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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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2
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Sandgren S, Novakova L, Axelsson M, Amirbeagi F, Kockum I, Olsson T, Malmestrom C, Lycke J. The role of autoimmune antibodies to predict secondary autoimmunity in patients with relapsing-remitting multiple sclerosis treated with alemtuzumab: A nationwide prospective survey. Front Neurol 2023; 14:1137665. [PMID: 37006489 PMCID: PMC10061078 DOI: 10.3389/fneur.2023.1137665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/17/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundAlemtuzumab (ALZ) is an immune reconstitution therapy for treating relapsing-remitting multiple sclerosis (RRMS). However, ALZ increases the risk of secondary autoimmune diseases (SADs).ObjectiveWe explored whether the detection of autoimmune antibodies (auto-Abs) could predict the development of SADs.MethodsWe included all patients with RRMS in Sweden who initiated ALZ treatment (n = 124, 74 female subjects) from 2009 to 2019. The presence of auto-Abs was determined in plasma samples obtained at the baseline and at 6, 12, and 24 months of follow-up, as well as in a subgroup of patients (n = 51), it was determined in plasma samples obtained at the remaining 3-month intervals up to 24 months. Monthly blood tests, urine tests, and the assessment of clinical symptoms were performed for monitoring safety including that of SADs.ResultsAutoimmune thyroid disease (AITD) developed in 40% of patients, within a median follow-up of 4.5 years. Thyroid auto-Abs were detected in 62% of patients with AITD. The presence of thyrotropin receptor antibodies (TRAbs) at the baseline increased the risk of AITD by 50%. At 24 months, thyroid auto-Abs were detected in 27 patients, and 93% (25/27) developed AITD. Among patients without thyroid auto-Abs, only 30% (15/51) developed AITD (p < 0.0001). In the subgroup of patients (n = 51) with more frequent sampling for auto-Abs, 27 patients developed ALZ-induced AITD, and 19 of them had detectable thyroid auto-Abs prior to the AITD onset, with a median interval of 216 days. Eight patients (6.5%) developed non-thyroid SAD, and none had detectable non-thyroid auto-Abs.ConclusionWe conclude that monitoring thyroid auto-Abs, essentially TRAbs, may improve the surveillance of AITD associated with ALZ treatment. The risk for non-thyroid SADs was low, and monitoring non-thyroid auto-Abs did not seem to provide any additional information for predicting non-thyroid SADs.
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Affiliation(s)
- Sofia Sandgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- *Correspondence: Sofia Sandgren
| | - Lenka Novakova
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Markus Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Firoozeh Amirbeagi
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Laboratory for Clinical Immunology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Clas Malmestrom
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Laboratory for Clinical Immunology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Ošep AB, Brecl E, Škerget M, Savšek L. An unforeseen reality: Hemophagocytic lymphohistiocytosis following alemtuzumab treatment for a multiple sclerosis. Clin Neurol Neurosurg 2023; 228:107675. [PMID: 36965418 DOI: 10.1016/j.clineuro.2023.107675] [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: 10/06/2022] [Revised: 02/05/2023] [Accepted: 03/13/2023] [Indexed: 03/16/2023]
Abstract
Alemtuzumab is a humanized monoclonal antibody indicated for treatment of highly active relapsing-remitting multiple sclerosis (HA-RRMS). It binds to CD52 antigen and produces a rapid and prolonged lymphocyte depletion followed by a different pattern of T and B cell repopulation. Among others, its adverse events are autoimmune diseases.In this article, we present a patient with HA-RRMS, who was subsequently treated with alemtuzumab and afterwards developed hemophagocytic lymphohistiocytosis (HLH). Albeit rarely, HLH can be triggered by alemtuzumab treatment.HLH can favourably respond to prompt immunosuppressant therapy.Multidisciplinary approach by a team consisting of a neurology, hematology and rheumatology specialist is needed to treat this potentially lethal condition.
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Affiliation(s)
- Anka Blagotinšek Ošep
- General Hospital Celje, Department of Neurology, Oblakova Ulica 5, 3000 Celje, Slovenia
| | - Eva Brecl
- General Hospital Celje, Department of Neurology, Oblakova Ulica 5, 3000 Celje, Slovenia.
| | - Matevž Škerget
- University Medical Centre Ljubljana, Department of Haematology, Zaloška Cesta 2, 1000 Ljubljana, Slovenia; University of Ljubljana, Faculty of Medicine, Vrazov Trg 2, 1000 Ljubljana, Slovenia
| | - Lina Savšek
- General Hospital Celje, Department of Neurology, Oblakova Ulica 5, 3000 Celje, Slovenia; University of Ljubljana, Faculty of Medicine, Vrazov Trg 2, 1000 Ljubljana, Slovenia
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4
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Zhou JC, Tan BB, Huang Y, Wu YY, Bai ZJ, Liang ML, Zhao WH. Intrathoracic infections in Hodgkin lymphoma (HL) patients may cooperate with HL to trigger hemophagocytic lymphohistiocytosis: A retrospective study. Medicine (Baltimore) 2022; 101:e29756. [PMID: 35777035 PMCID: PMC9239602 DOI: 10.1097/md.0000000000029756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Hodgkin lymphoma (HL)-related hemophagocytic lymphohistiocytosis (HLH) has been reported in the literature; however, there is almost no literature on the factors related to HL triggering HLH. One hundred forty patients with HL were retrospectively analyzed. The incidence of HL-related HLH (we call HL-related HLH as HL-HLH). And all HL-HLH patients in our cohort had HLH as the first manifestation and its clinical characteristics and the role of intrathoracic infection (ITI) in triggering HLH are discussed. The 140 patients with HL mainly included mixed-cellularity classic HL (MCCHL) in 81 (57.9%), nodular sclerosis classic HL (NSCHL) in 36 (25.7%), and lymphacyte-rich classic HL in 14 (10.0%) patients. Of the 137 patients who underwent chest computed tomography scans on admission, 44 had ITI, and most of these ITI were mildly ill and had no respiratory symptoms. Among 140 HL patients, 8 patients from MCCHL were diagnosed as HL-HLH. Among 81 MCCHL patients, 26 patients with ITI had a significantly higher incidence of HL-HLH than those without ITI (26.9% vs 1.8%, P = .002). The median survival time of 8 cases of HL-HLH was only 2 months. When HL patients were first admitted to the hospital, 5.7% had HLH as the first manifestation, and 32.1% had ITI. These ITI can cooperate with HL to trigger HLH, despite their mild illness. The prognosis of HL-HLH was poor.
