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Frahm N, Fneish F, Ellenberger D, Flachenecker P, Paul F, Warnke C, Kleinschnitz C, Parciak T, Krefting D, Hellwig K, Haas J, Rommer PS, Stahmann A, Zettl UK. Therapy Switches in Fingolimod-Treated Patients with Multiple Sclerosis: Long-Term Experience from the German MS Registry. Neurol Ther 2022; 11:319-336. [PMID: 35020157 PMCID: PMC8857375 DOI: 10.1007/s40120-021-00320-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTIONS Therapy switches in patients with multiple sclerosis (MS) receiving treatment with fingolimod occur frequently in clinical practice but are not well represented in real-world data. The aim of this study was to identify and characterize treatment switches and reveal sociodemographic/clinical changes over time in fingolimod-treated people with MS (PwMS). METHODS Data on 2536 fingolimod-treated PwMS extracted from the German MS Registry during different time periods were analyzed (2010-2019). RESULTS Overall, 28.3% of PwMS were treatment-naïve before fingolimod initiation. Interferon beta (30.7%) was the most common pre-fingolimod treatment. Ocrelizumab (19.8%) was the most frequent subsequent treatment in the 944 patients on fingolimod who switched. Between 2010 and 2019, median disease duration at fingolimod initiation decreased from 8.5 to 7.1 years (p < 0.001), and patients taking fingolimod for ≥ 1 year after treatment initiation decreased from 89.6 to 80.5% (p < 0.001). Females (p < 0.001) and young patients (p = 0.003) showed a shorter time on fingolimod. The most frequent reason for switching was disease activity (relapse/MRI) despite treatment. The annualized relapse rate increased from 0.37 in patients on fingolimod to 0.47 after treatment cessation, decreasing to 0.19 after treatment with a subsequent disease-modifying drug (DMD) was initiated. CONCLUSION Treatment switches from fingolimod to subsequent DMDs currently occur after shorter treatment durations than 10 years ago, possibly due to the growing treatment spectrum. Planning adequate washout periods is essential and should be done on an individualized basis.
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Affiliation(s)
- Niklas Frahm
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
- Neuroimmunological Section, Department of Neurology, University Medical Center of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany
| | - Firas Fneish
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
| | - David Ellenberger
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
| | - Peter Flachenecker
- Neurological Rehabilitation Center Quellenhof, Kuranlagenallee 2, 75323 Bad Wildbad, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité–Universitätsmedizin Berlin, Lindenberger Weg 80, 13125 Berlin, Germany
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center of Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Tina Parciak
- Department of Medical Informatics, University Medical Center Göttingen, Von-Siebold-Str. 3, 37075 Göttingen, Germany
| | - Dagmar Krefting
- Department of Medical Informatics, University Medical Center Göttingen, Von-Siebold-Str. 3, 37075 Göttingen, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Joseph and St. Elisabeth Hospital–Ruhr University, Gudrunstr. 56, 44791 Bochum, Germany
| | - Judith Haas
- Deutsche Multiple Sklerose Gesellschaft, Bundesverband e.V. (German Multiple Sclerosis Society [DMSG], Federal Association), Krausenstr. 50, 30171 Hannover, Germany
| | - Paulus S. Rommer
- Neuroimmunological Section, Department of Neurology, University Medical Center of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria
| | - Alexander Stahmann
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
| | - Uwe K. Zettl
- Neuroimmunological Section, Department of Neurology, University Medical Center of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany
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Deleu D, Canibaño B, Mesraoua B, Adeli G, Abdelmoneim MS, Ali Y, Elalamy O, Melikyan G, Boshra A. Management of relapsing-remitting multiple sclerosis in Qatar: an expert consensus. Curr Med Res Opin 2020; 36:251-260. [PMID: 31530036 DOI: 10.1080/03007995.2019.1669378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Healthcare systems vary greatly between countries. International, evidence-based guidelines for the management of multiple sclerosis (MS) may need to be adapted for use in particular countries. Two years ago, the authors published a comprehensive consensus guideline for the management of MS in Qatar. Since that time, the availability of disease-modifying treatments for relapsing-remitting MS (RRMS), and our understanding of how to apply those treatments, has increased. The authors present an update to our guidance, focussing on the management of relapsing-remitting RRMS. In particular, the authors consider the optimal use of different DMTs in patients presenting with mild, medium or high disease activity.
