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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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Rolfes L, Pawlitzki M, Pfeuffer S, Huntemann N, Wiendl H, Ruck T, Meuth SG. Failed, Interrupted, or Inconclusive Trials on Immunomodulatory Treatment Strategies in Multiple Sclerosis: Update 2015-2020. BioDrugs 2021; 34:587-610. [PMID: 32785877 PMCID: PMC7519896 DOI: 10.1007/s40259-020-00435-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the past decades, multiple sclerosis (MS) treatment has experienced vast changes resulting from major advances in disease-modifying therapies (DMT). Looking at the overall number of studies, investigations with therapeutic advantages and encouraging results are exceeded by studies of promising compounds that failed due to either negative or inconclusive results or have been interrupted for other reasons. Importantly, these failed clinical trials are informative experiments that can help us to understand the pathophysiological mechanisms underlying MS. In several trials, concepts taken from experimental models were not translatable to humans, although they did not lack a well-considered pathophysiological rationale. The lessons learned from these discrepancies may benefit future studies and reduce the risks for patients. This review summarizes trials on MS since 2015 that have either failed or have been interrupted for various reasons. We identify potential causes of failure or inconclusiveness, looking at the path from basic animal experiments to clinical trials, and discuss the implications for our current view on MS pathogenesis, clinical practice, and future study designs. We focus on anti-inflammatory treatment strategies, without including studies on already approved and effective DMT. Clinical trials addressing neuroprotective and alternative treatment strategies are presented in a separate article.
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Affiliation(s)
- Leoni Rolfes
- Department of Neurology With Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Marc Pawlitzki
- Department of Neurology With Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Steffen Pfeuffer
- Department of Neurology With Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Niklas Huntemann
- Department of Neurology With Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Tobias Ruck
- Department of Neurology With Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Sven G Meuth
- Department of Neurology With Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Krämer J, Krömer-Olbrisch T, Lakomek HJ, Schellinger PD, Foell D, Meuth SG, Straeten V. Case Report: Adult Still's Disease in an Alemtuzumab-Treated Multiple Sclerosis Patient. Front Immunol 2020; 11:2099. [PMID: 33013884 PMCID: PMC7493652 DOI: 10.3389/fimmu.2020.02099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/03/2020] [Indexed: 12/16/2022] Open
Abstract
Background Autoimmune adverse events are the most relevant risks of alemtuzumab therapy. We present a patient with relapsing-remitting multiple sclerosis, who developed adult-onset Still's disease (AOSD) following alemtuzumab treatment. Case Presentation The patient suffered from sore throat, swallowing difficulties, high spiking quotidian fever, generalized skin rash, arthritis, and myalgia 2 months after the second course of alemtuzumab. Laboratory tests revealed elevated acute-phase reactants, anemia, neutrophilic leukocytosis, and thrombocytosis. Serum calprotectin, interleukin-2, and interleukin-6 levels were strongly increased. Autoimmune, rheumatic, neoplastic, infectious, and granulomatous disorders were excluded. The NLRP1 and NLRP3 gene test, which was performed under the presumption of a cryopyrin-associated autoinflammatory syndrome, was negative. Based on the Yamaguchi and Fautrel criteria, and supported by the histological findings from a skin biopsy of the rash, the diagnosis of AOSD was established. Therapy with the anti-IL-1 agent (anakinra) led to a significant improvement of symptoms and blood parameters. However, anakinra had to be converted to rituximab due to generalized drug eruption. Following therapy with rituximab, the patient has fully recovered. Conclusion The current case highlights AOSD as another rare and potentially life-threatening secondary autoinflammatory/autoimmune event following alemtuzumab treatment.
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Affiliation(s)
- Julia Krämer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Tanja Krömer-Olbrisch
- Department of Dermatology, Venerology, Allergology, and Phlebology, Johannes-Wesling-Hospital Minden, University Hospital Ruhr University of Bochum, Minden, Germany
| | - Heinz-Jürgen Lakomek
- Department of Rheumatology and Physical Medicine, Johannes-Wesling-Hospital Minden, University Hospital Ruhr University of Bochum, Minden, Germany
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatrics, Johannes-Wesling-Hospital Minden, University Hospital Ruhr University of Bochum, Minden, Germany
| | - Dirk Foell
- Department of Pediatric Rheumatology and Immunology, University Hospital Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Vera Straeten
- Department of Neurology and Neurogeriatrics, Johannes-Wesling-Hospital Minden, University Hospital Ruhr University of Bochum, Minden, Germany
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