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Affiliation(s)
- Ji-Cheng Zhou
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
- *Correspondence: Ji-Cheng Zhou, Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, No. 6, Shuangyong Road, Nanning, 530021 Guangxi, P. R. China (e-mail: )
| | - Bin-Bin Tan
- Department of Hematology, Baise People’s Hospital, Baise, Guangxi, China
- *Correspondence: Ji-Cheng Zhou, Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, No. 6, Shuangyong Road, Nanning, 530021 Guangxi, P. R. China (e-mail: )
| | - Yan Huang
- Department of Hematology, Baise People’s Hospital, Baise, Guangxi, China
| | - Yin-Ying Wu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Zhen-Jie Bai
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Min-Lan Liang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Wei-Hua Zhao
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
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5
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Krajnc N, Bsteh G, Berger T, Mares J, Hartung HP. Monoclonal Antibodies in the Treatment of Relapsing Multiple Sclerosis: an Overview with Emphasis on Pregnancy, Vaccination, and Risk Management. Neurotherapeutics 2022; 19:753-773. [PMID: 35378683 PMCID: PMC8978776 DOI: 10.1007/s13311-022-01224-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/10/2023] Open
Abstract
Monoclonal antibodies have become a mainstay in the treatment of patients with relapsing multiple sclerosis (RMS) and provide some benefit to patients with primary progressive MS. They are highly precise by specifically targeting molecules displayed on cells involved in distinct immune mechanisms of MS pathophysiology. They not only differ in the target antigen they recognize but also by the mode of action that generates their therapeutic effect. Natalizumab, an [Formula: see text]4[Formula: see text]1 integrin antagonist, works via binding to cell surface receptors, blocking the interaction with their ligands and, in that way, preventing the migration of leukocytes across the blood-brain barrier. On the other hand, the anti-CD52 monoclonal antibody alemtuzumab and the anti-CD20 monoclonal antibodies rituximab, ocrelizumab, ofatumumab, and ublituximab work via eliminating selected pathogenic cell populations. However, potential adverse effects may be serious and can necessitate treatment discontinuation. Most importantly, those are the risk for (opportunistic) infections, but also secondary autoimmune diseases or malignancies. Monoclonal antibodies also carry the risk of infusion/injection-related reactions, primarily in early phases of treatment. By careful patient selection and monitoring during therapy, the occurrence of these potentially serious adverse effects can be minimized. Monoclonal antibodies are characterized by a relatively long pharmacologic half-life and pharmacodynamic effects, which provides advantages such as permitting infrequent dosing, but also creates disadvantages regarding vaccination and family planning. This review presents an overview of currently available monoclonal antibodies for the treatment of RMS, including their mechanism of action, efficacy and safety profile. Furthermore, we provide practical recommendations for risk management, vaccination, and family planning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Mares
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
- Brain and Mind Center, University of Sydney, Sydney, Australia.
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Rauma I, Mustonen T, Seppä JM, Ukkonen M, Männikkö M, Verkkoniemi-Ahola A, Kartau M, Saarinen JT, Luostarinen L, Simula S, Ryytty M, Ahmasalo R, Sipilä JOT, Pieninkeroinen I, Tapiola T, Remes AM, Kuusisto H. Safety of alemtuzumab in a nationwide cohort of Finnish multiple sclerosis patients. J Neurol 2021; 269:824-835. [PMID: 34255182 PMCID: PMC8782800 DOI: 10.1007/s00415-021-10664-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 12/05/2022]
Abstract
Background Alemtuzumab is an effective disease-modifying therapy (DMT) for highly active multiple sclerosis (MS). However, safety concerns limit its use in clinical practice. Objectives To evaluate the safety of alemtuzumab in a nationwide cohort of Finnish MS patients. Methods In this retrospective case series study, we analyzed the data of all but two MS patients who had received alemtuzumab in Finland until 2019. Data were systematically collected from patient files. Results Altogether 121 patients were identified, most of whom had received previous DMTs (82.6%). Median follow-up time after treatment initiation was 30.3 months and exceeded 24 months in 78 patients. Infusion-associated reactions (IARs) were observed in 84.3%, 57.3%, and 57.1% of patients during alemtuzumab courses 1–3, respectively. Serious adverse events (SAEs) were observed in 32.2% of patients, serious IARs in 12.4% of patients, and SAEs other than IARs in 23.1% of patients. Autoimmune adverse events were observed in 30.6% of patients. One patient died of hemophagocytic lymphohistiocytosis, and one patient died of pneumonia. A previously unreported case of thrombotic thrombocytopenic purpura was documented. Conclusions SAEs were more frequent in the present cohort than in previous studies. Even though alemtuzumab is a highly effective therapy for MS, vigorous monitoring with a long enough follow-up time is advised.