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Affiliation(s)
- Dirk Deleu
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation, Doha, Qatar
| | - Beatriz Canibaño
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation, Doha, Qatar
| | - Boulenouar Mesraoua
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation, Doha, Qatar
| | - Gholamreza Adeli
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation, Doha, Qatar
| | - Mohamed S Abdelmoneim
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation, Doha, Qatar
| | - Yasir Ali
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation, Doha, Qatar
| | - Osama Elalamy
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation, Doha, Qatar
| | - Gayane Melikyan
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation, Doha, Qatar
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Ziemssen T, Lang M, Tackenberg B, Schmidt S, Albrecht H, Klotz L, Haas J, Lassek C, Cornelissen C, Ettle B. Long-term real-world evidence for sustained clinical benefits of fingolimod following switch from natalizumab. Mult Scler Relat Disord 2019; 39:101893. [PMID: 31865273 DOI: 10.1016/j.msard.2019.101893] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/22/2019] [Accepted: 12/11/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The risk of progressive multifocal leukoencephalopathy limits the duration over which patients can receive natalizumab before requiring a switch to other therapies such as fingolimod. To date, no studies have assessed the long-term real-world effectiveness and safety of fingolimod following a switch from natalizumab. We aimed to investigate the benefit-risk profile of fingolimod over 48 months in patients switching from natalizumab, and the impact of washout duration after natalizumab discontinuation on outcomes during fingolimod treatment. METHODS This analysis used data from PANGAEA, an ongoing German multicenter, prospective, non-interventional, observational study. In total, 3912 patients were included: 530 had switched from natalizumab (natalizumab subpopulation), and a reference population of 3382 had switched from other treatments or were treatment-naïve (non-natalizumab subpopulation). The natalizumab subpopulation was stratified by washout duration (30-89 days, 90-149 days, and ≥ 150 days) prior to fingolimod initiation. RESULTS In the natalizumab subpopulation over 48 months of fingolimod treatment, 58.2% (n = 227/390) of patients remained on fingolimod. Over this period, mean annualized relapse rates (ARRs) and proportions of patients who relapsed were similar across washout durations, and ranged from 0.455 (95% confidence interval [CI]: 0.363-0.571) to 0.546 (95% CI: 0.446-0.669) and 54.1% (n = 92/170) to 60.2% (n = 127/211), respectively. Overall, 17.1% (n = 36/211) had 6-month confirmed disability worsening. In the non-natalizumab subpopulation, ARR was 0.300, 40.9% (n = 1325/3237) of patients relapsed, and a similar proportion to the natalizumab subpopulation had 6-month disability worsening (16.6% [n = 232/1394]). In both subpopulations, the safety profile of fingolimod was consistent with that observed in randomized controlled trials. CONCLUSIONS In patients discontinuing natalizumab, fingolimod has a favorable benefit-risk profile over 48 months. These findings also suggest using a short washout following natalizumab discontinuation, consistent with guidelines and current clinical practice in Germany.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden, D-01307, Germany.
| | - Michael Lang
- NeuroPoint Patient Academy and Neurological Practice, Ulm, Germany.
| | - Björn Tackenberg
- Department of Neurology, Center of Neuroimmunology, Philipps-University, Marburg, Germany.
| | | | | | - Luisa Klotz
- Department of Neurology, University Hospital Münster, Münster, Germany.
| | - Judith Haas
- Centre for Multiple Sclerosis, Jewish Hospital Berlin, Berlin, Germany.
