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Schett G, Nagy G, Krönke G, Mielenz D. B-cell depletion in autoimmune diseases. Ann Rheum Dis 2024:ard-2024-225727. [PMID: 38777374 DOI: 10.1136/ard-2024-225727] [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: 02/26/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024]
Abstract
B cells have a pivotal function in the pathogenesis of autoimmune diseases, such as rheumatoid arthritis, multiple sclerosis and systemic lupus erythematosus. In autoimmune disease, B cells orchestrate antigen presentation, cytokine production and autoantibody production, the latter via their differentiation into antibody-secreting plasmablasts and plasma cells. This article addresses the current therapeutic strategies to deplete B cells in order to ameliorate or potentially even cure autoimmune disease. It addresses the main target antigens in the B-cell lineage that are used for therapeutic approaches. Furthermore, it summarises the current evidence for successful treatment of autoimmune disease with monoclonal antibodies targeting B cells and the limitations and challenges of these approaches. Finally, the concept of deep B-cell depletion and immunological reset by chimeric antigen receptor T cells is discussed, as well as the lessons from this approach for better understanding the role of B cells in autoimmune disease.
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Affiliation(s)
- Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - György Nagy
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Hospital of the Hospitaller Order of Saint John of God, Budapest, Hungary
| | - Gerhard Krönke
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Department of Rheumatology, Charite, Berlin, Germany
| | - Dirk Mielenz
- Division of Molecular Immunology, Department of Internal Medicine 3, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
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Cree BAC, Kim HJ, Weinshenker BG, Pittock SJ, Wingerchuk DM, Fujihara K, Paul F, Cutter GR, Marignier R, Green AJ, Aktas O, Hartung HP, She D, Rees W, Smith M, Cimbora D, Katz E, Bennett JL. Safety and efficacy of inebilizumab for the treatment of neuromyelitis optica spectrum disorder: end-of-study results from the open-label period of the N-MOmentum trial. Lancet Neurol 2024; 23:588-602. [PMID: 38760098 DOI: 10.1016/s1474-4422(24)00077-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Inebilizumab, an anti-CD19 B-cell-depleting antibody, demonstrated safety and efficacy in neuromyelitis optica spectrum disorder in the randomised controlled period of the N-MOmentum trial. Here, end-of-study data, including the randomised controlled period and open-label extension period, are reported. METHODS In the double-blind, randomised, placebo-controlled, phase 2/3 N-MOmentum trial, adults aged 18 years and older with an neuromyelitis optica spectrum disorder diagnosis, Expanded Disability Status Scale score of 8·0 or less, and history of either at least one acute inflammatory attack requiring rescue therapy in the past year or two attacks requiring rescue therapy in the past 2 years, were recruited from 81 outpatient specialty clinics or hospitals in 24 countries. Eligible participants were randomly assigned (3:1), using a central interactive voice system or interactive web response system, and a permuted block randomisation scheme (block size of 4), to receive intravenous inebilizumab (300 mg) or identical placebo on days 1 and 15 of the randomised period, which lasted up to 197 days. Participants and all study staff were masked to treatment assignment. The primary endpoint of the randomised period of the trial was time to onset of adjudicated neuromyelitis optica spectrum disorder attack on or before day 197. Participants in the randomised controlled period who had an adjudicated attack, completed 197 days in the study, or were in the randomised controlled period when enrolment stopped, could voluntarily enter the open-label period. In the open-label period, participants either initiated inebilizumab if assigned placebo (receiving 300 mg on days 1 and 15 of the open-label period) or continued treatment if assigned inebilizumab (receiving 300 mg on day 1 and placebo on day 15, to maintain B-cell depletion and masking of the randomised controlled period). All participants subsequently received inebilizumab 300 mg every 6 months for a minimum of 2 years. The end-of-study analysis endpoints were time to adjudicated attack and annualised attack rate (assessed in all participants who received inebilizumab at any point during the randomised controlled period or open-label period [any inebilizumab population] and the aquaporin-4 [AQP4]-IgG seropositive subgroup [any inebilizumab-AQP4-IgG seropositive population]) and safety outcomes (in all participants who were exposed to inebilizumab, analysed as-treated). This study is registered with ClinicalTrials.gov, NCT02200770, and is now complete. FINDINGS Between Jan 6, 2015, and Sept 24, 2018, 467 individuals were screened, 231 were randomly assigned, and 230 received at least one dose of inebilizumab (n=174) or placebo (n=56). Between May 19, 2015, and Nov 8, 2018, 165 (95%) of 174 participants in the inebilizumab group and 51 (91%) of 56 in the placebo group entered the open-label period (mean age 42·9 years [SD 12·4], 197 [91%] of 216 were female, 19 [9%] were male, 115 [53%] were White, 45 [21%] were Asian, 19 [9%] were American Indian or Alaskan Native, and 19 [9%] were Black or African American). As of data cutoff for this end of study analysis (Dec 18, 2020; median exposure 1178 days [IQR 856-1538], total exposure of 730 person-years) 225 participants formed the any inebilizumab population, and 208 (92%) participants were AQP4-IgG seropositive. Overall, 63 adjudicated neuromyelitis optica spectrum disorder attacks occurred in 47 (21%) of 225 treated participants (60 attacks occurred in 44 [21%] of 208 in the AQP4-IgG seropositive subgroup); 40 (63%) of 63 attacks occurred in 34 (15%) of 225 treated participants during the first year of treatment. Of individuals who had an adjudicated attack while receiving inebilizumab, 36 (77%) of 47 were subsequently attack-free at the end of 4 years. Annualised attack rates decreased year-on-year, with end-of-study adjusted annualised attack rates being similar in the any inebilizumab-AQP4-IgG seropositive subgroup (0·097 [95% CI 0·070-0·14]) and any inebilizumab populations (0·092 [0·067-0·13]). Overall, 208 (92%) of 225 participants who received any inebilizumab had at least one treatment-emergent adverse event, the most frequent of which were urinary tract infection (59 [26%]), nasopharyngitis (47 [21%]), and arthralgia (39 [17%]). Infection rates did not increase over 4 years. Three (1%) of 225 participants in the any inebilizumab population died during the open-label period (one each due to a CNS event of unknown cause and pneumonia, respiratory insufficiency resulting from an neuromyelitis optica spectrum disorder attack and viral pneumonia related to COVID-19), all of which were deemed to be unrelated to treatment. INTERPRETATION Data from the end-of-study analysis of the N-MOmentum trial showed continued and sustained clinical benefits of long-term inebilizumab treatment in individuals with neuromyelitis optica spectrum disorder, which supports the role of inebilizumab as a CD19+ B-cell-depleting therapy in neuromyelitis optica spectrum disorder. FUNDING MedImmune and Viela Bio/Horizon Therapeutics, now part of Amgen.
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Affiliation(s)
- Bruce A C Cree
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA.
| | - Ho Jin Kim
- Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | | | - Sean J Pittock
- Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University, Fukushima, Japan; Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gary R Cutter
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuroinflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Ari J Green
- Department of Ophthalmology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Brain and Mind Center, University of Sydney, Sydney, NSW, Australia; Department of Neurology, Medical University of Vienna, Vienna, Austria; Department of Neurology, Palacký University Olomouc, Olomouc, Czech Republic
| | - Dewei She
- Horizon Therapeutics/Amgen, Deerfield, IL, USA
| | | | | | | | | | - Jeffrey L Bennett
- Departments of Neurology and Ophthalmology, Programs in Neuroscience and Immunology, University of Colorado School of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
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İNANÇ Y, NAZİK S. OCRELİZUMAB KULLANAN MULTİPL SKLEROZ HASTALARINDA HEPATİT B VİRÜSÜ SEROLOJİK DURUMU. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2022. [DOI: 10.17517/ksutfd.1158614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
IN PATIENTS WITH MULTIPLE SCLEROSIS USING OCRELIZUMAB
SEROLOGICAL STATUS OF HEPATITIS B VIRUS
Abstract
Objective
B-cell depleting treatments are associated with potential risks of viral infections. Hepatitis B virus (HBV) infection is the most common chronic viral infection and it is estimated that 30% of the world population has serological evidence of current or past infection
Material end methods
Our study is a single-center, retrospective, cross-sectional study. We retrospectively reviewed the clinical records of MS patients receiving ocrelizumab. Demographic and clinical characteristics of patients, Expanded Disability Status Scale (EDSS), drug history before ocrelizumab for MS; Mean ocrelizumab intake times, smoking status, hepatitis C virus, HIV serological status, HBV serological status, HBV treatment status were recorded.
Results
The study included 64 MS patients treated with ocrelizumab. The mean age was 41.6±9.8 years (min-max: 21-62 years). 75% of the cases were female (n:48), 25% were male (n:16).
HIV and hepatitis C virus serological tests were negative in all cases. HBsAg was found to be positive in 1.6% (n:1) and Anti-HBcIgG in 12.5% (n:8). The number of patients who were started on hepatitis B treatment was 12.5% (n:8), and tenofovir disoproxil was started in 2 patients (25%), entecavir in 5 patients (62.5%), and tenofovir alafenamide in 1 patient (12.5). The mean duration of taking ocrelizumab for the patients was 28.5±13.1 months (min-max: 6-46 months).
Conclusion
In conclusion, all patients should be screened for HBV before starting ocrelizumab therapy. Both HBsAg and Anti-HBcIg G tests should be used. The isolated presence of Anti-HBcIg G may cause HBV reactivation. Therefore, Anti-HBcIg G should be screened before immunosuppressive therapy.
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Mosch R, Guchelaar HJ. Immunogenicity of Monoclonal Antibodies and the Potential Use of HLA Haplotypes to Predict Vulnerable Patients. Front Immunol 2022; 13:885672. [PMID: 35784343 PMCID: PMC9249215 DOI: 10.3389/fimmu.2022.885672] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/24/2022] [Indexed: 01/14/2023] Open
Abstract
The use of monoclonal antibodies (mAbs) in the clinic has successfully expanded to treatment of cancer, viral infections, inflammations, and other indications. However, some of the classes of mAbs that are used in the clinic show the formation of anti-drug antibodies (ADAs) leading to loss of efficacy. This review describes ADA formation for the various mAbs, and its clinical effect. Lastly, this review considers the use of HLA-haplotypes as biomarkers to predict vulnerability of patients sensitive to formation of ADAs.
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Mueller AL, Payandeh Z, Mohammadkhani N, Mubarak SMH, Zakeri A, Alagheband Bahrami A, Brockmueller A, Shakibaei M. Recent Advances in Understanding the Pathogenesis of Rheumatoid Arthritis: New Treatment Strategies. Cells 2021; 10:cells10113017. [PMID: 34831240 PMCID: PMC8616543 DOI: 10.3390/cells10113017] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023] Open
Abstract
Rheumatoid arthritis (RA) is considered a chronic systemic, multi-factorial, inflammatory, and progressive autoimmune disease affecting many people worldwide. While patients show very individual courses of disease, with RA focusing on the musculoskeletal system, joints are often severely affected, leading to local inflammation, cartilage destruction, and bone erosion. To prevent joint damage and physical disability as one of many symptoms of RA, early diagnosis is critical. Auto-antibodies play a pivotal clinical role in patients with systemic RA. As biomarkers, they could help to make a more efficient diagnosis, prognosis, and treatment decision. Besides auto-antibodies, several other factors are involved in the progression of RA, such as epigenetic alterations, post-translational modifications, glycosylation, autophagy, and T-cells. Understanding the interplay between these factors would contribute to a deeper insight into the causes, mechanisms, progression, and treatment of the disease. In this review, the latest RA research findings are discussed to better understand the pathogenesis, and finally, treatment strategies for RA therapy are presented, including both conventional approaches and new methods that have been developed in recent years or are currently under investigation.
