Dramatic recovery of steroid-refractory relapsed multiple sclerosis following Fingolimod discontinuation using selective immune adsorption

Disease-modifying therapies and hematological disorders: a systematic review of case reports and case series

Introduction

Disease modifying therapies (DMTs) used to treat multiple sclerosis (MS) can be associated to the occurrence of hematological disorders. This systematic review aims to provide an overview of these events occurring in real-life conditions, by describing case reports and series published in the literature.

Methods

A literature search of all publications up to January 5th 2024 on the Medline and Embase databases was carried out. The results were presented both in the text and in tables.

Results

Sixty-seven case reports/series were included in this review, of which more than half related to alemtuzumab, natalizumab and ocrelizumab. The publication date of included studies ranged from 2006 to 2024. The majority of case reports and series described the occurrence of late-onset hematological disorders (events that occurred more than 30 days after the first DMT administration), mainly represented by case of neutropenia, autoimmune hemolytic anemia and immune thrombocytopenia. All cases reported a favorable outcome, apart one case report that described a fatal case. Among included cases, 4 articles, all related to natalizumab, described the occurrence of myeloid disorders in 13 newborns from mother receiving the DMT.

Discussion

Considering the limitations identified in the majority of included studies, further ad hoc studies are strongly needed to better evaluate the hematological disorders of DMTs. Meantime, the strict monitoring of treated patients for the occurrence of these toxicities should be highly recommended.

Current status and new developments in sphingosine-1-phosphate receptor antagonism: fingolimod and more

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.

Factors associated with fingolimod rebound: A single center real-life experience

Background It is still controversial whether the relapse experienced after discontinuation of fingolimod treatment is a rebound. Increasing cases of rebound have been reported in the literature. The rate of fingolimod rebound in patients after fingolimod cessation is reported between 5% and 52%. The present study aims to determine the rate of rebound after discontinuation of fingolimod treatment and the factors affecting the rebound. Methods This retrospective cohort study consists of adult MS patients who have been admitted to the Hacettepe University Hospital Neurology MS Center outpatient clinic between 2012 and 2020. Results During the study period, 642 patients received fingolimod and 23.1% discontinued the fingolimod treatment. Thirteen of 126 patients had a rebound (10.3%) after fingolimod discontinuation. The patients in the rebound group were significantly younger and washout period were significantly longer than those in the non-rebound group. After discontinuation of fingolimod treatment, the EDSS score of the rebound group was significantly higher than the non-rebound group, while Annualized Relapse Rates were similar. Conclusion Younger age, longer washout time, and previous treatment preferences may increase the occurrence probability of rebound. It is recommended that patients should be closely monitored after fingolimod discontinuation and appropriate disease-modifying therapy should be initiated as soon as possible.

Double Filtration Plasmapheresis Treatment of Refractory Multiple Sclerosis Relapsed on Fingolimod: A Case Report

Double filtration plasmapheresis (DFPP) is an emerging semi-selective apheretic method for treating immuno-mediated neurological diseases. Here we report the first case of steroid-refractory relapsed multiple sclerosis (MS) on Fingolimod (FTY), treated effectively by this technique, in a 37-year-old woman. This condition is thought to be caused by soluble inflammatory species, but its demyelinating pattern is unknown; moreover, despite megadoses of intravenous 6-methyl prednisolone, it induces severe neurological deterioration, but dramatically responded to DFPP in our patient. The clinical improvement was driven by a strong DFPP-induced anti-inflammatory effect, with significant reduction of C3/C4 components, total gamma globulin concentrations (IgG), and gamma-fibrinogen (FGG), resulting in a brain pseudoatrophy phenomenon. Our findings are: first, the steroid-refractory relapsed MS on FTY, however serious, can be treated with DFPP; second, given the good clinical improvement due to the DFPP-induced neuroinflammatory components removal, this clinical condition can be associated with a Lucchinetti pattern II of demyelination.

Severe Exacerbation of Multiple Sclerosis Following Withdrawal of Fingolimod

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.

Fingolimod Rebound: A Review of the Clinical Experience and Management Considerations

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.