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Affiliation(s)
- Ilkka Rauma
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. .,Department of Neurology, Tampere University Hospital, Tampere, Finland. .,Department of Neurology, Seinäjoki Central Hospital, Seinäjoki, Finland.
| | - Tiina Mustonen
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Maritta Ukkonen
- Department of Neurology, Tampere University Hospital, Tampere, Finland
| | - Marianne Männikkö
- Department of Neurology, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Auli Verkkoniemi-Ahola
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Marge Kartau
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | | | - Liisa Luostarinen
- Department of Neurology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Sakari Simula
- Department of Neurology, Mikkeli Central Hospital, Mikkeli, Finland
| | - Mervi Ryytty
- Medical Research Center, Oulu University Hospital, Oulu, Finland.,Research Unit of Clinical Neuroscience, University of Oulu, Faculty of Medicine, Oulu, Finland
| | - Riitta Ahmasalo
- Department of Neurology, Lapland Central Hospital, Rovaniemi, Finland
| | - Jussi O T Sipilä
- Department of Neurology, North Karelia Central Hospital, Siun Sote, Joensuu, Finland.,Department of Clinical Neurosciences, University of Turku, Turku, Finland
| | | | - Tero Tapiola
- Department of Neurology, South Karelia Central Hospital, Lappeenranta, Finland
| | - Anne M Remes
- Medical Research Center, Oulu University Hospital, Oulu, Finland.,Research Unit of Clinical Neuroscience, University of Oulu, Faculty of Medicine, Oulu, Finland
| | - Hanna Kuusisto
- Department of Neurology, Tampere University Hospital, Tampere, Finland.,Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kanta-Häme Central Hospital, Hämeenlinna, Finland
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7
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Coles AJ, Arnold DL, Bass AD, Boster AL, Compston DAS, Fernández Ó, Havrdová EK, Nakamura K, Traboulsee A, Ziemssen T, Jacobs A, Margolin DH, Huang X, Daizadeh N, Chirieac MC, Selmaj KW. Efficacy and safety of alemtuzumab over 6 years: final results of the 4-year CARE-MS extension trial. Ther Adv Neurol Disord 2021; 14:1756286420982134. [PMID: 34035833 PMCID: PMC8072102 DOI: 10.1177/1756286420982134] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/09/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In the 2-year CARE-MS I and II trials, alemtuzumab 12 mg administered on 5 consecutive days at core study baseline and on 3 consecutive days 12 months later significantly improved outcomes versus subcutaneous interferon beta-1a (SC IFNB-1a) in relapsing-remitting multiple sclerosis patients. Here, we present the final 6-year CARE-MS extension trial results (CAMMS03409), and compare outcomes over 6 years in patients randomized to both treatment groups at core study baseline. METHODS Over a 4-year extension, alemtuzumab patients (alemtuzumab-only) received as-needed additional alemtuzumab (⩾12 months apart) for disease activity after course 2. SC IFNB-1a patients who entered the extension discontinued SC IFNB-1a and received 2 alemtuzumab 12 mg courses (IFN-alemtuzumab), followed by additional, as-needed, alemtuzumab. RESULTS Through year 6, 63% of CARE-MS I and 50% of CARE-MS II alemtuzumab-only patients received neither additional alemtuzumab nor other disease-modifying therapy, with lasting suppression of disease activity, improved disability, and slowing of brain volume loss (BVL). In CARE-MS I patients (treatment-naive; less disability; shorter disease duration), disease activity and BVL were significantly reduced in IFN-alemtuzumab patients, similar to alemtuzumab-only patients at year 6. Among CARE-MS II patients (inadequate response to prior treatment; more disability; longer disease duration), alemtuzumab significantly improved clinical and magnetic resonance imaging outcomes, including BVL, in IFN-alemtuzumab patients; however, disability outcomes were less favorable versus alemtuzumab-only patients. Safety profiles, including infections and autoimmunities, following alemtuzumab were similar between treatment groups. CONCLUSION This study demonstrates the high efficacy of alemtuzumab over 6 years, with a similar safety profile between treatment groups. CLINICALTRIALSGOV IDENTIFIERS NCT00530348; NCT00548405; NCT00930553.
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Affiliation(s)
- Alasdair J. Coles
- Department of Clinical Neurosciences, University
of Cambridge, Box 165, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
| | - Douglas L. Arnold
- NeuroRx Research, Montréal, Québec, Canada
- Department of Neurology and Neurosurgery,
Montréal Neurological Institute, McGill University, Montréal, Québec,
Canada
| | - Ann D. Bass
- Neurology Center of San Antonio, San Antonio,
TX, USA
| | | | | | - Óscar Fernández
- Instituto de Investigación Biomédica de Málaga
(IBIMA), Málaga, Spain
| | - Eva Kubala Havrdová
- Department of Neurology and Center for Clinical
Neuroscience, First Medical Faculty, Charles University, Prague, Czech
Republic
| | - Kunio Nakamura
- Department of Biomedical Engineering, Cleveland
Clinic, Cleveland, OH, USA
| | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav
Carus University Hospital, Dresden, Germany
| | - Alan Jacobs
- Immunovant, Inc., New York, NY, USA
- Sanofi, Cambridge, MA, USA
| | | | - Xiaobi Huang
- Sanofi, Cambridge, MA, USA
- Biogen, Cambridge, MA, USA
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Yildiz H, Bailly S, Van Den Neste E, Yombi JC. Clinical Management of Relapsed/Refractory Hemophagocytic Lymphohistiocytosis in Adult Patients: A Review of Current Strategies and Emerging Therapies. Ther Clin Risk Manag 2021; 17:293-304. [PMID: 33888986 PMCID: PMC8056168 DOI: 10.2147/tcrm.s195538] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/25/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction Haemophagocytic lymphohistiocytosis (HLH) is a severe disorder with high mortality. The aim of this review is to update clinical management of relapsed/refractory HLH in adults, with a focus on current and new therapies. Methods We searched relevant articles in Embase and PUBMED with the MESH term “hemophagocytic lymphohistiocytosis; refractory; relapsing; adult.” Results One hundred eight papers were found; of these, 22 were retained for this review. The treatment of HLH in adult is based on the HLH-94 regimen. The response rate is lower than in pediatric patients, and 20–30% are refractory to this therapy. DEP regimen and allogenic hematopoietic stem cell transplantation (HSCT) are associated with complete response and partial response in 27% and 49.2%, respectively. However, many patients fail to achieve a stable condition before HSCT, and mortality is higher in them. New drugs have been developed, such as emapalumab, ruxolitinib, and alemtuzumab, and they may be used as bridges to the curative HSCT. They are relatively well tolerated and have few or mild side effects. With these agents, the rate of partial response ranges from 14.2% to 100%, while the rate of complete response is highly variable according to study and medication used. The number of patients who achieved HSCT ranged from 44.8% to 77%, with a survival rate of 55.9% to 100%. However, the populations in these studies are mainly composed of mixed-age patients (pediatric and adult patients), and studies including only adult patients are scarce. Conclusion Relapsed or refractory HLH in adult patients is associated with poor outcome, and consolidation with HSCT may be required in some cases. Mortality related to HSCT is mainly due to active HLH disease before HSCT and post HSCT complications. New drugs, such as empalumab, ruxolitinib, and alemtuzumab are interesting since these agents may be used as bridges to HSCT with increases in the numbers of patients proceeding to HSCT and survival rate.
