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Tunç A, Yetkin MF, Seferoğlu M, İnanç Y, Sıvacı AÖ, Türkoğlu ŞA, Baydar C, Güzel V, Bülbül NG, Sezer V, Altun Y. Recurring disease activity in relapsing remitting multiple sclerosis: The multicenter RDA-RMS study. Mult Scler Relat Disord 2024; 88:105757. [PMID: 38972107 DOI: 10.1016/j.msard.2024.105757] [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: 02/14/2024] [Revised: 06/23/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND This study investigates the gap in understanding the dynamics of recurring disease activity (RDA) in RRMS patients after fingolimod (FGL) treatment discontinuation. The aim is to investigate RDA in RRMS patients after stopping FGL, aiming to improve management and comprehension of disease progression post-treatment. METHODS In this multicenter, retrospective study, data from 172 of 944 RRMS patients aged 18-55, across nine centers in Turkey, who discontinued FGL treatment, were analyzed. The collected data included EDSS scores, annualized relapse rates (ARR), lymphocyte counts, and MRI findings, with follow-up assessments conducted at 6 months, 1 year, and up to 2 years. RESULTS RDA was observed in 31.9 % of patients, with incidences of rebound and reactivation at 20.3 % and 11.6 %, respectively. Factors like younger age, longer treatment duration, lower lymphocyte counts, and higher lesion burden increased RDA risk. Notably, 52.9 % of pregnant patients experienced RDA (16.4 % of the overall RDA group), with rebound occurring in six and reactivation in three. Patients with RDA had longer medication-free intervals and increased ARR. Discontinuation reasons varied, with disease progression linked to a lower RDA risk. CONCLUSION Findings highlight the necessity for personalized management and vigilant monitoring after FGL discontinuation in RRMS patients, offering critical insights into RDA risk factors, and the complex interplay between treatment cessation, pregnancy, and disease progression.
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Affiliation(s)
- Abdulkadir Tunç
- Sakarya University Faculty of Medicine, Department of Neurology, Sakarya, Turkey.
| | - Mehmet Fatih Yetkin
- Erciyes University Faculty of Medicine, Department of Neurology, Kayseri, Turkey
| | - Meral Seferoğlu
- University Of Health Sciences Bursa Yuksek Ihtisas Training And Research Hospital, Department of Neurology, Bursa, Turkey
| | - Yılmaz İnanç
- Kahramanmaraș Sütçü İmam University, Faculty of Medicine, Department of Neurology, Kahramanmaraș, Turkey
| | - Ali Özhan Sıvacı
- University Of Health Sciences Bursa Yuksek Ihtisas Training And Research Hospital, Department of Neurology, Bursa, Turkey
| | - Şule Aydın Türkoğlu
- Abant İzzet Baysal University Faculty of Medicine, Department of Neurology, Bolu, Turkey
| | - Caner Baydar
- Van Yüzüncü Yıl University Faculty of Medicine, Department of Neurology, Van, Turkey
| | - Vildan Güzel
- Bezmialem Vakıf University Faculty of Medicine, Department of Neurology, İstanbul, Turkey
| | - Nazlı Gamze Bülbül
- Haydarpaşa Sultan Abdülhamid Han Training And Research Hospital, Department of Neurology, İstanbul, Turkey
| | - Vasfiye Sezer
- Sakarya University Faculty of Medicine, Department of Neurology, Sakarya, Turkey
| | - Yaşar Altun
- Adıyaman University Faculty of Medicine, Department of Neurology, Adıyaman, Turkey
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Rabaneda-Lombarte N, Teniente-Serra A, Massuet-Vilamajó A, Ramo-Tello C, Presas-Rodríguez S. Case report: tumefactive demyelinating lesions after the second cycle of alemtuzumab in multiple sclerosis; immune cell profile and biomarkers. Front Immunol 2024; 15:1395749. [PMID: 39021563 PMCID: PMC11251942 DOI: 10.3389/fimmu.2024.1395749] [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: 03/04/2024] [Accepted: 04/22/2024] [Indexed: 07/20/2024] Open
Abstract
Objective We present a case of multiple tumefactive demyelinating lesions (TDLs) emerging 24 months after the second cycle of alemtuzumab treatment. Methods A woman with relapsing-remitting multiple sclerosis (MS) discontinued fingolimod treatment due to gestational desire, which resulted in a severe disease exacerbation. Alemtuzumab was initiated, accompanied by regular clinical, radiological, and immunological monitoring. Results She relapsed prior to the second cycle, exhibiting 12 T1Gd+ lesions, and peripheral blood showed an increase in B-cells and a decrease in T-cells. At 24 months following the second cycle, she developed cognitive impairment and multiple T1Gd+ lesions, including TDLs, were evident on the brain MRI. We found not only an increase in B-cells but also in Th1 central memory cells. Th1/Th17 cells increased 3 months before the detection of TDLs. Conclusions TDLs can appear 24 months after the second cycle of alemtuzumab treatment in MS. The increase in Th1/Th17 cells could be a candidate biomarker for TDLs in alemtuzumab-treated MS patients.
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Affiliation(s)
| | - Aina Teniente-Serra
- Immunology Division, Clinical Laboratory MetroNord (LCMN), Hospital Universitari Germans Trias i Pujol and Research Institute (IGTP), Badalona, Spain
- Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | - Cristina Ramo-Tello
- Neurosciences Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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Arena S, Chisari CG, Toscano S, Bucello S, Grimaldi LM, Ragonese P, Realmuto S, Cottone S, Maimone D, Finocchiaro C, Reitano P, Patti F. Real-World Effectiveness of Cladribine for Patients with Multiple Sclerosis: A Sicilian Multicentric Experience (Rewind Study). Curr Neuropharmacol 2024; 22:1271-1283. [PMID: 36946484 PMCID: PMC10964096 DOI: 10.2174/1570159x21666230322140711] [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: 07/17/2022] [Revised: 09/29/2022] [Accepted: 10/27/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Cladribine tablets are a highly effective option for the treatment of relapsingremitting multiple sclerosis (RRMS). OBJECTIVE The study aims to evaluate the effectiveness of cladribine in a real-world setting. METHODS This prospective real-world study consecutively screened all RRMS patients from seven different MS centers in Sicily (Italy) who completed the 2-year treatment course of cladribine tablets in the period between 11th March 2019 and 31st October 2021. Data about Expanded Disability Status Scale (EDSS), relapses, previous treatments, adverse events (AEs) and magnetic resonance imaging (MRI) were collected. Patients who were previously treated with other DMTs were further stratified into moderately active treatment (MAT) and highly active treatment (HAT) patients. RESULTS A total of 217 patients (70% women, with a mean age of 38.4 ± 11.3 years) were enrolled. Fifty patients (23.0%) were naïve to treatment and 167 (77%) switched from other disease modifying therapies. After the second year of treatment, about 80% were EDSS progression free, 88% remained relapse-free at T24, and 48% of patients were MRI activity-free. Kaplan Meier analyses showed significant differences between MT and HAT in terms of time to first clinical relapse (HR: 2.43, IC 1.02- 5.76; p = 0.04), time to the first new T1-gadolinium enhancing lesion (HR: 3.43, IC 1.35-8.70; p = 0.009) and time to MRI worsening (HR: 2.42, IC 1.15-5.09; p = 0.02). CONCLUSION This study confirmed that cladribine is an effective treatment for MS, particularly in naïve patients and those who have switched from MATs.
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Affiliation(s)
- Sebastiano Arena
- Department “GF Ingrassia” Section of Neurosciences, University of Catania, Catania, Italy
| | - Clara Grazia Chisari
- Department “GF Ingrassia” Section of Neurosciences, University of Catania, Catania, Italy
| | - Simona Toscano
- Department “GF Ingrassia” Section of Neurosciences, University of Catania, Catania, Italy
| | - Sebastiano Bucello
- Multiple Sclerosis
Center- PO Muscatello di Augusta, ASP Siracusa, Siracusa, Italy
| | - Luigi Maria Grimaldi
- Institute Foundation “G. Giglio”, Multiple Sclerosis Centre, Cefalù-Palermo, Italy
| | - Paolo Ragonese
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Sabrina Realmuto
- Multiple Sclerosis Centre, Neurology Unit and Stroke Unit, AOOR “Villa Sofia-Cervello”, United Hospitals, Palermo, Italy
| | - Salvatore Cottone
- Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione
“Civico Di Cristina e Benfratelli”, Palermo, Italy
| | - Davide Maimone
- Centro Sclerosi Multipla, UOC Neurologia, ARNAS Garibaldi,
Catania, Italy
| | - Chiara Finocchiaro
- Department “GF Ingrassia” Section of Neurosciences, University of Catania, Catania, Italy
| | - Paola Reitano
- Department “GF Ingrassia” Section of Neurosciences, University of Catania, Catania, Italy
| | - Francesco Patti
- Department “GF Ingrassia” Section of Neurosciences, University of Catania, Catania, Italy
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Vakrakou AG, Brinia ME, Alexaki A, Koumasopoulos E, Stathopoulos P, Evangelopoulos ME, Stefanis L, Stadelmann-Nessler C, Kilidireas C. Multiple faces of multiple sclerosis in the era of highly efficient treatment modalities: Lymphopenia and switching treatment options challenges daily practice. Int Immunopharmacol 2023; 125:111192. [PMID: 37951198 DOI: 10.1016/j.intimp.2023.111192] [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: 09/03/2023] [Revised: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 11/13/2023]
Abstract
The expanded treatment landscape in relapsing-remitting multiple sclerosis (MS) has resulted in highly effective treatment options and complexity in managing disease- or drug-related events during disease progression. Proper decision-making requires thorough knowledge of the immunobiology of MS itself and an understanding of the main principles behind the mechanisms that lead to secondary autoimmunity affecting organs other than the central nervous system as well as opportunistic infections. The immune system is highly adapted to both environmental and disease-modifying agents. Immune reconstitution following cell depletion or cell entrapment therapies eliminates pathogenic aspects of the disease but can also lead to distorted immune responses with harmful effects. Atypical relapses occur with second-line treatments or after their discontinuation and require appropriate clinical decisions. Lymphopenia is a result of the mechanism of action of many drugs used to treat MS. However, persistent lymphopenia and cell-specific lymphopenia could result in disease exacerbation, secondary autoimmunity, or the emergence of opportunistic infections. Clinicians treating patients with MS should be aware of the multiple faces of MS under novel, efficient treatment modalities and understand the intricate brain-immune cell interactions in the context of an altered immune system. MS relapses and disease progression still occur despite the current treatment modalities and are mediated either by failure to control effector mechanisms inherent to MS pathophysiology or by new drug-related mechanisms. The multiple faces of MS due to the highly adapted immune system of patients impose the need for appropriate switching therapies that safeguard disease remission and further clinical improvement.
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Affiliation(s)
- Aigli G Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neuropathology, University of Göttingen Medical Center, Göttingen, Germany.
| | - Maria-Evgenia Brinia
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Alexaki
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Koumasopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Stathopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Eleftheria Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
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Costa GD, Comi G. A safety review of current monoclonal antibodies used to treat multiple sclerosis. Expert Opin Drug Saf 2023; 22:1011-1024. [PMID: 37314699 DOI: 10.1080/14740338.2023.2224556] [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: 02/16/2023] [Accepted: 06/08/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system. Monoclonal antibodies (mAbs) have shown efficacy in reducing MS relapse rates, disease progression, and brain lesion activity. AREAS COVERED This article reviews the literature on the use of mAbs for the treatment of MS, including their mechanisms of action, clinical trial data, safety profiles, and long-term outcomes. The review focuses on the three main categories of mAbs used in MS: alemtuzumab, natalizumab, and anti-CD20 drugs. A literature search was conducted using relevant keywords and guidelines and reports from regulatory agencies were reviewed. The search covered studies published from inception to 31 December 202231 December 2022. The article also discusses the potential risks and benefits of these therapies, including their effects on infection rates, malignancies, and vaccination efficacy. EXPERT OPINION Monoclonal antibodies have revolutionized the treatment of MS, but safety concerns must be considered, particularly with regards to infection rates, malignancy risk, and vaccination efficacy. Clinicians must weigh the potential benefits and risks of mAbs on an individual patient basis, taking into account factors such as age, disease severity, and comorbidities. Ongoing monitoring and surveillance are essential to ensure the long-term safety and effectiveness of monoclonal antibody therapies in MS.