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Affiliation(s)
- Anna-Lena Mueller
- Musculoskeletal Research Group and Tumor Biology, Chair of Vegetative Anatomy, Institute of Anatomy, Faculty of Medicine, Ludwig-Maximilian-University Munich, 80336 Munich, Germany; (A.-L.M.); (A.B.)
| | - Zahra Payandeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5166-15731, Iran;
| | - Niloufar Mohammadkhani
- Department of Clinical Biochemistry, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran;
- Children’s Medical Center, Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran 1419733151, Iran
| | - Shaden M. H. Mubarak
- Department of Clinical Laboratory Science, Faculty of Pharmacy, University of Kufa, Najaf 1967365271, Iraq;
| | - Alireza Zakeri
- Department of Biology Sciences, Shahid Rajaee Teacher Training University, Tehran 1678815811, Iran;
| | - Armina Alagheband Bahrami
- Department of Biotechnology, School of Advanced Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran;
| | - Aranka Brockmueller
- Musculoskeletal Research Group and Tumor Biology, Chair of Vegetative Anatomy, Institute of Anatomy, Faculty of Medicine, Ludwig-Maximilian-University Munich, 80336 Munich, Germany; (A.-L.M.); (A.B.)
| | - Mehdi Shakibaei
- Musculoskeletal Research Group and Tumor Biology, Chair of Vegetative Anatomy, Institute of Anatomy, Faculty of Medicine, Ludwig-Maximilian-University Munich, 80336 Munich, Germany; (A.-L.M.); (A.B.)
- Correspondence: ; Tel.: +49-89-2180-72624
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B cells as target for immunotherapy in rheumatic diseases - current status. Immunol Lett 2021; 236:12-19. [PMID: 34077805 DOI: 10.1016/j.imlet.2021.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/16/2021] [Accepted: 05/25/2021] [Indexed: 01/16/2023]
Abstract
This mini-review is a short overview of different therapeutical strategies targeting B cells in systemic autoimmune rheumatic diseases, mainly: rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and primary Sjogren Syndrome (pSS). Many strategies and their rationale are discussed in this review: B cells' depletion (anti-CD20, anti-CD22), long-lived plasma cells depletion (anti-CD19, anti-CD27, anti-CD38 and anti-CD138), changing activation of B cells (anti-BAFF) and inhibiting proteasomes in plasma cells (bortezomib). The past successful therapies and less successful are shown, and the possible reasons for failures are discussed.
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Sormani MP, De Rossi N, Schiavetti I, Carmisciano L, Cordioli C, Moiola L, Radaelli M, Immovilli P, Capobianco M, Trojano M, Zaratin P, Tedeschi G, Comi G, Battaglia MA, Patti F, Salvetti M. Disease-Modifying Therapies and Coronavirus Disease 2019 Severity in Multiple Sclerosis. Ann Neurol 2021; 89:780-789. [PMID: 33480077 PMCID: PMC8013440 DOI: 10.1002/ana.26028] [Citation(s) in RCA: 331] [Impact Index Per Article: 110.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study was undertaken to assess the impact of immunosuppressive and immunomodulatory therapies on the severity of coronavirus disease 2019 (COVID-19) in people with multiple sclerosis (PwMS). METHODS We retrospectively collected data of PwMS with suspected or confirmed COVID-19. All the patients had complete follow-up to death or recovery. Severe COVID-19 was defined by a 3-level variable: mild disease not requiring hospitalization versus pneumonia or hospitalization versus intensive care unit (ICU) admission or death. We evaluated baseline characteristics and MS therapies associated with severe COVID-19 by multivariate and propensity score (PS)-weighted ordinal logistic models. Sensitivity analyses were run to confirm the results. RESULTS Of 844 PwMS with suspected (n = 565) or confirmed (n = 279) COVID-19, 13 (1.54%) died; 11 of them were in a progressive MS phase, and 8 were without any therapy. Thirty-eight (4.5%) were admitted to an ICU; 99 (11.7%) had radiologically documented pneumonia; 96 (11.4%) were hospitalized. After adjusting for region, age, sex, progressive MS course, Expanded Disability Status Scale, disease duration, body mass index, comorbidities, and recent methylprednisolone use, therapy with an anti-CD20 agent (ocrelizumab or rituximab) was significantly associated (odds ratio [OR] = 2.37, 95% confidence interval [CI] = 1.18-4.74, p = 0.015) with increased risk of severe COVID-19. Recent use (<1 month) of methylprednisolone was also associated with a worse outcome (OR = 5.24, 95% CI = 2.20-12.53, p = 0.001). Results were confirmed by the PS-weighted analysis and by all the sensitivity analyses. INTERPRETATION This study showed an acceptable level of safety of therapies with a broad array of mechanisms of action. However, some specific elements of risk emerged. These will need to be considered while the COVID-19 pandemic persists. ANN NEUROL 2021;89:780-789.
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Affiliation(s)
- Maria P Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Nicola De Rossi
- Centro Sclerosi Multipla ASST Spedali Civili di Brescia, Montichiari, Italy
| | - Irene Schiavetti
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Luca Carmisciano
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Cinzia Cordioli
- Centro Sclerosi Multipla ASST Spedali Civili di Brescia, Montichiari, Italy
| | - Lucia Moiola
- Department of Neurology, Multiple Sclerosis Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Marta Radaelli
- Department of Neurology and Multiple Sclerosis Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Paolo Immovilli
- Multiple Sclerosis Center, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Marco Capobianco
- Department of Neurology, Regional Referral Multiple Sclerosis Center, University Hospital San Luigi, Orbassano, Torino, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences, and Sense Organs, University of Bari, Bari, Italy
| | - Paola Zaratin
- Research Department, Italian Multiple Sclerosis Foundation, Genoa, Italy
| | - Gioacchino Tedeschi
- Department of Advanced Medical and Surgical Sciences, University of Campania, Naples, Italy
| | - Giancarlo Comi
- Institute of Experimental Neurology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Mario A Battaglia
- Research Department, Italian Multiple Sclerosis Foundation, Genoa, Italy.,Department of Life Sciences, University of Siena, Siena, Italy
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, University of Catania, Catania, Italy.,Centro Sclerosi Multipla, Policlinico Catania, University of Catania, Catania, Italy
| | - Marco Salvetti
- Department of Neuroscience, Mental Health, and Sensory Organs, Sapienza University of Rome, Rome, Italy.,Unit of Neurology, IRCCS Neuromed, Pozzilli, Italy
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Clinical Perspectives on the Molecular and Pharmacological Attributes of Anti-CD20 Therapies for Multiple Sclerosis. CNS Drugs 2021; 35:985-997. [PMID: 34370283 PMCID: PMC8351586 DOI: 10.1007/s40263-021-00843-8] [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] [Accepted: 07/05/2021] [Indexed: 11/26/2022]
Abstract
Anti-CD20 therapies have demonstrated considerable efficacy in the treatment of relapsing multiple sclerosis, constituting a high-efficacy treatment approach for reducing relapse risk and mitigating disability progression. These therapies have been shown to strongly deplete circulating B cells and small subsets of CD3+ CD4 and CD8 T cells that express low levels of CD20. While the clinical profiles of the various anti-CD20 monoclonal antibodies used in treating multiple sclerosis are well-described in the literature, greater understanding of the implications of their distinct molecular and pharmacological attributes is needed. In this review, we focus on four anti-CD20 monoclonal antibodies-rituximab, ocrelizumab, ofatumumab, and ublituximab-that are currently used, approved, or in late-stage clinical development for the treatment of multiple sclerosis. We provide clinical perspectives on the potential implications of differences in molecular structures, target epitopes, dosing regimens, mechanisms and impact on B-cell depletion and reconstitution, immunogenicity, administration-related reactions, and infection risks.
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Seery N, Sharmin S, Li V, Nguyen AL, Meaton C, Atvars R, Taylor N, Tunnell K, Carey J, Marriott MP, Buzzard KA, Roos I, Dwyer C, Baker J, Taylor L, Spriggs K, Kilpatrick TJ, Kalincik T, Monif M. Predicting Infection Risk in Multiple Sclerosis Patients Treated with Ocrelizumab: A Retrospective Cohort Study. CNS Drugs 2021; 35:907-918. [PMID: 33847902 PMCID: PMC8042832 DOI: 10.1007/s40263-021-00810-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ocrelizumab safety outcomes have been well evaluated in clinical trials and open-label extension (OLE) studies. However, risk factors for infection in patients with multiple sclerosis (MS) receiving ocrelizumab have not been extensively studied in the real-world setting. OBJECTIVE The aim of this study was to examine factors determining risk of self-reported infections and antimicrobial use in patients receiving ocrelizumab for MS. METHODS A retrospective, observational cohort study was conducted in patients receiving ocrelizumab at the Royal Melbourne Hospital. Infection type and number were reported by patients, and the associations of potential clinical and laboratory risk factors with self-reported infection and antimicrobial use were estimated using univariate and multivariable logistic regression models. RESULTS A total of 185 patients were included in the study; a total of 176 infections were reported in 89 patients (46.1%), and antimicrobial use was identified in 47 patients (25.3%). In univariate analyses, a higher serum IgA was associated with reduced odds of infection (OR 0.44, 95% CI 0.25-0.76). In multivariable analyses, older age (OR 0.94, 95% CI 0.88-0.99), higher serum IgA (OR 0.37, 95% CI 0.17-0.80) and higher serum IgG (OR 0.81, 95% CI 0.67-0.99) were associated with reduced odds of infection. Older age (OR 0.85, 95% CI 0.75-0.96) and higher serum IgA (OR 0.23, 95% CI 0.07-0.79) were associated with reduced odds of antimicrobial use, whilst longer MS disease duration (OR 1.22, 95% CI 1.06-1.41) and higher Expanded Disability Status Scale (EDSS) score (OR 1.99, 95% CI 1.02-3.86) were associated with increased odds of antimicrobial use. CONCLUSIONS Higher serum IgA and IgG and older age were associated with reduced odds of infection. Our findings highlight that infection risk is not uniform in patients with MS receiving ocrelizumab and substantiate the need to monitor immunoglobulin levels pre-treatment and whilst on therapy.