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Affiliation(s)
- Mehwish Saba Aslam
- Department of Microbiology and Immunology, School of Medicine, Southeast University, Nanjing, China
| | - Liudi Yuan
- Department of Microbiology and Immunology, School of Medicine, Southeast University, Nanjing, China
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Mariottini A, Innocenti C, Forci B, Magnani E, Mechi C, Barilaro A, Nistri R, Fani A, Saccardi R, Massacesi L, Repice AM. Safety and efficacy of autologous hematopoietic stem‐cell transplantation following natalizumab discontinuation in aggressive multiple sclerosis. Eur J Neurol 2018; 26:624-630. [DOI: 10.1111/ene.13866] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 11/06/2018] [Indexed: 12/29/2022]
Affiliation(s)
- A. Mariottini
- Department of Neurosciences Drug and Child Health University of Florence Florence
- Department of Neurology 2 and Multiple Sclerosis Regional Referral Centre Careggi University Hospital Florence
| | - C. Innocenti
- Cell Therapy and Transfusion Medicine Unit Careggi University Hospital Florence Italy
| | - B. Forci
- Department of Neurosciences Drug and Child Health University of Florence Florence
- Department of Neurology 2 and Multiple Sclerosis Regional Referral Centre Careggi University Hospital Florence
| | - E. Magnani
- Department of Neurosciences Drug and Child Health University of Florence Florence
- Department of Neurology 2 and Multiple Sclerosis Regional Referral Centre Careggi University Hospital Florence
| | - C. Mechi
- Department of Neurology 2 and Multiple Sclerosis Regional Referral Centre Careggi University Hospital Florence
| | - A. Barilaro
- Department of Neurology 2 and Multiple Sclerosis Regional Referral Centre Careggi University Hospital Florence
| | - R. Nistri
- Department of Neurosciences Drug and Child Health University of Florence Florence
| | - A. Fani
- Cell Therapy and Transfusion Medicine Unit Careggi University Hospital Florence Italy
| | - R. Saccardi
- Cell Therapy and Transfusion Medicine Unit Careggi University Hospital Florence Italy
| | - L. Massacesi
- Department of Neurosciences Drug and Child Health University of Florence Florence
- Department of Neurology 2 and Multiple Sclerosis Regional Referral Centre Careggi University Hospital Florence
| | - A. M. Repice
- Department of Neurology 2 and Multiple Sclerosis Regional Referral Centre Careggi University Hospital Florence
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Schwab N, Schneider-Hohendorf T, Hoyt T, Gross CC, Meuth SG, Klotz L, Foley JF, Wiendl H. Anti-JCV serology during natalizumab treatment: Review and meta-analysis of 17 independent patient cohorts analyzing anti-John Cunningham polyoma virus sero-conversion rates under natalizumab treatment and differences between technical and biological sero-converters. Mult Scler 2017; 24:563-573. [PMID: 28847222 DOI: 10.1177/1352458517728814] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Anti-John Cunningham virus (JCV) serology has been studied with varying results concerning longitudinal changes. OBJECTIVES AND METHODS Results from 17 published natalizumab-treated multiple sclerosis (MS) patient cohorts were analyzed with common parameters and subsequently verified in two large independent cohorts with 722 and 499 patients from Germany and the United States. RESULTS Published studies and the verification showed (1) a mean of 10.80% sero-negative patients presented with sero-status change to positivity per year; (2) patients, who sero-convert to index values <0.9, convert from near the threshold and have a high probability of reverting with time; (3) patients, who convert to index values >0.9, start with low index values; (4) while JCV sero-positive patients with low index values sometimes revert to sero-negativity, patients with high index values almost never revert; and (5) the conversion rate of natalizumab-treated patients is three to four times higher than the biological conversion by age. CONCLUSION JCV sero-conversion was comparable using standardized parameters and indicates influence of natalizumab on JCV immune control. Converters to low index values are probably consistently infected with JCV with varying low levels of activity, in line with their low risk to develop progressive multifocal leukoencephalopathy (PML). Patients with high index values rarely revert back to sero-negativity.
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Affiliation(s)
- Nicholas Schwab
- Department of Neurology, University of Münster, Münster, Germany
| | | | - Tammy Hoyt
- Rocky Mountain Multiple Sclerosis Clinic, Salt Lake City, UT, USA
| | | | - Sven G Meuth
- Department of Neurology, University of Münster, Münster, Germany
| | - Luisa Klotz
- Department of Neurology, University of Münster, Münster, Germany
| | - John F Foley
- Rocky Mountain Multiple Sclerosis Clinic, Salt Lake City, UT, USA
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
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Belova AN, Rasteryaeva MV, Zhulina NI, Belova EM, Boyko AN. [Immune reconstitution inflammatory syndrome and rebound syndrome in multiple sclerosis patients who stopped disease modification therapy: current understanding and a case report]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:74-84. [PMID: 28617365 DOI: 10.17116/jnevro20171172274-84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
More and more multiple sclerosis patients have been receiving treatment with new immunomodulatory drugs. Its discontinuation because of side-effects, lack of efficacy or pregnancy has been increasing as well. This paper reviews such severe complications of natalizumab and fingolimod cessation as immune reconstitution inflammatory syndrome (IRIS) and rebound. The short history, immunopathogenesis and diagnostic criteria of IRIS in individuals with human immunodeficiency virus infection are covered. Clinical and radiological presentations as well as possible pathogenic mechanisms of IRIS in patients treated with natalizumab and fingolimod are discussed. The authors also report the case of a woman with multiple sclerosis treated with fingolimod, who experienced a severe relapse when she stopped treatment. Diagnostic criteria and prognostic factors for IRIS and rebound are needed in patients with multiple sclerosis who discontinue the new disease modification therapy.
