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Standard Dose Weekly Intramuscular Beta Interferon-1a May Be Inadequate for Some Patients with Multiple Sclerosis: A 19-Year Clinical Experience Using Twice a Week Dosage. Neurol Ther 2022; 11:1399-1408. [PMID: 35796951 PMCID: PMC9338207 DOI: 10.1007/s40120-022-00377-1] [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: 02/22/2022] [Accepted: 06/07/2022] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION Results from several clinical trials suggest there is a dose-response effect for beta interferon-1a (INFβ1a) in multiple sclerosis (MS). METHODS Our objective was to confirm these results through a retrospective analysis of patients with MS who had breakthrough disease (BD) on intramuscular (IM) INFβ1a (Avonex®) once per week (QW), who were switched to twice per week (BIW) IM INFβ1a between 1995 and 2015. The primary outcome measure was no further BD for at least 24 months. A secondary outcome measure was decrease in mean percentage of disease activity over time. BD was defined as continued relapses, new T2 or enhanced lesions on magnetic resonance imaging (MRI) of the brain, or worsening of the Expanded Disability Status Scale (EDSS) or the neurological examination. RESULTS Among 92 patients on QW IM INFβ1a, 53 patients with BD were switched to BIW IM INFβ1a. Of these 53 patients, 44 had adequate follow-up for at least 2 years. Twenty-three of these had no further BD for 24 months or more (range 24-192 months). Beta interferon neutralizing antibody testing was negative in 19 patients. An intent-to-treat analysis of the uncensored data from 52 switched patients also supported a treatment benefit. CONCLUSION For patients with MS having breakthrough disease on QW INFβ1a, switching to more frequently administered INFβ may be an option. Advantages to using IM INFβ1a for this include no skin reactions and a lower incidence of neutralizing antibodies. Further pragmatic, observational, larger-group studies comparing treatment with Avonex® and higher dosed IM INFβ1a, such as the recently FDA-approved IM peginterferon beta-1a, may be indicated.
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Abstract
The development of antidrug antibodies (ADAs) is a major problem in several recombinant protein therapies used in the treatment of multiple sclerosis (MS). The etiology of ADAs is multifaceted. The predisposition for a breakdown of immune tolerance is probably genetically determined, and many factors may contribute to the immunogenicity, including structural properties, formation of aggregates, and presence of contaminants and impurities from the industrial manufacturing process. ADAs may have a neutralizing capacity and can reduce or abrogate the bioactivity and therapeutic efficacy of the drug and cause safety issues. Interferon (IFN)-β was the first drug approved for the treatment of MS, and-although it is generally recognized that neutralizing antibodies (NAbs) appear and potentially have a negative effect on therapeutic efficacy-the use of routine measurements of NAbs and the interpretation of the presence of NAbs has been debated at length. NAbs appear after 9-18 months of therapy in up to 40% of patients treated with IFNβ, and the frequency and titers of NAbs depend on the IFNβ preparation. Although all pivotal clinical trials of approved IFNβ products in MS exhibited a detrimental effect of NAbs after prolonged therapy, some subsequent studies did not observe clinical effects from NAbs, which led to the claim that NAbs did not matter. However, it is now largely agreed that persistently high titers of NAbs indicate an abrogation of the biological response and, hence, an absence of therapeutic efficacy, and this observation should lead to a change of therapy. Low and medium titers are ambiguous, and treatment decisions should be guided by determination of in vivo messenger RNA myxovirus resistance protein A induction after IFNβ administration and clinical disease activity. During treatment with glatiramer acetate, ADAs occur frequently but do not appear to adversely affect treatment efficacy or result in adverse events. ADAs occur in approximately 5% of patients treated with natalizumab within 6 months of therapy, and persistent NAbs are associated with a lack of efficacy and acute infusion-related reactions and should instigate a change of therapy. When using the anti-CD20 monoclonal antibodies ocrelizumab and ofatumumab in the treatment of MS, it is not necessary to test for NAbs as these occur very infrequently. Alemtuzumab is immunogenic, but routine measurements of ADAs are not recommended as the antibodies in the pivotal 2-year trials at the population level did not influence lymphocyte depletion or repopulation, efficacy, or safety. However, in some individuals, NAbs led to poor lymphocyte depletion.