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Affiliation(s)
| | - Giancarlo Comi
- Vita-Salute San Raffaele University, Milan, Italy
- Multiple Sclerosis Center, Casa di Cura Igea, Milan, Italy
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Abbadessa G, Miele G, Cavalla P, Valentino P, Marfia GA, Vercellino M, De Martino A, Simeon V, Lavorgna L, Bonavita S. Previous disease-modifying treatments influence T lymphocyte kinetics in people with multiple sclerosis switching to ocrelizumab. J Neuroimmunol 2023; 378:578072. [PMID: 36996621 DOI: 10.1016/j.jneuroim.2023.578072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/06/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Recently, concern has been raised about the influence of the previous disease-modifying treatments (DMTs) on the clinical efficacy of ocrelizumab (OCR). We aimed to evaluate whether the previous DMT affects the lymphocyte subset kinetics in people with Multiple Sclerosis (MS) switching to OCR. METHODS This is a multicenter, retrospective, real-world study on consecutive MS patients who started or switched to OCR. We grouped them by prior DMT in: (i) naïve-to-treatment (NTT), (ii) switching from fingolimod (SF) and (iii) switching from natalizumab (SN). Differences in absolute lymphocyte count and lymphocyte subset count changes, considering the period from baseline to 6 months, over all the three groups were assessed with an inverse-probability-weighted regression adjustment model. RESULTS Mean T CD4+ cell count reduction from baseline to the six-month follow-up was more pronounced in the SN group compared to the NTT (p = 0,026). Further, patients in the SF group experienced a less pronounced CD4 T cell number decrease than both NTT and SN groups (p = 0,04 and p < 0,001, respectively). Patients in the SF group experienced an increase in CD8 T cell absolute number, whereas those in the NTT and SN groups experienced a significant decrease (p = 0,015 and p < 0,001, respectively). Patients experiencing early inflammatory activity showed a lower CD8+ cell count at baseline than stable patients (p = 0,02). CONCLUSIONS Previous DMTs influence the lymphocyte kinetics in people with MS switching to OCR. Reassessment of these findings over a larger population may help optimize the switch.
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Zhong M, van der Walt A, Monif M, Hodgkinson S, Eichau S, Kalincik T, Lechner-Scott J, Buzzard K, Skibina O, Van Pesch V, Butler E, Prevost J, Girard M, Oh J, Butzkueven H, Jokubaitis V. Prediction of relapse activity when switching to cladribine for multiple sclerosis. Mult Scler 2023; 29:119-129. [PMID: 35894247 DOI: 10.1177/13524585221111677] [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: 02/01/2023]
Abstract
BACKGROUND Patients with relapsing-remitting multiple sclerosis commonly switch between disease-modifying therapies (DMTs). Identifying predictors of relapse when switching could improve outcomes. OBJECTIVE To determine predictors of relapse hazard when switching to cladribine. METHODS Data of patients who switched to cladribine, grouped by prior disease-modifying therapy (pDMT; interferon-β/glatiramer acetate, dimethyl fumarate, teriflunomide, fingolimod or natalizumab (NTZ)), were extracted from the MSBase Registry. Predictors of relapse hazard during the treatment gap and the first year of cladribine therapy were determined. RESULTS Of 513 patients, 22 relapsed during the treatment gap, and 38 within 1 year of starting cladribine. Relapse in the year before pDMT cessation predicted treatment gap relapse hazard (hazard ratio (HR) = 2.43, 95% confidence interval (CI) = 1.03-5.71). After multivariable adjustment, relapse hazard on cladribine was predicted by relapse before pDMT cessation (HR = 2.00, 95% CI = 1.01-4.02), treatment gap relapse (HR = 6.18, 95% confidence interval (CI) = 2.65-14.41), switch from NTZ (HR compared to injectable therapies 4.08, 95% CI = 1.35-12.33) and age at cladribine start (HR = 0.96, 95% CI = 0.91-0.99). CONCLUSION Relapse during or prior to the treatment gap, and younger age, are of prognostic relevance in the year after switching to cladribine. Switching from NTZ is also independently associated with greater relapse hazard.
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Affiliation(s)
- Michael Zhong
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Anneke van der Walt
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Mastura Monif
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia/MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Tomas Kalincik
- MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia/Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, NSW, Australia
| | - Katherine Buzzard
- MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia
| | - Olga Skibina
- Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia/Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia
| | | | | | | | - Marc Girard
- CHUM and Universite de Montreal, Montreal, QC, Canada
| | - Jiwon Oh
- Division of Neurology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Helmut Butzkueven
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Vilija Jokubaitis
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
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Meca-Lallana JE, Fernández-Prada M, García Vázquez E, Moreno Guillén S, Otero Romero S, Rus Hidalgo M, Villar Guimerans LM, Eichau Madueño S, Fernández Fernández Ó, Izquierdo Ayuso G, Álvarez Cermeño JC, Arnal García C, Arroyo González R, Brieva Ruiz L, Calles Hernández C, García Merino A, González Platas M, Hernández Pérez MÁ, Moral Torres E, Olascoaga Urtaza J, Oliva-Nacarino P, Oreja-Guevara C, Ortiz Castillo R, Oterino A, Prieto González JM, Ramió-Torrentá L, Rodríguez-Antigüedad A, Saiz A, Tintoré M, Montalbán Gairin X. Consensus statement on the use of alemtuzumab in daily clinical practice in Spain. Neurologia 2022; 37:615-630. [PMID: 31987648 DOI: 10.1016/j.nrl.2019.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Alemtuzumab is a highly effective drug approved by the European Medicines Agency as a disease-modifying drug for the treatment of relapsing-remitting multiple sclerosis. OBJECTIVE A consensus document was drafted on the management of alemtuzumab in routine clinical practice in Spain. DEVELOPMENT A group of multiple sclerosis specialists reviewed articles addressing treatment with alemtuzumab in patients with multiple sclerosis and published before December 2017. The included studies assessed the drug's efficacy, effectiveness, and safety; screening for infections and vaccination; and administration and monitoring aspects. The initial proposed recommendations were developed by a coordinating group and based on the available evidence and their clinical experience. The consensus process was carried out in 2 stages, with the initial threshold percentage for group agreement established at 80%. The final document with all the recommendations agreed by the working group was submitted for external review and the comments received were considered by the coordinating group. CONCLUSION The present document is intended to be used as a tool for optimising the management of alemtuzumab in routine clinical practice.
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Affiliation(s)
- J E Meca-Lallana
- CSUR Esclerosis Múltiple. Servicio de Neurología. Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-ARRIXACA), Cátedra de Neuroinmunología Clínica y Esclerosis Múltiple, UCAM. Universidad Católica San Antonio, Murcia, España.
| | - M Fernández-Prada
- Servicio de Medicina Preventiva y Salud Pública, Hospital Vital Álvarez-Buylla, Mieres (Asturias), España
| | - E García Vázquez
- Servicio de MI-Infecciosas. Hospital Clínico Universitario Virgen de la Arrixaca, Departamento de Medicina. Facultad de Medicina. Universidad de Murcia. IMIB-Arrixaca, Murcia, España
| | - S Moreno Guillén
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, España
| | - S Otero Romero
- Centro de Esclerosis Múltiple de Cataluña (Cemcat), Servicio de Neurología/Neuroinmunología, Hospital Universitario Vall de Hebrón, Barcelona, España
| | - M Rus Hidalgo
- Servicio de Neurología, Hospital Virgen Macarena, Sevilla, España
| | - L M Villar Guimerans
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, España
| | - S Eichau Madueño
- Servicio de Neurología, Hospital Virgen Macarena, Sevilla, España
| | - Ó Fernández Fernández
- Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Málaga, España
| | - G Izquierdo Ayuso
- Unidad de Investigación y Tratamiento de Esclerosis Múltiple, Hospital Vithas Nisa, Castilleja de la Cuesta (Sevilla), España
| | - J C Álvarez Cermeño
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, España
| | - C Arnal García
- Servicio de Neurología, Hospital Universitario Virgen de las Nieves, Hospital General, Granada, España
| | - R Arroyo González
- Hospital Universitario Quirónsalud Madrid, Pozuelo de Alarcón (Madrid), España
| | - L Brieva Ruiz
- Servicio de Neurología, Hospital Arnau de Vilanova, IRBLLEIDA, Lérida, España
| | | | - A García Merino
- Servicio de Neurología, Unidad de Neuroinmunología, Hospital Universitario Puerta de Hierro, Majadahonda (Madrid), España
| | - M González Platas
- Hospital Universitario de Canarias, La Cuesta (Santa Cruz de Tenerife), España
| | - M Á Hernández Pérez
- Servicio de Neurología, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, España
| | - E Moral Torres
- Servicio de Neurología, Hospital Moisés Broggi y Hospital General de ĺHospitaletí, Sant Joan Despí (Barcelona), España
| | - J Olascoaga Urtaza
- Unidad de EM Hospital Universitario Donostia-Instituto de Investigación BIODONOSTIA, San Sebastián (Guipúzcoa), España
| | - P Oliva-Nacarino
- Servicio de Neurología, Hospital Universitario Central de Asturias, Oviedo, España
| | - C Oreja-Guevara
- Neurología, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, España
| | | | - A Oterino
- Servicio de Neurología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - J M Prieto González
- Servicio de Neurología, Hospital Clínico Universitario de Santiago, Santiago de Compostela (La Coruña), España
| | - L Ramió-Torrentá
- Unidad de Neuroinmunología y Esclerosis Múltiple Territorial de Gerona, Servicio de Neurología. Hospital Universitario Doctor Josep Trueta, Grupo Neurodegeneración y Neuroinflamación. IDIBGI, Facultad de Medicina. Universidad de Gerona, Gerona, España
| | | | - A Saiz
- Servicio de Neurología, Hospital Clínico, Universidad de Barcelona, Barcelona, España
| | - M Tintoré
- Centro de Esclerosis Múltiple de Cataluña (Cemcat), Servicio de Neurología/Neuroinmunología, Hospital Universitario Vall de Hebrón, Barcelona, España
| | - X Montalbán Gairin
- Centro de Esclerosis Múltiple de Cataluña (Cemcat), Servicio de Neurología/Neuroinmunología, Hospital Universitario Vall de Hebrón, Barcelona, España
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Kvistad SAS, Burman J, Lehmann AK, Tolf A, Zjukovskaja C, Melve GK, Bø L, Torkildsen Ø. Impact of previous disease-modifying treatment on safety and efficacy in patients with MS treated with AHSCT. J Neurol Neurosurg Psychiatry 2022; 93:844-848. [PMID: 35508373 PMCID: PMC9304086 DOI: 10.1136/jnnp-2022-328797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/18/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Autologous haematopoietic stem cell transplantation (AHSCT) is a highly effective treatment for multiple sclerosis (MS). The impact of previous long-lasting disease-modifying treatments (DMT) for safety and efficacy of AHSCT is unknown. OBJECTIVE To explore whether previous DMTs with long-lasting effects on the immune system (anti-CD20 therapy, alemtuzumab and cladribine) affect treatment-related complications, long-term outcome and risk of new MS disease activity in patients treated with AHSCT. METHODS Retrospective observational study of 104 relapsing remitting patients with MS treated by AHSCT in Sweden and Norway from 2011 to 2021, grouped according to the last DMT used ≤6 months prior to AHSCT. The primary outcomes were early AHSCT-related complications (mortality, neutropenic fever and hospitalisation length), long-term complications (secondary autoimmunity) and proportion of patients with No Evidence of Disease Activity (NEDA-3 status): no new relapses, no MRI activity and no disease progression during the follow-up. RESULTS The mean follow-up time was 39.5 months (range 1-95). Neutropenic fever was a common AHSCT-related complication affecting 69 (66%) patients. There was no treatment-related mortality. During the follow-up period, 20 patients (19%) were diagnosed with autoimmunity. Occurrence of neutropenic fever, hospitalisation length or secondary autoimmunity did not vary dependent on the last DMT used prior to AHSCT. A total of 84 patients (81%) achieved NEDA-3 status, including all patients (100%) using rituximab, alemtuzumab or cladribine before AHSCT. CONCLUSION This study provides level 4 evidence that AHSCT in patients previously treated with alemtuzumab, cladribine or rituximab is safe and efficacious.
