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Bellanca CM, Augello E, Mariottini A, Bonaventura G, La Cognata V, Di Benedetto G, Cantone AF, Attaguile G, Di Mauro R, Cantarella G, Massacesi L, Bernardini R. Disease Modifying Strategies in Multiple Sclerosis: New Rays of Hope to Combat Disability? Curr Neuropharmacol 2024; 22:1286-1326. [PMID: 38275058 PMCID: PMC11092922 DOI: 10.2174/1570159x22666240124114126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/21/2023] [Accepted: 09/22/2023] [Indexed: 01/27/2024] Open
Abstract
Multiple sclerosis (MS) is the most prevalent chronic autoimmune inflammatory- demyelinating disorder of the central nervous system (CNS). It usually begins in young adulthood, mainly between the second and fourth decades of life. Usually, the clinical course is characterized by the involvement of multiple CNS functional systems and by different, often overlapping phenotypes. In the last decades, remarkable results have been achieved in the treatment of MS, particularly in the relapsing- remitting (RRMS) form, thus improving the long-term outcome for many patients. As deeper knowledge of MS pathogenesis and respective molecular targets keeps growing, nowadays, several lines of disease-modifying treatments (DMT) are available, an impressive change compared to the relative poverty of options available in the past. Current MS management by DMTs is aimed at reducing relapse frequency, ameliorating symptoms, and preventing clinical disability and progression. Notwithstanding the relevant increase in pharmacological options for the management of RRMS, research is now increasingly pointing to identify new molecules with high efficacy, particularly in progressive forms. Hence, future efforts should be concentrated on achieving a more extensive, if not exhaustive, understanding of the pathogenetic mechanisms underlying this phase of the disease in order to characterize novel molecules for therapeutic intervention. The purpose of this review is to provide a compact overview of the numerous currently approved treatments and future innovative approaches, including neuroprotective treatments as anti-LINGO-1 monoclonal antibody and cell therapies, for effective and safe management of MS, potentially leading to a cure for this disease.
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Affiliation(s)
- Carlo Maria Bellanca
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Egle Augello
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Alice Mariottini
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Gabriele Bonaventura
- Institute for Biomedical Research and Innovation (IRIB), Italian National Research Council, 95126 Catania, Italy
| | - Valentina La Cognata
- Institute for Biomedical Research and Innovation (IRIB), Italian National Research Council, 95126 Catania, Italy
| | - Giulia Di Benedetto
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Anna Flavia Cantone
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppe Attaguile
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Rosaria Di Mauro
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppina Cantarella
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Luca Massacesi
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Renato Bernardini
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
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Sottini A, Quaresima V, Barbaro M, Moiola L, Filippi M, Malentacchi M, Capobianco M, Puthenparampil M, Gallo P, Cocco E, Frau J, Zaffaroni M, Guaschino C, Stampatori C, Mancinelli C, Brambilla L, Clerici VT, Vianello M, Vitetta F, Ferraro D, Rosettani P, Danni MC, Conti M, Grimoldi M, Capra R, Imberti L. Clinical relevance of thymic and bone marrow outputs in multiple sclerosis patients treated with alemtuzumab. J Neuroimmunol 2023; 382:578170. [PMID: 37579546 DOI: 10.1016/j.jneuroim.2023.578170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/16/2023]
Abstract
Thymic and bone marrow outputs were evaluated in 13 sequential samples of 68 multiple sclerosis patients who initiated alemtuzumab and were clinically followed for 48 months. Three months after alemtuzumab infusions, the levels of new T lymphocytes were significantly reduced, but progressively increased reaching the highest values at 36 months, indicating the remarkable capacity of thymic function recovery. Newly produced B cells exceeded baseline levels as early as 3 months after alemtuzumab initiation. Heterogeneous patterns of new T- and B-cell recovery were identified, but without associations with age, sex, previous therapies, development of secondary autoimmunity or infections, and disease re-emergence. Trial registration version 2.0-27/01/2016.