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Thrombotic Thrombocytopenic Purpura in Interferon Beta-1a-Treated Patient Diagnosed with Relapsing-Remitting Multiple Sclerosis: A Case Report. LIFE (BASEL, SWITZERLAND) 2022; 12:life12010080. [PMID: 35054473 PMCID: PMC8778067 DOI: 10.3390/life12010080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 12/04/2022]
Abstract
Background: Secondary thrombotic thrombocytopenic purpura (TTP) due to interferon beta-1a intramuscular (im) treatment is an uncommon adverse effect with only a few cases in multiple sclerosis patients reported worldwide. TTP together with haemolytic uremic syndrome (HUS) are classic forms of thrombotic microangiopathy, characterized by small-vessel platelet micro-thrombi that manifest clinically in a similar manner. Most common signs and symptoms include bruises and ecchymosis, neurologic symptoms and renal impairment. Interferon beta-1a represents one of the first-line therapies for relapsing-remitting multiple sclerosis due to its accessibility and efficacy. Case presentation: A 36-year-old woman who was previously diagnosed with relapsing-remitting multiple sclerosis had received weekly intramuscular injections with beta-interferon-1a (Avonex 30 mcg). After 9 months of treatment, she presented bruises and ecchymosis on her limbs and torso, epistaxis, gingival bleeding aggravated within 48 h and a persistent headache that was non-responsive to common analgesics. Haematology tests revealed typical results for thrombotic microangiopathy, including severe thrombocytopenia (4000/mm3) and microangiopathic haemolytic anaemia with frequent schistocytes on the peripheral blood smear. Once the beta-interferon administration was ceased and upon the initiation of methylprednisolone, the symptoms remitted. Conclusions: In this case study, we portrayed the particular association between the remission phase of multiple sclerosis and the violent onset of interferon-induced thrombotic thrombocytopenic purpura.
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Cohan SL, Hendin BA, Reder AT, Smoot K, Avila R, Mendoza JP, Weinstock-Guttman B. Interferons and Multiple Sclerosis: Lessons from 25 Years of Clinical and Real-World Experience with Intramuscular Interferon Beta-1a (Avonex). CNS Drugs 2021; 35:743-767. [PMID: 34228301 PMCID: PMC8258741 DOI: 10.1007/s40263-021-00822-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 12/15/2022]
Abstract
Recombinant interferon (IFN) β-1b was approved by the US Food and Drug Administration as the first disease-modifying therapy (DMT) for multiple sclerosis (MS) in 1993. Since that time, clinical trials and real-world observational studies have demonstrated the effectiveness of IFN therapies. The pivotal intramuscular IFN β-1a phase III trial published in 1996 was the first to demonstrate that a DMT could reduce accumulation of sustained disability in MS. Patient adherence to treatment is higher with intramuscular IFN β-1a, given once weekly, than with subcutaneous formulations requiring multiple injections per week. Moreover, subcutaneous IFN β-1a is associated with an increased incidence of injection-site reactions and neutralizing antibodies compared with intramuscular administration. In recent years, revisions to MS diagnostic criteria have improved clinicians' ability to identify patients with MS and have promoted the use of magnetic resonance imaging (MRI) for diagnosis and disease monitoring. MRI studies show that treatment with IFN β-1a, relative to placebo, reduces T2 and gadolinium-enhancing lesions and gray matter atrophy. Since the approval of intramuscular IFN β-1a, a number of high-efficacy therapies have been approved for MS, though the benefit of these high-efficacy therapies should be balanced against the increased risk of serious adverse events associated with their long-term use. For some subpopulations of patients, including pregnant women, the safety profile of IFN β formulations may provide a particular benefit. In addition, the antiviral properties of IFNs may indicate potential therapeutic opportunities for IFN β in reducing the risk of viral infections such as COVID-19.