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Affiliation(s)
- Silje Agnethe Stokke Kvistad
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway .,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Joachim Burman
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden
| | - Anne Kristine Lehmann
- Department of Medicine, Section of Hematology, Haukeland University Hospital, Bergen, Norway
| | - Andreas Tolf
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden.,Department of Neurology, Akademiska sjukhuset, Uppsala, Sweden
| | | | - Guro Kristin Melve
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neurology, Norwegian Multiple Sclerosis Competence Centre, Bergen, Norway
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10
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Zhong M, van der Walt A, Stankovich J, Kalincik T, Buzzard K, Skibina O, Boz C, Hodgkinson S, Slee M, Lechner-Scott J, Macdonell R, Prevost J, Kuhle J, Laureys G, Van Hijfte L, Alroughani R, Kermode AG, Butler E, Barnett M, Eichau S, van Pesch V, Grammond P, McCombe P, Karabudak R, Duquette P, Girard M, Taylor B, Yeh W, Monif M, Gresle M, Butzkueven H, Jokubaitis VG. Prediction of multiple sclerosis outcomes when switching to ocrelizumab. Mult Scler 2022; 28:958-969. [PMID: 34623947 DOI: 10.1177/13524585211049986] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Increasingly, people with relapsing-remitting multiple sclerosis (RRMS) are switched to highly effective disease-modifying therapies (DMTs) such as ocrelizumab. OBJECTIVE To determine predictors of relapse and disability progression when switching from another DMT to ocrelizumab. METHODS Patients with RRMS who switched to ocrelizumab were identified from the MSBase Registry and grouped by prior disease-modifying therapy (pDMT; interferon-β/glatiramer acetate, dimethyl fumarate, teriflunomide, fingolimod or natalizumab) and washout duration (<1 month, 1-2 months or 2-6 months). Survival analyses including multivariable Cox proportional hazard regression models were used to identify predictors of on-ocrelizumab relapse within 1 year, and 6-month confirmed disability progression (CDP). RESULTS After adjustment, relapse hazard when switching from fingolimod was greater than other pDMTs, but only in the first 3 months of ocrelizumab therapy (hazard ratio (HR) = 3.98, 95% confidence interval (CI) = 1.57-11.11, p = 0.004). The adjusted hazard for CDP was significantly higher with longer washout (2-6 m compared to <1 m: HR = 9.57, 95% CI = 1.92-47.64, p = 0.006). CONCLUSION The risk of disability worsening during switch to ocrelizumab is reduced by short treatment gaps. Patients who cease fingolimod are at heightened relapse risk in the first 3 months on ocrelizumab. Prospective evaluation of strategies such as washout reduction may help optimise this switch.
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Affiliation(s)
- Michael Zhong
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Anneke van der Walt
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Jim Stankovich
- Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Tomas Kalincik
- CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia/MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Katherine Buzzard
- MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/Department of Neurology, Box Hill Hospital, Melbourne, VIC, Australia/Monash University, Melbourne, VIC, Australia
| | - Olga Skibina
- Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia/Department of Neurology, Box Hill Hospital, Melbourne, VIC, Australia/Monash University, Melbourne, VIC, Australia
| | - Cavit Boz
- KTU Medical Faculty, Farabi Hospital, Trabzon, Turkey
| | | | - Mark Slee
- Flinders University, Adelaide, SA, Australia
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia/Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, NSW, Australia
| | | | | | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Guy Laureys
- Department of Neurology, University Hospital Ghent, Ghent, Belgium
| | | | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Allan G Kermode
- Perron Institute, The University of Western Australia, Perth, WA, Australia/Institute of Immunology and Infectious Diseases, Murdoch University, Perth, WA, Australia
| | | | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | | | - Pamela McCombe
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Rana Karabudak
- Department of Neurology, Hacettepe University, Ankara, Turkey
| | | | - Marc Girard
- CHUM and Universite de Montreal, Montreal, QC, Canada
| | | | - Wei Yeh
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Mastura Monif
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia/MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Melissa Gresle
- Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Helmut Butzkueven
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Vilija G Jokubaitis
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia
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11
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Frahm N, Fneish F, Ellenberger D, Flachenecker P, Paul F, Warnke C, Kleinschnitz C, Parciak T, Krefting D, Hellwig K, Haas J, Rommer PS, Stahmann A, Zettl UK. Therapy Switches in Fingolimod-Treated Patients with Multiple Sclerosis: Long-Term Experience from the German MS Registry. Neurol Ther 2022; 11:319-336. [PMID: 35020157 PMCID: PMC8857375 DOI: 10.1007/s40120-021-00320-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTIONS Therapy switches in patients with multiple sclerosis (MS) receiving treatment with fingolimod occur frequently in clinical practice but are not well represented in real-world data. The aim of this study was to identify and characterize treatment switches and reveal sociodemographic/clinical changes over time in fingolimod-treated people with MS (PwMS). METHODS Data on 2536 fingolimod-treated PwMS extracted from the German MS Registry during different time periods were analyzed (2010-2019). RESULTS Overall, 28.3% of PwMS were treatment-naïve before fingolimod initiation. Interferon beta (30.7%) was the most common pre-fingolimod treatment. Ocrelizumab (19.8%) was the most frequent subsequent treatment in the 944 patients on fingolimod who switched. Between 2010 and 2019, median disease duration at fingolimod initiation decreased from 8.5 to 7.1 years (p < 0.001), and patients taking fingolimod for ≥ 1 year after treatment initiation decreased from 89.6 to 80.5% (p < 0.001). Females (p < 0.001) and young patients (p = 0.003) showed a shorter time on fingolimod. The most frequent reason for switching was disease activity (relapse/MRI) despite treatment. The annualized relapse rate increased from 0.37 in patients on fingolimod to 0.47 after treatment cessation, decreasing to 0.19 after treatment with a subsequent disease-modifying drug (DMD) was initiated. CONCLUSION Treatment switches from fingolimod to subsequent DMDs currently occur after shorter treatment durations than 10 years ago, possibly due to the growing treatment spectrum. Planning adequate washout periods is essential and should be done on an individualized basis.
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Affiliation(s)
- Niklas Frahm
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
- Neuroimmunological Section, Department of Neurology, University Medical Center of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany
| | - Firas Fneish
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
| | - David Ellenberger
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
| | - Peter Flachenecker
- Neurological Rehabilitation Center Quellenhof, Kuranlagenallee 2, 75323 Bad Wildbad, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité–Universitätsmedizin Berlin, Lindenberger Weg 80, 13125 Berlin, Germany
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center of Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Tina Parciak
- Department of Medical Informatics, University Medical Center Göttingen, Von-Siebold-Str. 3, 37075 Göttingen, Germany
| | - Dagmar Krefting
- Department of Medical Informatics, University Medical Center Göttingen, Von-Siebold-Str. 3, 37075 Göttingen, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Joseph and St. Elisabeth Hospital–Ruhr University, Gudrunstr. 56, 44791 Bochum, Germany
| | - Judith Haas
- Deutsche Multiple Sklerose Gesellschaft, Bundesverband e.V. (German Multiple Sclerosis Society [DMSG], Federal Association), Krausenstr. 50, 30171 Hannover, Germany
| | - Paulus S. Rommer
- Neuroimmunological Section, Department of Neurology, University Medical Center of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria
| | - Alexander Stahmann
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
| | - Uwe K. Zettl
- Neuroimmunological Section, Department of Neurology, University Medical Center of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany
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12
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Korsen M, Pfeuffer S, Rolfes L, Meuth SG, Hartung HP. Neurological update: treatment escalation in multiple sclerosis patients refractory to fingolimod-potentials and risks of subsequent highly active agents. J Neurol 2022; 269:2806-2818. [PMID: 34999925 PMCID: PMC9021111 DOI: 10.1007/s00415-021-10956-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/30/2021] [Indexed: 12/01/2022]
Abstract
A critical issue in the management of relapsing MS (RMS) is the discontinuation of disease-modifying treatments (DMT) due to lack of efficacy, intolerability or impending risks. With new therapeutic agents introduced into the treatment of RMS, immediate- and long-term consequences of sequential drug use, as well as the effect of the sequence in which the drugs are given, are unclear but may affect efficacy, adverse events, and long-term immunocompetence. In the absence of clinical studies specifically addressing these concerns, observations from clinical practice are of particular value in guiding current management algorithms. Prompted by a study published by Ferraro et al. in this journal, we set out to provide an overview of the published real-world evidence on the effectiveness and safety of switching from fingolimod to another DMT in patients with active RMS. Seventeen publications reporting relevant information were identified. The literature suggests that immune cell depletion induced by alemtuzumab or ocrelizumab is associated with an increased risk of relapse and worsening disability in patients switching from fingolimod compared to patients switching from other therapeutic agents. However, the evidence reported for natalizumab and cladribine is inconclusive. While shortening of the washout period may limit early disease reactivation after fingolimod discontinuation, there is no strong evidence that the duration of the washout period or the absolute lymphocyte count at baseline are predictors of attenuated long-term efficacy. Further real-world studies are required to better understand outcomes among patients who are under-represented in controlled trials.
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Affiliation(s)
- Melanie Korsen
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | | | - Leoni Rolfes
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
- Brain and Mind Centre, University of Sydney, Sydney, Australia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
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13
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Goncuoglu C, Tuncer A, Bayraktar-Ekincioglu A, Ayvacioglu Cagan C, Acar-Ozen P, Cakan M, Karabulut E, Karabudak R. Factors associated with fingolimod rebound: A single center real-life experience. Mult Scler Relat Disord 2021; 56:103278. [PMID: 34655957 DOI: 10.1016/j.msard.2021.103278] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Cansu Goncuoglu
- Hacettepe University Faculty of Pharmacy, Department of Clinical Pharmacy, P.O. Box 06100, Sihhiye, Ankara, Turkey.
| | - Asli Tuncer
- Hacettepe University, Faculty of Medicine, Department of Neurology, P.O. Box 06100, Sihhiye, Ankara, Turkey
| | - Aygin Bayraktar-Ekincioglu
- Hacettepe University Faculty of Pharmacy, Department of Clinical Pharmacy, P.O. Box 06100, Sihhiye, Ankara, Turkey
| | - Cansu Ayvacioglu Cagan
- Hacettepe University, Faculty of Medicine, Department of Neurology, P.O. Box 06100, Sihhiye, Ankara, Turkey
| | - Pinar Acar-Ozen
- Hacettepe University, Faculty of Medicine, Department of Neurology, P.O. Box 06100, Sihhiye, Ankara, Turkey
| | - Melike Cakan
- Hacettepe University, Faculty of Medicine, Department of Neurology, P.O. Box 06100, Sihhiye, Ankara, Turkey
| | - Erdem Karabulut
- Hacettepe University, Faculty of Medicine, Department of Biostatistics, P.O. Box 06100, Sihhiye, Ankara, Turkey
| | - Rana Karabudak
- Hacettepe University, Faculty of Medicine, Department of Neurology, P.O. Box 06100, Sihhiye, Ankara, Turkey
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14
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Russo CV, Saccà F, Frau J, Annovazzi P, Signoriello E, Bonavita S, Grasso R, Clerico M, Cordioli C, Laroni A, Capobianco M, Torri Clerici V, Sartori A, Cavalla P, Maniscalco GT, La Gioia S, Caleri F, Giugno A, Iodice R, Carotenuto A, Cocco E, Fenu G, Zaffaroni M, Baroncini D, Lus G, Gallo A, De Mercanti SF, Lapucci C, Di Francescantonio V, Brambilla L, Sormani MP, Signori A. A real-world study of alemtuzumab in a cohort of Italian patients. Eur J Neurol 2021; 29:257-266. [PMID: 34558755 PMCID: PMC9293282 DOI: 10.1111/ene.15121] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/16/2021] [Accepted: 09/19/2021] [Indexed: 01/02/2023]
Abstract
Background and purpose Real‐world data on alemtuzumab are limited and do not provide evidence of its effectiveness after various disease‐modifying therapies (DMTs). Our aim was to provide real‐world data on the impact of clinical variables and previous DMTs on clinical response to alemtuzumab. Methods Sixteen Italian multiple sclerosis centers retrospectively included patients who started alemtuzumab from January 2015 to December 2018, and recorded demographics, previous therapies, washout duration, relapses, Expanded Disability Status Scale (EDSS) score, and magnetic resonance imaging data. Negative binomial regression models were used to assess the effect of factors on annualized relapse (ARR) after alemtuzumab initiation. Results We studied 322 patients (mean age 36.8 years, median EDSS score 3, median follow‐up 1.94 years). Previous treatments were: fingolimod (106), natalizumab (80), first‐line oral agents (56), first‐line injectables (interferon/glatiramer acetate; 30), and other drugs (15). Thirty‐five patients were treatment‐naïve. The pre‐alemtuzumab ARR was 0.99 and decreased to 0.13 during alemtuzumab treatment (p < 0.001). The number of previous‐year relapses was associated with alemtuzumab ARR (adjusted risk ratio [RR] 1.38, p = 0.009). Progression‐free survival was 94.5% after 1 year, and 89.2% after 2 years of alemtuzumab treatment. EDSS score improvement occurred in 13.5% after 1 year, and 20.6% after 2 years. Re‐baselining patients after 6 months of alemtuzumab treatment, led to no evidence of disease activity status in 71.6% after 1 year and 58.9% after 2 years. Conclusions Alemtuzumab decreases ARR independent of previous therapy, including patients with disease activity during natalizumab treatment. Overall, 90% of patients showed no disease progression, and 20% an improvement after 2 years of alemtuzumab.