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Affiliation(s)
- Halil Yildiz
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Sarah Bailly
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Eric Van Den Neste
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Jean Cyr Yombi
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
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9
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Nosher S, Fuad S, Mishra N, Alrashid ZA, Rathod B, Mohan D, Basavanagowda DM, Kaur A, Heindl SE. Role of Monoclonal Antibody "Alemtuzumab" in the Treatment of Multiple Sclerosis. Cureus 2021; 13:e13246. [PMID: 33728194 PMCID: PMC7948316 DOI: 10.7759/cureus.13246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 11/30/2022] Open
Abstract
This article will review current treatment options for multiple sclerosis (MS) while keeping our primary focus on alemtuzumab, as it is now approved in more than 65 countries. From a pathophysiological point of view, MS is a disabling disease impacting a patient's life both physically and mentally, leading to devastating social and economic impact. This review will elaborate on alemtuzumab's role in treating relapsing-remitting MS (RRMS) by comparing its efficacy, side effects, and monitoring with other disease-modifying therapies (DMTs) available in the market. It is a point of great concern not only for physicians but also for neurologists, nephrologists, endocrinologists, dermatologists, and oncologists when encountering long-term effects of alemtuzumab in the life of treated MS patients. We hope that our review will not only benefit treating faculties but also those who are suffering from this devastating disease.
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Affiliation(s)
- Sadia Nosher
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sehrish Fuad
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nupur Mishra
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Zaid A Alrashid
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- School of Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | - Bindu Rathod
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Devyani Mohan
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Deepak M Basavanagowda
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Arveen Kaur
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Stacey E Heindl
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Medicine, Avalon University School of Medicine, Willemstad, CUW
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10
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Prevention and management of adverse effects of disease modifying treatments in multiple sclerosis. Curr Opin Neurol 2021; 33:286-294. [PMID: 32374570 DOI: 10.1097/wco.0000000000000824] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To summarize the currently known side effects of the approved therapies of multiple sclerosis and to suggest monitoring procedures. RECENT FINDINGS The progress in the treatment of multiple sclerosis with new very effective therapies is accompanied by a number of side effects. Some of these have already been described in the approval studies, but some only after approval in a real world situation. The reason for this is the short duration of the clinical studies, the very heterogeneous patient profile in the real world setting with a number of comorbidities, pretherapies, and wider age range. The side effects may occur during application of therapies or afterwards during the course of the treatment. The side effects may range from mild infections, mild laboratory abnormalities, secondary autoimmune diseases to life-threatening side effects such as progressive multifocal leukoencephalopathy. SUMMARY It has to be pointed out that these side effects are not to be considered as final and neurologists should be vigilant against new unknown side effects. The doctor should be aware of these undesirable effects, should weigh the benefits of the therapies against the risks, but at the same time she/he should keep in mind that multiple sclerosis can be a very disabling disease if not treated properly.
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11
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Jalkh G, Abi Nahed R, Macaron G, Rensel M. Safety of Newer Disease Modifying Therapies in Multiple Sclerosis. Vaccines (Basel) 2020; 9:12. [PMID: 33375365 PMCID: PMC7823546 DOI: 10.3390/vaccines9010012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022] Open
Abstract
In the past decade, the therapeutic arsenal for multiple sclerosis has expanded greatly. Newer more potent disease modifying therapies (DMTs) with varying mechanisms of actions are increasingly used early in the disease course. These newer DMTs include oral therapies (teriflunomide, dimethyl fumarate, fingolimod, siponimod, ozanimod, and cladribine) and infusion therapies (natalizumab, alemtuzumab, and ocrelizumab), and are associated with better control of disease activity and long-term outcomes in patients with MS compared to older injectable therapies (interferon beta and glatiramer acetate). However, they are associated with safety concerns and subsequent monitoring requirements. Adverse events are initially observed in phase 2 and 3 clinical trials, and further long-term data are collected in phase 3 extension studies, case series, and post-marketing reports, which highlight the need to periodically re-evaluate and adjust monitoring strategies to optimize treatment safety in an individualized approach.
