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de Seze J, Dive D, Ayrignac X, Castelnovo G, Payet M, Rayah A, Gobbi C, Vermersch P, Zecca C. Narrative Review on the Use of Cladribine Tablets as Exit Therapy for Stable Elderly Patients with Multiple Sclerosis. Neurol Ther 2024; 13:519-533. [PMID: 38587749 PMCID: PMC11136913 DOI: 10.1007/s40120-024-00603-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
The number of ageing people with relapsing multiple sclerosis (RMS) is increasing. The efficacy of disease-modifying therapies (DMTs) for RMS declines with age. Also, older persons with MS may be more susceptible to infections, hospitalisations and malignancy. Aging people with MS have higher rates of comorbidities versus aged-matched controls, increasing the individual risk of disability. We review the therapeutic properties of cladribine tablets (CladT) in ageing people with RMS, with regard to their utility for allowing these individuals to cease continuous administration of a DMT (i.e. to act as an "exit therapy"). CladT is thought to be an immune reconstitution therapy, in that two short courses of oral treatment 1 year apart provide suppression of MS disease activity in responders that far outlasts the duration of treatment and post-treatment reductions in lymphocyte counts. Post hoc analyses, long-term follow-up of populations with RMS in randomised trials, and real-world evidence suggest that the efficacy of CladT is probably independent of age, although more data in the elderly are still needed. No clear adverse signals for lymphopenia or other adverse safety signals have emerged with increasing age, although immunosenescence in the setting of age-related "inflammaging" may predispose elderly patients to a higher risk of infections. Updating vaccination status is recommended, especially against pneumococci and herpes zoster for older patients, to minimise the risk of these infections. CladT may be a useful alternative treatment for ageing people with MS who often bear a burden of multiple comorbidities and polypharmacy and who are more exposed to the adverse effects of continuous immunosuppressive therapy.
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Affiliation(s)
- Jerome de Seze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France.
| | - Dominique Dive
- Department of Neurology, Liège University Hospital, Liège, Belgium
| | - Xavier Ayrignac
- Department of Neurology, University of Montpellier, INM, INSERM, Montpellier University Hospital, Montpellier, France
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Marianne Payet
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Amel Rayah
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Claudio Gobbi
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Patrick Vermersch
- University of Lille, INSERM U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Chiara Zecca
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
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Jouvenot G, Courbon G, Lefort M, Rollot F, Casey R, Le Page E, Michel L, Edan G, de Seze J, Kremer L, Bigaut K, Vukusic S, Mathey G, Ciron J, Ruet A, Maillart E, Labauge P, Zephir H, Papeix C, Defer G, Lebrun-Frenay C, Moreau T, Laplaud DA, Berger E, Stankoff B, Clavelou P, Thouvenot E, Heinzlef O, Pelletier J, Al-Khedr A, Casez O, Bourre B, Cabre P, Wahab A, Magy L, Camdessanché JP, Doghri I, Moulin S, Ben-Nasr H, Labeyrie C, Hankiewicz K, Neau JP, Pottier C, Nifle C, Collongues N, Kerbrat A. High-Efficacy Therapy Discontinuation vs Continuation in Patients 50 Years and Older With Nonactive MS. JAMA Neurol 2024; 81:490-498. [PMID: 38526462 PMCID: PMC10964164 DOI: 10.1001/jamaneurol.2024.0395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/05/2024] [Indexed: 03/26/2024]
Abstract
Importance A recent randomized clinical trial concluded that discontinuing medium-efficacy therapy might be a reasonable option for older patients with nonactive multiple sclerosis (MS), but there is a lack of data on discontinuing high-efficacy therapy (HET). In younger patients, the discontinuation of natalizumab and fingolimod is associated with a risk of rebound of disease activity. Objective To determine whether discontinuing HET in patients 50 years and older with nonactive MS is associated with an increased risk of relapse compared with continuing HET. Design, Setting, and Participants This observational cohort study used data from 38 referral centers from the French MS registry (Observatoire Français de la Sclérose en Plaques [OFSEP] database). Among 84704 patients in the database, data were extracted for 1857 patients 50 years and older with relapsing-remitting MS treated by HET and with no