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Affiliation(s)
- A N Belova
- Privolzskyi Federal Medical Research Center, Nizhny Novgorod, Russia
| | - M V Rasteryaeva
- Privolzskyi Federal Medical Research Center, Nizhny Novgorod, Russia
| | - N I Zhulina
- Nizhny Novgorod State Medical Academy, Nizhny Novgorod, Russia
| | - E M Belova
- Nizhny Novgorod State Medical Academy, Nizhny Novgorod, Russia
| | - A N Boyko
- Pirogov National Russian Scientific Medical University, Moscow, Russia ,Center for demyelination diseases 'Neuroclinic', Moscow, Russia
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Heesen C, Kleiter I, Meuth SG, Krämer J, Kasper J, Köpke S, Gaissmaier W. Benefit-risk perception of natalizumab therapy in neurologists and a large cohort of multiple sclerosis patients. J Neurol Sci 2017; 376:181-190. [DOI: 10.1016/j.jns.2017.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/07/2017] [Accepted: 03/02/2017] [Indexed: 01/27/2023]
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Krämer J, Tenberge JG, Kleiter I, Gaissmaier W, Ruck T, Heesen C, Meuth SG. Is the risk of progressive multifocal leukoencephalopathy the real reason for natalizumab discontinuation in patients with multiple sclerosis? PLoS One 2017; 12:e0174858. [PMID: 28406921 PMCID: PMC5391008 DOI: 10.1371/journal.pone.0174858] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/16/2017] [Indexed: 12/29/2022] Open
Abstract
Background Progressive multifocal leukoencephalopathy (PML) is one of the major risks of natalizumab therapy. Despite introduction of the currently employed PML risk stratification algorithm, the incidence of natalizumab-associated PML cases is not decreasing. Objectives We addressed the following questions: How do natalizumab-treated multiple sclerosis patients and their treating physicians assess and deal with PML risk? Is PML risk the real reason for natalizumab discontinuation? Methods 699 natalizumab-treated multiple sclerosis patients and 99 physicians were included in this prospective observational study. Questionnaires were completed at 5 different time points. Patients were stratified into 5 subgroups according to the presence of PML risk factors (prior immunosuppression, anti-JCV antibody status, treatment duration). Patients with prior immunosuppression (n = 30, treated by n = 7 physicians) were excluded from analyses, because patient numbers were too small. Patients’ anti-JCV antibody index was not considered because data recruitment ended in 2014. Using Bayesian network and regression analysis, we examined the relationship between different patient- and physician-related factors and patients’ discontinuation of natalizumab. Results Patients of all subgroups and physicians assessed the PML risk as low. Overall patient adherence to natalizumab was high (87%). Only 13% of patients discontinued therapy. Natalizumab treatment cessation was associated with different patient- and physician-related factors (physicians’ assessment of general PML risk, number of treated patients per year, natalizumab treatment duration, relapses during the course of study) upon which only physicians’ judgment on treatment continuation, patients’ perception of personal PML risk, and JCV seroconversion showed significant relationships. Conclusion According to the currently employed risk stratification algorithm, the objective PML risk probably doesn’t play a dominant role in a patients’ decision to continue or stop natalizumab treatment. The decision-making process is rather guided by subjective views and experiences of patients and treating neurologists. Treating physicians should consider this discrepancy in their advice to improve the risk-benefit-ratio for the individual patient.