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Affiliation(s)
- Nabil Seery
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - Sifat Sharmin
- grid.1008.90000 0001 2179 088XClinical Outcomes Research Unit, University of Melbourne, Melbourne, VIC 3010 Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine, University of Melbourne, Melbourne, VIC 3010 Australia
| | - Vivien Li
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia ,grid.1008.90000 0001 2179 088XFlorey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC 3052 Australia
| | - Ai-Lan Nguyen
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia ,grid.1008.90000 0001 2179 088XClinical Outcomes Research Unit, University of Melbourne, Melbourne, VIC 3010 Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine, University of Melbourne, Melbourne, VIC 3010 Australia
| | - Claire Meaton
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - Roberts Atvars
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - Nicola Taylor
- grid.416153.40000 0004 0624 1200Day Medical Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - Kelsey Tunnell
- grid.416153.40000 0004 0624 1200Day Medical Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - John Carey
- grid.416153.40000 0004 0624 1200Day Medical Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - Mark P. Marriott
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia ,grid.414366.20000 0004 0379 3501Department of Neuroscience, Eastern Health Clinical School, Eastern Health, Box Hill, VIC 3128 Australia
| | - Katherine A. Buzzard
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia ,grid.414366.20000 0004 0379 3501Department of Neuroscience, Eastern Health Clinical School, Eastern Health, Box Hill, VIC 3128 Australia
| | - Izanne Roos
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia ,grid.1008.90000 0001 2179 088XClinical Outcomes Research Unit, University of Melbourne, Melbourne, VIC 3010 Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine, University of Melbourne, Melbourne, VIC 3010 Australia
| | - Chris Dwyer
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia ,grid.1008.90000 0001 2179 088XFlorey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC 3052 Australia
| | - Josephine Baker
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - Lisa Taylor
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - Kymble Spriggs
- grid.1008.90000 0001 2179 088XDepartment of Medicine, University of Melbourne, Melbourne, VIC 3010 Australia ,grid.416153.40000 0004 0624 1200Department of Immunology, The Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - Trevor J. Kilpatrick
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia ,grid.1008.90000 0001 2179 088XFlorey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC 3052 Australia
| | - Tomas Kalincik
- grid.416153.40000 0004 0624 1200Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC 3050 Australia ,grid.1008.90000 0001 2179 088XClinical Outcomes Research Unit, University of Melbourne, Melbourne, VIC 3010 Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine, University of Melbourne, Melbourne, VIC 3010 Australia
| | - Mastura Monif
- Department of Neurology, Melbourne MS Centre, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia. .,Department of Neuroscience, Monash University, Melbourne, VIC, 3004, Australia. .,MS and Neuroimmunology Department, Alfred Hospital, Melbourne, VIC, 3004, Australia.
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The Disease-Modifying Therapies of Relapsing-Remitting Multiple Sclerosis and Liver Injury: A Narrative Review. CNS Drugs 2021; 35:861-880. [PMID: 34319570 PMCID: PMC8354931 DOI: 10.1007/s40263-021-00842-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 02/08/2023]
Abstract
In this narrative review, we analyze pre-registration and post-marketing data concerning hepatotoxicity of all disease-modifying therapies (DMTs) available for the treatment of relapsing-remitting multiple sclerosis, including beta interferon, glatiramer acetate, fingolimod, teriflunomide, dimethyl fumarate, cladribine, natalizumab, alemtuzumab, and ocrelizumab. We review the proposed causal mechanisms described in the literature and we also address issues like use of DMTs in patients with viral hepatitis or liver cirrhosis. Most data emerged in the post-marketing phase by reports to national pharmacovigilance agencies and published case reports or case series. Serious liver adverse events are rare, but exact incidence is largely unknown, as are predictive factors. Unfortunately, none of the DMTs currently available for the treatment of multiple sclerosis is free of potential hepatic toxic effects. Cases of acute liver failure have been reported for beta-interferon, fingolimod, natalizumab, alemtuzumab, and ocrelizumab by different mechanisms (idiosyncratic reaction, autoimmune hepatitis, or viral reactivation). Patients with multiple sclerosis should be informed about possible hepatic side effects of their treatment. Most cases of liver injury are idiosyncratic and unpredictable. The specific monitoring schedule for each DMT has been reviewed and the clinician should be ready to recognize clinical symptoms suggestive for liver injury. Not all DMTs are indicated in cirrhotic patients. For some DMTs, screening for hepatitis B virus and hepatitis C virus is required before starting treatment and a monitoring or antiviral prophylaxis schedule has been established. Beta interferon, glatiramer acetate, natalizumab, and alemtuzumab are relatively contraindicated in autoimmune hepatitis due to the risk of disease exacerbation.
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Zhong M, van der Walt A, Campagna MP, Stankovich J, Butzkueven H, Jokubaitis V. The Pharmacogenetics of Rituximab: Potential Implications for Anti-CD20 Therapies in Multiple Sclerosis. Neurotherapeutics 2020; 17:1768-1784. [PMID: 33058021 PMCID: PMC7851267 DOI: 10.1007/s13311-020-00950-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 12/13/2022] Open
Abstract
There are a broad range of disease-modifying therapies (DMTs) available in relapsing-remitting multiple sclerosis (RRMS), but limited biomarkers exist to personalise DMT choice. All DMTs, including monoclonal antibodies such as rituximab and ocrelizumab, are effective in preventing relapses and preserving neurological function in MS. However, each agent harbours its own risk of therapeutic failure or adverse events. Pharmacogenetics, the study of the effects of genetic variation on therapeutic response or adverse events, could improve the precision of DMT selection. Pharmacogenetic studies of rituximab in MS patients are lacking, but pharmacogenetic markers in other rituximab-treated autoimmune conditions have been identified. This review will outline the wider implications of pharmacogenetics and the mechanisms of anti-CD20 agents in MS. We explore the non-MS rituximab literature to characterise pharmacogenetic variants that could be of prognostic relevance in those receiving rituximab, ocrelizumab or other monoclonal antibodies for MS.
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Affiliation(s)
- Michael Zhong
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia.
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia.
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Maria Pia Campagna
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Jim Stankovich
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
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12
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The ocrelizumab phase II extension trial suggests the potential to improve the risk: Benefit balance in multiple sclerosis. Mult Scler Relat Disord 2020; 44:102279. [DOI: 10.1016/j.msard.2020.102279] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023]
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13
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Smith JB, Hellwig K, Fink K, Lyell DJ, Piehl F, Langer-Gould A. Rituximab, MS, and pregnancy. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:e734. [PMID: 32358226 PMCID: PMC7217660 DOI: 10.1212/nxi.0000000000000734] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 03/24/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe the safety and efficacy of rituximab (RTX) in MS and pregnancy, we conducted a retrospective cohort study of 74 pregnancies among 55 women treated with RTX for MS and their offspring. METHODS We used prospectively collected information from the electronic health record at Kaiser Permanente Southern California between 2012 and 2019 of mother and baby to identify treatment history, pregnancy outcomes, and relapses. RESULTS Last RTX exposure before conception occurred between 1.8 and 5.2 months in 32 (49%) of 65 pregnancies and accidentally during the first trimester in 9 (12%). Among 38 live births, adverse pregnancy outcomes were as follows: 3 preterm deliveries (including 1 set of twins), 1 neonatal death (preterm twin), and 1 perinatal stroke (full-term). No stillbirths, chorioamnionitis, or major malformations were found. Fifteen (27%) women had at least one first-trimester miscarriage, of whom 8 (53%) had a history of infertility. Cumulative dose or timing of last RTX infusion was not associated with an increased risk of miscarriage. Only 2 (5.4%) women experienced relapses, one during pregnancy and the other postpartum. CONCLUSION We observed no increase in adverse pregnancy outcomes compared with expected national incidence rates and remarkably little disease activity in RTX-treated women with MS, particularly when compared with periconceptional natalizumab-treated cohorts. However, larger studies are needed to fully assess the safety of RTX use before pregnancy, especially risks associated with prolonged B-cell depletion and hypogammaglobulinemia. Until these data are available, we recommend restricting RTX use before pregnancy to women who require highly effective MS treatments. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for pregnant women with MS, RTX controls disease activity and does not increase adverse pregnancy outcomes.
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Affiliation(s)
- Jessica B Smith
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Kerstin Hellwig
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Katharina Fink
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Deirdre J Lyell
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Fredrik Piehl
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Annette Langer-Gould
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA.
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Infectious Complications of Biological and Small Molecule Targeted Immunomodulatory Therapies. Clin Microbiol Rev 2020; 33:33/3/e00035-19. [PMID: 32522746 DOI: 10.1128/cmr.00035-19] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The past 2 decades have seen a revolution in our approach to therapeutic immunosuppression. We have moved from relying on broadly active traditional medications, such as prednisolone or methotrexate, toward more specific agents that often target a single receptor, cytokine, or cell type, using monoclonal antibodies, fusion proteins, or targeted small molecules. This change has transformed the treatment of many conditions, including rheumatoid arthritis, cancers, asthma, and inflammatory bowel disease, but along with the benefits have come risks. Contrary to the hope that these more specific agents would have minimal and predictable infectious sequelae, infectious complications have emerged as a major stumbling block for many of these agents. Furthermore, the growing number and complexity of available biologic agents makes it difficult for clinicians to maintain current knowledge, and most review articles focus on a particular target disease or class of agent. In this article, we review the current state of knowledge about infectious complications of biologic and small molecule immunomodulatory agents, aiming to create a single resource relevant to a broad range of clinicians and researchers. For each of 19 classes of agent, we discuss the mechanism of action, the risk and types of infectious complications, and recommendations for prevention of infection.
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15
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Abstract
Biologic therapies including monoclonal antibodies, tyrosine kinase inhibitors, and other agents represent a notable expansion in the pharmacotherapy armamentarium in treatment of a variety of diseases. Many of these therapies possess direct or indirect immunosuppressive and immunomodulatory effects, which have been associated with bacterial, viral, and fungal opportunistic infections. Careful screening of baseline risk factors before initiation, targeted preventive measures, and vigilant monitoring while on active biologic therapy mitigate these risks as use of biologics becomes more commonplace. This review compiles reported evidence of fungal infections associated with these agents with a focus on the tumor necrosis factor-α inhibitor class.
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Affiliation(s)
- Matthew R Davis
- Department of Pharmacy, University of California, Los Angeles Ronald Reagan Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095, USA.