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Affiliation(s)
| | - Francesco Saccà
- NSRO Department, University of Naples Federico II, Napoli, Italy
| | - Jessica Frau
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna); Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Pietro Annovazzi
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | | | | | | | - Marinella Clerico
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Torino, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Center, ASST Spedali Civili di Brescia, Montichiari Hospital, Montichiari, Italy
| | - Alice Laroni
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research (CEBR) and IRCCS San Martino-IST, University of Genova, Genova, Italy
| | - Marco Capobianco
- SC Neurologia e Centro di Riferimento Regionale SM - AOU S. Luigi, Orbassano, Torino, Italy
| | - Valentina Torri Clerici
- Neuro-Immunology and Neuromuscolar Diseases Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milano, Italy
| | - Arianna Sartori
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, ASUGI, University of Trieste, Trieste, Italy
| | - Paola Cavalla
- MS Center, City of Health & Science University Hospital, Torino, Italy
| | | | - Sara La Gioia
- Centro Sclerosi Multipla, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Francesca Caleri
- Neurology Department, F. Tappeiner Hospital Meran (BZ) of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Alessia Giugno
- Institute of Neurology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Rosa Iodice
- NSRO Department, University of Naples Federico II, Napoli, Italy
| | | | - Eleonora Cocco
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna); Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Giuseppe Fenu
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna); Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | - Damiano Baroncini
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | - Giacomo Lus
- University of Campania Luigi Vanvitelli, Napoli, Italy
| | - Antonio Gallo
- University of Campania "Luigi Vanvitelli", Napoli, Italy
| | | | - Caterina Lapucci
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research (CEBR) and IRCCS San Martino-IST, University of Genova, Genova, Italy
| | | | - Laura Brambilla
- Neuro-Immunology and Neuromuscolar Diseases Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milano, Italy
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genova, Genova, Italy
| | - Alessio Signori
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genova, Genova, Italy
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15
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Pfeuffer S, Ruck T, Pul R, Rolfes L, Korsukewitz C, Pawlitzki M, Wildemann B, Klotz L, Kleinschnitz C, Scalfari A, Wiendl H, Meuth SG. Impact of previous disease-modifying treatment on effectiveness and safety outcomes, among patients with multiple sclerosis treated with alemtuzumab. J Neurol Neurosurg Psychiatry 2021; 92:1007-1013. [PMID: 33712515 PMCID: PMC8372391 DOI: 10.1136/jnnp-2020-325304] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/14/2021] [Accepted: 02/07/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Alemtuzumab is effective in patients with active multiple sclerosis but has a complex safety profile, including the development of secondary autoimmunity. Most of patients enrolled in randomised clinical trials with alemtuzumab were either treatment naïve or pretreated with injectable substances. Other previous disease-modifying treatments (DMTs) were not used in the study cohorts, and therefore, associated risks might yet remain unidentified. METHODS We retrospectively evaluated a prospective dual-centre alemtuzumab cohort of 170 patients. We examined the baseline characteristics as well as safety and effectiveness outcomes, including the time to first relapse, the time to 3 months confirmed disability worsening and the time to secondary autoimmunity. RESULTS The regression analysis showed that, among all previously used DMTs, the pretreatment with fingolimod (n=33 HRs for the time to first relapse (HR 5.420, 95% CI 2.520 to 11.660; p<0.001)) and for the time to worsening of disability (HR 7.676, 95% CI 2.870 to 20.534; p<0.001). Additionally, patients pretreated with fingolimod were more likely to experience spinal relapses (55% vs 10% among previously naïve patients; p<0.001) and had an increased risk of secondary autoimmunity (HR 5.875, 95% CI 2.126 to 16.27; p<0.001). CONCLUSION In the real-world setting, we demonstrated suboptimal disease control and increased risk of secondary autoimmunity following alemtuzumab, among patients previously treated with fingolimod. These data can provide guidance for improving MS therapeutic management.
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Affiliation(s)
- Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Refik Pul
- Department of Neurology, Universitat Duisburg-Essen, Duisburg, Germany
| | - Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Catharina Korsukewitz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Brigitte Wildemann
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | | | - Antonio Scalfari
- Centre for Neuroscience, Division of Experimental Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany
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16
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Ferraro D, Iaffaldano P, Guerra T, Inglese M, Capobianco M, Brescia Morra V, Zaffaroni M, Mirabella M, Lus G, Patti F, Cavalla P, Cellerino M, Malucchi S, Pisano E, Vitetta F, Paolicelli D, Sola P, Trojano M. Risk of multiple sclerosis relapses when switching from fingolimod to cell-depleting agents: the role of washout duration. J Neurol 2021; 269:1463-1469. [PMID: 34292396 DOI: 10.1007/s00415-021-10708-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/28/2021] [Accepted: 07/12/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fingolimod (FTY) induces sequestration of lymphocytes in secondary lymphoid organs and the average lymphocyte recovery following discontinuation takes 1-2 months. It has been hypothesized that the therapeutic effects of subsequent cell-depleting agents may be compromised if initiated before lymphocyte recovery has occurred. OBJECTIVE To assess the risk of relapses following FTY discontinuation and the initiation of a B/T cell-depleting agent in relation to washout duration using data from the Italian MS Register. METHODS The risk of relapses was assessed in relation to different washout durations (< 6, 6-11, 12-17 and > / = 18 weeks) in patients starting alemtuzumab, rituximab, ocrelizumab or cladribine following FTY discontinuation. RESULTS We included 329 patients in the analysis (226F, 103 M; mean age 41 ± 10 years). During the cell-depleting treatment, the incidence rate ratio for a relapse was significantly greater in patients with a washout period of 12-17 and > / = 18 weeks compared to the reference period (< 6 weeks). The risk of a relapse was significantly influenced by the occurrence of relapses during FTY treatment and by washout length, with hazard ratios markedly increasing with the washout duration. CONCLUSION The risk of relapses increases with the washout duration when switching from FTY to lymphocyte-depleting agents.
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Affiliation(s)
- D Ferraro
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy. .,Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Via Pietro Giardini 1355, 41126, Modena, Italy.
| | - P Iaffaldano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico, Bari, Italy
| | - T Guerra
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico, Bari, Italy
| | - M Inglese
- Department of Neuroscience, Rehabilitation, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - M Capobianco
- Regional Referral MS Center, Neurological Unit, University Hospital San Luigi, Orbassano, Italy
| | | | - M Zaffaroni
- Multiple Sclerosis Center, Gallarate Hospital, ASST Della Valle Olona, Gallarate, Italy
| | - M Mirabella
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - G Lus
- MS Center, II Division of Neurology, Univ. Della Campania "L. Vanvitelli", Naples, Italy
| | - F Patti
- Multiple Sclerosis Centre, AOU Policlinico "G. Rodolico", Catania, Italy.,Department of Medical and Surgical and Advanced Technologies, GF Ingrassia, University of Catania, Catania, Italy
| | - P Cavalla
- MS Centre, I Division of Neurology, City of Health and Science Turin Univ. Hospital, Turin, Italy
| | - M Cellerino
- Department of Neuroscience, Rehabilitation, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - S Malucchi
- Regional Referral MS Center, Neurological Unit, University Hospital San Luigi, Orbassano, Italy
| | - E Pisano
- MS Center-AOU Policlinico Federico II, Naples, Italy
| | - F Vitetta
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - D Paolicelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico, Bari, Italy
| | - P Sola
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - M Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico, Bari, Italy
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17
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Bigaut K, Cohen M, Durand-Dubief F, Maillart E, Planque E, Zephir H, Lebrun-Frenay C, de Seze J. How to switch disease-modifying treatments in multiple sclerosis: Guidelines from the French Multiple Sclerosis Society (SFSEP). Mult Scler Relat Disord 2021; 53:103076. [PMID: 34161898 DOI: 10.1016/j.msard.2021.103076] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/25/2021] [Accepted: 06/02/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Today, there are no recommendations on switching disease-modifying treatments (DMTs) in multiple sclerosis (MS). OBJECTIVES To establish guidelines on switching DMTs MS. METHODS A Steering Committee composed of seven MS experts from the French Group for Recommendations in Multiple Sclerosis (France4MS) defined 15 proposals. These proposals were then submitted to a Rating Group, composed of 48 French MS experts, for evaluation. The proposals were classified as 'appropriate', 'inappropriate' or 'uncertain'. RESULTS Switching from a first-line therapy to another first-line therapy or a second-line therapy could be done without a washout period. Switching from a second-line therapy to a first-line therapy could be done without a washout period with fingolimod or natalizumab, after 3 months with ocrelizumab or mitoxantrone, and, if disease activity occurs with alemtuzumab or cladribine. The switch from a second-line therapy to another second-line therapy could be done after a washout period of 1 month with fingolimod or natalizumab, after 3 months with ocrelizumab, after 6 months with mitoxantrone, and, if disease activity occurs, with alemtuzumab or cladribine. CONCLUSION This expert consensus approach provides physicians with some guidelines on optimizing the benefit/risk ratio when switching DMTs in patients with MS.
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Affiliation(s)
- Kévin Bigaut
- Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
| | - Mikaël Cohen
- Service de Neurologie, Centre Hospitalier Universitaire Pasteur 2, Nice, France
| | - Françoise Durand-Dubief
- Service de Neurologie, Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, Lyon, France
| | - Elisabeth Maillart
- Service de Neurologie, Hôpital de la Pitié-Salpêtrière, APHP, Paris, France
| | - Evelyne Planque
- Service de Neurologie, Centre Hospitalier Emile Durkheim, Epinal, France
| | - Hélène Zephir
- Service de Neurologie, Centre Hospitalo-Universitaire de Lille, Lille, France
| | | | - Jérôme de Seze
- Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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18
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Signoriello E, Lus G, Bonavita S, Lanzillo R, Saccà F, Landi D, Frau J, Baroncini D, Zaffaroni M, Maniscalco GT, Curti E, Sartori A, Cepparulo S, Marfia GA, Nicoletti CG, Carotenuto A, Nociti V, Caleri F, Sormani MP, Signori A. Switch from sequestering to anti-CD20 depleting treatment: disease activity outcomes during wash-out and in the first 6 months of ocrelizumab therapy. Mult Scler 2021; 28:93-101. [PMID: 33855897 DOI: 10.1177/13524585211005657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Switching between treatments is an opportunity for patients with multiple sclerosis (MS) to ameliorate disease control or safety. The aim of this study was to investigate the impact of switching from fingolimod (FTY) or natalizumab (NTZ) to ocrelizumab (OCR) on disease activity. METHODS We retrospectively enrolled 165 patients treated with OCR from 11 MS centres. We assessed the association of demographic and clinical characteristics on relapse rate (RR) and activity on magnetic resonance imaging (MRI) during wash-out and after 6 months of treatment with OCR through univariable and multivariable negative binomial regression models. RESULTS We registered a total of 35 relapses during the wash-out period. Previous treatment with FTY, relapses in the previous year, and relapsing-remitting course were associated with higher RR. In the first 6 months of OCR, 12 patients had clinical or MRI disease activity. Higher Expanded Disability Status Scale (EDSS) and higher lymphocyte count at OCR start were associated with a reduced probability of relapse. DISCUSSION AND CONCLUSION This study confirms that withdrawal from sequestering agents as FTY increases the risk of relapses in the wash-out period. Nevertheless, starting OCR before achieving complete immune reconstitution could limit its effectiveness in the first 6 months probably because trapped lymphocytes escape the CD20-mediated depletion.