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Affiliation(s)
- Julia Krämer
- Department of Neurology, Clinic of Neurology and Institute of Translational Neurology, Westfälische Wilhelms University, Münster, Germany
- * E-mail: (JK); (SGM)
| | - Jan-Gerd Tenberge
- Department of Neurology, Clinic of Neurology and Institute of Translational Neurology, Westfälische Wilhelms University, Münster, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University-Bochum, Bochum, Germany
| | | | - Tobias Ruck
- Department of Neurology, Clinic of Neurology and Institute of Translational Neurology, Westfälische Wilhelms University, Münster, Germany
| | - Christoph Heesen
- Department of Neurology, Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sven G. Meuth
- Department of Neurology, Clinic of Neurology and Institute of Translational Neurology, Westfälische Wilhelms University, Münster, Germany
- * E-mail: (JK); (SGM)
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González-Suarez I, Rodríguez de Antonio L, Orviz A, Moreno-García S, Valle-Arcos MD, Matias-Guiu JA, Valencia C, Jorquera Moya M, Oreja-Guevara C. Catastrophic outcome of patients with a rebound after Natalizumab treatment discontinuation. Brain Behav 2017; 7:e00671. [PMID: 28413713 PMCID: PMC5390845 DOI: 10.1002/brb3.671] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/30/2017] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Natalizumab (NTZ) is an effective drug for the treatment of relapsing-remitting multiple sclerosis. In some patients discontinuation is mandatory due to the risk of progressive multifocal leukoencephalopathy. However, severe clinical and radiological worsening has been described after drug cessation. Our aim was to describe the clinical and radiological features of the rebound phenomenon. MATERIAL AND METHODS Patients switched from NTZ to Fingolimod (FTY) who had presented a rebound after discontinuation were selected. Clinical and magnetic resonance imaging (MRI) data were collected. RESULTS Four JC virus positive patients were included. The mean disease duration was 9.5 years (SD: 4.12) with a mean time of 3.1 years on NTZ. All patients started FTY within 3-4 months. Neurological deterioration started in a mean time of 3.5 months (SD: 2.08) with multifocal involvement: 75% motor disturbances, 50% cognitive impairment, 25% seizures. The average worsening in Expanded Disability Status Scale [EDSS] was of 3.25 points (SD: 2.33). The MRI showed a very large increase in T2 and gadolinium-enhanced lesions (mean: 23.67, SD: 18.58). All patients received 5 days of IV methylprednisolone, one patient required plasma exchange. All the patients presented neurological deterioration with an EDSS worsening of 1.13 points (SD: 0.48). After the rebound three patients continued treatment with FTY, only one patient restarted NTZ. CONCLUSION Discontinuation of NTZ treatment may trigger a severe rebound with marked clinical and radiological worsening. A very careful evaluation of benefit-risk should be considered before NTZ withdrawal, and a close monitoring and a short washout period is recommended after drug withdrawal.
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Affiliation(s)
- Inés González-Suarez
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | | | - Aida Orviz
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | - Sara Moreno-García
- Demyelinating Disease Unit Neurology Department Hospital Universitario 12 de Octubre Madrid Spain
| | - María D Valle-Arcos
- Demyelinating Disease Unit Neurology Department Hospital Universitario 12 de Octubre Madrid Spain
| | - Jordi A Matias-Guiu
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | - Cristina Valencia
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | | | - Celia Oreja-Guevara
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
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Prosperini L, Pontecorvo S. Dimethyl fumarate in the management of multiple sclerosis: appropriate patient selection and special considerations. Ther Clin Risk Manag 2016; 12:339-50. [PMID: 27042079 PMCID: PMC4780395 DOI: 10.2147/tcrm.s85099] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Delayed-release dimethyl fumarate (DMF), also known as gastroresistant DMF, is the most recently approved oral disease-modifying treatment (DMT) for relapsing multiple sclerosis. Two randomized clinical trials (Determination of the Efficacy and Safety of Oral Fumarate in Relapsing-Remitting MS [DEFINE] and Comparator and an Oral Fumarate in Relapsing-Remitting Multiple Sclerosis [CONFIRM]) demonstrated significant efficacy in reducing relapse rate and radiological signs of disease activity, as seen on magnetic resonance imaging. The DEFINE study also indicated a significant effect of DMF on disability worsening, while the low incidence of confirmed disability worsening in the CONFIRM trial rendered an insignificant reduction among the DMF-treated groups when compared to placebo. DMF also demonstrated a good safety profile and acceptable tolerability, since the most common side effects (gastrointestinal events and flushing reactions) are usually transient and mild to moderate in severity. Here, we discuss the place in therapy of DMF for individuals with relapsing multiple sclerosis, providing a tentative therapeutic algorithm to manage newly diagnosed patients and those who do not adequately respond to self-injectable DMTs. Literature data supporting the potential role of DMF as a first-line therapy are presented. The possibility of using DMF as switching treatment or even as an add-on strategy in patients with breakthrough disease despite self-injectable DMTs will also be discussed. Lastly, we argue about the role of DMF as an exit strategy from natalizumab-treated patients who are considered at risk for developing multifocal progressive leukoencephalopathy.