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California Davis Health, 4150 V Street, Sacramento, CA 95817, USA; Department of Medical Microbiology and Immunology, University of California Davis Health, 4150 V Street, Sacramento, CA 95817, USA
| | - Thomas F Patterson
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at San Antonio, South Texas Veterans Health Care System, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
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16
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Faissner S, Schwake C, Gotzmann M, Mügge A, Schmidt S, Gold R. Endocarditis following ocrelizumab in relapsing-remitting MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/3/e680. [PMID: 32014890 PMCID: PMC7051193 DOI: 10.1212/nxi.0000000000000680] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/07/2020] [Indexed: 11/23/2022]
Affiliation(s)
- Simon Faissner
- From the Department of Neurology (S.F., C.S., R.G.) and Department of Cardiology (M.G., A.M.), St. Josef-Hospital, Ruhr-University Bochum, Bochum; and Neurologische Gemeinschaftspraxis (S.S.), Bonn, Germany.
| | - Carolin Schwake
- From the Department of Neurology (S.F., C.S., R.G.) and Department of Cardiology (M.G., A.M.), St. Josef-Hospital, Ruhr-University Bochum, Bochum; and Neurologische Gemeinschaftspraxis (S.S.), Bonn, Germany
| | - Michael Gotzmann
- From the Department of Neurology (S.F., C.S., R.G.) and Department of Cardiology (M.G., A.M.), St. Josef-Hospital, Ruhr-University Bochum, Bochum; and Neurologische Gemeinschaftspraxis (S.S.), Bonn, Germany
| | - Andreas Mügge
- From the Department of Neurology (S.F., C.S., R.G.) and Department of Cardiology (M.G., A.M.), St. Josef-Hospital, Ruhr-University Bochum, Bochum; and Neurologische Gemeinschaftspraxis (S.S.), Bonn, Germany
| | - Stephan Schmidt
- From the Department of Neurology (S.F., C.S., R.G.) and Department of Cardiology (M.G., A.M.), St. Josef-Hospital, Ruhr-University Bochum, Bochum; and Neurologische Gemeinschaftspraxis (S.S.), Bonn, Germany
| | - Ralf Gold
- From the Department of Neurology (S.F., C.S., R.G.) and Department of Cardiology (M.G., A.M.), St. Josef-Hospital, Ruhr-University Bochum, Bochum; and Neurologische Gemeinschaftspraxis (S.S.), Bonn, Germany
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17
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Luna G, Alping P, Burman J, Fink K, Fogdell-Hahn A, Gunnarsson M, Hillert J, Langer-Gould A, Lycke J, Nilsson P, Salzer J, Svenningsson A, Vrethem M, Olsson T, Piehl F, Frisell T. Infection Risks Among Patients With Multiple Sclerosis Treated With Fingolimod, Natalizumab, Rituximab, and Injectable Therapies. JAMA Neurol 2020; 77:184-191. [PMID: 31589278 PMCID: PMC6784753 DOI: 10.1001/jamaneurol.2019.3365] [Citation(s) in RCA: 320] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/16/2019] [Indexed: 12/25/2022]
Abstract
Importance Although highly effective disease-modifying therapies for multiple sclerosis (MS) have been associated with an increased risk of infections vs injectable therapies interferon beta and glatiramer acetate (GA), the magnitude of potential risk increase is not well established in real-world populations. Even less is known about infection risk associated with rituximab, which is extensively used off-label to treat MS in Sweden. Objective To examine the risk of serious infections associated with disease-modifying treatments for MS. Design, Setting, and Participants This nationwide register-based cohort study was conducted in Sweden from January 1, 2011, to December 31, 2017. National registers with prospective data collection from the public health care system were used. All Swedish patients with relapsing-remitting MS whose data were recorded in the Swedish MS register as initiating treatment with rituximab, natalizumab, fingolimod, or interferon beta and GA and an age-matched and sex-matched general population comparator cohort were included. Exposures Treatment with rituximab, natalizumab, fingolimod, and interferon beta and GA. Main Outcomes and Measures Serious infections were defined as all infections resulting in hospitalization. Additional outcomes included outpatient treatment with antibiotic or herpes antiviral medications. Adjusted hazard ratios (HRs) were estimated in Cox regressions. Results A total of 6421 patients (3260 taking rituximab, 1588 taking natalizumab, 1535 taking fingolimod, and 2217 taking interferon beta/GA) were included, plus a comparator cohort of 42 645 individuals. Among 6421 patients with 8600 treatment episodes, the mean (SD) age at treatment start ranged from 35.0 (10.1) years to 40.4 (10.6) years; 6186 patients were female. The crude rate of infections was higher in patients with MS taking interferon beta and GA than the general population (incidence rate, 8.9 [95% CI, 6.4-12.1] vs 5.2 [95% CI, 4.8-5.5] per 1000 person-years), and higher still in patients taking fingolimod (incidence rate, 14.3 [95% CI, 10.8-18.5] per 1000 person-years), natalizumab (incidence rate, 11.4 [95% CI, 8.3-15.3] per 1000 person-years), and rituximab (incidence rate, 19.7 [95% CI, 16.4-23.5] per 1000 person-years). After confounder adjustment, the rate remained significantly higher for rituximab (HR, 1.70 [95% CI, 1.11-2.61]) but not fingolimod (HR, 1.30 [95% CI, 0.84-2.03]) or natalizumab (HR, 1.12 [95% CI, 0.71-1.77]) compared with interferon beta and GA. In contrast, use of herpes antiviral drugs during rituximab treatment was similar to that of interferon beta and GA and lower than that of natalizumab (HR, 1.82 [1.34-2.46]) and fingolimod (HR, 1.71 [95% CI, 1.27-2.32]). Conclusions and Relevance Patients with MS are at a generally increased risk of infections, and this differs by treatment. The rate of infections was lowest with interferon beta and GA; among newer treatments, off-label use of rituximab was associated with the highest rate of serious infections. The different risk profiles should inform the risk-benefit assessments of these treatments.
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Affiliation(s)
- Gustavo Luna
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Peter Alping
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Katharina Fink
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Fogdell-Hahn
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Martin Gunnarsson
- Center for Health and Medical Psychology, Örebro University, Örebro, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annette Langer-Gould
- Clinical and Translational Neuroscience, Southern California Permanente Medical Group, Kaiser Permanente, Pasadena
| | - Jan Lycke
- Department of Clinical Neuroscience and Rehabilitation, University of Gothenburg, Gothenburg, Sweden
| | - Petra Nilsson
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Jonatan Salzer
- Department of Pharmacology and Clinical Neuroscience, Umea University, Umea, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Vrethem
- Department of Clinical and Experimental Medicine, Linkoping University, Linkoping, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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18
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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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Zecca C, Bovis F, Novi G, Capobianco M, Lanzillo R, Frau J, Repice AM, Hakiki B, Realmuto S, Bonavita S, Curti E, Brambilla L, Mataluni G, Cavalla P, Di Sapio A, Signoriello E, Barone S, Maniscalco GT, Maietta I, Maraffi I, Boffa G, Malucchi S, Nozzolillo A, Coghe G, Mechi C, Salemi G, Gallo A, Sacco R, Cellerino M, Malentacchi M, De Angelis M, Lorefice L, Magnani E, Prestipino E, Sperli F, Brescia Morra V, Fenu G, Barilaro A, Abbadessa G, Signori A, Granella F, Amato MP, Uccelli A, Gobbi C, Sormani MP. Treatment of multiple sclerosis with rituximab: A multicentric Italian-Swiss experience. Mult Scler 2019; 26:1519-1531. [PMID: 31573386 DOI: 10.1177/1352458519872889] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Rituximab, an anti-CD20 monoclonal antibody leading to B lymphocyte depletion, is increasingly used as an off-label treatment option for multiple sclerosis (MS). OBJECTIVE To investigate the effectiveness and safety of rituximab in relapsing-remitting (RR) and progressive MS. METHODS This is a multicenter, retrospective study on consecutive MS patients treated off-label with rituximab in 22 Italian and 1 Swiss MS centers. Relapse rate, time to first relapse, Expanded Disability Status Scale (EDSS) progression, incidence of adverse events, and radiological outcomes from 2009 to 2019 were analyzed. RESULTS A total of 355/451 enrolled subjects had at least one follow-up visit and were included in the outcome analysis. Annualized relapse rate significantly decreases after rituximab initiation versus the pre-rituximab start year in RRMS (from 0.86 to 0.09, p < .0001) and in secondary-progressive (SP) MS (from 0.34 to 0.06, p < .0001) and had a slight decrease in primary-progressive (PP) MS patients (from 0.12 to 0.07, p = 0.45). After 3 years from rituximab start, the proportion of patients with a confirmed EDSS progression was 14.6% in the RRMS group, 24.7% in the SPMS group, and 41.5% in the PPMS group. No major safety concerns arose. CONCLUSION Consistently with other observational studies, our data show effectiveness of rituximab in reducing disease activity in patients with MS.
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Affiliation(s)
- Chiara Zecca
- Neurocentre of Southern Switzerland, Department of Neurology, Ospedale Civico, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Francesca Bovis
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Giovanni Novi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Capobianco
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi, Orbassano, Italy
| | - Roberta Lanzillo
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Jessica Frau
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Sabrina Realmuto
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy/AOOR Villa Sofia-Cervello, Centro di Neuroimmunologia, UOC di Neurologia e Stroke Unit, Palermo, Italy
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Erica Curti
- Neurosciences Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Laura Brambilla
- Department of Neuroimmunology and Neuromuscular Diseases, Foundation IRCCS Neurological Institute Carlo Besta, Milan, Italy
| | - Giorgia Mataluni
- Multiple Sclerosis Unit, Department of System Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paola Cavalla
- Multiple Sclerosis Center, Department of Neurosciences and Mental Health, City of Health and Science University Hospital of Turin, Turin, Italy
| | - Alessia Di Sapio
- Department of Neurology, Ospedale Regina Montis Regalis-ASLCN1, Mondovì, Italy
| | - Elisabetta Signoriello
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Stefania Barone
- Institute of Neurology, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Giorgia T Maniscalco
- Neurological Clinic and Multiple Sclerosis Center, "AORN A.Cardarelli," Naples, Italy
| | - Ilaria Maietta
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Isabella Maraffi
- Neurocentre of Southern Switzerland, Department of Neurology, Ospedale Civico, Lugano, Switzerland
| | - Giacomo Boffa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Simona Malucchi
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi, Orbassano, Italy
| | - Agostino Nozzolillo
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Giancarlo Coghe
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Claudia Mechi
- Regional MS Center, Careggi University Hospital, Florence, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Antonio Gallo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Rosaria Sacco
- Neurocentre of Southern Switzerland, Department of Neurology, Ospedale Civico, Lugano, Switzerland
| | - Maria Cellerino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maria Malentacchi
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi, Orbassano, Italy
| | - Marcello De Angelis
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Lorena Lorefice
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Eliana Magnani
- Regional MS Center, Careggi University Hospital, Florence, Italy
| | - Elio Prestipino
- NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Francesca Sperli
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi, Orbassano, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Giuseppe Fenu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Gianmarco Abbadessa
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Alessio Signori
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Franco Granella
- Neurosciences Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Pia Amato
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy/NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Antonio Uccelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Claudio Gobbi
- Neurocentre of Southern Switzerland, Department of Neurology, Ospedale Civico, Lugano, Switzerland
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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20
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Cost of disease modifying therapies for multiple sclerosis: Is front-loading the answer? J Neurol Sci 2019; 404:19-28. [DOI: 10.1016/j.jns.2019.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 07/03/2019] [Accepted: 07/09/2019] [Indexed: 01/10/2023]
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21
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Abstract
PURPOSE OF REVIEW Induction of lymphocyte depletion is increasingly used as a therapeutic strategy for central and peripheral neuroinflammatory disease. However, there is also a growing recognition of the treatment-related complication of secondary antibody deficiency (SAD). Although the occurrence of hypogammaglobulinaemia is a recognized phenomenon during immunomodulation, robust data on the coexistence of impaired responses to immunization, and significant and/or atypical infections is scarce. Here we review the literature on SAD in anti-CD20 therapy. RECENT FINDINGS Several factors that may increase the incidence of SAD have now been identified, including low levels of immunoglobulins prior to the commencement of B-cell ablation therapy, duration of maintenance therapy, and concurrent or prior use of other immunosuppressing agents such as cyclophosphamide and steroids. Measurement of disease-specific antibodies and vaccine response are likely to be helpful adjuncts to measurement of serum immunoglobulin levels during B-cell depleting therapy. Supportive treatment may include amending the treatment schedule to limit cumulative dose. SUMMARY B-cell depleting agents offer considerable therapeutic benefit in neurology. We propose modifications in current practice that include risk stratification and early identification of SAD, with the aim of minimising morbidity and mortality related to this underappreciated condition.