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Affiliation(s)
- Stanley L. Cohan
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, Portland, OR USA
| | | | | | - Kyle Smoot
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, Portland, OR USA
| | | | | | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, State University of New York, 1010 Main St., 2nd floor, Buffalo, NY, 14202, USA.
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Hermanrud C, van Capel TMM, Auer M, Karrenbauer V, Deisenhammer F, de Jong EC, Fogdell-Hahn A. Different Interferon Beta Preparations Induce the Same Qualitative Immune Response in Human Skin. J Interferon Cytokine Res 2019; 39:302-313. [PMID: 30848986 DOI: 10.1089/jir.2018.0038] [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] [Indexed: 11/12/2022] Open
Abstract
Interferon beta (IFNβ) is used as a first-line treatment for multiple sclerosis (MS) and is injected intramuscularly or subcutaneously (s.c.). The subcutaneous route is considered more immunogenic as it is associated with increased antidrug antibody-positive patients. The skin contains dendritic cells (DCs) and it is unclear whether these contribute to immunogenicity. To assess the effect of IFNβ on skin-resident cells, IFNβ was injected intradermally (i.d.) ex vivo using a human skin explant model or s.c. in vivo in MS patients. Ex vivo, intradermal IFNβ injections reduced migration and enhanced surface CD86 expression of dermal DCs, and an increased expression of HLA-DR+ was observed in skin biopsies taken after subcutaneous IFNβ injection (in vivo). In both models, IFNβ elevated the expression of several inflammatory cytokines when compared to the control biopsies. Our results show that 3 different IFNβ preparations, normalized in dose and injection site, induce similar immune responses, suggesting that the differences in immunogenicity are likely due to the route and frequency of administration.
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Affiliation(s)
- Christina Hermanrud
- 1 Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Toni M M van Capel
- 2 Department of Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael Auer
- 3 Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Virginija Karrenbauer
- 1 Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Florian Deisenhammer
- 3 Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Esther C de Jong
- 2 Department of Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands
| | - Anna Fogdell-Hahn
- 1 Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
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Chen C, Wu N, Watson C. Multiple sclerosis patients who are stable on interferon therapy show better outcomes when staying on same therapy than patients who switch to another interferon. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:723-730. [PMID: 30464565 PMCID: PMC6219109 DOI: 10.2147/ceor.s163907] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Real-world outcomes from staying on an interferon beta (IFNβ) vs switching to another IFNβ could help guide treatment decisions. This study's objective was to compare outcomes of stable multiple sclerosis (MS) patients on an IFNβ who stayed on therapy vs those who switched to another IFNβ. Methods MS patients were identified from the Optum Insights Clinformatics Data Mart Multi-Plan who were 18-64 years old and relapse-free (stable) over 1 year while continuously being treated with an IFNβ. Patients were propensity score matched 3:1 using age, gender, initial IFNβ, adherence, and month and year for patients who stayed on the initial IFNβ (No Switch) to patients who switched to another IFNβ (Switch). Patients had to be continuously enrolled for 1 year prior to and 1 year after the index date (date of the first claim of the switched-to IFNβ or the match date when continuing on initial IFNβ treatment). Patients were enrolled with index dates between January 1, 2005 and September 30, 2014. Relapses were recorded during the 1-year follow-up period after index date. Results After matching, there were 381 patients in the Switch group and 1,143 in the No Switch group. Baseline characteristics were well matched between groups (average age 46 years, 72% female). The percentage of patients experiencing a relapse during the follow-up was significantly higher in the Switch group than in the No Switch group (21% vs 12%, P<0.0001). Annual relapse rate during the follow-up was significantly higher in the Switch group than in the No Switch group (0.35 vs 0.20, P<0.0001). Conclusion MS patients stable on IFNβ therapy who remain on initial therapy had significantly better outcomes (lower annual relapse rate and percentage of patients with relapses) than patients who switched to another IFNβ. This supports the benefits of allowing patients to remain on current IFNβ therapy when stable.