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Affiliation(s)
- Georges Jalkh
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Rachelle Abi Nahed
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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12
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Gasparini S, Russo M, Dattola V, Ferlazzo E, Aguglia U. Cryptogenic cerebral venous thrombosis in a multiple-sclerosis-patient treated with Alemtuzumab. Mult Scler Relat Disord 2020; 44:102246. [DOI: 10.1016/j.msard.2020.102246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 11/30/2022]
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13
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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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14
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Soleimani B, Murray K, Hunt D. Established and Emerging Immunological Complications of Biological Therapeutics in Multiple Sclerosis. Drug Saf 2020; 42:941-956. [PMID: 30830572 DOI: 10.1007/s40264-019-00799-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Biologic immunotherapies have transformed the treatment landscape of multiple sclerosis. Such therapies include recombinant proteins (interferon beta), as well as monoclonal antibodies (natalizumab, alemtuzumab, daclizumab, rituximab and ocrelizumab). Monoclonal antibodies show particular efficacy in the treatment of the inflammatory phase of multiple sclerosis. However, the immunological perturbations caused by biologic therapies are associated with significant immunological adverse reactions. These include development of neutralising immunogenicity, secondary immunodeficiency and secondary autoimmunity. These complications can affect the balance of risks and benefits of biologic agents, and 2018 saw the withdrawal from the market of daclizumab, an anti-CD25 monoclonal antibody, due to concerns about the development of severe, unpredictable autoimmunity. Here we review established and emerging risks associated with multiple sclerosis biologic agents, with an emphasis on their immunological adverse effects. We also discuss the specific challenges that multiple sclerosis biologics pose to drug safety systems, and the potential for improvements in safety frameworks.
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Affiliation(s)
| | - Katy Murray
- Anne Rowling Clinic, University of Edinburgh, Edinburgh, UK
| | - David Hunt
- Anne Rowling Clinic, University of Edinburgh, Edinburgh, UK. .,MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK.
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15
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Romero A, Midaglia L, Salcedo MT, Viladomiu L, Guillén E, Bajaña I, Escolà-Vergé L, Tintoré M, Montalban X, Len O. Hemophagocytic syndrome following alemtuzumab treatment for multiple sclerosis: A case report. Mult Scler Relat Disord 2020; 40:101973. [PMID: 32028116 DOI: 10.1016/j.msard.2020.101973] [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: 11/12/2019] [Revised: 01/14/2020] [Accepted: 01/28/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Alemtuzumab is a monoclonal antibody targeting CD-52, used for treating relapsing-remitting multiple sclerosis (RRMS). METHODS We present a case of a 44-year-old male with RRMS who was admitted due to fever and jaundice after starting treatment with alemtuzumab 12 months ago. RESULTS He was diagnosed with hemophagocytic syndrome (HS). Liver biopsy revealed images of hemophagocytosis in Kupffer cells of lobular sinusoid. Management consisted of treatment with corticosteroids. CONCLUSION HS is a severe condition marked by an excessive activation of the immune system that leads to a rapid and progressive multi-organ failure, so it is important to consider it in the differential diagnosis of a fever syndrome following the administration of alemtuzumab.
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Affiliation(s)
- A Romero
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - L Midaglia
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M T Salcedo
- Department of Pathological Anatomy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - L Viladomiu
- Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - E Guillén
- Department of Clinical Pharmacology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - I Bajaña
- Department of Intensive Care Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - L Escolà-Vergé
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - M Tintoré
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - X Montalban
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Division of Neurology, University of Toronto. St Michael's Hospital, Toronto, Canada
| | - O Len
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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16
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Förster M, Küry P, Aktas O, Warnke C, Havla J, Hohlfeld R, Mares J, Hartung HP, Kremer D. Managing Risks with Immune Therapies in Multiple Sclerosis. Drug Saf 2020; 42:633-647. [PMID: 30607830 DOI: 10.1007/s40264-018-0782-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Since the introduction of the interferons in the 1990s, a multitude of different immunomodulatory and immunosuppressant disease-modifying therapies for multiple sclerosis (MS) have been developed. They have all shown positive effects on clinical endpoints such as relapse rate and disease progression and are a heterogeneous group of therapeutics comprising recombinant pegylated and non-pegylated interferon-β variants, peptide combinations, monoclonal antibodies, and small molecules. However, they have relevant side effect profiles, which necessitate thorough monitoring and straightforward patient education. In individual cases, side effects can be severe and potentially life-threatening, which is why knowledge about (neurological and non-neurological) adverse drug reactions is essential for prescribing neurologists as well as general practitioners. This paper aims to provide an overview of currently available MS therapies, their modes of action and safety profiles, and the necessary therapy monitoring.
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Affiliation(s)
- Moritz Förster
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Patrick Küry
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Clemens Warnke
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilian-Universität München, Munich, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilian-Universität München, Munich, Germany.,The Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Jan Mares
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - David Kremer
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
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17
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Affiliation(s)
- Joep Killestein
- Department of Neurology, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Bob van Oosten
- Department of Neurology, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
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18
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Rolfes L, Pfeuffer S, Ruck T, Windhagen S, Oschlies I, Pavenstädt HJ, Angenendt L, Wiendl H, Krämer J, Meuth SG. A case of idiopathic multicentric Castleman disease in an alemtuzumab-treated patient with MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 7:7/1/e638. [PMID: 31704887 PMCID: PMC6865849 DOI: 10.1212/nxi.0000000000000638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/06/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Leoni Rolfes
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany.