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Affiliation(s)
- Elisabetta Signoriello
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Giacomo Lus
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Simona Bonavita
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Roberta Lanzillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Francesco Saccà
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Jessica Frau
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna)/Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Damiano Baroncini
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | | | - Erica Curti
- Multiple Sclerosis Center, Neurology Unit, University Hospital of Parma, Parma, Italy
| | - Arianna Sartori
- Multiple Sclerosis Center, Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, ASUGI, University of Trieste, Trieste, Italy
| | - Simone Cepparulo
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Carolina Gabri Nicoletti
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Antonio Carotenuto
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Viviana Nociti
- Multiple Sclerosis Center, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy
| | - Francesca Caleri
- Neurology Department, F. Tappeiner Hospital Meran (BZ), Meran, Italy
| | | | - Alessio Signori
- Department of Health Sciences, University of Genova, Genova, Italy
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19
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Immune phenotyping study revealing caveats regarding a switch from fingolimod to cladribine. Mult Scler Relat Disord 2020; 48:102727. [PMID: 33418308 DOI: 10.1016/j.msard.2020.102727] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/22/2020] [Accepted: 12/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recent data support a key role of B cells in the pathogenesis of multiple sclerosis. Due to the pronounced effect of cladribine on memory B cells, we initiated an immune phenotyping study, which included monitoring of memory B cells of patients newly assigned to this treatment option. A patient with ongoing disease activity in the first year of cladribine after a long-standing fingolimod treatment caught our attention. OBJECTIVE To report about differences in the immune phenotype of the case compared to patients without disease activity and to discuss possible causes for the deviations as caveats regarding treatment sequelae. METHODS Clinical data and immune phenotyping data collected at baseline (before treatment) and after three, six and ten/twelve months after cladribine initiation were compared between our case and six patients with a stable disease course (controls). RESULTS Both, the case and controls showed similar reductions of memory B cells in response to cladribine. The case however, showed an accelerated repopulation dynamic of naïve B cells with an almost 3-fold hyperrepopulation compared to baseline levels, and lower pre-treatment levels of CD4+ and CD8+ T cells and memory B cells compared to controls. CONCLUSION We propose a prolonged pre-treatment with fingolimod as possible cause for the lack of response to cladribine. Autoreactive cells sequestrated within lymph nodes may have evaded cladribine depletion on top of a delay of recirculating regulatory T cells. In addition, we want to raise awareness of the importance of monitoring T and B cells for bridging the current lack of evidence regarding sequencing therapies in the real life setting.
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20
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Comi G, Dalla Costa G, Moiola L. Newly approved agents for relapsing remitting multiple sclerosis: how real-world evidence compares with randomized clinical trials? Expert Rev Neurother 2020; 21:21-34. [PMID: 33043718 DOI: 10.1080/14737175.2021.1829478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION In recent years, many treatment options have become available for relapsing remitting MS. Randomized clinical trials and real-world studies are complementary sources of information, and together have the potential to offer a comprehensive understanding of the safety and efficacy profiles of each drug, a critical factor for a personalized management of the disease. AREAS COVERED In this review, the authors provide an up-to-date review of both RCTs and real-world studies assessing the safety and efficacy profiles of recently developed disease-modifying drugs for relapsing remitting MS. These include fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab and ocrelizumab. EXPERT OPINION From the authors' review of the literature, the efficacy profiles resulted from RCTs were confirmed by observational studies with regard to the disease-modifying drugs considered. The magnitude of the effects on annualized relapse rates and MRI active lesions was generally even larger in the observational studies compared to RCTs. From the safety point of view, observational studies revealed new adverse events, mostly in the area of bacterial and opportunistic infections, not seen in the relative registration programme. This is a very important gain because it allows to elaborate appropriate strategies to prevent and handle the risks.
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Affiliation(s)
- Giancarlo Comi
- Institute of Experimental Neurology of San Raffaele Hospital , Milan, Italy
| | - Gloria Dalla Costa
- Institute of Experimental Neurology of San Raffaele Hospital , Milan, Italy.,Vita-Salute San Raffaele University , Milan, Italy
| | - Lucia Moiola
- Institute of Experimental Neurology of San Raffaele Hospital , Milan, Italy.,Neurology Unit and MS Center, San Raffaele Hospital , Milan, Italy
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21
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Brannigan J, Jones JL, Stacpoole SRL. Severe paradoxical disease activation following alemtuzumab treatment for multiple sclerosis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/5/e799. [PMID: 32522766 PMCID: PMC7309519 DOI: 10.1212/nxi.0000000000000799] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/22/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Jamie Brannigan
- From Jesus College (J.B., S.R.L.S.), Cambridge University, UK; Department of Neurology (J.L.J., S.R.L.S.), Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; and Department of Neurology (S.R.L.S.), Peterborough City Hospital, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - Joanne L Jones
- From Jesus College (J.B., S.R.L.S.), Cambridge University, UK; Department of Neurology (J.L.J., S.R.L.S.), Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; and Department of Neurology (S.R.L.S.), Peterborough City Hospital, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - Sybil R L Stacpoole
- From Jesus College (J.B., S.R.L.S.), Cambridge University, UK; Department of Neurology (J.L.J., S.R.L.S.), Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; and Department of Neurology (S.R.L.S.), Peterborough City Hospital, North West Anglia NHS Foundation Trust, Peterborough, UK.
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22
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Meca-Lallana J, Fernández-Prada M, García Vázquez E, Moreno Guillén S, Otero Romero S, Rus Hidalgo M, Villar Guimerans L, Eichau Madueño S, Fernández Fernández Ó, Izquierdo Ayuso G, Álvarez Cermeño J, Arnal García C, Arroyo González R, Brieva Ruiz L, Calles Hernández C, García Merino A, González Plata M, Hernández Pérez M, Moral Torres E, Olascoaga Urtaza J, Oliva-Nacarino P, Oreja-Guevara C, Ortiz Castillo R, Oterino A, Prieto González J, Ramió-Torrentá L, Rodríguez-Antigüedad A, Saiz A, Tintoré M, Montalbán Gairin X. Consensus statement on the use of alemtuzumab in daily clinical practice in Spain. NEUROLOGÍA (ENGLISH EDITION) 2020; 37:615-630. [DOI: 10.1016/j.nrleng.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 11/04/2019] [Indexed: 10/24/2022] Open
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23
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Baker D, Ali L, Saxena G, Pryce G, Jones M, Schmierer K, Giovannoni G, Gnanapavan S, Munger KC, Samkoff L, Goodman A, Kang AS. The Irony of Humanization: Alemtuzumab, the First, But One of the Most Immunogenic, Humanized Monoclonal Antibodies. Front Immunol 2020; 11:124. [PMID: 32117274 PMCID: PMC7034358 DOI: 10.3389/fimmu.2020.00124] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/17/2020] [Indexed: 12/22/2022] Open
Abstract
Alemtuzumab was designed to reduce the immunogenicity of the parent CD52-specific rat immunoglobulin. Although originally marketed for use in cancer (Mabcampath®), alemtuzumab is currently licensed and formulated for the treatment of relapsing multiple sclerosis (Lemtrada®). Perhaps due to its history as the first humanized antibody, the potential of immunogenicity of the molecule has been considered inconsequential, and anti-drug antibodies (ADA) responses were similarly reported as being clinically insignificant. Nonetheless, despite humanization and depletion of peripheral T and B cells, alemtuzumab probably generates the highest frequency of binding and neutralizing ADA of all humanized antibodies currently in clinical use, and they occur rapidly in a large majority of people with MS (pwMS) on alemtuzumab treatment. These ADA appear to be an inherent issue of the biology of the molecule-and more importantly, the target-such that avoidance of immunogenicity-related effects has been facilitated by the dosing schedule used in clinical practice. At the population level this enables the drug to work in most pwMS, but in some individuals, as we show here, antibody neutralization appears to be sufficiently severe to reduce efficacy and allow disease breakthrough. It is therefore imperative that efficacy of lymphocyte depletion and the anti-drug response is monitored in people requiring additional cycles of treatment, notably following disease breakthrough. This may help inform whether to re-treat or to switch to another disease-modifying treatment.
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Affiliation(s)
- David Baker
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Liaqat Ali
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Department of Biological Sciences, National University of Medical Sciences (NUMS), Rawalpindi, Pakistan
| | - Gauri Saxena
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Gareth Pryce
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Meleri Jones
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Klaus Schmierer
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Clinical Board: Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Clinical Board: Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Sharmilee Gnanapavan
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Clinical Board: Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Kathleen C. Munger
- Department of Neurology, University of Rochester Medical Center, School of Medicine and Dentistry, Rochester, NY, United States
| | - Lawrence Samkoff
- Department of Neurology, University of Rochester Medical Center, School of Medicine and Dentistry, Rochester, NY, United States
| | - Andrew Goodman
- Department of Neurology, University of Rochester Medical Center, School of Medicine and Dentistry, Rochester, NY, United States
| | - Angray S. Kang
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Centre for Oral Immunobiology and Regenerative Medicine, Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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24
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Rojas JI, Pappolla A, Patrucco L, Cristiano E, Sánchez F. Do clinical trials for new disease modifying treatments include real world patients with multiple sclerosis? Mult Scler Relat Disord 2020; 39:101931. [PMID: 31924592 DOI: 10.1016/j.msard.2020.101931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/31/2019] [Accepted: 01/02/2020] [Indexed: 01/31/2023]
Abstract
We often see that clinical and demographic characteristics of real-world studies (RWS) do not differ from patients included in randomized controlled trials (RCT). OBJECTIVE to compare clinical and demographic aspects of patients included in RCT and RWS that evaluated new disease modifying treatment in multiple sclerosis (MS). METHODS a systematic non-language-restricted literature search of RCT and RWS that evaluated new disease modifying treatments (natalizumab, alemtuzumab, ocrelizumab, fingolimod, teriflunomide, dimethyl fumarate and cladribine) from January 2005 to January 2019. Demographic and clinical data were extracted, described and compared. RESULTS 18 RCT and 73 RWS were included. We found no differences in clinical and demographic aspects between RCT and RWS except in the frequency of naïve patients included in RCT vs. RWS 65.6% (95%CI 52-74) vs. 36.4% (95%CI 21-46), respectively, (p = 0.013) at study entry, as well as for the inclusion of patients that used previous treatment 34.4% (95%CI 22-41) vs. 63.6% (95%CI 53-74) in RCT and RWS, respectively,(p = 0.007) at study entry. CONCLUSION We did not observe significant differences in most clinical and demographic aspects of included patients in RCT and RWS. Studies that include the full spectrum of MS patients followed in clinical practice are needed.
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Affiliation(s)
- Juan Ignacio Rojas
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina.
| | - Agustín Pappolla
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Liliana Patrucco
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Edgardo Cristiano
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Francisco Sánchez
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
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25
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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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26
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Switching from fingolimod to alemtuzumab in patients with highly active relapsing-remitting multiple sclerosis: Α case series. Mult Scler Relat Disord 2019; 38:101517. [PMID: 31751858 DOI: 10.1016/j.msard.2019.101517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/02/2019] [Accepted: 11/10/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The management of "aggressive" and "highly-active" relapsing-remitting multiple sclerosis remains problematic. Although a number of highly efficacious agents are currently available, the optimal timing of their use and the balancing between efficacy and immediate and long-term consequences are still a matter of conjecture. METHODS We describe the clinical, radiological and immunological profile of three multiple sclerosis patients with persistent clinical and radiological disease activity under fingolimod treatment. After fingolimod cessation patients demonstrated severe disease exacerbation and were successfully treated with alemtuzumab. RESULTS All patients experienced significant improvement after the administration of alemtuzumab and achieved no evidence of disease activity status that persisted after a median of 19 months of follow-up (range: 17-25 months). Confirmed disability improvement was achieved in all cases. Quantitative MRI data demonstrated a reduction of the T2 lesion load in 2 out of 3 patients and complete abrogation of inflammatory activity in all patients after the administration of alemtuzumab. Α patient presented a previously unreported, persistent lymphocytosis after alemtuzumab administration, that was not associated with infectious, lymphoproliferative or autoimmune diseases and had no apparent clinical implications. CONCLUSIONS Alemtuzumab appears to be an effective and safe short-term therapeutic option both as a rescue therapy for the disease flare-up associated with fingolimod withdrawal, as well as for the reversal of the deteriorating course observed in patients who fail treatment with fingolimod.