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Affiliation(s)
- Alessandra Sottini
- Diagnostic Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy.
| | - Virginia Quaresima
- Diagnostic Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Mosè Barbaro
- Diagnostic Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy; Laboratorio analisi, Ospedale Civile di Sondrio, ASST Valtellina e Alto Lario, Sondrio, Italy
| | - Lucia Moiola
- Neurology Department-Multiple Sclerosis Center, IRCCS San Raffaele Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neurology and Neurorehabilitation Units, MS Center, Headache Center, Epilepsy Center, and Stroke Unit, Neurophysiology Service, and Neuroimaging Research Unit, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Malentacchi
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi Gonzaga, Orbassano, Italy
| | - Marco Capobianco
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi Gonzaga, Orbassano, Italy
| | - Marco Puthenparampil
- Department of Neuroscience (DNS), School of Medicine - University of Padua, Padua, Italy
| | - Paolo Gallo
- Department of Neuroscience (DNS), School of Medicine - University of Padua, Padua, Italy
| | - Eleonora Cocco
- Centro Sclerosi Multipla AOU Cagliari - University of Cagliari, Italy
| | | | - Mauro Zaffaroni
- Centro Sclerosi Multipla, Ospedale di Gallarate, ASST della Valle Olona, Gallarate, Italy
| | - Clara Guaschino
- Centro Sclerosi Multipla, Ospedale di Gallarate, ASST della Valle Olona, Gallarate, Italy
| | - Chiara Stampatori
- Centro Regionale per la Sclerosi Multipla, ASST Spedali Civili di Brescia, Montichiari, Brescia, Italy
| | - Chiara Mancinelli
- Centro Regionale per la Sclerosi Multipla, ASST Spedali Civili di Brescia, Montichiari, Brescia, Italy; U.O. Neuroimmunologia e Malattie Neuromuscolari, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Laura Brambilla
- U.O. Neuroimmunologia e Malattie Neuromuscolari, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Valentina Torri Clerici
- U.O. Neuroimmunologia e Malattie Neuromuscolari, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Francesca Vitetta
- Centro Malattie Demielinizzanti, Ospedale Civile Baggiovara, AOU Modena, Italy
| | - Diana Ferraro
- Centro Malattie Demielinizzanti, Ospedale Civile Baggiovara, AOU Modena, Italy
| | - Pamela Rosettani
- Clinica Neurologica, Azienda Ospedaliero Universitaria delle Marche, Torrette, Ancona, Italy
| | - Maura Chiara Danni
- Clinica Neurologica, Azienda Ospedaliero Universitaria delle Marche, Torrette, Ancona, Italy
| | - Marta Conti
- Department of Neurology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Maria Grimoldi
- Department of Neurology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ruggero Capra
- Centro Regionale per la Sclerosi Multipla, ASST Spedali Civili di Brescia, Montichiari, Brescia, Italy
| | - Luisa Imberti
- Diagnostic Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy; Section of Microbiology, University of Brescia, P. le Spedali Civili, 1, Brescia, Italy
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Managing Multiple Sclerosis: Treatment Initiation, Modification, and Sequencing. Can J Neurol Sci 2018; 45:489-503. [DOI: 10.1017/cjn.2018.17] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AbstractRecent therapeutic advances in the management of multiple sclerosis (MS) have raised questions about the selection of appropriate patient candidates for various treatments and, if the plan is to move from one treatment to another, the appropriate sequencing of these therapies. The selected approach should provide optimal disease management without limiting future therapeutic options based on safety concerns, and recognize potential future treatments and the possibility of combination therapies. Additional challenges include incorporation of patient needs and preferences into the overall therapeutic approach, in order to ensure optimal outcomes in the short and long term. The objective of this manuscript is to provide an overview of what is currently known regarding the impact of various therapies for MS on future therapeutic choices (sequencing). In this context, we reviewed the available evidence in support of various treatments and, based on the presence of disease activity, suggested a scheme for switching or escalating therapy with the main focus on sequencing of therapeutic approaches.