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Affiliation(s)
- Chao Chen
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Ning Wu
- Value and Access, Biogen, Cambridge, MA, USA,
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Jakimovski D, Kolb C, Ramanathan M, Zivadinov R, Weinstock-Guttman B. Interferon β for Multiple Sclerosis. Cold Spring Harb Perspect Med 2018; 8:cshperspect.a032003. [PMID: 29311124 DOI: 10.1101/cshperspect.a032003] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite that the availability of new therapeutic options has expanded the multiple sclerosis (MS) disease-modifying therapy arsenal, interferon β (IFN-β) remains an important therapy option in the current decision-making process. This review will summarize the present knowledge of IFN-β mechanism of action, the overall safety, and the short- and long-term efficacy of its use in relapsing remitting MS and clinically isolated syndromes. Data on secondary progressive MS is also provided, although no clear benefit was identified.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York 14203
| | - Channa Kolb
- Jacobs MS Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York 14202
| | - Murali Ramanathan
- Jacobs MS Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York 14202.,Department of Pharmaceutical Sciences, School of Medicine and Biomedical Sciences, State University of New York, Buffalo, New York 14214
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York 14203.,MR Imaging Clinical Translational Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York 14203
| | - Bianca Weinstock-Guttman
- Jacobs MS Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York 14202
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Einarson TR, Bereza BG, Machado M. Comparative effectiveness of interferons in relapsing-remitting multiple sclerosis: a meta-analysis of real-world studies. Curr Med Res Opin 2017; 33:579-593. [PMID: 28027680 DOI: 10.1080/03007995.2016.1276895] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Differences between interferons have been evaluated for over 20 years. While randomized controlled trial (RCT) data is mainly used for assessments and strong data for causal inferences, it does not necessarily reflect everyday practice. Real-world data may provide additional information. PURPOSE To assess the results, quality, and representativeness of observational studies directly comparing interferons (IFNs) in RRMS. METHODS Medline and Embase were searched for observational studies comparing IFN-beta-1a 30 mcg IM (Avonex 1 ), IFN-beta-1a 44 mcg SC (Rebif 2 ) and/or IFN-beta-1b 250 mcg SC (Betaseron 3 ). Outcomes included annualized relapse rate (ARR), proportions relapse free, confirmed progression free, treatment persistence, and neutralizing antibodies rates (NABs) measured up to 5 years of treatment. Data was combined using random effects meta-analyses. Categorical values were analyzed using chi-squared and Mann-Whitney tests. RESULTS Thirty-six studies examining 32,026 patients (72.5% females, age = 39.2 ± 3.7 years, disease duration = 5.6 ± 2.0 years) were identified. Thirty-three studies investigated IFN-beta-1a IM (N = 11,925), 30 IFN-beta-1a SC (N = 10,684) and 34 IFN-beta-1b SC (N = 9417). Baseline ARRs were similar (1.37 ± 0.35, 1.51 ± 0.27 and 1.55 ± 0.23, respectively; P = .101) as were EDSS scores (2.24 ± 0.39, 2.33 ± 0.30, 2.55 ± 0.38; P = .070) and >75% were naïve to IFNs. On treatment, ARRs were comparable (IFN-beta-1a IM 0.52 ± 0.27, IFN-beta-1a SC 0.51 ± 0.24, IFN-beta-1b SC 0.55 ± 0.23; P = .595). Proportions of relapse-free patients were similar between drugs (P > .05 for all data points), except that IFN-beta-1a SC was superior to IFN-beta-1b SC in years 3-5 (all P ≤ .001). After 1 year, EDSS scores were comparable; after 2 years, IFN-beta-1a IM and IFN-beta-1a SC incurred less disease progression than IFN-beta-1b SC (P < .02). Confirmed progression-free rates and persistence were similar over 5 years. Fewer patients developed NABs with IFN-beta-1a IM (4.7 ± 1.5%) versus IFN-beta-1a SC (21.4 ± 2.8%) (P < 0.001) or IFN-beta-1b SC (32.2% ± 3.3%) (P < .001). CONCLUSIONS In this comprehensive meta-analysis of real-world studies in RRMS, IFN-beta-1a IM, IFN-beta-1a SC and IFN-beta-1b SC had similar clinical profiles. When selecting an IFN, practitioners should consider observational data in their decision making process.