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Van Wijmeersch B, Singer BA, Boster A, Broadley S, Fernández Ó, Freedman MS, Izquierdo G, Lycke J, Pozzilli C, Sharrack B, Steingo B, Wiendl H, Wray S, Ziemssen T, Chung L, Margolin DH, Thangavelu K, Vermersch P. Efficacy of alemtuzumab over 6 years in relapsing-remitting multiple sclerosis patients who relapsed between courses 1 and 2: Post hoc analysis of the CARE-MS studies. Mult Scler 2019; 26:1719-1728. [PMID: 31675266 PMCID: PMC7604550 DOI: 10.1177/1352458519881759] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Alemtuzumab is administered as two annual courses for relapsing-remitting multiple sclerosis (MS). Patients may relapse before completing the two-course regimen. OBJECTIVE The objective was to evaluate 6-year outcomes in patients who relapsed between alemtuzumab Courses 1 and 2 (early relapsers). METHODS Post hoc analysis of patients from the Comparison of Alemtuzumab and Rebif® Efficacy in Multiple Sclerosis (CARE-MS) studies who enrolled in the extension. RESULTS Early relapsers (CARE-MS I: 15%; CARE-MS II: 24%) had more relapses in 1-2 years pre-alemtuzumab and higher mean baseline Expanded Disability Status Scale score than patients without relapse. Their annualized relapse rate declined from Year 1 (CARE-MS I: 1.3; CARE-MS II: 1.2) to Year 2 following Course 2 (0.3; 0.5) and remained low thereafter. Over 6 years, 60% remained free of 6-month confirmed disability worsening; 24% (CARE-MS I) and 34% (CARE-MS II) achieved 6-month confirmed disability improvement. During Year 6, 69% (CARE-MS I) and 68% (CARE-MS II) were free of magnetic resonance imaging (MRI) disease activity. Median percent yearly brain volume loss (Year 1: -0.67% (CARE-MS I); -0.47% (CARE-MS II)) declined after Course 2 (Year 6: -0.24%; -0.13%). CONCLUSION Early relapsers' outcomes improved after completing the second alemtuzumab course. These findings support administering the approved two-course regimen to maximize clinical benefit. CLINICALTRIALS.GOV REGISTRATION NUMBERS CARE-MS I, II, extension: NCT00530348, NCT00548405, NCT00930553.
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Affiliation(s)
- Bart Van Wijmeersch
- Rehabilitation and MS Center Overpelt; BIOMED, Hasselt University, Hasselt, Belgium
| | - Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA
| | - Aaron Boster
- OhioHealth Neurological Physicians, Columbus, OH, USA
| | - Simon Broadley
- School of Medicine, Griffith University, Southport, QLD, Australia
| | - Óscar Fernández
- Fundación IMABIS, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Mark S Freedman
- University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Jan Lycke
- Institution of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Basil Sharrack
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals, University of Sheffield, Sheffield, UK
| | - Brian Steingo
- Fort Lauderdale Multiple Sclerosis Center, Fort Lauderdale, FL, USA
| | | | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, Dresden, Germany
| | | | | | | | - Patrick Vermersch
- University of Lille, INSERM U995, CHU Lille, FHU Imminent, Lille, France
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Boyko AN, Davydovskaya MV, Khachanova NV, Zakharova MN, Spirin NN, Popova EV, Alifirova VM, Vlasov YV, Sivertseva SA, Khabirov FA, Shumilina MV, Evdoshenko EP. Clinical recommendations for the use of ocrelizumab in patients with multiple sclerosis. ACTA ACUST UNITED AC 2019. [DOI: 10.14412/2074-2711-2019-3-16-25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The paper presents a detailed algorithm for the treatment and follow-up of patients with recurrent multiple sclerosis and primary progressive multiple sclerosis in the use of ocrelizumab.
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Affiliation(s)
- A. N. Boyko
- N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia Federal Center for Cerebrovascular Disease and Stroke, Ministry of Health of Russia
| | - M. V. Davydovskaya
- N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia
| | - N. V. Khachanova
- N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia
| | | | - N. N. Spirin
- Yaroslavl State Medical University, Ministry of Health of Russia
| | - E. V. Popova
- City Clinical Hospital Twenty-Four, Moscow Healthcare Department
| | - V. M. Alifirova
- Siberian State Medical University, Ministry of Health of Russia
| | - Ya. V. Vlasov
- Samara State Medical University, Ministry of Health of Russia
| | | | - F. A. Khabirov
- Republican Clinical and Diagnostic Center for Demyelinating Diseases, Ministry of Health of the Republic of Tatarstan
| | - M. V. Shumilina
- City Clinical Hospital Thirty-One, City Center for Multiple Sclerosis Treatment
| | - E. P. Evdoshenko
- City Clinical Hospital Thirty-One, City Center for Multiple Sclerosis Treatment
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Sepúlveda M, Montejo C, Llufriu S, Sola-Valls N, Reyes D, Martinez-Lapiscina EH, Zubizarreta I, Pulido-Valdeolivas I, Martinez-Hernandez E, Ariño H, Baños N, Saiz A, Blanco Y. Rebound of multiple sclerosis activity after fingolimod withdrawal due to planning pregnancy: Analysis of predisposing factors. Mult Scler Relat Disord 2019; 38:101483. [PMID: 31734621 DOI: 10.1016/j.msard.2019.101483] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/03/2019] [Accepted: 10/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Rebound of multiple sclerosis (MS) activity has been described after the withdrawal of high-efficacy drugs, but its impact during pregnancy is less known. We describe a series of cases of rebound syndrome after the cessation of fingolimod due to pregnancy planning. METHODS The clinical and radiological data of 7 MS patients who discontinued fingolimod therapy between May 2012 and March 2018 to plan a pregnancy was analysed. RESULTS Three (42.8%) of the 7 patients experienced a rebound effect, all of whom became pregnant. During pregnancy, the 3 patients had a mean (SD) of 5.3 (1.3) relapses, and 13 of the 15 relapses were treated with intravenous steroids and/or immunoglobulin. These patients experienced a median increase of 3 points in the Expanded Disability Status Scale (range, 2-4), as well as a median increase of 27 new gadolinium-enhancing lesions (range, 9-40) and 38 new T2 lesions in a post-partum MRI (range, 21-70). The 3 pregnancies resulted in the delivery of healthy babies. A strong correlation was found between the lymphocyte count at fingolimod onset and the annual relapse rate in the period without therapy (r= -0.84, p = 0.005). The time to first relapse was shorter in patients who had <300/μl lymphocytes at fingolimod onset (median time 46 vs 426 days, p = 0.010). CONCLUSION Rebound activity after fingolimod suspension represents a severe long-lasting inflammatory syndrome that may affect up to 40% of female MS patient who discontinue therapy due to pregnancy planning. Lymphopenia (<300/μl) in the first 3 months of fingolimod onset may predispose patients to suffer earlier and higher disease activity upon cessation.
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Affiliation(s)
- Maria Sepúlveda
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Carmen Montejo
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Sara Llufriu
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Nuria Sola-Valls
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - David Reyes
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Elena H Martinez-Lapiscina
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Irati Zubizarreta
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Irene Pulido-Valdeolivas
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Eugenia Martinez-Hernandez
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Helena Ariño
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Nuria Baños
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Universitat de Barcelona, Spain
| | - Albert Saiz
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain
| | - Yolanda Blanco
- Center of Neuroimmunology, Service of Neurology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Universitat de Barcelona, Barcelona, Spain.
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Baker D, Pryce G, Amor S, Giovannoni G, Schmierer K. Learning from other autoimmunities to understand targeting of B cells to control multiple sclerosis. Brain 2019; 141:2834-2847. [PMID: 30212896 DOI: 10.1093/brain/awy239] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/01/2018] [Indexed: 12/15/2022] Open
Abstract
Although many suspected autoimmune diseases are thought to be T cell-mediated, the response to therapy indicates that depletion of B cells consistently inhibits disease activity. In multiple sclerosis, it appears that disease suppression is associated with the long-term reduction of memory B cells, which serves as a biomarker for disease activity in many other CD20+ B cell depletion-sensitive, autoimmune diseases. Following B cell depletion, the rapid repopulation by transitional (immature) and naïve (mature) B cells from the bone marrow masks the marked depletion and slow repopulation of lymphoid tissue-derived, memory B cells. This can provide long-term protection from a short treatment cycle. It seems that memory B cells, possibly via T cell stimulation, drive relapsing disease. However, their sequestration in ectopic follicles and the chronic activity of B cells and plasma cells in the central nervous system may drive progressive neurodegeneration directly via antigen-specific mechanisms or indirectly via glial-dependent mechanisms. While unproven, Epstein-Barr virus may be an aetiological trigger of multiple sclerosis. This infects mature B cells, drives the production of memory B cells and possibly provides co-stimulatory signals promoting T cell-independent activation that breaks immune tolerance to generate autoreactivity. Thus, a memory B cell centric mechanism can integrate: potential aetiology, genetics, pathology and response to therapy in multiple sclerosis and other autoimmune conditions with ectopic B cell activation that are responsive to memory B cell-depleting strategies.
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Affiliation(s)
- David Baker
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gareth Pryce
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sandra Amor
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Pathology Department, Free University Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Gavin Giovannoni
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Klaus Schmierer
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
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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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Kahovec C, Levin MC. Stabilization Without Rituximab After Disease Activation in an Alemtuzumab-Treated Patient with Multiple Sclerosis and a Literature Overview. Int J MS Care 2019; 21:125-128. [PMID: 31191177 DOI: 10.7224/1537-2073.2018-030] [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: 11/18/2022]
Abstract
There has been an increasing number of reports describing B-cell-associated disease activation in patients with multiple sclerosis after alemtuzumab treatment. Herein, 4.5 months after a first alemtuzumab infusion, a 33-year-old female patient had altered gait and vision loss associated with gadolinium enhancement of the optic nerves and chiasm on brain magnetic resonance imaging. The patient's blood showed normal B-cell counts concurrent with abnormally low T-cell counts. The patient stabilized after receiving steroids and prolonged plasma exchange without the use of rituximab. This case report adds to the growing body of literature of B-cell-associated disease activation after alemtuzumab infusion and provides a therapeutic strategy to stabilize patients when rituximab is not readily available or if contraindications to its use exist.
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Efficacy and safety of alemtuzumab in a real-life cohort of patients with multiple sclerosis. J Neurol 2019; 266:1405-1411. [DOI: 10.1007/s00415-019-09272-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 10/27/2022]
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Treatment with alemtuzumab or rituximab after fingolimod withdrawal in relapsing-remitting multiple sclerosis is effective and safe. J Neurol 2019; 266:726-734. [PMID: 30661133 DOI: 10.1007/s00415-019-09195-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/28/2018] [Accepted: 01/08/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND It has been described that treating relapsing-remitting multiple sclerosis (RRMS) patients with alemtuzumab following fingolimod could be less effective due to the different dynamics of lymphocyte repopulation. Effectiveness and safety of alemtuzumab compared to rituximab after fingolimod withdrawal were analyzed. PATIENTS AND METHODS A follow-up of a cohort of RRMS patients treated with alemtuzumab or rituximab after fingolimod withdrawal was accomplished. Effectiveness, measured by the percentage of patients with no evidence of disease activity (NEDA), and the presence of side effects (SE) were registered. RESULTS Fifty-five patients, 28 with alemtuzumab and 27 with rituximab, were analyzed. No differences in the washout period or in the baseline lymphocytes counts were observed. After a mean follow-up period of 28.8 months, the annualized relapsing rate was significantly reduced in the alemtuzumab group from 1.29 to 0.004 (p < 0.001) and in the rituximab group from 1.24 to 0.02 (p < 0.001), without differences. A significant reduction of the median EDSS from 2.8 to 2.0 in the alemtuzumab group and from 3.5 to 2.5 (p < 0.01) in the rituximab group was observed, without differences. Eighty-two per cent (n = 28) of patients in alemtuzumab group and 69.2% (n = 26) in rituximab group achieved NEDA criteria, without differences (p = 0.3). Symptoms related to the infusion were the most frequent SE in both groups. No serious SE were registered. CONCLUSION Treating RRMS patients with alemtuzumab or rituximab after fingolimod withdrawal is effective and safe, without significant differences between both groups in our series.