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22
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Osherov M, Milo R. B Cell-based Therapies for Multiple Sclerosis. EMERGING DRUGS AND TARGETS FOR MULTIPLE SCLEROSIS 2019. [DOI: 10.1039/9781788016070-00134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The traditional view of multiple sclerosis (MS) as a T cell mediated autoimmune disease of the central nervous system (CNS) has evolved into a concept of an immune-mediated disease where complex bi-directional interactions between T cells, B cells and myeloid cells underlie and shape CNS-directed autoimmunity. B cells are now recognized as major contributors to the pathogenesis of MS, largely due to increased understanding of their biology and the profound anti-inflammatory effects demonstrated by B cell depletion in MS. In this chapter we discuss the fundamental roles B cells play in the pathogenesis of MS and review current and future therapeutic strategies targeting B cells in MS, including B cell depletion with various monoclonal antibodies (mAbs) against the B cell surface markers CD20 and CD19, anti-B cell cytokine therapies, blocking Bruton's tyrosine kinase (BTK) in B cells, and various immunomodulatory and immunosuppressive effects exerted on B cells by virtually all other approved therapies for MS.
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Affiliation(s)
- Michael Osherov
- Department of Neurology, Barzilai University Medical Center 2 Hahistadrut St. Ashkelon 7830604 Israel
| | - Ron Milo
- Department of Neurology, Barzilai University Medical Center 2 Hahistadrut St. Ashkelon 7830604 Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev Beer-Sheva Israel
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23
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Ayrignac X, Bilodeau PA, Prat A, Girard M, Labauge P, Le Lorier J, Larochelle C, Duquette P. Assessing the risk of multiple sclerosis disease-modifying therapies. Expert Rev Neurother 2019; 19:695-706. [DOI: 10.1080/14737175.2019.1627201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Xavier Ayrignac
- Neurology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | | | - Alexandre Prat
- Neurology, Centre Hospitalier de l’Université de Montréal (CHUM),Montreal, Quebec, Canada
| | - Marc Girard
- Neurology, Centre Hospitalier de l’Université de Montréal (CHUM),Montreal, Quebec, Canada
| | - Pierre Labauge
- Neurology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Jacques Le Lorier
- Pharmacology, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Catherine Larochelle
- Neurology, Centre Hospitalier de l’Université de Montréal (CHUM),Montreal, Quebec, Canada
| | - Pierre Duquette
- Neurology, Centre Hospitalier de l’Université de Montréal (CHUM),Montreal, Quebec, Canada
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24
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Baker D, Jacobs BM, Gnanapavan S, Schmierer K, Giovannoni G. Plasma cell and B cell-targeted treatments for use in advanced multiple sclerosis. Mult Scler Relat Disord 2019; 35:19-25. [PMID: 31279232 DOI: 10.1016/j.msard.2019.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 06/10/2019] [Accepted: 06/25/2019] [Indexed: 12/15/2022]
Abstract
There is increasing evidence that agents that target peripheral B cells and in some instances plasma cells can exhibit marked effects on relapsing multiple sclerosis. In addition, B cells, including plasma cells, within the central nervous system compartment are likely to play an important role in disease progression in both relapsing and progressive MS. However, current B cell-targeting antibodies may not inhibit these, because of poor penetration into the central nervous system and often oligoclonal bands of immunoglobulin persist within the cerebrospinal fluid despite immunotherapy. Through targeting B cells and plasma cells in the CNS, it may be possible to obtain additional benefit above simple peripheral depletion of B cells. As such there are a number of inhibitors of B cell function and B cell depleting agents that have been developed for myeloma and B cell leukaemia and lymphoma, which could potentially be used off-label or as an experimental treatment for advanced (progressive) MS.
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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, 4 Newark Street, London E1 2AT, United Kingdom.
| | - Benjamin M Jacobs
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom
| | - Sharmilee Gnanapavan
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London E1 1BB, United Kingdom
| | - Klaus Schmierer
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London E1 1BB, United Kingdom
| | - Gavin Giovannoni
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London E1 1BB, United Kingdom
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25
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Ancau M, Berthele A, Hemmer B. CD20 monoclonal antibodies for the treatment of multiple sclerosis: up-to-date. Expert Opin Biol Ther 2019; 19:829-843. [DOI: 10.1080/14712598.2019.1611778] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mihai Ancau
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, München,
Germany
| | - Achim Berthele
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, München,
Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, München,
Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich,
Germany
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26
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Patel SY, Carbone J, Jolles S. The Expanding Field of Secondary Antibody Deficiency: Causes, Diagnosis, and Management. Front Immunol 2019; 10:33. [PMID: 30800120 PMCID: PMC6376447 DOI: 10.3389/fimmu.2019.00033] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022] Open
Abstract
Antibody deficiency or hypogammaglobulinemia can have primary or secondary etiologies. Primary antibody deficiency (PAD) is the result of intrinsic genetic defects, whereas secondary antibody deficiency may arise as a consequence of underlying conditions or medication use. On a global level, malnutrition, HIV, and malaria are major causes of secondary immunodeficiency. In this review we consider secondary antibody deficiency, for which common causes include hematological malignancies, such as chronic lymphocytic leukemia or multiple myeloma, and their treatment, protein-losing states, and side effects of a number of immunosuppressive agents and procedures involved in solid organ transplantation. Secondary antibody deficiency is not only much more common than PAD, but is also being increasingly recognized with the wider and more prolonged use of a growing list of agents targeting B cells. SAD may thus present to a broad range of specialties and is associated with an increased risk of infection. Early diagnosis and intervention is key to avoiding morbidity and mortality. Optimizing treatment requires careful clinical and laboratory assessment and may involve close monitoring of risk parameters, vaccination, antibiotic strategies, and in some patients, immunoglobulin replacement therapy (IgRT). This review discusses the rapidly evolving list of underlying causes of secondary antibody deficiency, specifically focusing on therapies targeting B cells, alongside recent advances in screening, biomarkers of risk for the development of secondary antibody deficiency, diagnosis, monitoring, and management.
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Affiliation(s)
- Smita Y. Patel
- Clinical Immunology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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27
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Whittam DH, Tallantyre EC, Jolles S, Huda S, Moots RJ, Kim HJ, Robertson NP, Cree BAC, Jacob A. Rituximab in neurological disease: principles, evidence and practice. Pract Neurol 2019; 19:5-20. [PMID: 30498056 DOI: 10.1136/practneurol-2018-001899] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Rituximab is a widely used B-cell-depleting monoclonal antibody. It is unlicensed for use in neurological disorders and there are no treatment guidelines. However, as a rapidly acting, targeted therapy with growing evidence of efficacy and tolerability in several neuroinflammatory disorders, it is an attractive alternative to conventional immunomodulatory medications. This practical review aims to explain the basic principles of B-cell depletion with therapeutic monoclonal antibodies. We present the evidence for using rituximab in neurological diseases, and describe the practical aspects of prescribing, including dosing, monitoring, safety, treatment failure and its use in special circumstances such as coexisting viral hepatitis, pregnancy and lactation. We provide an administration guide, checklist and patient information leaflet, which can be adapted for local use. Finally, we review the safety data of rituximab and ocrelizumab (a newer and recently licensed B-cell-depleting therapy for multiple sclerosis) and suggest monitoring and risk reduction strategies.
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Affiliation(s)
- Daniel H Whittam
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Emma C Tallantyre
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Saif Huda
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Robert J Moots
- Department of Musculoskeletal Diseases, Institute of Ageing and Chronic Diseases, University of Liverpool, Liverpool, UK
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Neil P Robertson
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Bruce A C Cree
- Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Anu Jacob
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- School of Medicine, University of Liverpool, Liverpool, UK
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28
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Ciardi MR, Iannetta M, Zingaropoli MA, Salpini R, Aragri M, Annecca R, Pontecorvo S, Altieri M, Russo G, Svicher V, Mastroianni CM, Vullo V. Reactivation of Hepatitis B Virus With Immune-Escape Mutations After Ocrelizumab Treatment for Multiple Sclerosis. Open Forum Infect Dis 2018; 6:ofy356. [PMID: 30697576 PMCID: PMC6343960 DOI: 10.1093/ofid/ofy356] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/11/2018] [Accepted: 12/21/2018] [Indexed: 12/14/2022] Open
Abstract
Ocrelizumab is an anti-CD20 monoclonal antibody for the treatment of multiple sclerosis (MS) that is closely related to rituximab. We describe a case of hepatitis B virus (HBV) reactivation in an MS patient with resolved HBV infection receiving ocrelizumab. HBV reactivation was monitored with HBV-DNA and HBV surface antigen periodic assessment. Anti-HBV treatment with entecavir was started after HBV-DNA detection. Ocrelizumab can reactivate viral replication in patients with resolved HBV infection. HBV reactivation monitoring seems an effective and safe option for the management of these patients. More studies are needed to assess the optimal management of HBV reactivation in MS patients on ocrelizumab treatment.
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Affiliation(s)
- Maria R Ciardi
- Department of Public Health and Infectious Diseases, Sapienza, University of Rome, Rome, Italy
| | - Marco Iannetta
- Department of Public Health and Infectious Diseases, Sapienza, University of Rome, Rome, Italy
| | - Maria A Zingaropoli
- Department of Public Health and Infectious Diseases, Sapienza, University of Rome, Rome, Italy
| | - Romina Salpini
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Marianna Aragri
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Rosanna Annecca
- Department of Human Neurosciences, Sapienza, University of Rome, Rome, Italy
| | - Simona Pontecorvo
- Department of Human Neurosciences, Sapienza, University of Rome, Rome, Italy
| | - Marta Altieri
- Department of Human Neurosciences, Sapienza, University of Rome, Rome, Italy
| | - Gianluca Russo
- Department of Public Health and Infectious Diseases, Sapienza, University of Rome, Rome, Italy
| | - Valentina Svicher
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Claudio M Mastroianni
- Department of Public Health and Infectious Diseases, Sapienza, University of Rome, Rome, Italy
| | - Vincenzo Vullo
- Department of Public Health and Infectious Diseases, Sapienza, University of Rome, Rome, Italy
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29
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Taylor JC, Bongartz T, Massey J, Mifsud B, Spiliopoulou A, Scott IC, Wang J, Morgan M, Plant D, Colombo M, Orchard P, Twigg S, McInnes IB, Porter D, Freeston JE, Nam JL, Cordell HJ, Isaacs JD, Strathdee JL, Arnett D, de Hair MJH, Tak PP, Aslibekyan S, van Vollenhoven RF, Padyukov L, Bridges SL, Pitzalis C, Cope AP, Verstappen SMM, Emery P, Barnes MR, Agakov F, McKeigue P, Mushiroda T, Kubo M, Weinshilboum R, Barton A, Morgan AW, Barrett JH. Genome-wide association study of response to methotrexate in early rheumatoid arthritis patients. THE PHARMACOGENOMICS JOURNAL 2018; 18:528-538. [PMID: 29795407 DOI: 10.1038/s41397-018-0025-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 10/10/2017] [Accepted: 02/09/2018] [Indexed: 11/09/2022]
Abstract
Methotrexate (MTX) monotherapy is a common first treatment for rheumatoid arthritis (RA), but many patients do not respond adequately. In order to identify genetic predictors of response, we have combined data from two consortia to carry out a genome-wide study of response to MTX in 1424 early RA patients of European ancestry. Clinical endpoints were change from baseline to 6 months after starting treatment in swollen 28-joint count, tender 28-joint count, C-reactive protein and the overall 3-component disease activity score (DAS28). No single nucleotide polymorphism (SNP) reached genome-wide statistical significance for any outcome measure. The strongest evidence for association was with rs168201 in NRG3 (p = 10-7 for change in DAS28). Some support was also seen for association with ZMIZ1, previously highlighted in a study of response to MTX in juvenile idiopathic arthritis. Follow-up in two smaller cohorts of 429 and 177 RA patients did not support these findings, although these cohorts were more heterogeneous.