| | - Steffen Pfeuffer
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany
| | - Tobias Ruck
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany
| | - Susanne Windhagen
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany
| | - Ilske Oschlies
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany
| | - Hermann-Joseph Pavenstädt
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany
| | - Linus Angenendt
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany
| | - Heinz Wiendl
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany
| | - Julia Krämer
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany
| | - Sven G Meuth
- From the Clinic of Neurology with Institute of Translational Neurology (L.R., S.P., T.R., H.W., J.K., S.G.M.), University Hospital Münster; Department of Neurology and Neurological Rehabilitation (S.W.), Hospital Osnabrück, Am Finkenhügel 1; Department of Pathology (I.O.), Hematopathology Section and Lymph Node Registry, University-Hospital Schleswig-Holstein, Campus Kiel; Department of General Internal Medicine (H.-J.P.), Nephrology, Hypertensiology, and Rheumatology, University Hospital Münster; and Department of Hematology (L.A.), Hemostaseology, Oncology, and Pneumology, University Hospital Münster, Germany
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19
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Chisari CG, Toscano S, D’Amico E, Lo Fermo S, Zanghì A, Arena S, Zappia M, Patti F. An update on the safety of treating relapsing-remitting multiple sclerosis. Expert Opin Drug Saf 2019; 18:925-948. [DOI: 10.1080/14740338.2019.1658741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Clara G. Chisari
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Simona Toscano
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Emanuele D’Amico
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Salvatore Lo Fermo
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Aurora Zanghì
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Sebastiano Arena
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Mario Zappia
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Francesco Patti
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
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20
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Holmøy T, Fevang B, Olsen DB, Spigset O, Bø L. Adverse events with fatal outcome associated with alemtuzumab treatment in multiple sclerosis. BMC Res Notes 2019; 12:497. [PMID: 31405369 PMCID: PMC6689881 DOI: 10.1186/s13104-019-4507-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/20/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Sporadic fatal adverse events have been reported during treatment of multiple sclerosis with alemtuzumab. To provide a systematic overview, we searched the centralized European Medicines Agency database of suspected adverse reactions related to medicinal products (EudraVigilance) for fatal adverse events associated with treatment with alemtuzumab (Lemtrada®) for multiple sclerosis. Four independent reviewers with expertise on MS, clinical immunology, infectious diseases and clinical pharmacology reviewed the reports, and scored the likelihood for causality. RESULTS We identified nine cases with a probable and one case with a possible causal relationship between alemtuzumab treatment and a fatal adverse event. Six of these patients died within one month after treatment; one from intracerebral hemorrhage, two from acute multiple organ failure and septic shock, one from listeriosis, one from pneumonia and one from agranulocytosis. Four patients died several months after administration of alemtuzumab from either autoimmune hepatitis, immune-mediated thrombocytopenia, autoimmune hemolytic anemia or agranulocytosis. Four of the 10 cases had been published previously in case reports or congress abstracts. Fatal adverse events related to treatment with alemtuzumab occur more frequently than previously published in the literature. A significant proportion occurs in the first month after treatment.
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Affiliation(s)
- Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Post Office Box 1000, 1478, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Børre Fevang
- Centre for Rare Disorders, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
| | - David Benee Olsen
- Department of Pharmacovigilance, Norwegian Medicines Agency, Post Office Box 240, Skøyen, 0213, Oslo, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olavs University Hospital, Post Office Box 3250, Torgarden, 7006, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lars Bø
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Post Office Box 1400, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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21
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Ruck T, Schulte-Mecklenbeck A, Pfeuffer S, Heming M, Klotz L, Windhagen S, Kleinschnitz C, Gross CC, Wiendl H, Meuth SG. Pretreatment anti-thyroid autoantibodies indicate increased risk for thyroid autoimmunity secondary to alemtuzumab: A prospective cohort study. EBioMedicine 2019; 46:381-386. [PMID: 31371192 PMCID: PMC6711888 DOI: 10.1016/j.ebiom.2019.07.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/19/2019] [Accepted: 07/24/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Alemtuzumab is approved for the treatment of active relapsing-remitting multiple sclerosis (RRMS). Alemtuzumab-related secondary autoimmune disorders (sAID) are common, with thyroid sAID being the most frequent, and fundamentally affect the risk-benefit ratio. Therefore, biomarkers indicating the development of sAID are urgently needed to instruct clinical decisions. METHODS We evaluated whether the anti-thyroid autoantibodies (ThyAb) anti-thyroglobulin (anti-TG) and anti-thyroid-peroxidase (anti-TPO) detected at baseline by standard testing are able to indicate increased risk for thyroid sAID following alemtuzumab treatment in a multicentre prospective cohort of 106 alemtuzumab-treated RRMS patients. We here present an interim-analysis with a median follow-up of 36 months. FINDINGS Baseline characteristics demonstrated no significant differences between patients with or without thyroid sAID. 29/106 (27·4%) patients developed thyroid sAID between 5 and 51 months following alemtuzumab treatment initiation. 14/29 patients (48·3%) were positive for ThyAb at baseline and developed thyroid sAID. Hazard ratio for time to thyroid autoimmunity was 12.15 (95% CI 4.73-31.2) indicating a highly increased risk for ThyAb positive patients. Baseline ThyAb were associated with shorter time to sAID, but not with a specific disease entity of thyroid sAID. Hazard ratios for age, sex, previous treatment, disease duration, disability and smoking status demonstrated no significant association with thyroid autoimmunity. INTERPRETATION Standard ThyAb-testing for anti-TPO and anti-TG antibodies at baseline was able to indicate increased risk for clinically manifest thyroid sAID and should therefore be used in clinical decisions concerning alemtuzumab treatment initiation. FUND: German Ministry of Education, Science, Research and Technology and the German Research foundation.