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Topliss DJ. Clinical Update in Aspects of the Management of Autoimmune Thyroid Diseases. Endocrinol Metab (Seoul) 2016; 31:493-499. [PMID: 28029020 PMCID: PMC5195823 DOI: 10.3803/enm.2016.31.4.493] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 11/11/2016] [Accepted: 11/17/2016] [Indexed: 12/24/2022] Open
Abstract
Aspects of autoimmune thyroid disease updated in this review include: immunoglobulin G4 (IgG4)-related thyroid disease (Riedel's thyroiditis, fibrosing variant of Hashimoto's thyroiditis, IgG4-related Hashimoto's thyroiditis, and Graves' disease with elevated IgG4 levels); recent epidemiological studies from China and Denmark indicating that excess iodine increases the incidence of Hashimoto's thyroiditis and hypothyroidism; immunomodulatory agents (ipilimumab, pembrolizumab, nivolumab) activate immune response by inhibiting T-cell surface receptors which down-regulate immune response, i.e., cytotoxic T-lymphocyte antigen 4 and programmed cell death protein 1 pathways; alemtuzumab is a humanised monoclonal antibody to CD52 which causes immune depletion and thyroid autoimmune disease especially Graves' hyperthyroidism; small molecule ligand (SML) agonists which activate receptors, SML neutral antagonists, which inhibit receptor activation by agonists, and SML inverse agonists which inhibit receptor activation by agonists and inhibit constitutive agonist independent signaling have been identified. SML antagonism of thyroid-stimulating hormone-receptor stimulatory antibody could treat Graves' hyperthyroidism and Graves' ophthalmopathy; and thyroxine treatment of subclinical hypothyroidism can produce iatrogenic subclinical hyperthyroidism with the risk of atrial fibrillation and osteoporosis. The increased risk of harm from subclinical hyperthyroidism may be stronger than the potential benefit from treatment of subclinical hypothyroidism.
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Affiliation(s)
- Duncan J Topliss
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, Australia
- Department of Medicine, Monash University, Melbourne, Australia.
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Thomas K, Eisele J, Rodriguez-Leal FA, Hainke U, Ziemssen T. Acute effects of alemtuzumab infusion in patients with active relapsing-remitting MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e228. [PMID: 27213173 PMCID: PMC4853056 DOI: 10.1212/nxi.0000000000000228] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/24/2016] [Indexed: 02/04/2023]
Abstract
Objective: Alemtuzumab exerts its clinical efficacy by its specific pattern of depletion and repopulation of different immune cells. Beyond long-term immunologic and clinical data, little is known about acute changes in immunologic and routine laboratory parameters and their clinical relevance during the initial alemtuzumab infusion. Methods: Fifteen patients with highly active MS were recruited. In addition to parameters including heart rate, blood pressure, body temperature, and monitoring of adverse events, complete blood cell count, liver enzymes, kidney function, acute-phase proteins, serum cytokine profile, complement activation, peripheral immune cell distribution, and their potential of cytokine release were investigated prior to and after methylprednisolone and after alemtuzumab on each day of alemtuzumab infusion. Results: After the first alemtuzumab infusion, both the total leukocyte and granulocyte counts markedly increased, whereas lymphocyte counts dramatically decreased. In addition to lymphocyte depletion, cell subtypes important for innate immunity also decreased within the first week after alemtuzumab infusion. Although patients reported feeling well, C-reactive protein and procalcitonin peaked at serum levels consistent with septic conditions. Increases in liver enzymes were detected, although kidney function remained stable. Proinflammatory serum cytokine levels clearly rose after the first alemtuzumab infusion. Alemtuzumab led to impaired cytokine release ex vivo in nondepleted cells. Normal clinical parameters and mild adverse events were presented. Conclusions: Dramatic immunologic effects were observed. Standardized infusion procedure and pretreatment management attenuated infusion-related reactions. Alemtuzumab-mediated effects led to artificially altered parameters in standard blood testing. We recommend clinical decision-making based on primarily clinical symptoms within the first alemtuzumab treatment week.
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Affiliation(s)
- Katja Thomas
- Center of Clinical Neuroscience, University Hospital, Dresden, Germany
| | - Judith Eisele
- Center of Clinical Neuroscience, University Hospital, Dresden, Germany
| | | | - Undine Hainke
- Center of Clinical Neuroscience, University Hospital, Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital, Dresden, Germany
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De Genst E, Chirgadze DY, Klein FAC, Butler DC, Matak-Vinković D, Trottier Y, Huston JS, Messer A, Dobson CM. Structure of a single-chain Fv bound to the 17 N-terminal residues of huntingtin provides insights into pathogenic amyloid formation and suppression. J Mol Biol 2015; 427:2166-78. [PMID: 25861763 PMCID: PMC4451460 DOI: 10.1016/j.jmb.2015.03.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 03/17/2015] [Accepted: 03/30/2015] [Indexed: 10/25/2022]
Abstract
Huntington's disease is triggered by misfolding of fragments of mutant forms of the huntingtin protein (mHTT) with aberrant polyglutamine expansions. The C4 single-chain Fv antibody (scFv) binds to the first 17 residues of huntingtin [HTT(1-17)] and generates substantial protection against multiple phenotypic pathologies in situ and in vivo. We show in this paper that C4 scFv inhibits amyloid formation by exon1 fragments of huntingtin in vitro and elucidate the structural basis for this inhibition and protection by determining the crystal structure of the complex of C4 scFv and HTT(1-17). The peptide binds with residues 3-11 forming an amphipathic helix that makes contact with the antibody fragment in such a way that the hydrophobic face of this helix is shielded from the solvent. Residues 12-17 of the peptide are in an extended conformation and interact with the same region of another C4 scFv:HTT(1-17) complex in the asymmetric unit, resulting in a β-sheet interface within a dimeric C4 scFv:HTT(1-17) complex. The nature of this scFv-peptide complex was further explored in solution by high-resolution NMR and physicochemical analysis of species in solution. The results provide insights into the manner in which C4 scFv inhibits the aggregation of HTT, and hence into its therapeutic potential, and suggests a structural basis for the initial interactions that underlie the formation of disease-associated amyloid fibrils by HTT.