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Affiliation(s)
- John C Taylor
- Leeds Institute of Cancer and Pathology, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Jonathan Massey
- Arthritis Research UK Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Manchester BRC, Central Manchester Foundation Trust, Manchester, UK
| | - Borbala Mifsud
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University, London, UK
| | - Athina Spiliopoulou
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh Old Medical School, Teviot Place, Edinburgh, UK.,Pharmatics Ltd., 9, Little France Road, Edinburgh, UK
| | - Ian C Scott
- Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University and Department of Rheumatology, Haywood Hospital, High Lane, Burslem, Staffordshire, UK.,Department of Medical and Molecular Genetics, King's College London, London, UK
| | | | - Michael Morgan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Wellcome Trust Sanger Institute, Genome Campus, Hinxton, Cambridge, UK
| | - Darren Plant
- Arthritis Research UK Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Manchester BRC, Central Manchester Foundation Trust, Manchester, UK
| | - Marco Colombo
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh Old Medical School, Teviot Place, Edinburgh, UK
| | - Peter Orchard
- Pharmatics Ltd., 9, Little France Road, Edinburgh, UK
| | - Sarah Twigg
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Duncan Porter
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Jane E Freeston
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jackie L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - John D Isaacs
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University and NIHR Newcastle Biomedical Research Centre in Ageing and Long Term Conditions, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jenna L Strathdee
- Leeds Institute of Cancer and Pathology, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Donna Arnett
- University of Kentucky College of Public Health, Lexington, KY, 40536, USA
| | | | - Paul P Tak
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,GlaxoSmithKline, Stevenage, UK.,Cambridge University, Cambridge, UK.,Ghent University, Ghent, Belgium
| | - Stella Aslibekyan
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ronald F van Vollenhoven
- Rheumatology Unit, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Leonid Padyukov
- Rheumatology Unit, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - S Louis Bridges
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Costantino Pitzalis
- Barts and The London School of Medicine & Dentistry, William Harvey Research Institute, Queen Mary University, London, UK
| | - Andrew P Cope
- Academic Department of Rheumatology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Suzanne M M Verstappen
- Arthritis Research UK Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Manchester BRC, Central Manchester Foundation Trust, Manchester, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Michael R Barnes
- Barts and The London School of Medicine & Dentistry, William Harvey Research Institute, Queen Mary University, London, UK
| | - Felix Agakov
- Pharmatics Ltd., 9, Little France Road, Edinburgh, UK
| | - Paul McKeigue
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh Old Medical School, Teviot Place, Edinburgh, UK
| | | | - Michiaki Kubo
- RIKEN Center for Integrative Medical Sciences, Tokyo, Japan
| | | | - Anne Barton
- Arthritis Research UK Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Manchester BRC, Central Manchester Foundation Trust, Manchester, UK
| | - Ann W Morgan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Jennifer H Barrett
- Leeds Institute of Cancer and Pathology, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Tallantyre EC, Whittam DH, Jolles S, Paling D, Constantinesecu C, Robertson NP, Jacob A. Secondary antibody deficiency: a complication of anti-CD20 therapy for neuroinflammation. J Neurol 2018; 265:1115-1122. [PMID: 29511864 PMCID: PMC5937879 DOI: 10.1007/s00415-018-8812-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/23/2018] [Accepted: 02/24/2018] [Indexed: 12/20/2022]
Abstract
B-cell depleting anti-CD20 monoclonal antibody therapies are being increasingly used as long-term maintenance therapy for neuroinflammatory disease compared to many non-neurological diseases where they are used as remission-inducing agents. While hypogammaglobulinaemia is known to occur in over half of patients treated with medium to long-term B-cell-depleting therapy (in our cohort IgG 38, IgM 56 and IgA 18%), the risk of infections it poses seems to be under-recognised. Here, we report five cases of serious infections associated with hypogammaglobulinaemia occurring in patients receiving rituximab for neuromyelitis optica spectrum disorders. Sixty-four per cent of the whole cohort of patients studied had hypogammaglobulinemia. We discuss the implications of these cases to the wider use of anti-CD20 therapy in neuroinflammatory disease.
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Affiliation(s)
- E C Tallantyre
- University Hospital of Wales, Cardiff, UK
- Cardiff University School of Medicine, Cardiff, UK
| | - D H Whittam
- The Walton Centre NHS Trust, Liverpool, L97LJ, UK
- University of Liverpool, Liverpool, UK
| | - S Jolles
- University Hospital of Wales, Cardiff, UK
- Cardiff University School of Medicine, Cardiff, UK
| | - D Paling
- NIHR Sheffield Biomedical Research Centre (Translational Neuroscience), Sheffield, UK
- Royal Hallamshire Hospital, Sheffield, UK
| | | | - N P Robertson
- University Hospital of Wales, Cardiff, UK
- Cardiff University School of Medicine, Cardiff, UK
| | - A Jacob
- The Walton Centre NHS Trust, Liverpool, L97LJ, UK.
- University of Liverpool, Liverpool, UK.
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Hofmann K, Clauder AK, Manz RA. Targeting B Cells and Plasma Cells in Autoimmune Diseases. Front Immunol 2018; 9:835. [PMID: 29740441 PMCID: PMC5924791 DOI: 10.3389/fimmu.2018.00835] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/05/2018] [Indexed: 12/29/2022] Open
Abstract
Success with B cell depletion using rituximab has proven the concept that B lineage cells represent a valid target for the treatment of autoimmune diseases, and has promoted the development of other B cell targeting agents. Present data confirm that B cell depletion is beneficial in various autoimmune disorders and also show that it can worsen the disease course in some patients. These findings suggest that B lineage cells not only produce pathogenic autoantibodies, but also significantly contribute to the regulation of inflammation. In this review, we will discuss the multiple pro- and anti-inflammatory roles of B lineage cells play in autoimmune diseases, in the context of recent findings using B lineage targeting therapies.
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Affiliation(s)
- Katharina Hofmann
- Institute for Systemic Inflammation Research, University of Luebeck, Luebeck, Schleswig-Holstein, Germany
| | - Ann-Katrin Clauder
- Institute for Systemic Inflammation Research, University of Luebeck, Luebeck, Schleswig-Holstein, Germany
| | - Rudolf Armin Manz
- Institute for Systemic Inflammation Research, University of Luebeck, Luebeck, Schleswig-Holstein, Germany
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Piehl F, Hillert J. Rituximab is an acceptable alternative to ocrelizumab for treating multiple sclerosis - Yes. Mult Scler 2018; 24:1157-1159. [PMID: 29468952 DOI: 10.1177/1352458518757930] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden/Department of Neurology, Karolinska University Hospital, Stockholm, Sweden/Neuroimmunology Unit, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden/Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Agents targeting lymphoid cells surface antigens [I]: CD19, CD20 and CD52). Clin Microbiol Infect 2018; 24 Suppl 2:S71-S82. [PMID: 29447988 DOI: 10.1016/j.cmi.2018.02.003] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/28/2018] [Accepted: 02/03/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies. AIMS To review, from an Infectious Diseases perspective, the safety profile of agents targeting CD19, CD20 and CD52 and to suggest preventive recommendations. SOURCES Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT Although CD19-targeted agents (blinatumomab or inebilizumab) are not associated with an increased risk of infection, they may cause IgG hypogammaglobulinaemia and neutropenia. The requirement for prolonged intravenous infusion of blinatumomab may increase the risk of catheter-associated bloodstream infections. Infection remains the most common non-haematological adverse effect of anti-CD20 monoclonal antibodies, including severe respiratory tract infection, hepatitis B virus (HBV) reactivation and varicella-zoster virus infection. Screening for chronic or resolved HBV infection is recommended for patients receiving anti-CD20 monoclonal antibodies. Antiviral prophylaxis should be offered for 12-18 months to hepatitis B surface antigen (HBsAg)-positive and HBsAg-negative/anti-hepatitis B core antibody (HBc)-positive patients. Anti-Pneumocystis prophylaxis should be considered in patients receiving concomitant chemotherapy, particularly steroids. Alemtuzumab (anti-CD52) increases the risk of infections, in particular among leukaemia and solid organ transplant patients. These populations benefit from anti-Pneumocystis prophylaxis, prevention strategies for cytomegalovirus infection, and screening for HBV, hepatitis C virus and tuberculosis. Antiviral prophylaxis for at least 6-12 months should be provided for HBsAg-positive patients. IMPLICATIONS As there are limited clinical data for many of the reviewed agents, special attention must be given to promptly detect and report emerging infectious complications.
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Abstract
The pace of antibody therapeutics development accelerated in 2017, and this faster pace is projected to continue through 2018. Notably, the annual number of antibody therapeutics granted a first approval in either the European Union (EU) or United States (US) reached double-digits (total of 10) for the first time in 2017. The 10 antibodies granted approvals are: brodalumab, dupilumab, sarilumab, guselkumab, benralizumab, ocrelizumab, inotuzumab ozogamicin, avelumab, duvalumab, and emicizumab. Brodalumab, however, had already been approved in Japan in 2016. As of December 1, 2017, nine antibody therapeutics (ibalizumab, burosumab, tildrakizumab, caplacizumab, erenumab, fremanezumab, galcanezumab, romosozumab, mogamulizumab) were in regulatory review in the EU or US, and regulatory actions on their marketing applications are expected by the end of 2018. Based on company announcements and estimated clinical study primary completion dates, and assuming the study results are positive, marketing applications for at least 12 antibody therapeutics that are now being evaluated in late-stage clinical studies may be submitted by the end of 2018. Of the 12 candidates, 8 are for non-cancer indications (lanadelumab, crizanlizumab, ravulizumab, eptinezumab, risankizumab, satralizumab, brolucizumab, PRO140) and 4 are for cancer (sacituzumab govitecan, moxetumomab pasudotox, cemiplimab, ublituximab). Additional antibody therapeutics to watch in 2018 include 19 mAbs undergoing evaluation in late-stage studies with primary completion dates in late 2017 or during 2018. Of these mAbs, 9 are for non-cancer indications (lampalizumab, roledumab, emapalumab, fasinumab, tanezumab, etrolizumab, NEOD001, gantenerumab, anifrolumab) and 10 are for cancer indications (tremelimumab, isatuximab, BCD-100, carotuximab, camrelizumab, IBI308, glembatumumab vedotin, mirvetuximab soravtansine, oportuzumab monatox, L19IL2/L19TNF). Positive clinical study results may enable marketing application submissions in 2018. Brief summaries of these antibody therapeutics are provided in this installment of the ‘Antibodies to watch’ article series.