Disease Exacerbation after the Cessation of Fingolimod Treatment in Japanese Patients with Multiple Sclerosis

Objective In Japan, following the launch of dimethyl fumarate (DMF) after fingolimod as a disease-modifying drug in multiple sclerosis (MS), some patients switched from fingolimod to DMF. The aim of this study was to determine the follow-up status of MS patients who switched to DMF after fingolimod cessation. Methods Clinical and magnetic resonance imaging (MRI) data in 19 patients with MS who switched to DMF were collected for at least for 6 months after fingolimod cessation. Results Ten patients (52.6%) experienced clinical or MRI exacerbation after fingolimod cessation. The peripheral blood lymphocyte counts at the time of fingolimod cessation in those with disease exacerbation were significantly lower than in those without exacerbation. The patients with disease exacerbation were further classified into three groups based on MRI findings: those with some new T2-weighted lesions with or without gadolinium (Gd) enhancement (group I), those with more new and/or enlarged T2-weighted lesions with Gd enhancement compared to pre-fingolimod induction (group II), and those with multifocal tumefactive demyelinating lesions. In group II, the clinical disease activity, which was similar to that at fingolimod initiation in group I, was higher than the clinical disease activity observed before fingolimod initiation. Conversely, group III exhibited unexpected new MRI findings that were not evident before fingolimod initiation. Conclusion Cessation of fingolimod might precipitate rebound or reactivation of clinical disease in patients with MS, and careful follow-up is necessary for patients who discontinue fingolimod.

Fulminant rebound of relapsing–remitting multiple sclerosis after discontinuation of dimethyl fumarate: A case report

Background:

Rebound phenomena after discontinuation of different treatments for relapsing–remitting multiple sclerosis (RRMS) have previously been described. Systematic database research in PubMed did not show any report with relapse directly associated with dimethyl fumarate (DMF) cessation.

Case presentation:

Here, we report on a 38-year-old Caucasian male patient suffering from a relatively mild course of RRMS who developed a fulminant clinical rebound 2 months after discontinuation of DMF therapy. Radiological alterations presented impressively with primarily spinal involvement. The patient received intensive care and multiple immunomodulating therapies.

Conclusion:

We report on this case to raise neurologist’s awareness of complications of basic therapy discontinuation in RRMS.

Cladribine to treat disease exacerbation after fingolimod discontinuation in progressive multiple sclerosis

Rebound disease following cessation of disease modifying treatment (DMT) has been reported in people with both relapsing and progressive multiple sclerosis (pwRMS, pwPMS) questioning strict separation between these two phenotypes. While licensed DMT is available for pwRMS to counter rebound disease, no such option exists for pwPMS. We report on a pwPMS who developed rebound disease, with 45 Gadolinium-enhancing lesions on T1 weighted MRI brain, within 6 months after fingolimod 0.5 mg/day was stopped. Treatment with a short course of subcutaneous cladribine 60 mg led to effective suppression of inflammatory activity and partial recovery with no short-term safety issues or adverse events.

Neurological safety of fingolimod: An updated review

Fingolimod (FTY) is the first oral medication approved for treatment of relapsing–remitting multiple sclerosis (RRMS). Its effectiveness and safety were confirmed in several phase III clinical trials, but proper evaluation of safety in the real patient population requires long‐term post‐marketing monitoring. Since the approval of FTY for RRMS in Japan in 2011, it has been administered to approximately 5000 MS patients, and there have been side‐effect reports from 1750 patients. Major events included infectious diseases, hepatobiliary disorders, nervous system disorders and cardiac disorders. In the present review, we focus especially on central nervous system adverse events. The topics covered are: (i) clinical utility of FTY; (ii) safety profile; (iii) post‐marketing adverse events in Japan; (iv) white matter (tumefactive) lesions; (v) rebound after FTY withdrawal; (vi) relationship between FTY and progressive multifocal leukoencephalopathy; (vii) FTY and progressive multifocal leukoencephalopathy‐related immune reconstitution inflammatory syndrome; and (viii) neuromyelitis optica and leukoencephalopathy.

