this drug. The aim of this study is the sequencing and description of these events, along with the identification of the risk factors leading to their development. MATERIALS AND METHODS We conducted a retrospective observational study identifying patients with relapsing-remitting multiple sclerosis (RRMS) and GD-IA, studying their baseline clinical features and variables related to the natural history of the disease. RESULTS A total of 121 participants treated with Alemtuzumab were included, of whom 41 developed GD-IA (33.9%). A higher percentage of first-degree relatives with autoimmune thyroid disease was documented in the subgroup who developed the abovementioned event (14.6% vs 1.5%; p < 0.01). A total of 70.7% of patients diagnosed with GD-IA (n = 29/41) had fluctuations in thyroid function during follow-up, and 24.4% (n = 10/41) required total thyroidectomy for resolution of the condition. In 54.8% of participants diagnosed with GD-IA, a pattern of significant TSH decline was identified in the month prior to diagnosis of the event, with high predictive ability and associated with a more favorable clinical course (fewer weeks to normalization of thyroid function, HR = 8.99; 95% CI [2.11-38.44]; p = 0.0003). CONCLUSION GD-IA has an atypical course compared to classical forms of the disease. The identification of risk factors for the development of the disease before starting treatment with Alemtuzumab and early monitoring of thyroid function once this treatment is initiated prove to be useful strategies in the diagnosis and clinical management of this condition.
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Affiliation(s)
| | - J J García-González
- Endocrinology and Nutrition Department, University Hospital Virgen Macarena, Seville, Spain
| | - R Ravé-García
- Endocrinology and Nutrition Department, University Hospital Virgen Macarena, Seville, Spain
| | - R López Ruiz
- Neurology Department, University Hospital Virgen Macarena, Seville, Spain
| | - A Torres-Cuadro
- Endocrinology and Nutrition Department, University Hospital Virgen Macarena, Seville, Spain
| | - S Eichau-Madueño
- Neurology Department, University Hospital Virgen Macarena, Seville, Spain
| | - C García-García
- Endocrinology and Nutrition Department, University Hospital Virgen Macarena, Seville, Spain
| | - T Martín-Hernández
- Endocrinology and Nutrition Department, University Hospital Virgen Macarena, Seville, Spain
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Manso J, Zhu YH, Margoni M, Rinaldi F, Censi S, Carducci S, Cosma C, Plebani M, Gallo P, Mian C. Alemtuzumab-induced autoimmune thyroid events in patients with relapsing-remitting multiple sclerosis: A real-life and monocentric experience at a tertiary-level centre. Clin Endocrinol (Oxf) 2022; 97:331-338. [PMID: 34724236 DOI: 10.1111/cen.14616] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/01/2021] [Accepted: 10/01/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Alemtuzumab-induced autoimmune thyroid events (AIATEs) are the most common adverse effects observed in relapsing-remitting multiple sclerosis (RRMS) patients. This study aims to explore the clinical and biochemical characteristics of such AIATEs, and to examine the risk factors for their occurrence, particularly for the worst clinical phenotype of fluctuating Graves' disease (GD). DESIGN, PATIENTS, MEASUREMENTS We retrospectively analysed a real-life single-centre consecutive series of 57 RRMS patients treated with alemtuzumab whose clinical and biochemical parameters were collected before starting the treatment and then monthly during their follow-up. RESULTS AIATEs developed in 39% of patients a mean 17 months ± 11 after the first cycle of alemtuzumab. The most common AIATEs were GD (64%), followed by Hashimoto's thyroiditis with hypothyroidism (23%), TSH-receptor-antibody (TRAb)-positive hypothyroidism (9%), and silent thyroiditis (4%). GD showed a fluctuating course in 57% of cases. Baseline positivity for anti-thyroperoxidase antibodies, and higher absolute titers of anti-thyroglobulin and anti-thyroperoxidase antibodies correlated significantly with the risk of developing AIATEs, but TRAb positivity did not. Higher TRAb titers at the time of GD being diagnosed correlated strongly with a greater risk of the fluctuating GD phenotype. On ROC curve analysis, we found that a cut-off of 7.3 IU/L could be used to predict the risk of developing a fluctuating GD, with a positive predictive value of 100%. CONCLUSIONS TRAb levels measured with commercial automatic methods at the time of a patient being diagnosed with alemtuzumab-induced GD emerged as a novel biomarker for predicting a fluctuating disease phenotype, with an influence on subsequent therapeutic decisions and patients' follow-up.
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Affiliation(s)
- Jacopo Manso
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Yi Hang Zhu
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Monica Margoni
- Veneto Regional Multiple Sclerosis Center (CeSMuV), Padua University Hospital, Padua, Italy
| | - Francesca Rinaldi
- Veneto Regional Multiple Sclerosis Center (CeSMuV), Padua University Hospital, Padua, Italy
| | - Simona Censi
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Sofia Carducci
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Chiara Cosma
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Paolo Gallo
- Veneto Regional Multiple Sclerosis Center (CeSMuV), Padua University Hospital, Padua, Italy
- Department of Neurosciences, Padua University, Padua, Italy
| | - Caterina Mian
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
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