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Evan JR, Bozkurt SB, Thomas NC, Bagnato F. Alemtuzumab for the treatment of multiple sclerosis. Expert Opin Biol Ther 2018; 18:323-334. [PMID: 29309202 DOI: 10.1080/14712598.2018.1425388] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Alemtuzumab is a monoclonal antibody that targets for the destruction CD52+ cells, particularly B and T cells. Alemtuzumab is approved in more than 50 countries around the world for the treatment of adult patients with relapsing remitting multiple sclerosis (MS). Areas covered: In this review, the authors summarize biological, clinical and safety data related to the use of alemtuzumab in patients with MS. The authors then provide their expert opinion on alemtuzumab and the field as of whole before providing their perspectives for the future. Expert opinion: Alemtuzumab is highly efficacious; more so than first line treatments but comparable to natalizumab. Treatment schedule makes alemtuzumab administration easy and attractive to patients. However, its safety profile makes it a choice for a very limited number of patients, in a specific disease window. As of now, a cure for MS remains elusive and there is an unmet need for a safe and highly potent agent at the level of and beyond the blood brain barrier.
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Affiliation(s)
- Jennifer R Evan
- a Department of Neurology, Neuroimmunology Division/Neuroimaging Unit , Vanderbilt University Medical Center , Nashville , TN , USA.,b MedStar Health Union Memorial Hospital , Baltimore , MD , USA
| | - Subutay B Bozkurt
- a Department of Neurology, Neuroimmunology Division/Neuroimaging Unit , Vanderbilt University Medical Center , Nashville , TN , USA.,c University of Szeged Medical School , Szeged , Hungary
| | - Nikita C Thomas
- a Department of Neurology, Neuroimmunology Division/Neuroimaging Unit , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Francesca Bagnato
- a Department of Neurology, Neuroimmunology Division/Neuroimaging Unit , Vanderbilt University Medical Center , Nashville , TN , USA
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Pfeuffer S, Schmidt R, Straeten FA, Pul R, Kleinschnitz C, Wieshuber M, Lee DH, Linker RA, Doerck S, Straeten V, Windhagen S, Pawlitzki M, Aufenberg C, Lang M, Eienbroeker C, Tackenberg B, Limmroth V, Wildemann B, Haas J, Klotz L, Wiendl H, Ruck T, Meuth SG. Efficacy and safety of alemtuzumab versus fingolimod in RRMS after natalizumab cessation. J Neurol 2018; 266:165-173. [DOI: 10.1007/s00415-018-9117-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/04/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
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Rasche L, Paul F. Ozanimod for the treatment of relapsing remitting multiple sclerosis. Expert Opin Pharmacother 2018; 19:2073-2086. [PMID: 30407868 DOI: 10.1080/14656566.2018.1540592] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Ozanimod is a selective sphingosine 1-phosphate receptor 1 and 5 modulator under development by Celgene, for the treatment of relapsing remitting multiple sclerosis. Extensive clinical experience has become available for the related compound fingolimod, favoring the sphingosine 1-phosphate therapeutic concept. Off-target effects have been attributed to its low receptor specificity and have prompted the development of next generation sphingosine 1-phosphate receptor modulators. Areas covered: The authors evaluate the literature of ozanimod, using the PubMed database as well as repositories of the European Committee for Treatment and Research in Multiple Sclerosis and the American and European Academy of Neurology. Specifically, the authors cover and discuss the preclinical data on ozanimod, pharmacokinetics and dynamics, and data on efficacy and safety from the pivotal trials. Expert opinion: Superiority of ozanimod over intramuscular interferon β-1a with regard to reduction in annualized relapse rate and magnetic resonance imaging outcomes has been shown in two phase III trials. The beneficial effect on brain volume and gray matter loss are encouraging and in line with data on other newer immunomodulators. Ozanimod is a valuable contribution to the therapeutic armamentarium in MS, although the effect on disability progression is unclear and requires further investigations.
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Affiliation(s)
- Ludwig Rasche
- a NeuroCure Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany
| | - Friedemann Paul
- a NeuroCure Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany.,b Experimental and Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany.,c Department of Neurology , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health , Berlin , Germany
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Bernard-Valnet R, Pignolet B, Biotti D, Ciron J, Lafontan JF, Dumas H, Bonneville F, Brassat D. Unexpected high multiple sclerosis activity after switching from fingolimod to alemtuzumab. Mult Scler Relat Disord 2018; 25:216-218. [DOI: 10.1016/j.msard.2018.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 08/02/2018] [Accepted: 08/05/2018] [Indexed: 01/20/2023]
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Grand'Maison F, Yeung M, Morrow SA, Lee L, Emond F, Ward BJ, Laneuville P, Schecter R. Sequencing of disease-modifying therapies for relapsing-remitting multiple sclerosis: a theoretical approach to optimizing treatment. Curr Med Res Opin 2018; 34:1419-1430. [PMID: 29583054 DOI: 10.1080/03007995.2018.1458023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Multiple sclerosis (MS) is a chronic disease which usually begins in young adulthood and is a lifelong condition. Individuals with MS experience physical and cognitive disability resulting from inflammation and demyelination in the central nervous system. Over the past decade, several disease-modifying therapies (DMTs) have been approved for the management of relapsing-remitting MS (RRMS), which is the most prevalent phenotype. The chronic nature of the disease and the multiple treatment options make benefit-risk-based sequencing of therapy essential to ensure optimal care. The efficacy and short- and long-term risks of treatment differ for each DMT due to their different mechanism of action on the immune system. While transitioning between DMTs, in addition to immune system effects, factors such as age, disease duration and severity, disability status, monitoring requirements, preference for the route of administration, and family planning play an important role. Determining a treatment strategy is therefore challenging as it requires careful consideration of the differences in efficacy, safety and tolerability, while at the same time minimizing risks of immune modulation. In this review, we discuss a sequencing approach for treating RRMS, with importance given to the long-term risks and individual preference when devising a treatment plan. Evidence-based strategies to counter breakthrough disease are also addressed.
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Affiliation(s)
| | - Michael Yeung
- b Clinical Neurosciences, Foothills Medical Centre , Calgary , Alberta , Canada
| | - Sarah A Morrow
- c London Health Sciences Center (LHSC), Western University , London , Ontario , Canada
| | - Liesly Lee
- d Department of Neurology , Sunnybrook Health Sciences Centre , Toronto , Ontario , Canada
| | - Francois Emond
- e CHU de Québec - hôpital de l'Enfant-Jésus , Quebec City , Quebec , Canada
| | - Brian J Ward
- f Department of Microbiology & Immunology , McGill University , Montreal , Quebec , Canada
| | - Pierre Laneuville
- g Department of Medicine , McGill University , Montreal , Quebec , Canada
| | - Robyn Schecter
- h Novartis Pharmaceuticals Canada Inc. , Dorval , Quebec , Canada
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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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Alemtuzumab as rescue therapy in a cohort of 50 relapsing–remitting MS patients with breakthrough disease on fingolimod: a multi-center observational study. J Neurol 2018; 265:1521-1527. [DOI: 10.1007/s00415-018-8871-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 04/06/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
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Ceronie B, Jacobs BM, Baker D, Dubuisson N, Mao Z, Ammoscato F, Lock H, Longhurst HJ, Giovannoni G, Schmierer K. Cladribine treatment of multiple sclerosis is associated with depletion of memory B cells. J Neurol 2018; 265:1199-1209. [PMID: 29550884 PMCID: PMC5937883 DOI: 10.1007/s00415-018-8830-y] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/05/2018] [Accepted: 03/08/2018] [Indexed: 12/13/2022]
Abstract
Background The mechanism of action of oral cladribine, recently licensed for relapsing multiple sclerosis, is unknown. Objective To determine whether cladribine depletes memory B cells consistent with our recent hypothesis that effective, disease-modifying treatments act by physical/functional depletion of memory B cells. Methods A cross-sectional study examined 40 people with multiple sclerosis at the end of the first cycle of alemtuzumab or injectable cladribine. The relative proportions and absolute numbers of peripheral blood B lymphocyte subsets were measured using flow cytometry. Cell-subtype expression of genes involved in cladribine metabolism was examined from data in public repositories. Results Cladribine markedly depleted class-switched and unswitched memory B cells to levels comparable with alemtuzumab, but without the associated initial lymphopenia. CD3+ T cell depletion was modest. The mRNA expression of metabolism genes varied between lymphocyte subsets. A high ratio of deoxycytidine kinase to group I cytosolic 5′ nucleotidase expression was present in B cells and was particularly high in mature, memory and notably germinal centre B cells, but not plasma cells. Conclusions Selective B cell cytotoxicity coupled with slow repopulation kinetics results in long-term, memory B cell depletion by cladribine. These may offer a new target, possibly with potential biomarker activity, for future drug development. Electronic supplementary material The online version of this article (10.1007/s00415-018-8830-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bryan Ceronie
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Benjamin M Jacobs
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - David Baker
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Nicolas Dubuisson
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Zhifeng Mao
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Francesca Ammoscato
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Helen Lock
- Haematology Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Hilary J Longhurst
- Haematology Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Gavin Giovannoni
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.,Emergency Care and Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Klaus Schmierer
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.,Emergency Care and Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Abstract
Multiple sclerosis treatment faces tremendous changes as a result of the approval of new medications. The new medications have differing safety considerations and risks after long-term treatment, which are important for treating physicians to optimize and individualize multiple sclerosis care. Since the approval of the first multiple sclerosis capsule, fingolimod, the armamentarium of multiple sclerosis therapy has grown with the orally available medications dimethyl fumarate and teriflunomide. Fingolimod is mainly associated with cardiac side effects, dimethyl fumarate with bowel symptoms. Several reports about progressive multifocal leukoencephalopathy as a result of dimethyl fumarate or fingolimod therapy raised the awareness of fatal opportunistic infections. Alemtuzumab, a CD52-depleting antibody, is highly effective in reducing relapses but leads to secondary immunity with mainly thyroid disorders in about 30% of patients. Development of secondary B-cell-mediated disease might also be a risk of this antibody. The follow-up drug of the B-cell-depleting antibody rituximab, ocrelizumab, is mainly associated with infusion-related reactions; long-term data are scarce. The medication daclizumab high yield process, acting via the activation of CD56bright natural killer cells, can induce the elevation of liver function enzymes, but also fulminant liver failure has been reported. Therefore, daclizumab has been retracted from the market. Long-term data on the purine nucleoside cladribine in MS therapy, recently authorized in the European Union, have been acquired during the long-term follow-up of the cladribine studies. The small molecule laquinimod is currently under development. We review data of clinical trials and their extensions regarding long-term efficacy and side effects, which might be associated with long-term treatment.
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Affiliation(s)
- Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, Bochum, 44791, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, Bochum, 44791, Germany.
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Wehrum T, Beume LA, Stich O, Mader I, Mäurer M, Czaplinski A, Weiller C, Rauer S. Activation of disease during therapy with alemtuzumab in 3 patients with multiple sclerosis. Neurology 2018; 90:e601-e605. [PMID: 29352101 DOI: 10.1212/wnl.0000000000004950] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 10/18/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report 3 patients with multiple sclerosis showing severe activation of disease during immunotherapy with alemtuzumab. METHODS Retrospective case series. RESULTS Patient 1, a 21-year-old woman, developed severe cognitive impairment, sight deterioration, severe gait ataxia, urinary retention, and extensive progression of cerebral lesion load, including new lesions that exhibited gadolinium ring enhancement and dominance of CD19/20-positive B lymphocytes, 6 months after induction of alemtuzumab. Patient 2, a 28-year-old man, developed left-sided hemihypesthesia and ∼60 new cerebral and spinal lesions including lesions with gadolinium ring enhancement 6 months after induction of alemtuzumab. Patient 3, a 37-year-old woman, developed ataxia and numbness of the left thigh, 16 new gadolinium-positive supratentorial lesions, and partly ring-enhancing and dominance of CD19/20-positive B lymphocytes 6 months after induction of alemtuzumab. CONCLUSION This is a case series reporting severe activation of disease during immunotherapy with alemtuzumab. All patients showed onset of symptoms 6 months after induction of alemtuzumab, strikingly similar MRI lesion morphology, and unexpected high total B cell count, which may suggest a B-cell-mediated activation of disease. Whether this is due to different rates of B- and T cell repopulation has to be the subject of further research. Moreover, further effects on the interactions between the adaptive and innate immunity as well as between B and T cell lineages might explain the observed disease activation.