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Affiliation(s)
| | - Basil G Bereza
- a Leslie Dan Faculty of Pharmacy , University of Toronto , Canada
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Ke X, Navaratnam P, Sasane R, Eisenberg Lawrence DF, Friedman HS, Tulsi BB, Vollmer T. Determinants of high cost in multiple sclerosis patients: a claims and chart review study. Curr Med Res Opin 2016; 32:1589-97. [PMID: 27207562 DOI: 10.1080/03007995.2016.1192529] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To identify factors associated with high cost multiple sclerosis (MS) patients using integrated administrative claims and medical charts data. METHODS This study identified newly diagnosed MS patients (≥18 years) in a large United States managed care claims database between 1 January 2007 and 30 April 2011 using the ICD-9-CM code (340.xx). Mean annualized MS-related costs higher than the third quartile were categorized as high cost, lower than the first quartile as low, and the rest as medium. Patients were compared across cohorts with descriptive and inferential statistics. Baseline high cost factors were identified with multivariable logistic regression models. RESULTS Administrative claims (n = 4342) and medical chart records (n = 400) data was evaluated. Mean (SD) annualized MS-related costs were $6313 ($14,177) for patients overall and $18,398 ($24,483) for high cost patients. Inpatient costs accounted for the largest proportion (49.69%) of MS-related costs among high cost patients. MS relapses and MS-related comorbidities were more prevalent in the high cost patients. In the multivariable analyses, patients with baseline use of antidepressants or corticosteroids, baseline muscle weakness, and initial treatment from a non-neurologist were likelier to be high cost MS patients. LIMITATIONS MS-related clinical information was not completely available from medical chart data. The specificity of true MS-related costs may have been limited and the definition of the cost-based cohort segmentations was arbitrary. CONCLUSIONS Overall, baseline use of MS-related medications, the presence of baseline MS-related comorbidities, MS relapses, and MS-related hospitalizations were significantly associated with high cost patients. Future comparative effectiveness studies of currently approved disease modifying therapies for MS may help to identify best strategies for individual patients to minimize clinical events that are associated with high disease related costs.
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Affiliation(s)
- Xuehua Ke
- a HealthCore Inc. , Wilmington , DE , USA
| | | | - Rahul Sasane
- c Novartis Pharmaceuticals , East Hanover , NJ , USA
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Govindappa K, Sathish J, Park K, Kirkham J, Pirmohamed M. Development of interferon beta-neutralising antibodies in multiple sclerosis--a systematic review and meta-analysis. Eur J Clin Pharmacol 2015; 71:1287-98. [PMID: 26268445 DOI: 10.1007/s00228-015-1921-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/31/2015] [Indexed: 01/25/2023]
Abstract
PURPOSE Interferon beta (IFN-β) is the drug of choice for treatment of relapsing forms of multiple sclerosis and is known to reduce the frequency and severity of relapses. This systematic review determines the occurrence of neutralising antibodies (NAbs) against different formulations of IFN-β: IFN-β-1a Avonex™, IFN-β-1a Rebif™ and IFN-β-1b Betaferon/Betaseron™. METHODS The databases used in the review included MEDLINE Ovid (from 1950 to March 2015), Embase Ovid (from 1980 to March 2015), CENTRAL on The Cochrane Library (2011, Issue 4) and ClinicalTrials.gov (from 1997 to March 2015). All studies that compared the efficacy of the different formulations of IFN-β in patients with relapsing forms of multiple sclerosis including IFN-β-1a Avonex™, IFN-β-1a Rebif™, IFN-β-1b Betaferon/Betaseron™ and IFN-β-1b Extavia™ were included. RESULTS Assessment of randomised controlled trials demonstrated that Avonex™ was 76% less likely than Rebif™ to lead to the formation of NAbs. Avonex™ was 88% less likely than Betaferon/Betaseron™ to lead to the formation of NAbs. Similar findings were also observed in the non-randomised controlled studies, with Avonex™ having the lowest risk. The formation of NAbs was dose dependent: Avonex™ at 30 μg was 64% less risky than Avonex™ at 60 μg. CONCLUSIONS Our data show that 2.0-18.9% of patients developed NAbs to Avonex™, 16.5-35.4% of patients developed NAbs to Rebif™ and 27.3-53.3% of patients developed NAbs to Betaferon/Betaseron™.