relapse or magnetic resonance imaging activity for at least 2 years. After verification of the medical records, 1620 patients were classified as having discontinued HET or having remained taking treatment and were matched 1:1 using a dynamic propensity score (including age, sex, disease phenotype, disability, treatment of interest, and time since last inflammatory activity). Patients were included from February 2008 to November 2021, with a mean (SD) follow-up of 5.1 (2.9) years. Data were extracted in June 2022. Exposures Natalizumab, fingolimod, rituximab, and ocrelizumab. Main Outcomes and Measures Time to first relapse. Results Of 1620 included patients, 1175 (72.5%) were female, and the mean (SD) age was 54.7 (4.8) years. Among the 1452 in the HET continuation group and 168 in the HET discontinuation group, 154 patients in each group were matched using propensity scores (mean [SD] age, 57.7 [5.5] years; mean [SD] delay since the last inflammatory activity, 5.6 [3.8] years; mean [SD] follow-up duration after propensity score matching, 2.5 [2.1] years). Time to first relapse was significantly reduced in the HET discontinuation group compared with the HET continuation group (hazard ratio, 4.1; 95% CI, 2.0-8.5; P < .001) but differed between HETs, with a hazard ratio of 7.2 (95% CI, 2.1-24.5; P = .001) for natalizumab, 4.5 (95% CI, 1.3-15.5; P = .02) for fingolimod, and 1.1 (95% CI, 0.3-4.8; P = .85) for anti-CD20 therapy. Conclusion and Relevance As in younger patients, in patients 50 years and older with nonactive MS, the risk of relapse increased significantly after stopping HETs that impact immune cell trafficking (natalizumab and fingolimod). There was no significant increase in risk after stopping HETs that deplete B-cells (anti-CD20 therapy). This result may inform decisions about stopping HETs in clinical practice.
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Affiliation(s)
- Guillaume Jouvenot
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Guilhem Courbon
- Department of Neurology, University Hospital of Rennes, Rennes, France
| | - Mathilde Lefort
- University of Rennes, EHESP, CNRS, INSERM, Arènes—UMR 6051, RSMS (Recherche sur les Services et Management en Santé)—U 1309, Rennes, France
| | - Fabien Rollot
- Université de Lyon, Université Claude Bernard, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 and CNRS UMR 5292, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Romain Casey
- Université de Lyon, Université Claude Bernard, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 and CNRS UMR 5292, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Emmanuelle Le Page
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
| | - Laure Michel
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
| | - Gilles Edan
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
| | - Jérome de Seze
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Laurent Kremer
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Kevin Bigaut
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Sandra Vukusic
- Université de Lyon, Université Claude Bernard, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 and CNRS UMR 5292, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Guillaume Mathey
- Department of Neurology, Nancy University Hospital, Nancy, France
- Université de Lorraine, APEMAC, Nancy, France
| | - Jonathan Ciron
- CRC-SEP, Department of Neurology, CHU de Toulouse, Toulouse, France
| | - Aurélie Ruet
- Department of Neurology, CHU de Bordeaux, CIC Bordeaux CIC1401, Bordeaux, France
| | - Elisabeth Maillart
- Département de Neurologie, Hôpital Pitié-Salpêtrière, APHP, Centre de Ressources et de Compétences SEP, Paris, France
| | | | | | - Caroline Papeix
- Department of Neurology, Fondation Rothschild, Paris, France
| | - Gilles Defer
- Department of Neurology, MS Expert Centre, CHU de Caen, Caen, France
| | - Christine Lebrun-Frenay
- Neurology, UR2CA-URRIS, Centre Hospitalier Universitaire Pasteur2, Université Nice Côte d’Azur, Nice, France
| | | | - David Axel Laplaud
- Department of Neurology, CHU de Nantes, Nantes, France
- Nantes Université, CHU Nantes, INSERM, CIC 14131413, Center for Research in Translational Immunology, UMR 1064, Nantes, France
| | - Eric Berger
- Service de Neurologie, CHU de Besançon, Besançon, France
| | - Bruno Stankoff
- Department of Neurology, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Pierre Clavelou
- Department of Neurology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Eric Thouvenot
- Department of Neurology, Nimes University Hospital, Nimes, France
| | | | - Jean Pelletier
- Service de Neurologie, APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille, France