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Affiliation(s)
- Erwin De Genst
- Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge CB2 1EW, UK.
| | - Dimitri Y Chirgadze
- Department of Biochemistry, University of Cambridge, Tennis Court Road, Cambridge CB2 1GA, UK
| | - Fabrice A C Klein
- Translational Medicine and Neurogenetics Programme, Institute of Genetics and Molecular and Cellular Biology, 67404 Illkirch Cédex, France
| | - David C Butler
- Neural Stem Cell Institute, Regenerative Research Foundation, Rensselaer, NY 12144, USA; Department of Biomedical Sciences, University at Albany, Albany, NY 12208, USA
| | - Dijana Matak-Vinković
- Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge CB2 1EW, UK
| | - Yvon Trottier
- Translational Medicine and Neurogenetics Programme, Institute of Genetics and Molecular and Cellular Biology, 67404 Illkirch Cédex, France
| | - James S Huston
- James S. Huston, The Antibody Society, Newton, MA 02462, USA
| | - Anne Messer
- Neural Stem Cell Institute, Regenerative Research Foundation, Rensselaer, NY 12144, USA; Department of Biomedical Sciences, University at Albany, Albany, NY 12208, USA
| | - Christopher M Dobson
- Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge CB2 1EW, UK
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Fragoso YD, Adoni T, Anacleto A, Brooks JBB, Carvalho MDJ, Claudino R, Damasceno A, Ferreira MLB, Gama PDD, Goncalves MVM, Grzesiuk AK, Matta APDC, Parolin MFK. How do we manage and treat a patient with multiple sclerosis at risk of tuberculosis? Expert Rev Neurother 2014; 14:1251-60. [PMID: 25242167 DOI: 10.1586/14737175.2014.962517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Tuberculosis continues to be a serious health problem worldwide. The disease continues to be underdiagnosed and not properly treated. In conditions that affect the immune system, such as multiple sclerosis (MS), latent tuberculosis may thrive and reactivate during the use of immunomodulatory and immunosuppressive drugs. Among the best treatment options for patients with latent or active tuberculosis who have MS are IFN-β, glatiramer acetate and mitoxantrone. Drugs leading to a reduced number and/or function of lymphocytes should be avoided or used with caution. Tuberculosis must always be investigated in patients with MS and treated with rigor.