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Affiliation(s)
- Luca Prosperini
- Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Simona Pontecorvo
- Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
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Ayzenberg I, Hoepner R, Kleiter I. Fingolimod for multiple sclerosis and emerging indications: appropriate patient selection, safety precautions, and special considerations. Ther Clin Risk Manag 2016; 12:261-72. [PMID: 26929636 PMCID: PMC4767105 DOI: 10.2147/tcrm.s65558] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Fingolimod (FTY720), an immunotherapeutic drug targeting the sphingosine-1-phosphate receptor, is a widely used medication for relapsing-remitting multiple sclerosis (MS). Apart from the pivotal Phase III trials demonstrating efficacy against placebo and interferon-β-1a once weekly, sufficient clinical data are now available to assess its real-world efficacy and safety profile. Approved indications of fingolimod differ between countries. This discrepancy, to some extent, reflects the intermediate position of fingolimod in the expanding lineup of MS medications. With individualization of therapy, appropriate patient selection gets more important. We discuss various scenarios for fingolimod use in relapsing-remitting MS and their pitfalls: as first-line therapy, as escalation therapy after failure of previous immunotherapies, and as de-escalation therapy following highly potent immunotherapies. Potential side effects such as bradycardia, infections, macular edema, teratogenicity, and progressive multifocal leukoencephalopathy as well as appropriate safety precautions are outlined. Disease reactivation has been described upon fingolimod cessation; therefore, patients should be closely monitored for MS activity for several months after stopping fingolimod. Finally, we discuss preclinical and clinical data indicating neuroprotective effects of fingolimod, which might open the way to future indications such as stroke, Alzheimer’s disease, and other neurodegenerative disorders.
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Affiliation(s)
- Ilya Ayzenberg
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Robert Hoepner
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Ingo Kleiter
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Evangelopoulos ME, Koutoulidis V, Andreadou E, Evangelopoulos DS, Kilidireas C. Pulsed corticosteroid treatment in MS patients stabilizes disease activity following natalizumab withdrawal prior to switching to fingolimod. Int J Neurosci 2016; 126:1097-102. [DOI: 10.3109/00207454.2015.1127919] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Haile Y, Carmine-Simmen K, Olechowski C, Kerr B, Bleackley RC, Giuliani F. Granzyme B-inhibitor serpina3n induces neuroprotection in vitro and in vivo. J Neuroinflammation 2015; 12:157. [PMID: 26337722 PMCID: PMC4558826 DOI: 10.1186/s12974-015-0376-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/16/2015] [Indexed: 11/16/2022] Open
Abstract
Background Multiple sclerosis (MS) is an autoimmune inflammatory and neurodegenerative disease of the central nervous system (CNS). It is widely accepted that inflammatory cells play major roles in the pathogenesis of MS, possibly through the use of serine protease granzyme B (GrB) secreted from the granules of cytotoxic T cells. We have previously identified GrB as a mediator of axonal injury and neuronal death. In this study, our goal was to evaluate the effect of GrB inhibition in the human system in vitro, and in vivo in EAE using the newly isolated GrB-inhibitor serpina3n. Methods We used a well-established in vitro model of neuroinflammation characterized by a co-culture system between human fetal neurons and lymphocytes. In vivo, we induced EAE in 10- to 12-week-old female C57/BL6 mice and treated them intravenously with serpina3n. Results In the in vitro co-culture system, pre-treatment of lymphocytes with serpina3n prevented neuronal killing and cleavage of the cytoskeletal protein alpha-tubulin, a known substrate for GrB. Moreover, in EAE, 50 μg serpina3n substantially reduced the severity of the disease. This dose was administered intravenously twice at days 7 and 20 post EAE induction. serpina3n treatment reduced axonal and neuronal injury compared to the vehicle-treated control group and maintained the integrity of myelin. Interestingly, serpina3n treatment did not seem to reduce the infiltration of immune cells (CD4+ and CD8+ T cells) into the CNS. Conclusion Our data suggest further studies on serpina3n as a potentially novel therapeutic strategy for the treatment of inflammatory-mediated neurodegenerative diseases such as MS. Electronic supplementary material The online version of this article (doi:10.1186/s12974-015-0376-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yohannes Haile