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Affiliation(s)
- Karthik Govindappa
- Clinical Research and Healthcare Innovations, Mazumdar Shaw Medical Centre, Narayana Health, 258/A Bommasandra Industrial Area Hosur Road, Bangalore, Karnataka, 560099, India. .,MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, England, UK.
| | - Jean Sathish
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, England, UK
| | - Kevin Park
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, England, UK
| | - Jamie Kirkham
- Department of Biostatistics, University of Liverpool, Liverpool, England, UK
| | - Munir Pirmohamed
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, England, UK.,The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, England, UK
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Rojko JL, Evans MG, Price SA, Han B, Waine G, DeWitte M, Haynes J, Freimark B, Martin P, Raymond JT, Evering W, Rebelatto MC, Schenck E, Horvath C. Formation, Clearance, Deposition, Pathogenicity, and Identification of Biopharmaceutical-related Immune Complexes. Toxicol Pathol 2014; 42:725-64. [DOI: 10.1177/0192623314526475] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Vascular inflammation, infusion reactions, glomerulopathies, and other potentially adverse effects may be observed in laboratory animals, including monkeys, on toxicity studies of therapeutic monoclonal antibodies and recombinant human protein drugs. Histopathologic and immunohistochemical (IHC) evaluation suggests these effects may be mediated by deposition of immune complexes (ICs) containing the drug, endogenous immunoglobulin, and/or complement components in the affected tissues. ICs may be observed in glomerulus, blood vessels, synovium, lung, liver, skin, eye, choroid plexus, or other tissues or bound to neutrophils, monocytes/macrophages, or platelets. IC deposition may activate complement, kinin, and/or coagulation/fibrinolytic pathways and result in a systemic proinflammatory response. IC clearance is biphasic in humans and monkeys (first from plasma to liver and/or spleen, second from liver or spleen). IC deposition/clearance is affected by IC composition, immunomodulation, and/or complement activation. Case studies are presented from toxicity study monkeys or rats and indicate IHC-IC deposition patterns similar to those predicted by experimental studies of IC-mediated reactions to heterologous protein administration to monkeys and other species. The IHC-staining patterns are consistent with findings associated with generalized and localized IC-associated pathology in humans. However, manifestations of immunogenicity in preclinical species are generally not considered predictive to humans.
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Affiliation(s)
| | | | - Shari A. Price
- Charles River Pathology Associates, Frederick, Maryland, USA
| | - Bora Han
- Pfizer, Inc, San Diego, California, USA
| | - Gary Waine
- CSL Limited, Parkville, Melbourne, Australia
| | | | - Jill Haynes
- CSL Limited, Parkville, Melbourne, Australia
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Abstract
The advancement of knowledge relies on scientific investigations. The timing between asking a question and data collection defines if a study is prospective or retrospective. Prospective studies look forward from a point in time, are less prone to bias and are considered superior to retrospective studies. This conceptual framework conflicts with the nature of biomarker research. New candidate biomarkers are discovered in a retrospective manner. There are neither resources nor time for prospective testing in all cases. Relevant sources for bias are not covered. Ethical questions arise through the time penalty of an overly dogmatic concept. The timing of sample collection can be separated from testing biomarkers. Therefore the moment of formulating a hypothesis may be after sample collection was completed. A conceptual framework permissive to asking research questions without the obligation to bow to the human concept of calendar time would simplify biomarker research, but will require new safeguards against bias.