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Affiliation(s)
- Hélène Kaplon
- a Laboratory UMRS 1138 "Cancer, Immune Control and Escape" , Cordeliers Research Centre , Paris , France
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Frau J, Coghe G, Lorefice L, Fenu G, Cocco E. New horizons for multiple sclerosis therapeutics: milestones in the development of ocrelizumab. Neuropsychiatr Dis Treat 2018; 14:1093-1099. [PMID: 29719400 PMCID: PMC5922247 DOI: 10.2147/ndt.s147874] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Multiple Sclerosis (MS) is an inflammatory and neurodegenerative disease of the central nervous system, and both T and B cells are involved in its pathogenesis. The vast majority of disease-modifying drugs used for MS act on the inflammatory component of the disease and are approved for use in relapsing-remitting (RR) patients. Ocrelizumab (OCR) is the only MS drug that has been approved by the US Food and Drug Administration (FDA) not only for patients with RRMS but also for patients with primary progressive (PP) MS. OCR is a humanized anti-CD20 monoclonal antibody that can deplete the targeted B cells through antibody-dependent cellular cytotoxicity. Treatment involves administration by intravenous infusion every 6 months. OCR can cause long-lasting B-cell depletion and change the pool of reconstituted B cells. Phase III clinical trials have confirmed the results of previous Phase II studies. In particular, OPERA I and II trials, which were performed in patients with RRMS, showed a reduction in the annualized relapse rate, the risk of disability progression, and the number of new/enlarging T2 lesions and enhancing lesions measured using brain magnetic resonance. The ORATORIO trial, performed in PP subjects, showed that OCR can reduce disability progression, improve performance on the timed 25-foot walk, and decrease the total volume of T2 lesions and the mean number of new or enlarging T2 lesions. The most frequent adverse events were the infusion-related reactions and infections. Infections were mostly nasopharyngitis, as well as upper respiratory and urinary tract infections. OCR gives no indication for severe or opportunistic infections. There is not a clear increased risk of malignancies. Nevertheless, it could not be excluded. Real-life registries will provide more information about the long-term safety, the risk of exposure during pregnancy, and the risk of rare adverse events. In this review, we analyze the evidence regarding the efficacy and the safety of OCR.
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Affiliation(s)
- Jessica Frau
- Multiple Sclerosis Center Binaghi Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giancarlo Coghe
- Multiple Sclerosis Center Binaghi Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Lorena Lorefice
- Multiple Sclerosis Center Binaghi Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giuseppe Fenu
- Multiple Sclerosis Center Binaghi Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Eleonora Cocco
- Multiple Sclerosis Center Binaghi Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Greenfield AL, Hauser SL. B-cell Therapy for Multiple Sclerosis: Entering an era. Ann Neurol 2018; 83:13-26. [PMID: 29244240 PMCID: PMC5876115 DOI: 10.1002/ana.25119] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/01/2017] [Accepted: 12/09/2017] [Indexed: 12/12/2022]
Abstract
Monoclonal antibodies that target CD20 expressing B cells represent an important new treatment option for patients with multiple sclerosis (MS). B-cell-depleting therapy is highly effective against relapsing forms of the disease and is also the first treatment approach proven to protect against disability worsening in primary progressive MS. Moreover, evolving clinical experience with B-cell therapy, combined with a more sophisticated understanding of humoral immunity in preclinical models and in patients with MS, has led to major progress in deciphering the immune pathogenesis of MS. Here, we review the nuanced roles of B cells in MS autoimmunity, the clinical data supporting use of ocrelizumab and other anti-CD20 therapies in the treatment of MS, as well as safety and practical considerations for prescribing. Last, we summarize remaining unanswered questions regarding the proper role of anti-CD20 therapy in MS, its limitations, and the future landscape of B-cell-based approaches to treatment. Ann Neurol 2018;83:13-26.
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Affiliation(s)
- Ariele L. Greenfield
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California
| | - Stephen L. Hauser
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California
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37
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Stahnke AM, Holt KM. Ocrelizumab: A New B-cell Therapy for Relapsing Remitting and Primary Progressive Multiple Sclerosis. Ann Pharmacother 2017; 52:473-483. [PMID: 29232960 DOI: 10.1177/1060028017747635] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review the pharmacology, pharmacokinetics, efficacy, and safety of ocrelizumab, a new B-cell-targeted therapy for multiple sclerosis (MS). DATA SOURCES A comprehensive search of PubMed and OVID/MEDLINE was conducted using search terms ocrelizumab and multiple sclerosis using the date range of 1946 through October 2017. STUDY SELECTION AND DATA EXTRACTION All English-language, human-subject articles related to ocrelizumab and MS were evaluated. DATA SYNTHESIS Ocrelizumab was approved in March 2017 for the treatment of relapsing or primary progressive MS (PPMS). A phase II trial established 600 mg intravenously every 6 months as the preferred dosing schedule. Two phase III trials evaluated the efficacy of ocrelizumab in patients with relapsing remitting MS, and individual and pooled analysis demonstrated a significant reduction in annualized relapse rate ( P < 0.001 pooled), disability progression at 12 weeks ( P < 0.001 pooled), and gadolinium-enhancing lesions on magnetic resonance imaging (MRI; P < 0.001). Patients with PPMS were evaluated in a third phase III trial, which showed a significant decrease in disease progression at 12 weeks ( P = 0.03) and volume of T2-weighted lesions on MRI ( P < 0.001). As with other monoclonal antibodies, adverse effects seen with ocrelizumab were primarily infusion-related reactions and infection. CONCLUSIONS Ocrelizumab demonstrated efficacy in the treatment of relapsing and PPMS and is the first therapy approved for patients with PPMS.
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Affiliation(s)
- Amanda M Stahnke
- 1 University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, USA
| | - Kathryn M Holt
- 1 University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, USA
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Graf J, Leussink VI, Dehmel T, Ringelstein M, Goebels N, Adams O, MacKenzie CR, Warnke C, Feldt T, Lammerskitten A, Klotz L, Meuth S, Wiendl H, Hartung HP, Aktas O, Albrecht P. Infectious risk stratification in multiple sclerosis patients receiving immunotherapy. Ann Clin Transl Neurol 2017; 4:909-914. [PMID: 29296620 PMCID: PMC5740259 DOI: 10.1002/acn3.491] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 01/26/2023] Open
Abstract
The increasing number of potent treatments for multiple sclerosis warrants screening for infections. To investigate the prevalence of infections in two independent German patient cohorts with multiple sclerosis/neuromyelitis optica spectrum disorders (NMOSD), we performed a retrospective chart review study of multiple sclerosis/NMOSD patients who underwent testing for infections between 2014 and 2016. We show that 6 out of 80 tested patients (Düsseldorf cohort) and 2 out of 97 tested patients (Münster cohort) had a latent tuberculosis infection; total 3.95%, 95% CI: 2-8%. Our findings suggest that latent tuberculosis infection is frequent (>1%). Screening should be performed before embarking on immunomodulatory therapies to allow treatment and mitigation of the risk of a reactivation.
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Affiliation(s)
- Jonas Graf
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Verena I Leussink
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | | | - Marius Ringelstein
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Norbert Goebels
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Ortwin Adams
- Institute of Virology University Hospital Heinrich-Heine-University Düsseldorf Germany
| | - Colin R MacKenzie
- Institute of Medical Microbiology and Hospital Hygiene University Hospital Heinrich-Heine-University Düsseldorf Germany
| | - Clemens Warnke
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany.,Department of Neurology University Hospital of Cologne Cologne Germany
| | - Torsten Feldt
- Department of Gastroenterology, Hepatology and Infectious Diseases University Hospital Heinrich-Heine-University Düsseldorf Germany
| | | | - Luisa Klotz
- Department of Neurology University Hospital of Münster Münster Germany
| | - Sven Meuth
- Department of Neurology University Hospital of Münster Münster Germany
| | - Heinz Wiendl
- Department of Neurology University Hospital of Münster Münster Germany
| | - Hans-Peter Hartung
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Orhan Aktas
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Philipp Albrecht
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
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Du FH, Mills EA, Mao-Draayer Y. Next-generation anti-CD20 monoclonal antibodies in autoimmune disease treatment. AUTOIMMUNITY HIGHLIGHTS 2017; 8:12. [PMID: 29143151 PMCID: PMC5688039 DOI: 10.1007/s13317-017-0100-y] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/03/2017] [Indexed: 01/02/2023]
Abstract
The clinical success of anti-CD20 monoclonal antibody (mAb)-mediated B cell depletion therapy has contributed to the understanding of B cells as major players in several autoimmune diseases. The first therapeutic anti-CD20 mAb, rituximab, is a murine-human chimera to which many patients develop antibodies and/or experience infusion-related reactions. A second generation of anti-CD20 mAbs has been designed to be more effective, better tolerated, and of lower immunogenicity. These include the humanized versions: ocrelizumab, obinutuzumab, and veltuzumab, and the fully human, ofatumumab. We conducted a literature search of relevant randomized clinical trials in the PubMed database and ongoing trials in Clinicaltrials.gov. Most of these trials have evaluated intravenous ocrelizumab or subcutaneous ofatumumab in rheumatoid arthritis, multiple sclerosis, or systemic lupus erythematosus. Understanding how newer anti-CD20 mAbs compare with rituximab in terms of efficacy, safety, convenience, and cost is important for guiding future management of anti-CD20 mAb therapy in autoimmune diseases.
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Affiliation(s)
| | - Elizabeth A Mills
- Molecular and Behavioral Neuroscience Institute, University of Michigan Medical School, Ann Arbor, USA
| | - Yang Mao-Draayer
- Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, USA. .,Department of Neurology, University of Michigan Medical School, 4015 A Alfred Taubman Biomedical Sciences Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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40
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Li PH, Lau CS. Secondary antibody deficiency and immunoglobulin replacement. HONG KONG BULLETIN ON RHEUMATIC DISEASES 2017. [DOI: 10.1515/hkbrd-2017-0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Antibody deficiencies can be either primary or secondary, leading to significant morbidity and mortality without appropriate management. Secondary antibody deficiency can be due to various diseases or iatrogenic causes, especially with the use of immunosuppressive agents such as B-cell depleting therapies. Unlike its primary counterpart, little is known regarding the management of secondary antibody deficiency and it remains an underappreciated entity. This is a growing concern with the growing numbers of patients on various immunosuppressant therapies and increasing survivors of autoimmune diseases and haematological malignancies. In this report, we review the diagnosis and management of secondary antibody deficiency, especially after rituximab-induced hypogammaglobulinemia.