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Affiliation(s)
- Yara Dadalti Fragoso
- Department of Neurology and MS Reference Center, Universidade Metropolitana de Santos, SP, Brazil
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Minagar A. Multiple Sclerosis: An Overview of Clinical Features, Pathophysiology, Neuroimaging, and Treatment Options. ACTA ACUST UNITED AC 2014. [DOI: 10.4199/c00116ed1v01y201408isp055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Tovey MG, Lallemand C. Immunogenicity and other problems associated with the use of biopharmaceuticals. Ther Adv Drug Saf 2014; 2:113-28. [PMID: 25083207 DOI: 10.1177/2042098611406318] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Biopharmaceuticals are used widely for the treatment of cancer, chronic viral hepatitis, inflammatory, and autoimmune diseases. Biopharmaceuticals such as interferons are well tolerated for the most part with the most common adverse events observed being 'flu-like' symptoms that resolve rapidly after initial treatment. Prolonged treatment is associated, however, with more serious adverse events including leucopenia, thrombocytopenia, and neuropsychiatric effects, which may necessitate dose reduction or even cessation of treatment in some patients. Recombinant growth factors, such as erythropoietin (EPO), granulocyte colony-stimulating factor, or granulocyte macrophage colony-stimulating factor, are for the most part well tolerated, although severe complications have been reported in patients with cancer or chronic kidney disease treated with EPO. Similarly, treatment of patients with cancer with high doses of interleukin-2 is associated with significant toxicity. Treatment of chronic inflammatory diseases, such as rheumatoid arthritis, psoriasis, and Crohn's disease, with antitumor necrosis factor-alpha monoclonal antibodies is associated with an increased risk of granulomatous infections and, in particular, tuberculosis. The monoclonal antibody, natalizumab, that targets alpha4 integrins is effective in the treatment of multiple sclerosis but is associated with the activation of JC virus and development of progressive multifocal leukoencephalopathy. Repeated administration of recombinant proteins can cause a break in immune tolerance in some patients resulting in the production of a polyclonal antibody response that can adversely affect pharmacokinetics and clinical response. In addition, neutralizing antibodies that cross react with nonredundant essential proteins such as EPO can cause severe autoimmune reactions.
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Affiliation(s)
- Michael G Tovey
- Laboratory of Viral Oncology, FRE3238 CNRS, Institut André Lwoff, 7 rue Guy Moquet, 94801 Villejuif, France
| | - Christophe Lallemand
- Laboratory of Viral Oncology, FRE3238 CNRS, Institut André Lwoff, 94801 Villejuif, France
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Attarian S, Wang CY, Romero J, Barta SK, Aparo S, Menegus MA. Alemtuzumab induced ST-segment elevation and acute myocardial dysfunction. J Cardiol Cases 2014; 10:176-179. [PMID: 30534236 DOI: 10.1016/j.jccase.2014.07.004] [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: 04/28/2014] [Revised: 06/22/2014] [Accepted: 07/02/2014] [Indexed: 10/25/2022] Open
Abstract
Cardiac toxicity as a side effect of chemotherapeutic agents has been well reported in the literature. Cardiac toxicity secondary to alemtuzumab has been reported, presenting as congestive heart failure and arrhythmias. Here we report a case of acute myocardial dysfunction after administration of a test dose of alemtuzumab. Our patient was a 66-year-old man with a history of small lymphocytic lymphoma/chronic lymphocytic lymphoma who received a test dose of alemtuzumab. Twenty minutes post administration, the patient developed nausea, vomiting, rigors, and tachycardia. Electrocardiography (ECG) showed acute ST-segment elevations in contiguous leads V2-V6, I, and AVL with no associated chest pain. Bedside echocardiogram showed akinesis of the anterior septum, apex, distal anterior wall, and decreased left ventricular ejection fraction. Cardiac catheterization showed non-critical occlusive disease and no intervention was undertaken. Post-catheterization ECG revealed resolution of ST segment elevations, TWI in V4-V6, and prolongation of corrected QT. Repeat echocardiogram 10 days after the event demonstrated no improvement in wall motion or ejection fraction. We discuss the possible mechanisms causing ST-elevations and acute myocardial dysfunction after treatment with alemtuzumab. <Learning objective: Alemtuzumab can cause acute myocardial dysfunction after administration of a test dose. Considering that this is a serious adverse effect, detailed cardiac evaluation and a high level of caution are recommended before administration of alemtuzumab. While no clear etiology could be identified for this side effect, excessive and acute cytokine release triggered by alemtuzumab administration is a possible explanation. This could be potentially attenuated by using anti-interleukin-6 or tumor necrosis factor inhibitors.>.
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Affiliation(s)
- Shirin Attarian
- Department of Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Cindy Y Wang
- Department of Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jorge Romero
- Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Stefan K Barta
- Fox Chase Cancer Center, Temple BMT Program, Temple University Health System, Philadelphia, PA, USA
| | - Santiago Aparo
- Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mark A Menegus
- Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Rommer PS, Dudesek A, Stüve O, Zettl UK. Monoclonal antibodies in treatment of multiple sclerosis. Clin Exp Immunol 2014; 175:373-84. [PMID: 24001305 DOI: 10.1111/cei.12197] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2013] [Indexed: 01/14/2023] Open
Abstract
Monoclonal antibodies (mAbs) are used as therapeutics in a number of disciplines in medicine, such as oncology, rheumatology, gastroenterology, dermatology and transplant rejection prevention. Since the introduction and reintroduction of the anti-alpha4-integrin mAb natalizumab in 2004 and 2006, mAbs have gained relevance in the treatment of multiple sclerosis (MS). At present, numerous mAbs have been tested in clinical trials in relapsing-remitting MS, and in progressive forms of MS. One of the agents that might soon be approved for very active forms of relapsing-remitting MS is alemtuzumab, a humanized mAb against CD52. This review provides insights into clinical studies with the mAbs natalizumab, alemtuzumab, daclizumab, rituximab, ocrelizumab and ofatumumab.