| | | | - Olivier Casez
- CHU Grenoble Alpes, Department of Neurology, Neurology MS Clinic Grenoble, Grenoble Alpes University Hospital, Grenoble, France
| | | | - Philippe Cabre
- Department of Neurology, CHU de la Martinique, Fort-de-France, France
| | - Abir Wahab
- Department of Neurology, APHP, Hôpital Henri Mondor, Créteil, France
| | - Laurent Magy
- Department of Neurology, CHU de Limoges, Hôpital Dupuytren, Limoges, France
| | | | - Ines Doghri
- Department of Neurology, CHU de Tours, Hôpital Bretonneau, Tours, France
| | - Solène Moulin
- Department of Neurology, CHU de Reims, CRC-SEP, Reims, France
| | - Haifa Ben-Nasr
- Hôpital Sud Francilien, Department of Neurology, Corbeil-Essonnes, France
| | - Céline Labeyrie
- Department of Neurology, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Karolina Hankiewicz
- Department of Neurology, Hôpital Pierre Delafontaine, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Jean-Philippe Neau
- Department of Neurology, CHU La Milétrie, Hôpital Jean Bernard, Poitiers, France
| | - Corinne Pottier
- Department of Neurology, CH de Pontoise, Hôpital René Dubos, Pontoise, France
| | - Chantal Nifle
- Departement of Neurology, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Nicolas Collongues
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
- Department of Pharmacology, Addictology, Toxicology and Therapeutics, Strasbourg University, Strasbourg, France
| | - Anne Kerbrat
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
- Empenn U1228, University of Rennes, Inria, CNRS, INSERM, IRISA UMR 6074, Rennes, France
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Prosperini L, Haggiag S, Ruggieri S, Tortorella C, Gasperini C. Stopping Disease-Modifying Treatments in Multiple Sclerosis: A Systematic Review and Meta-Analysis of Real-World Studies. CNS Drugs 2023; 37:915-927. [PMID: 37740822 DOI: 10.1007/s40263-023-01038-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND The question of whether multiple sclerosis requires life-long disease-modifying treatments (DMTs) remains unanswered. Some studies suggest that older patients with stable disease may safely discontinue their DMTs, yet comprehensive evidence-based data are scarce and real-world studies have provided mixed results. OBJECTIVE The aim of this study was to assess the rate of disease reactivation and associated risk factors after discontinuation of DMTs in patients with multiple sclerosis. METHODS We searched scientific databases (PubMed/MEDLINE, Scopus and Google Scholar) to identify real-world studies published until 31 July, 2023 that reported the number of patients who experienced relapses and/or disability accrual (outcomes of interest) following a therapy discontinuation longer than 12 months. Magnetic resonance activity and treatment re-start after DMT discontinuation were also considered as additional outcomes. We excluded studies where therapy discontinuation was explicitly related to an unintended or planned pregnancy or preceded a treatment switch. We ran random-effects meta-analyses, subgroup analyses and meta-regression models to provide pooled estimates of post-discontinuation relapse and disability events, and to identify their potential moderators (predictors). RESULTS After an independent screening, 22 articles met the eligibility criteria, yielding a pooled sample size of 2942 patients followed for 1-7 years after discontinuation (11,689 patient-years). The pooled rates for relapse and disability events were 6.7 and 5.8 per 100 patient-years, respectively. However, available data did not allow us to disentangle isolated disability accrual from relapse-associated worsening. Studies including older patients (β = -0.65, p = 0.006), patients with a longer exposure to DMTs (β = -2.22, p = 0.001) and patients with a longer period of disease stability (β = -2.74, p = 0.002) showed a lower risk of relapse events. According to meta-regression equations, the risk of relapse events after DMT discontinuation became negligible (arbitrarily set at < 1% per year) at approximately 60 years of age, and after either 10 years of DMT exposure, or 8 years of disease stability. Additional analyses showed pooled rates for magnetic resonance imaging activity and re-start events of 16.7 and 17.5 per 100 patient-years, respectively. CONCLUSIONS Based on our quantitative synthesis of real-world data, in the absence of definitive answers from clinical trials, DMT discontinuation appears feasible with a high degree of certainty in selected patients. While our findings are robust regarding relapse events, future efforts are warranted to determine if DMT discontinuation is associated with isolated disability accrual.