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Affiliation(s)
- Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital , University of Hong Kong , Hong Kong , Hong Kong
| | - Chak-Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital , University of Hong Kong , Hong Kong , Hong Kong
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Md Yusof MY, Shaw D, El-Sherbiny YM, Dunn E, Rawstron AC, Emery P, Vital EM. Predicting and managing primary and secondary non-response to rituximab using B-cell biomarkers in systemic lupus erythematosus. Ann Rheum Dis 2017; 76:1829-1836. [PMID: 28684557 PMCID: PMC5705851 DOI: 10.1136/annrheumdis-2017-211191] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/27/2017] [Accepted: 06/06/2017] [Indexed: 12/18/2022]
Abstract
Objective To assess factors associated with primary and secondary non-response to rituximab in systemic lupus erythematosus (SLE) and evaluate management of secondary non-depletion non-response (2NDNR). Methods 125 patients with SLE treated with rituximab over 12 years were studied prospectively. A major clinical response was defined as improvement of all active British Isles Lupus Assessment Group (BILAG)-2004 domains to grade C/better and no A/B flare. Partial responders were defined by one persistent BILAG B. B-cell subsets were measured using highly sensitive flow cytometry. Patients with 2NDNR, defined by infusion reaction and defective depletion, were treated with ocrelizumab or ofatumumab. Results 117 patients had evaluable data. In cycle 1 (C1), 96/117 (82%) achieved BILAG response (major=50%, partial=32%). In multivariable analysis, younger age (OR 0.97, 95% CI 0.94 to 1.00) and B-cell depletion at 6 weeks (OR 3.22, 95% CI 1.24 to 8.33) increased the odds of major response. Complete depletion was predicted by normal complement and lower pre-rituximab plasmablasts and was not associated with increased serious infection post-rituximab. Seventy-seven (with data on 72) C1 responders were retreated on clinical relapse. Of these, 61/72 (85%) responded in cycle 2 (C2). Of the 11 C2 non-responders, nine met 2NDNR criteria (incidence=12%) and tested positive for anti-rituximab antibodies. Lack of concomitant immunosuppressant and higher pre-rituximab plasmablasts predicted 2NDNR. Five were switched to ocrelizumab/ofatumumab, and all depleted and responded. Conclusion Treatment with anti-CD20 agents can be guided by B-cell monitoring and should aim to achieve complete depletion. 2NDNR is associated with anti-rituximab antibodies, and switching to humanised agents restores depletion and response. In SLE, alternative anti-CD20 antibodies may be more consistently effective.
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Affiliation(s)
- Md Yuzaiful Md Yusof
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Chapeltown Road, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Daniel Shaw
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Chapeltown Road, Leeds, UK
| | - Yasser M El-Sherbiny
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Chapeltown Road, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Clinical Pathology, Faculty of Medicine, Mansoura University, Egypt
| | - Emma Dunn
- Department of Nephrology, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andy C Rawstron
- Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Chapeltown Road, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Chapeltown Road, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Jakimovski D, Weinstock-Guttman B, Ramanathan M, Kolb C, Hojnacki D, Minagar A, Zivadinov R. Ocrelizumab: a B-cell depleting therapy for multiple sclerosis. Expert Opin Biol Ther 2017; 17:1163-1172. [PMID: 28658986 DOI: 10.1080/14712598.2017.1347632] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is the most common neurological disease responsible for early disability in the young working population. In the last two decades, based on retrospective/prospective data, the use of disease-modifying therapies has been shown to slow the rate of disability progression and prolonged the time to conversion into secondary-progressive MS (SPMS). However, despite the availability of several approved therapies, disability progression cannot be halted significantly in all MS patients. Areas covered: This article reviews the immunopathology of the B-cells, and their role in pathogenesis of MS and their attractiveness as a potential therapeutic target in MS. The review focuses on the recently published ocrelizumab phase III trials in terms of its efficacy, safety, and tolerability as well as its future considerations. Expert opinion: B lymphocyte cell depletion therapy offers a compelling and promising new option for MS patients. Nonetheless, there is a need for heightened vigilance and awareness in detecting potential long-term consequences that currently remain unknown.
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Affiliation(s)
- Dejan Jakimovski
- a Buffalo Neuroimaging Analysis Center, Department of Neurology , Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Bianca Weinstock-Guttman
- b Jacobs MS Center, Department of Neurology , Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Murali Ramanathan
- c Department of Pharmaceutical Sciences , Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Channa Kolb
- b Jacobs MS Center, Department of Neurology , Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo , NY , USA
| | - David Hojnacki
- b Jacobs MS Center, Department of Neurology , Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Alireza Minagar
- d Department of Neurology , Louisiana State University Health Sciences Center , Shreveport , LA , USA
| | - Robert Zivadinov
- a Buffalo Neuroimaging Analysis Center, Department of Neurology , Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo , NY , USA.,e Translational Imaging Center at Clinical Translational Science Institute , Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo , NY , USA
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Nguyen A, Gresle M, Marshall T, Butzkueven H, Field J. Monoclonal antibodies in the treatment of multiple sclerosis: emergence of B-cell-targeted therapies. Br J Pharmacol 2017; 174:1895-1907. [PMID: 28319650 PMCID: PMC5466523 DOI: 10.1111/bph.13780] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 02/26/2017] [Accepted: 03/03/2017] [Indexed: 12/16/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the CNS, and one of the most common causes of disability in young adults. Over the last decade, new disease-modifying therapies have emerged, including monoclonal antibodies (mAbs) that provide highly targeted therapies with greater efficacy than platform therapies. In particular, monoclonal antibodies directed against CD20-positive B cells have shown remarkable results in recent clinical trials and renewed interest in the mechanism of B cell-depleting therapies to ameliorate relapse activity and progression in MS. Here, we review the mechanisms of action and clinical evidence of approved and emerging mAbs, with a focus on B cell-targeted therapies.
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Affiliation(s)
- Ai‐Lan Nguyen
- Melbourne Brain Centre and Department of Medicine at the Royal Melbourne HospitalUniversity of MelbourneParkvilleVic.Australia
| | - Melissa Gresle
- Melbourne Brain Centre and Department of Medicine at the Royal Melbourne HospitalUniversity of MelbourneParkvilleVic.Australia
| | - Tessa Marshall
- Multiple Sclerosis DivisionThe Florey Institute of Neuroscience and Mental HealthParkvilleVic.Australia
| | - Helmut Butzkueven
- Melbourne Brain Centre and Department of Medicine at the Royal Melbourne HospitalUniversity of MelbourneParkvilleVic.Australia
- Eastern HealthMonash UniversityClaytonVic.Australia
| | - Judith Field
- Multiple Sclerosis DivisionThe Florey Institute of Neuroscience and Mental HealthParkvilleVic.Australia
- Department of Anatomy and NeuroscienceUniversity of MelbourneParkvilleVic.Australia
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Abstract
Ocrelizumab (Ocrevus™) is a humanised anti-CD20 monoclonal antibody that has been developed by Genentech, Inc. (a subsidiary of Roche) for the treatment of multiple sclerosis (MS). The drug is designed to deplete B cells, which play an important role in the pathogenesis of MS. In March 2017, ocrelizumab was approved in the USA for the treatment of patients with relapsing or primary progressive forms of MS; currently, it is awaiting approval in the EU for the same indications. This article summarizes the milestones in the development of ocrelizumab leading to its first global approval for the treatment of MS.
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Blinkenberg M, Soelberg Sørensen P. Monoclonal Antibodies for Relapsing Multiple Sclerosis: A Review of Recently Marketed and Late-Stage Agents. CNS Drugs 2017; 31:357-371. [PMID: 28285378 DOI: 10.1007/s40263-017-0414-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Treatment of multiple sclerosis (MS) has improved considerably over the last decade because of new insights into MS pathology and biotechnological advances. This has led to the development of new potent pharmaceutical compounds targeting different processes in the complex autoimmune pathology leading to chronic central nervous system (CNS) demyelination, neural loss, and, finally, neurological disability. Although a number of disease-modifying treatments are available for the treatment of the inflammatory phase of MS, there is still a need for highly efficacious therapies with an acceptable safety profile in order to gain therapeutic control early in the disease course. Monoclonal antibodies have proven to be some of the most efficacious disease-modifying therapies in the field of MS, and recent developments in clinical research hold promise for new compounds fulfilling the need for improved safety and high efficacy. We review recent developments in the field of therapeutic monoclonal antibodies used for the treatment of MS and current information on the mode of action, efficacy, and safety of existing and emerging therapeutic monoclonal antibodies as well as their place within the context of different treatment strategies. Finally, we consider the most important future developments.
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Affiliation(s)
- Morten Blinkenberg
- Danish Multiple Sclerosis Center, Department of Neurology 2082, Rigshospitalet and University of Copenhagen, 2100, Copenhagen, Denmark
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology 2082, Rigshospitalet and University of Copenhagen, 2100, Copenhagen, Denmark.
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Staun-Ram E, Miller A. Effector and regulatory B cells in Multiple Sclerosis. Clin Immunol 2017; 184:11-25. [PMID: 28461106 DOI: 10.1016/j.clim.2017.04.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 04/27/2017] [Indexed: 12/21/2022]
Abstract
The role of B cells in the pathogenesis of Multiple Sclerosis (MS), an autoimmune neurodegenerative disease, is becoming eminent in recent years, but the specific contribution of the distinct B cell subsets remains to be elucidated. Several B cell subsets have shown regulatory, anti-inflammatory capacities in response to stimuli in vitro, as well as in the animal model of MS: Experimental Autoimmune Encephalomyelitis (EAE). However, the functional role of the B regulatory cells (Bregs) in vivo and specifically in the human disease is yet to be clarified. In the present review, we have summarized the updated information on the roles of effector and regulatory B cells in MS and the immune-modulatory effects of MS therapeutic agents on their phenotype and function.
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Affiliation(s)
- Elsebeth Staun-Ram
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ariel Miller
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Neuroimmunology Unit & Multiple Sclerosis Center, Carmel Medical Center, Haifa, Israel.
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Abstract
PURPOSE OF REVIEW Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system most often characterized by clinical relapses and periods of remission. RECENT FINDINGS The past decade has seen a dramatic increase in disease-modifying therapies for MS. Fourteen FDA-approved immunomodulatory drugs are currently available, and more medications are in development. A growing number of reported opportunistic infections, including progressive multifocal leukoencephalopathy (PML), highlight the serious complications of these new drugs and the need for specific screening guidelines. Using data from Phase II and III randomized controlled trials, case reports, drug manufacturing data, and clinical experience, we outline the most common and serious infections associated with novel MS therapies.
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Infections Associated with Immunobiologics. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00088-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Bittner S, Ruck T, Wiendl H, Grauer OM, Meuth SG. Targeting B cells in relapsing-remitting multiple sclerosis: from pathophysiology to optimal clinical management. Ther Adv Neurol Disord 2016; 10:51-66. [PMID: 28450895 DOI: 10.1177/1756285616666741] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease that is caused by an autoimmune response against central nervous system (CNS) structures. Traditionally considered a T-cell-mediated disorder, the contribution of B cells to the pathogenesis of MS has long been debated. Based on recent promising clinical results from CD20-depleting strategies by three therapeutic monoclonal antibodies in clinical phase II and III trials (rituximab, ocrelizumab and ofatumumab), targeting B cells in MS is currently attracting growing interest among basic researchers and clinicians. Many questions about the role of B and plasma cells in MS remain still unanswered, ranging from the role of specific B-cell subsets and functions to the optimal treatment regimen of B-cell depletion and monitoring thereafter. Here, we will assess our current knowledge of the mechanisms implicating B cells in multiple steps of disease pathology and examine current and future therapeutic approaches for the treatment of MS.
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Affiliation(s)
- Stefan Bittner
- Department of Neurology, University of Mainz, Mainz, Germany
| | - Tobias Ruck
- Department of Neurology, University of Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Oliver M Grauer
- Department of Neurology, University of Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster, Münster, Germany
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Menge T, Dubey D, Warnke C, Hartung HP, Stüve O. Ocrelizumab for the treatment of relapsing-remitting multiple sclerosis. Expert Rev Neurother 2016; 16:1131-9. [DOI: 10.1080/14737175.2016.1227242] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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