- Department of Medicine, Division of Neurology, University of Alberta, 4C Kaye Edmonton Clinic, Edmonton, Alberta, T6G 1Z1, Canada
| | | | - Camille Olechowski
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Canada
| | - Bradley Kerr
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Canada.,Department of Pharmacology, University of Alberta, Edmonton, Canada.,Centre for Neuroscience, University of Alberta, Edmonton, Canada
| | | | - Fabrizio Giuliani
- Department of Medicine, Division of Neurology, University of Alberta, 4C Kaye Edmonton Clinic, Edmonton, Alberta, T6G 1Z1, Canada.
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De Giglio L, Gasperini C, Tortorella C, Trojano M, Pozzilli C. Natalizumab discontinuation and disease restart in pregnancy: a case series. Acta Neurol Scand 2015; 131:336-40. [PMID: 25598313 DOI: 10.1111/ane.12364] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The humanized monoclonal alpha4-integrin antibody Natalizumab (NTZ) (Tysabri(©) , Biogen Idec, Cambridge, MA, USA) has shown to be effective in multiple sclerosis (MS) therapy; however, the interruption of the drug has been related to a disease restart. This risk has to be carefully considered in case of accidental or desired pregnancies. AIM OF THE STUDY To report the risk of disease restart in patients who interrupted NTZ because of pregnancy and discuss the implication of NTZ choice in female childbearing patients with MS. METHODS Clinical histories and MRI images of four pregnant women with MS who interrupted NTZ. RESULTS Despite pregnancy is usually related with disease stability, the cases presented here showed an abrupt increase of disability with high number of MRI lesions, some of them with a mass effect. CONCLUSIONS We recommend that female patients on childbearing age must be informed before starting NTZ treatment of the risk of a return of disease activity when the drug is discontinued. The risk occurs even during pregnancy a condition that is considered as protective for women with MS.
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Affiliation(s)
- L. De Giglio
- Department of Neurology and Psychiatry; “Sapienza” Unversity of Rome; Rome Italy
| | - C. Gasperini
- Department of Neuroscience; “S. Camillo Forlanini” Hopsital; Rome Italy
| | - C. Tortorella
- Department of Department of Basic Medical Sciences; Neurosciences and Sense Organs; University of Bari; Bari Italy
| | - M. Trojano
- Department of Department of Basic Medical Sciences; Neurosciences and Sense Organs; University of Bari; Bari Italy
| | - C. Pozzilli
- Department of Neurology and Psychiatry; “Sapienza” University of Rome; Rome Italy
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D’Amico E, Caserta C, Patti F. Monoclonal antibody therapy in multiple sclerosis: critical appraisal and new perspectives. Expert Rev Neurother 2015; 15:251-68. [DOI: 10.1586/14737175.2015.1008458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Prosperini L, Annovazzi P, Capobianco M, Capra R, Buttari F, Gasperini C, Galgani S, Solaro C, Centonze D, Bertolotto A, Pozzilli C, Ghezzi A. Natalizumab discontinuation in patients with multiple sclerosis: Profiling risk and benefits at therapeutic crossroads. Mult Scler 2015; 21:1713-22. [PMID: 25698174 DOI: 10.1177/1352458515570768] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 12/21/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this paper is to estimate the risk of reaching well-established disability milestones after withdrawal of natalizumab (NTZ) due to concern about the risk of progressive multifocal leukoencephalopathy in patients with multiple sclerosis (MS). METHODS Data from 415 patients with MS followed-up for six years after starting NTZ were collected from seven tertiary MS centers. The risk of disability worsening, i.e. reaching Expanded Disability Status Scale (EDSS) scores of 4.0 or 6.0, and the likelihood of experiencing a disability reduction of one EDSS point (or more), were assessed by propensity score-adjusted analyses in patients who discontinued and in those still on treatment at the end of follow-up. RESULTS A total of 318 patients who received standard NTZ treatment without experiencing evidence of disability worsening in the first two years were included in the six-year follow-up analysis, with 196 (61.6%) still on treatment and 122 (38.4%) discontinuing after a median time of 3.5 years. Patients in the discontinuing group had a more than two-fold increased risk of disability worsening (p = 0.007), and a 68% decreased likelihood of experiencing disability reduction (p = 0.009) compared with the continuing group. CONCLUSION While discussing the overall risk/benefit profile of NTZ, patients should be advised that, in case of treatment discontinuation, the risk of disability worsening is one in three, and increases to one in two if the EDSS score at NTZ start is above 3.0.