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Affiliation(s)
- Luca Prosperini
- Department of Neurology, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152, Rome, Italy.
| | - Shalom Haggiag
- Department of Neurology, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152, Rome, Italy
| | - Serena Ruggieri
- Department of Human Neurosciences, Sapienza University, Viale dell'Università 30, 00185, Rome, Italy
- Neuroimmunology Unit, Santa Lucia Foundation, Via del Fosso di Fiorano 64/65, 00143, Rome, Italy
| | - Carla Tortorella
- Department of Neurology, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152, Rome, Italy
| | - Claudio Gasperini
- Department of Neurology, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152, Rome, Italy
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Kaminsky AL, Omorou AY, Soudant M, Pittion-Vouyovitch S, Michaud M, Anxionnat R, Guillemin F, Debouverie M, Mathey G. Discontinuation of disease-modifying treatments for multiple sclerosis in patients aged over 50 with disease Inactivity. J Neurol 2020; 267:3518-3527. [PMID: 32617659 DOI: 10.1007/s00415-020-10029-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Treatments may become redundant in older patients with multiple sclerosis (MS). Our aim was to explore whether stopping treatments might be possible in patients aged over 50 with disease inactivity. METHODS Patients over 50 were included from the population-based MS Lorraine registry if they had a relapsing-remitting course at onset and had experienced no relapse for ≥ 3 years. Patients who stopped treatments were defined as "stoppers", and the others as "stayers". The outcomes were the time to first relapse, to first disability progression, and to the occurrence of EDSS score of 6, assessed by multivariate analysis using a propensity score. RESULTS 132 stoppers and 366 stayers had a median follow-up of 7 years. There was no difference in Log-rank tests for the times to first relapse (p = 0.61) and to first disability progression (p = 0.22). In Cox models, stopping treatments was not associated with an increased risk of relapse (adjusted Hazard ratio (aHR) = 0.92 [0.72-1.16; p = 0.47]) or of an increase in EDSS score (aHR = 0.89 [0.71-1.13; p = 0.34]). However, stopping was associated with a higher risk of occurrence of EDSS score of 6 (aHR = 3.29 [2.22-4.86; p < 0.0001]), with a significant difference for the time to occurrence of EDSS score of 6 (p = 0.003). CONCLUSION Our study suggests that stopping injectable disease-modifying treatments, in patients over 50 with disease inactivity, is not associated with an increased risk of relapse or EDSS progression, but there might be a higher risk of reaching EDSS 6. These results have to be confirmed by interventional studies.
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Affiliation(s)
- Anne-Laure Kaminsky
- Department of Neurology, University Hospital of Nancy, 29 avenue Maréchal de Lattre de Tassigny, 60034-54035, Nancy, CO, France.
| | - Abdou Yacoubou Omorou
- Inserm, CIC-1433 Clinical Epidemiology, University Hospital of Nancy, Université de Lorraine, Vandœuvre-Lès-Nancy, France
| | - Marc Soudant
- Inserm, CIC-1433 Clinical Epidemiology, University Hospital of Nancy, Université de Lorraine, Vandœuvre-Lès-Nancy, France
| | - Sophie Pittion-Vouyovitch
- Department of Neurology, University Hospital of Nancy, 29 avenue Maréchal de Lattre de Tassigny, 60034-54035, Nancy, CO, France
| | - Maud Michaud
- Department of Neurology, University Hospital of Nancy, 29 avenue Maréchal de Lattre de Tassigny, 60034-54035, Nancy, CO, France
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Francis Guillemin
- Inserm, CIC-1433 Clinical Epidemiology, University Hospital of Nancy, Université de Lorraine, Vandœuvre-Lès-Nancy, France
| | - Marc Debouverie
- Department of Neurology, University Hospital of Nancy, 29 avenue Maréchal de Lattre de Tassigny, 60034-54035, Nancy, CO, France
| | - Guillaume Mathey
- Department of Neurology, University Hospital of Nancy, 29 avenue Maréchal de Lattre de Tassigny, 60034-54035, Nancy, CO, France
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