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Affiliation(s)
- Axel Petzold
- Department of Molecular Neuroscience, UCL, ION, The Wolfson Center for Neurodegeneration, London, UK
| | - Robert Bowser
- Gregory W Fulton ALS and Neuromuscular Research Center, Divisions of Neurology and Neurobiology, Barrow Neurological Institute St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Paolo Calabresi
- Clinica Neurologica, Università di Perugia Ospedale S. Maria della Misericordia, Andrea delle Fratte Perugia, Italy and IRCCS Fondazione S Lucia Rome, Italy
| | - Henrik Zetterberg
- Department of Molecular Neuroscience, UCL, ION, The Wolfson Center for Neurodegeneration, London, UK
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Bernard MJ Uitdehaag
- Department of Neurology, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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Immunoglobulin G1 and immunoglobulin G4 antibodies in multiple sclerosis patients treated with IFNβ interact with the endogenous cytokine and activate complement. Clin Immunol 2013; 148:177-85. [PMID: 23770627 PMCID: PMC3779799 DOI: 10.1016/j.clim.2013.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 05/04/2013] [Accepted: 05/11/2013] [Indexed: 11/23/2022]
Abstract
A subset of patients with relapsing-remitting multiple sclerosis (RRMS) on therapy with interferon beta (IFNβ) develop neutralising anti-drug antibodies (ADA) resulting in reduced, or loss of, therapeutic efficacy. The aims were to characterise the relative contributions of anti-IFNβ antibody isotypes to drug neutralising activity, ability of these antibodies to cross-react with endogenous IFNβ, to form immune complexes and activate complement. IFNβ-specific ADA were measured in plasma from RRMS patients treated with IFNβ1a (Rebif®). Neutralisation of endogenous and therapeutic IFNβ by ADA was determined by IFNβ bioassay. IFNβ-ADA profile was predominantly comprised of IgG1 and IgG4 antibody isotypes. The contribution of IgG4-ADA towards neutralising activity was found to be minimal. Neutralising IFNβ-ADA blocks endogenous IFNβ activity. ADA interaction with therapeutic IFNβ results in immune complex formation and complement activation. In summary, IgG1 and IgG4 IFNβ-ADA have the ability to neutralise therapeutic and endogenous protein and to activate complement. IgG4 and IgG1 contributes to IFNβ-ADA profile Neutralising IFNβ-ADA cross reacts and blocks endogenous IFNβ activity. ADA-IFNβ results in IC formation and complement activation
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Giovannoni G, Southam E, Waubant E. Systematic review of disease-modifying therapies to assess unmet needs in multiple sclerosis: tolerability and adherence. Mult Scler 2012; 18:932-46. [PMID: 22249762 DOI: 10.1177/1352458511433302] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Reviews of therapeutic drugs usually focus on the highly selected and closely monitored patient populations from randomized controlled trials. The objective of this study was to review systematically the tolerability and adherence of multiple sclerosis disease-modifying therapies, using data from both randomized controlled trials and observational settings. Relevant literature was identified using predefined search terms, and adverse event and study discontinuation data were extracted and categorized according to study type (randomized controlled trial or observational) and study duration. A total of 151 papers were selected for analysis; 33% were classified as randomized controlled trials and 62% as observational studies. Most of the papers concerned interferon preparations and glatiramer acetate; the limited available information on mitoxantrone and natalizumab precluded extensive examination of these. The most common adverse events were flu-like symptoms (interferon therapies only) and injection-site reactions. Mean discontinuation rates ranged from 16% to 27%. There were no marked differences in tolerability or adherence data from randomized controlled trials and observational studies, but the incidence of adverse events remained high in lengthy studies and discontinuations accumulated with time. The present systematic review of randomized clinical trial and observational data highlights the tolerability and adherence issues associated with commonly used first-line multiple sclerosis treatments.