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Affiliation(s)
- P S Rommer
- Clinic and Policlinic of Neurology, University of Rostock, Rostock, Germany; Department of Neurology, Medical University of Vienna, Vienna, Austria
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Rommer PS, Zettl UK, Kieseier B, Hartung HP, Menge T, Frohman E, Greenberg BM, Hemmer B, Stüve O. Requirement for safety monitoring for approved multiple sclerosis therapies: an overview. Clin Exp Immunol 2014; 175:397-407. [PMID: 24102425 DOI: 10.1111/cei.12206] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2013] [Indexed: 12/12/2022] Open
Abstract
During the last two decades, treatment options for patients with multiple sclerosis (MS) have broadened tremendously. All agents that are currently approved for clinical use have potential side effects, and a careful risk-benefit evaluation is part of a decision algorithm to identify the optimal treatment choice for an individual patient. Whereas glatiramer acetate and interferon beta preparations have been used in MS for decades and have a proven safety record, more recently approved drugs appear to be more effective, but potential risks might be more severe. The potential complications of some novel therapies might not even have been identified to their full extent. This review is aimed at the clinical neurologist in that it offers insights into potential adverse events of each of the approved MS therapeutics: interferon beta, glatiramer acetate, mitoxantrone, natalizumab, fingolimod and teriflunomide, as well as recently approved therapeutics such as dimethyl fumarate and alemtuzumab. It also provides recommendations for monitoring the different drugs during therapy in order to avoid common side effects.
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Affiliation(s)
- P S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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14
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Gorson KC. An update on the management of chronic inflammatory demyelinating polyneuropathy. Ther Adv Neurol Disord 2013; 5:359-73. [PMID: 23139706 DOI: 10.1177/1756285612457215] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an immune mediated disorder of the peripheral nervous system with clinical features that include weakness, sensory loss, imbalance, pain and impaired ambulation which may lead to substantial disability. This review highlights current treatment strategies for CIDP, how best to utilize proven therapies such as intravenous immunoglobulin, oral prednisone, pulse dexamethasone, and plasma exchange, and when and how to use alternative immunosuppressive agents when first-line therapies are ineffective or poorly tolerated.
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Affiliation(s)
- Kenneth C Gorson
- Department of Neurology, St. Elizabeth's Medical Center, 736 Cambridge Street, Boston, MA 02135, USA
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Minagar A. Current and future therapies for multiple sclerosis. SCIENTIFICA 2013; 2013:249101. [PMID: 24278770 PMCID: PMC3820353 DOI: 10.1155/2013/249101] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 01/13/2013] [Indexed: 05/07/2023]
Abstract
With the introduction of interferon- β 1b in 1993 as the first FDA-approved treatment for multiple sclerosis, the era of treatment of this incurable disease began, and its natural course was permanently changed. Currently, seven different treatments for patients with multiple sclerosis with different mechanisms of action and dissimilar side effect profiles exist. These medications include interferon- β 1a intramuscular (Avonex), interferon- β 1a subcutaneous (Rebif), interferon- β 1b subcutaneous (Betaseron/Extavia), glatiramer acetate (Copaxone), natalizumab (Tysabri), fingolimod (Gilenya), teriflunomide (Aubagio), and mitoxantrone (Novantrone). In addition, a large number of clinical trials are being conducted to assess the safety and efficacy of various experimental agents in patients with multiple sclerosis, including alemtuzumab, dimethyl fumarate, laquinimod, rituximab, daclizumab, and cladribine. In this paper, the author presents a concise and comprehensive review of present and potential treatments for this incurable disease.