[Immune reconstitution inflammatory syndrome and rebound syndrome in multiple sclerosis patients who stopped disease modification therapy: current understanding and a case report]

More and more multiple sclerosis patients have been receiving treatment with new immunomodulatory drugs. Its discontinuation because of side-effects, lack of efficacy or pregnancy has been increasing as well. This paper reviews such severe complications of natalizumab and fingolimod cessation as immune reconstitution inflammatory syndrome (IRIS) and rebound. The short history, immunopathogenesis and diagnostic criteria of IRIS in individuals with human immunodeficiency virus infection are covered. Clinical and radiological presentations as well as possible pathogenic mechanisms of IRIS in patients treated with natalizumab and fingolimod are discussed. The authors also report the case of a woman with multiple sclerosis treated with fingolimod, who experienced a severe relapse when she stopped treatment. Diagnostic criteria and prognostic factors for IRIS and rebound are needed in patients with multiple sclerosis who discontinue the new disease modification therapy.

Severe disease exacerbations in patients with multiple sclerosis after discontinuing fingolimod

Discontinuation of fingolimod in patients with multiple sclerosis (MS) can lead to disease reactivation. In this review, we describe cases of severe exacerbations in patients with MS following discontinuation of fingolimod, including three cases from our center. We consider potential mechanisms of disease reactivation after cessation of fingolimod, and the evidence supporting this rebound effect. We conclude that discontinuation of fingolimod results in the return of disease activity, which then leads to severe exacerbations (i.e., rebounds) in a clinically significant proportion of patients. Lastly, we consider disease-modifying treatment options for patients who discontinue fingolimod.

Immunoadsorption therapy in autoimmune encephalitides

Objective:

It was hypothesized that in encephalitides with autoantibodies directed to CNS surface antigens an antibody-removing intervention might speed up recovery.

Methods:

The outcome of autoimmune encephalitis in 19 patients with antibodies against surface antigens (leucine-rich, glioma inactivated 1 [LGI1], n = 3; contactin-associated protein-2 [CASPR2], n = 4; NMDA receptor [NMDAR], n = 7) and intracellular antigens (glutamic acid decarboxylase [GAD], n = 5) after immunoadsorption in addition to corticosteroid therapy was evaluated retrospectively. Modified Rankin scale (mRS) scores and data on seizures, memory, and antibody titers directly after immunoadsorption (early follow-up) and after a median of 4 months (late follow-up) were compiled.

Results:

Immediately after immunoadsorption, 9 of 14 patients with antibodies against LGI1, CASPR2, or NMDAR (64%), but none with GAD antibodies, had improved by at least one mRS point. Five of the 7 patients with LGI1 or CASRP2 antibodies had become seizure-free, and 2 patients with NMDAR antibodies had a memory improvement of more than 1 SD of a normal control population. At late follow-up, 12 of 14 patients with surface antibodies had improved (86%), and none of the patients with GAD antibodies.

Conclusions:

It is suggested that addition of immunoadsorption to immunosuppression therapy in patients with surface antibodies may accelerate recovery. This supports the pathogenic role of surface antibodies.

Classification of evidence:

This study provides Class IV evidence that immunoadsorption combined with immunosuppression therapy is effective in patients with autoimmune encephalitis with surface antibodies.

Fingolimod for multiple sclerosis and emerging indications: appropriate patient selection, safety precautions, and special considerations

Fingolimod (FTY720), an immunotherapeutic drug targeting the sphingosine-1-phosphate receptor, is a widely used medication for relapsing-remitting multiple sclerosis (MS). Apart from the pivotal Phase III trials demonstrating efficacy against placebo and interferon-β-1a once weekly, sufficient clinical data are now available to assess its real-world efficacy and safety profile. Approved indications of fingolimod differ between countries. This discrepancy, to some extent, reflects the intermediate position of fingolimod in the expanding lineup of MS medications. With individualization of therapy, appropriate patient selection gets more important. We discuss various scenarios for fingolimod use in relapsing-remitting MS and their pitfalls: as first-line therapy, as escalation therapy after failure of previous immunotherapies, and as de-escalation therapy following highly potent immunotherapies. Potential side effects such as bradycardia, infections, macular edema, teratogenicity, and progressive multifocal leukoencephalopathy as well as appropriate safety precautions are outlined. Disease reactivation has been described upon fingolimod cessation; therefore, patients should be closely monitored for MS activity for several months after stopping fingolimod. Finally, we discuss preclinical and clinical data indicating neuroprotective effects of fingolimod, which might open the way to future indications such as stroke, Alzheimer’s disease, and other neurodegenerative disorders.