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Affiliation(s)
- G Giovannoni
- Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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15
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Waubant E. Improving outcomes in multiple sclerosis through early diagnosis and effective management. Prim Care Companion CNS Disord 2012; 14:11016co2cc. [PMID: 23469314 DOI: 10.4088/pcc.11016co2cc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
The development of neutralizing antibodies (NAbs) is a major problem in multiple sclerosis (MS) patients treated with interferon-beta (IFN-ß). Whereas binding antibodies (BAbs) can be demonstrated in the vast majority of patients, only a smaller proportion of patients develop NAbs. The principle in NAb in vitro assays is the utilization of cultured cell lines that are responsive to IFN-ß. The cytopathic effect (CPE) assay measures the capacity of NAbs to neutralize IFN- ß's protective effect on cells challenged with virus and the MxA induction assay measures the ability of NAbs to reduce the IFN-ß-induced expression of MxA, either at the mRNA or the protein level. A titer of >20 neutralizing units/ml traditionally defines NAb posi-tivity. NAbs in high titers completely abrogate the in vivo response to IFN-ß, whereas the effect of low and intermediate titers is unpredictable. As clinically important NAbs appear only after 9-18 months IFN- ß0 therapy, short-term studies of two years or less are unsuitable for evaluation of clinical NAb effects. All long-term trials of three years or more concordantly show evidence of a detrimental effect of NAbs on relapses, disease activity on MRI, or on disease progression. Persistent high titers of NAbs indicate an abrogation of the biological response and, hence, absence of therapeutic efficacy, and this observation should lead to a change of therapy. As low and medium titers are ambiguous treatment decisions in patients with low NAb titres should be guided by determination of in vivo mRNA MxA induction and clinical disease activity.
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Affiliation(s)
- Per Soelberg Sorensen
- Danish Multiple Sclerosis Research Center Department of Neurology 2082, Copenhagen University Hospital Rigshospitalet, DK-2100 Copenhagen, Denmark.
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Limmroth V. The interferon beta therapies for treatment of relapsing-remitting multiple sclerosis: are they equally efficacious? A comparative review of open-label studies evaluating the efficacy, safety, or dosing of different interferon beta formulations alone or in combination. Ther Adv Neurol Disord 2011; 4:281-96. [PMID: 22010041 PMCID: PMC3187676 DOI: 10.1177/1756285611413825] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Interferon beta preparations are the most widely used initial therapies prescribed for patients with relapsing-remitting multiple sclerosis. Phase III studies have demonstrated comparable efficacy on clinical measures of disease activity, variable benefits on radiological measures, and good overall tolerability. Subsequent clinical studies have attempted to compare directly the three available interferon beta preparations, reporting both safety and efficacy data. We review the literature on studies evaluating interferon beta therapy for patients with relapsing-remitting multiple sclerosis, discuss reasons for discrepant findings, and assess the utility of interferon beta-based combination regimens as the focus of future studies in the increasingly complex multiple sclerosis therapy landscape.
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Affiliation(s)
- Volker Limmroth
- Department of Neurology, Cologne City Hospitals (Merheim), Ostmerheimer Strasse 200, 51109 Cologne, Germany
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Oliver BJ, Kohli E, Kasper LH. Interferon therapy in relapsing-remitting multiple sclerosis: A systematic review and meta-analysis of the comparative trials. J Neurol Sci 2011; 302:96-105. [DOI: 10.1016/j.jns.2010.11.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 11/01/2010] [Indexed: 11/24/2022]
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Dieterich M, Hamann GF. [Report from NeuroUpdate in Wiesbaden (13/14 February 2009)]. DER NERVENARZT 2009; 80:720-724. [PMID: 19404601 DOI: 10.1007/s00115-009-2730-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- M Dieterich
- Klinik für Neurologie, Klinikum Grosshadern, Ludwig-Maximilians-Universität, München, Deutschland.
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Boster A, Racke MK. Pharmacotherapy of multiple sclerosis: the PROOF trial. Expert Opin Pharmacother 2009; 10:1235-7. [DOI: 10.1517/14656560902927856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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