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Affiliation(s)
- Tobias Ruck
- Clinic of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany.
| | | | - Steffen Pfeuffer
- Clinic of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Michael Heming
- Clinic of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Luisa Klotz
- Clinic of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | | | | | - Catharina C Gross
- Clinic of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Heinz Wiendl
- Clinic of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Sven G Meuth
- Clinic of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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Goischke HK. Vitamin D supplementation for the prevention or depletion of side effects of therapy with alemtuzumab in multiple sclerosis. Ther Clin Risk Manag 2019; 15:891-904. [PMID: 31371976 PMCID: PMC6636607 DOI: 10.2147/tcrm.s188941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/16/2019] [Indexed: 12/22/2022] Open
Abstract
PURPOSE OF REVIEW Not only the multiple sclerosis specialist but also the general neurologist and primary care practitioner are increasingly aware of possible adverse events (AEs) by treatment with alemtuzumab (over 47% risk of secondary autoimmune-mediated diseases). Vitamin D supplementation's effect (VDS) to reduce these autoimmune AEs is poorly performed in routine practice. This article seeks to justify why this simple, inexpensive, patient-friendly therapy should be seriously discussed. RECENT FINDINGS Patients who have developed autoimmunity also show a high basal level of IL-21, a cytokine which increases the growth of auto-reactive T-cells. For side effects such as thyroid dysfunction, autoimmune thrombocytopenia, autoimmune hemolytic anemia, autoimmune hepatitis, diabetes mellitus type 1, and alopecia areata/alopecia totalis, VDS may have an impact on the immunological mechanism, in particular lowering levels of IL-17 and IL-21. SUMMARY The potential role of vitamin D in influencing autoimmune diseases is evident. If a life-threatening side-effect can be prevented by high-dose VDS, it is ethical to initiate this add-on therapy despite contradictory results in studies on the effectiveness of VDS.
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Affiliation(s)
- Hans-Klaus Goischke
- Independent Research, Internal Medicine, Rehabilitation Medicine, Social Medicine, Bad Brückenau, Bavaria, Germany
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Sorensen PS, Sellebjerg F. Pulsed immune reconstitution therapy in multiple sclerosis. Ther Adv Neurol Disord 2019; 12:1756286419836913. [PMID: 30944586 PMCID: PMC6440030 DOI: 10.1177/1756286419836913] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 02/02/2019] [Indexed: 12/02/2022] Open
Abstract
Whereas drugs used for maintenance/escalation therapy do not maintain their beneficial effect after cessation of therapy, some new highly effective therapies can show prolonged treatment effects after a short treatment course. Such therapies have been named pulsed immune reconstitution therapies or pulsed immunosuppressive therapies, and typical representatives are alemtuzumab and cladribine. Autologous haematopoietic stem cell transplantation could be considered as the strongest immune reconstitution therapy. Both alemtuzumab and cladribine induce depletion of lymphocytes, and a common mechanism of action is preferential depletion of class-switched and unswitched memory B-cells. Whereas CD-19+ B-lymphocytes repopulate within 6 months, CD4+ T-cells repopulate at a slower rate, taking 1–2 years to reach the lower level of normal. In general, the depletion of lymphocytes is more profound and the repletion of T-cells is slower after alemtuzumab than after cladribine treatment. Both drugs have a strong effect on relapses and magnetic resonance imaging (MRI) activity, and reduce disability worsening. The therapeutic effect is maintained beyond the period of active treatment in a large proportion of patients, which is best documented for alemtuzumab. Adverse effects include reactivation of latent infections such as tuberculosis and risk of herpes zoster. The main disadvantage in alemtuzumab-treated patients is the risk of secondary immune-mediated disorders. Pulsed immune reconstitution therapy is an option as initial therapy in relapsing-remitting multiple sclerosis patients with high disease activity and in patients on treatment with another disease-modifying therapy with significant relapse and/or MRI activity.
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Affiliation(s)
- Per Soelberg Sorensen
- Department of Neurology 2082, Danish Multiple Sclerosis Center, University of Copenhagen, Rigshospitalet, 9, Blegdamsvej, DK-2100 Copenhagen, Denmark
| | - Finn Sellebjerg
- Department of Neurology, Danish Multiple Sclerosis Center, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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Muller I, Willis M, Healy S, Nasser T, Loveless S, Butterworth S, Zhang L, Draman MS, Taylor PN, Robertson N, Dayan CM, Ludgate ME. Longitudinal Characterization of Autoantibodies to the Thyrotropin Receptor (TRAb) During Alemtuzumab Therapy: Evidence that TRAb May Precede Thyroid Dysfunction by Many Years. Thyroid 2018; 28:1682-1693. [PMID: 30351224 DOI: 10.1089/thy.2018.0232] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Thyroid autoimmunity, especially Graves' disease or hypothyroidism with positive autoantibodies (TRAb) to the thyrotropin receptor (TSHR), occurs in 30-40% of patients with relapsing multiple sclerosis following treatment with alemtuzumab (ALTZ). ALTZ therapy therefore provides a unique opportunity to study the evolution of TRAb prior to clinical presentation. TRAb can stimulate (TSAb), block (TBAb), or not affect ("neutral") the TSHR function, causing hyperthyroidism, hypothyroidism, or euthyroidism, respectively. METHODS A longitudinal retrospective analysis was conducted of TRAb bioactivity over a period of nine years in 45 multiple sclerosis patients receiving ALTZ using available stored serum. Of these 45 patients, 31 developed thyroid dysfunction (TD) and 14 remained euthyroid despite being followed for a minimum of five years (NO-TD). The presence of TRAb was evaluated at standardized time points: (i) before ALTZ, (ii) latest time available following ALTZ and before TD onset, and (iii) following ALTZ during/after TD onset. Serum TRAb were detected by published in-house assays (ihTRAb): flow cytometry detecting any TSHR-binding TRAb, and luciferase bioassays detecting TSAb/TBAb bioactivity. Purified immunoglobulin G was used to verify TSAb/TBAb in selected hypothyroid cases. Standard clinical automated measurements of TRAb, antithyroid peroxidase autoantibodies (TPOAb), thyrotropin, free thyroxine, and free triiodothyronine were also collected. RESULTS Before ALTZ, combined ihTRAb (positive with flow cytometry and/or luciferase bioassay) but not automated TRAb were present in 5/16 (31.2%) TD versus 0/14 (0%) NO-TD (p = 0.017). Detectable ihTRAb preceded TD development in 9/28 (32.1%) and by a median of 1.2 years (range 28 days-7.3 years). Combination testing of ihTRAb and TPOAb at baseline predicted 20% of subsequent cases of hyperthyroidism and 83% of hypothyroidism. CONCLUSIONS Evidence is presented that TRAb measured with custom-made assays can be detected prior to any change in thyroid function in up to a third of cases of ALTZ-related TD. Furthermore, the presence of ihTRAb prior to ALTZ treatment was strongly predictive of subsequent TD. The findings suggest that a period of affinity maturation of TRAb may precede clinical disease onset in some cases. Combined testing of TPOAb and ihTRAb may increase the ability to predict those who will develop TD following ALTZ.