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Affiliation(s)
- Alireza Minagar
- Department of Neurology, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71130, USA
- *Alireza Minagar:
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Abstract
Multiple sclerosis, the clinical features and pathological correlate for which were first described by Charcot, is a chronic neuroinflammatory disease with unknown etiology and variable clinical evolution. Although neuroinflammation is a descriptive denominator in multiple sclerosis based on histopathological observations, namely the penetration of leukocytes into the central nervous system, the clinical symptoms of relapses, remissions and progressive paralysis are the result of losses of myelin and neurons. In the absence of etiological factors as targets for prevention and therapy, the definition of molecular mechanisms that form the basis of inflammation, demyelination and toxicity for neurons have led to a number of treatments that slow down disease progression in specific patient cohorts, but that do not cure the disease. Current therapies are directed to block the immune processes, both innate and adaptive, that are associated with multiple sclerosis. In this review, we analyze the role of cytokines in the multiple sclerosis pathogenesis and current/future use of them in treatments of multiple sclerosis.
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Loma I, Heyman R. Multiple sclerosis: pathogenesis and treatment. Curr Neuropharmacol 2012; 9:409-16. [PMID: 22379455 PMCID: PMC3151595 DOI: 10.2174/157015911796557911] [Citation(s) in RCA: 206] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 10/02/2010] [Accepted: 10/05/2010] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory autoimmune demyelinating disease of the central nervous system. It affects approximately 400,000 people in the United States and onset is usually during young adulthood. There are four clinical forms of MS, of which relapsing remitting type is the most common. As the etiology of MS is unknown, finding a cure will remain challenging. The main mechanism of injury appears to be inflammation and 8 agents are now FDA approved to help control MS. These agents for relapsing forms of MS target different parts of the immune system, with the end goal of decreasing and avoiding further inflammation. No agents are FDA approved for the primary progressive version of MS. FDA approved agents include four preparations of interferon β (Avonex, Rebif, Betaseron and Extavia), glatiramer acetate (Copaxone), mitoxantrone (Novantrone), natalizumab (Tysabri) and fingolimod (Gilenya). There are several drug undergoing phase II and III trials. The heterogeneity of the MS disease process, individual patient response, and medication toxicities continue to challenge the treating physician.
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Affiliation(s)
- Ingrid Loma
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Identification of early gene expression changes during human Th17 cell differentiation. Blood 2012; 119:e151-60. [PMID: 22544700 DOI: 10.1182/blood-2012-01-407528] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Th17 cells play an essential role in the pathogenesis of autoimmune and inflammatory diseases. Most of our current understanding on Th17 cell differentiation relies on studies carried out in mice, whereas the molecular mechanisms controlling human Th17 cell differentiation are less well defined. In this study, we identified gene expression changes characterizing early stages of human Th17 cell differentiation through genome-wide gene expression profiling. CD4(+) cells isolated from umbilical cord blood were used to determine detailed kinetics of gene expression after initiation of Th17 differentiation with IL1β, IL6, and TGFβ. The differential expression of selected candidate genes was further validated at protein level and analyzed for specificity in initiation of Th17 compared with initiation of other Th subsets, namely Th1, Th2, and iTreg. This first genome-wide profiling of transcriptomics during the induction of human Th17 differentiation provides a starting point for defining gene regulatory networks and identifying new candidates regulating Th17 differentiation in humans.
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Current status of the immunomodulation and immunomediated therapeutic strategies for multiple sclerosis. Clin Dev Immunol 2011; 2012:970789. [PMID: 22203863 PMCID: PMC3235500 DOI: 10.1155/2012/970789] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 09/12/2011] [Indexed: 12/25/2022]
Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system, and CD4(+) T cells form the core immunopathogenic cascade leading to chronic inflammation. Traditionally, Th1 cells (interferon-γ-producing CD4(+) T cells) driven by interleukin 12 (IL12) were considered to be the encephalitogenic T cells in MS and experimental autoimmune encephalomyelitis (EAE), an animal model of MS. Currently, Th17 cells (Il17-producing CD4(+) T cells) are considered to play a fundamental role in the immunopathogenesis of EAE. This paper highlights the growing evidence that Th17 cells play the core role in the complex adaptive immunity of EAE/MS and discusses the roles of the associated immune cells and cytokines. These constitute the modern immunological basis for the development of novel clinical and preclinical immunomodulatory therapies for MS discussed in this paper.
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Oddo S, Laroni A, Uccelli A, Giusti M. A case of thyroiditis during natalizumab therapy for multiple sclerosis. J Endocrinol Invest 2011; 34:408-9. [PMID: 21677508 DOI: 10.1007/bf03347466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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