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Affiliation(s)
- Thomas Wehrum
- From the Departments of Neurology and Neuroscience (T.W., L.-A.B., O.S., C.W., S.R.) and Neuroradiology (I.M.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg; Department of Neurology (M.M.), Stiftung Juliusspital Würzburg, Germany; and Neurozentrum Bellevue (A.C.), Zürich, Switzerland.
| | - Lena-Alexandra Beume
- From the Departments of Neurology and Neuroscience (T.W., L.-A.B., O.S., C.W., S.R.) and Neuroradiology (I.M.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg; Department of Neurology (M.M.), Stiftung Juliusspital Würzburg, Germany; and Neurozentrum Bellevue (A.C.), Zürich, Switzerland
| | - Oliver Stich
- From the Departments of Neurology and Neuroscience (T.W., L.-A.B., O.S., C.W., S.R.) and Neuroradiology (I.M.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg; Department of Neurology (M.M.), Stiftung Juliusspital Würzburg, Germany; and Neurozentrum Bellevue (A.C.), Zürich, Switzerland
| | - Irina Mader
- From the Departments of Neurology and Neuroscience (T.W., L.-A.B., O.S., C.W., S.R.) and Neuroradiology (I.M.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg; Department of Neurology (M.M.), Stiftung Juliusspital Würzburg, Germany; and Neurozentrum Bellevue (A.C.), Zürich, Switzerland
| | - Mathias Mäurer
- From the Departments of Neurology and Neuroscience (T.W., L.-A.B., O.S., C.W., S.R.) and Neuroradiology (I.M.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg; Department of Neurology (M.M.), Stiftung Juliusspital Würzburg, Germany; and Neurozentrum Bellevue (A.C.), Zürich, Switzerland
| | - Adam Czaplinski
- From the Departments of Neurology and Neuroscience (T.W., L.-A.B., O.S., C.W., S.R.) and Neuroradiology (I.M.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg; Department of Neurology (M.M.), Stiftung Juliusspital Würzburg, Germany; and Neurozentrum Bellevue (A.C.), Zürich, Switzerland
| | - Cornelius Weiller
- From the Departments of Neurology and Neuroscience (T.W., L.-A.B., O.S., C.W., S.R.) and Neuroradiology (I.M.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg; Department of Neurology (M.M.), Stiftung Juliusspital Würzburg, Germany; and Neurozentrum Bellevue (A.C.), Zürich, Switzerland
| | - Sebastian Rauer
- From the Departments of Neurology and Neuroscience (T.W., L.-A.B., O.S., C.W., S.R.) and Neuroradiology (I.M.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg; Department of Neurology (M.M.), Stiftung Juliusspital Würzburg, Germany; and Neurozentrum Bellevue (A.C.), Zürich, Switzerland
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Dubuisson N, Baker D, Kang AS, Pryce G, Marta M, Visser LH, Hofmann WE, Gnanapavan S, Giovannoni G, Schmierer K. Alemtuzumab depletion failure can occur in multiple sclerosis. Immunology 2018; 154:253-260. [PMID: 29247512 DOI: 10.1111/imm.12879] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/19/2017] [Accepted: 11/23/2017] [Indexed: 12/25/2022] Open
Abstract
Alemtuzumab is a lymphocyte-depleting antibody and one of the most effective treatments for relapsing multiple sclerosis. However, it also causes loss of immune-tolerance leading to secondary autoimmunity and marked anti-drug antibody responses. Although these anti-drug responses have been reported to be of no significance, we hypothesized that they will affect the depleting capacity and treatment response in some individuals. This was found following analysis of the regulatory submission of the pivotal phase III trials, which was obtained from the European Medicines Agency. At the population level there was lack of influence of 'ever-positive' alemtuzumab-specific antibody responses on lymphocyte depletion, clinical efficacy and adverse effects during the 2-year trial. This was not surprising as no one before the first infusion, and only 0·6% of people before the second-infusion, had pre-infusion, neutralizing antibodies (NAbs). However, at the individual level, NAbs led to poor lymphocyte depletion. Importantly, it was evident that 31% of people had NAbs and 75% had binding antibodies at the end of treatment-cycle 2, which suggests that problems may occur in people requiring additional alemtuzumab cycles. In addition, we also identified individuals, following 'post-marketing' alemtuzumab use, whose lymphocyte level was never effectively depleted after the first infusion cycle. Hence, although alemtuzumab depletes lymphocytes in most individuals, some people fail to deplete/deplete poorly, probably due to biological-response variation and NAbs, and this may lead to treatment failure. Monitoring depletion following infusion and assessment of the neutralizing response before re-infusion may help inform the decision to retreat or switch therapy to limit treatment failure.
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Affiliation(s)
- Nicolas Dubuisson
- BartsMS, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - David Baker
- BartsMS, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Angray S Kang
- BartsMS, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Gareth Pryce
- BartsMS, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Monica Marta
- BartsMS, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Leo H Visser
- Neurology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Werner E Hofmann
- Gemeinschaftspraxis Drs Hofmann & Olschewski, Aschaffenburg, Germany
| | - Sharmilee Gnanapavan
- BartsMS, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Gavin Giovannoni
- BartsMS, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Klaus Schmierer
- BartsMS, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Giovannoni G, Hawkes C, Levy M, Lublin F, Waubant E. Editors’ Welcome. Mult Scler Relat Disord 2018; 19:A1-A2. [DOI: 10.1016/j.msard.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Rolla S, De Mercanti SF, Bardina V, Horakova D, Habek M, Adamec I, Cocco E, Annovazzi P, Vladic A, Novelli F, Durelli L, Clerico M. Lack of CD4+ T cell percent decrease in alemtuzumab-treated multiple sclerosis patients with persistent relapses. J Neuroimmunol 2017; 313:89-91. [PMID: 29153614 DOI: 10.1016/j.jneuroim.2017.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 10/04/2017] [Accepted: 10/15/2017] [Indexed: 01/01/2023]
Abstract
Alemtuzumab, a highly effective treatment for relapsing remitting multiple sclerosis (RRMS), induces lymphopenia especially of CD4+ T cells. Here, we report the atypical CD4+ T population behaviour of two patients with persistent disease activity despite repeated alemtuzumab treatments. Whereas lymphocytes count decreased and fluctuated accordingly to alemtuzumab administration, their CD4+ cell percentage was not or just mildly affected and was slightly below the lowest normal limit already before alemtuzumab. These cases anticipate further studies aimed to investigate whether the evaluation of the CD4+ cell percentage could represent a helpful tool to address the individual clinical response to alemtuzumab.
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Affiliation(s)
- Simona Rolla
- Clinical and Biological Sciences Department, University of Torino, San Luigi Gonzaga Hospital, Orbassano (TO), Italy
| | - Stefania Federica De Mercanti
- Clinical and Biological Sciences Department, University of Torino, San Luigi Gonzaga Hospital, Orbassano (TO), Italy
| | - Valentina Bardina
- Clinical and Biological Sciences Department, University of Torino, San Luigi Gonzaga Hospital, Orbassano (TO), Italy
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University, General University Hospital, Czech Republic
| | - Mario Habek
- Department of Neurology, Referral Center for Autonomic Nervous System, University Hospital Center, University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Ivan Adamec
- Department of Neurology, Referral Center for Autonomic Nervous System, University Hospital Center, University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Eleonora Cocco
- Multiple Sclerosis Center, Department of Medical Science and Public Health, University of Cagliari, Italy
| | - Pietro Annovazzi
- Multiple Sclerosis Study Center, AO S. Antonio Abate, Gallarate (VA), Italy
| | - Anton Vladic
- Department of Neurology, Clinical Hospital Sveti Duh Zagreb, Medical Faculty University, J.J. Strossmayer, Osijek, Croatia
| | - Francesco Novelli
- Center for Experimental Research and Medical Studies (CERMS), Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Luca Durelli
- Clinical and Biological Sciences Department, University of Torino, San Luigi Gonzaga Hospital, Orbassano (TO), Italy
| | - Marinella Clerico
- Clinical and Biological Sciences Department, University of Torino, San Luigi Gonzaga Hospital, Orbassano (TO), Italy.
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Baker D, Herrod SS, Alvarez-Gonzalez C, Giovannoni G, Schmierer K. Interpreting Lymphocyte Reconstitution Data From the Pivotal Phase 3 Trials of Alemtuzumab. JAMA Neurol 2017; 74:961-969. [PMID: 28604916 DOI: 10.1001/jamaneurol.2017.0676] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Alemtuzumab, a CD52-depleting monoclonal antibody, effectively inhibits relapsing multiple sclerosis (MS) but is associated with a high incidence of secondary B-cell autoimmunities that limit use. These effects may be avoided through control of B-cell hyperproliferation. Objective To investigate whether the data describing the effect of alemtuzumab on lymphocyte subsets collected during the phase 3 trial program reveal mechanisms explaining efficacy and the risk for secondary autoimmunity with treatment of MS. Design, Setting, and Participants Lymphocyte reconstitution data from regulatory submissions of the pivotal Comparison of Alemtuzumab and Rebif Efficacy in Multiple Sclerosis I and II (CARE-MS I and II) trials were obtained from the European Medicines Agency via Freedom of Information requests. Data used in this study were reported from June 22 to October 12, 2016. Main Outcomes and Measures Tabulated data from T- and B-lymphocyte subset analysis and antidrug antibody responses were extracted from the supplied documents. Results Alemtuzumab depleted CD4+ T cells by more than 95%, including regulatory cells (-80%) and CD8+ T cells (>80% depletion), which remained well below reference levels throughout the trials. However, although CD19+ B cells were initially also depleted (>85%), marked (180% increase) hyperrepopulation of immature B cells occurred with conversion to mature B cells over time. These lymphocyte kinetics were associated with rapid development of alemtuzumab-binding and -neutralizing antibodies and subsequent occurrence of secondary B-cell autoimmunity. Hyperrepopulation of B cells masked a marked, long-term depletion of CD19+ memory B cells that may underpin efficacy in MS. Conclusions and Relevance Although blockade of memory T and B cells may limit MS, rapid CD19+ B-cell subset repopulation in the absence of effective T-cell regulation has implications for the safety and efficacy of alemtuzumab. Controlling B-cell proliferation until T-cell regulation recovers may limit secondary autoimmunity, which does not occur with other B-cell-depleting agents.
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Affiliation(s)
- David Baker
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England
| | - Samuel S Herrod
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England
| | - Cesar Alvarez-Gonzalez
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England
| | - Gavin Giovannoni
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England.,Emergency Care and Acute Medicine, Clinical Academic Group Neuroscience, Barts Health NHS (National Health Service) Trust, The Royal London Hospital, London, England
| | - Klaus Schmierer
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England.,Emergency Care and Acute Medicine, Clinical Academic Group Neuroscience, Barts Health NHS (National Health Service) Trust, The Royal London Hospital, London, England
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Ziemssen T, Thomas K. Alemtuzumab in the long-term treatment of relapsing-remitting multiple sclerosis: an update on the clinical trial evidence and data from the real world. Ther Adv Neurol Disord 2017; 10:343-359. [PMID: 28966663 PMCID: PMC5607928 DOI: 10.1177/1756285617722706] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/23/2017] [Indexed: 12/12/2022] Open
Abstract
Alemtuzumab is a humanized monoclonal antibody approved for the treatment of relapsing-remitting multiple sclerosis (RRMS), given as two annual courses on five consecutive days at baseline and on three consecutive days 12 months later. Here we provide an update on the long-term efficacy and safety of alemtuzumab in RRMS, including real-world experience, and advances in our understanding of its mechanism of action. Recent data from the phase II/III extension study have demonstrated that alemtuzumab reduces relapse rates, disability worsening, and the rate of brain volume loss over the long term, with many patients achieving no evidence of disease activity. In high proportions of patients, preexisting disability remained stable or improved. Alemtuzumab is associated with a consistent safety profile over the long term, with no new safety signals emerging and the overall annual incidence of reported adverse events decreasing after the first year on treatment. Acyclovir prophylaxis reduces herpetic infections, and monitoring has been shown to mitigate the risk of autoimmune adverse events, allowing early detection and overall effective management. Data from clinical practice and ongoing observational studies are providing additional information on the real-world use of alemtuzumab. Recent evidence on the mechanism of action of alemtuzumab indicates that in addition to its previously known effects of inducing depletion and repopulation of T and B lymphocytes, it also results in a relative increase of cells with memory and regulatory phenotypes and a decrease in cells with a proinflammatory signature, and may further promote an immunoregulatory environment through an impact on other innate immune cells (e.g. dendritic cells) that play a role in MS. These effects may allow preservation of innate immunity and immunosurveillance. Together, these lines of evidence help explain the durable clinical efficacy of alemtuzumab, in the absence of continuous treatment, in patients with RRMS.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav Carus University Clinic, Dresden University of Technology, Dresden, Germany
| | - Katja Thomas
- Center of Clinical Neuroscience, Carl Gustav Carus University Clinic, Dresden University of Technology, Dresden, Germany
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