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Affiliation(s)
- Ilaria Muller
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Mark Willis
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Sarah Healy
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Taha Nasser
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Samantha Loveless
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Sara Butterworth
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Lei Zhang
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Mohd S Draman
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Peter N Taylor
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Neil Robertson
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Colin M Dayan
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Marian E Ludgate
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
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Pfeuffer S. Sarcoidosis following alemtuzumab treatment: Autoimmunity mediated by T cells and interferon-γ. Mult Scler 2018; 24:1783-1784. [DOI: 10.1177/1352458518804124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
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Willis MD, Hope-Gill B, Flood-Page P, Joseph F, Needham E, Jones J, Coles A, Robertson NP. Sarcoidosis following alemtuzumab treatment for multiple sclerosis. Mult Scler 2018; 24:1779-1782. [PMID: 30307364 DOI: 10.1177/1352458518790391] [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] [Indexed: 11/16/2022]
Abstract
Despite proven efficacy of alemtuzumab in multiple sclerosis (MS), approximately 50% of individuals will develop a new autoimmune disease following treatment. To date, these have largely been antibody mediated and organ specific (primarily affecting the thyroid gland). In a retrospective case series of 187 patients from two UK specialist centres (Cardiff and Cambridge) followed up for a median of 10 years, we report three (1.6%) cases of sarcoidosis following alemtuzumab treatment of MS. This report increases the spectrum of auto-inflammatory disease following alemtuzumab and should be considered by clinicians when using this therapeutic agent for MS.
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Affiliation(s)
- Mark D Willis
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University and University Hospital of Wales, Cardiff, UK; Department of Neurology, University Hospital of Wales, Cardiff, UK
| | - Ben Hope-Gill
- Department of Respiratory Medicine, University Hospital Llandough, Llandough, UK
| | | | - Fady Joseph
- Department of Neurology, Royal Gwent Hospital, Newport, UK
| | - Ed Needham
- Department of Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Joanne Jones
- Department of Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Alasdair Coles
- Department of Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Neil P Robertson
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University and University Hospital of Wales, Cardiff, UK; Department of Neurology, University Hospital of Wales, Cardiff, UK
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Sadaat M, Jang S. Hemophagocytic lymphohistiocytosis with immunotherapy: brief review and case report. J Immunother Cancer 2018; 6:49. [PMID: 29871698 PMCID: PMC5989389 DOI: 10.1186/s40425-018-0365-3] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/22/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Hemophagocytic Lymphohistiocytosis (HLH), a rare but potentially fatal syndrome of immune hyperactivation, may be an under-recognized immune-related adverse event (irAE). Unlike other irAEs, HLH triggered by immune checkpoint blockade is not well described; no particular diagnostic guidelines and treatment regimens exist. The HLH-2004 criteria remain as the common diagnostic guide. For the treatment of HLH, various combinations of chemotherapeutic, immunosuppressive and glucocorticoid agents are used. CASE PRESENTATION We report a case of HLH in a 58-year-old metastatic melanoma patient who was undergoing immune checkpoint blockade with pembrolizumab, a programmed cell death-1 (PD-1) receptor inhibitor. The patient presented with fever, upper normal sized spleen, anemia, thrombocytopenia, hypertriglyceridemia, hyperferritinemia, reduced NK cell activity and elevated sCD163 levels, fulfilling the Histiocyte Society HLH-2004 diagnostic criteria. Our patient was successfully treated with oral prednisone (1 mg/kilogram/day), suggesting that HLH from immune checkpoint inhibitors may respond to steroids alone. CONCLUSION Early diagnosis and treatment of HLH are critical to avoid progressive tissue damage, organ failure and possibly death. HLH should be suspected in clinical presentations with fever, cytopenias and hyperinflammatory markers. HLH in the setting of immune checkpoint blockade may be treated with steroids only but further evidence is required.
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Affiliation(s)
- Masood Sadaat
- Inova Center for Personalized Health, Inova Schar Cancer Institute, 3225 Gallows Rd, 7th Floor, Tower D, Fairfax, VA 22031 USA
| | - Sekwon Jang
- Inova Center for Personalized Health, Inova Schar Cancer Institute, 8505 Arlington Blvd Suite 140, Fairfax, VA 22031 USA
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Muraro PA, Scolding NJ, Fox RJ. Rare side effects of alemtuzumab remind us of the need for postmarketing surveillance. Neurology 2018; 90:819-820. [DOI: 10.1212/wnl.0000000000005409] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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