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Affiliation(s)
- Luca Prosperini
- Department of Neurology and Psychiatry, Sapienza University, Italy
| | | | - Marco Capobianco
- Neurologia 2 - CRESM (Centro Riferimento Regionale Sclerosi Multipla), University Hospital San Luigi Gonzaga, Italy
| | - Ruggero Capra
- Regional Referring MS Center, Spedali Civili of Brescia, Montichiari Hospital, Italy
| | - Fabio Buttari
- Department of Neurosciences Tor Vergata University, Italy/IRCCS Neuromed, Italy
| | | | | | - Claudio Solaro
- Neurology Unit, Department Head and Neck, ASL 3 genovese, Genova, Italy
| | - Diego Centonze
- Department of Neurosciences Tor Vergata University, Italy/S. Lucia Foundation IRCCS, Italy
| | - Antonio Bertolotto
- Neurologia 2 - CRESM (Centro Riferimento Regionale Sclerosi Multipla), University Hospital San Luigi Gonzaga, Italy
| | - Carlo Pozzilli
- Department of Neurology and Psychiatry, Sapienza University, Italy
| | - Angelo Ghezzi
- Department of Neurology and Psychiatry, Sapienza University, ItalyMS Centre, S. Antonio Abate Hospital, ItalyNeurologia 2 - CRESM (Centro Riferimento Regionale Sclerosi Multipla), University Hospital San Luigi Gonzaga, ItalyRegional Referring MS Center, Spedali Civili of Brescia, Montichiari Hospital, ItalyDepartment of Neurosciences Tor Vergata University, Italy/IRCCS Neuromed, ItalyDepartment of Neurosciences, S. Camillo-Forlanini Hospital, ItalyDepartment of Neurosciences, S. Camillo-Forlanini Hospital, ItalyNeurology Unit, Department Head and Neck, ASL 3 genovese, Genova, ItalyDepartment of Neurosciences Tor Vergata University, Italy/S. Lucia Foundation IRCCS, ItalyNeurologia 2 - CRESM (Centro Riferimento Regionale Sclerosi Multipla), University Hospital San Luigi Gonzaga, ItalyDepartment of Neurology and Psychiatry, Sapienza University, ItalyMS Centre, S. Antonio Abate Hospital, Italy
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Bianco A, Patanella AK, Nociti V, Marti A, Frisullo G, Plantone D, De Fino C, Fetta A, Batocchi AP, Rossini PM, Mirabella M. Second-line therapy with fingolimod for relapsing-remitting multiple sclerosis in clinical practice: the effect of previous exposure to natalizumab. Eur Neurol 2014; 73:57-65. [PMID: 25402749 DOI: 10.1159/000365968] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 07/13/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND To evaluate efficacy and safety of fingolimod for relapsing-remitting multiple sclerosis, particularly in patients previously exposed to natalizumab. METHOD Prospective observational single-centre second-line cohort study. RESULTS Among 71 patients treated with fingolimod 0.5 mg/day for a mean duration of 21.75 ± 12.60 months, the annualized relapse rate was 0.66 (C.I. 95% 0.27-1.05) with a significant difference between 26 patients with prior natalizumab exposure (1.15; C.I. 95% 0.12-2.17) and 45 not exposed (0.38; C.I. 95% 0.18-0.57; p = 0.002). In a multivariate negative regression model, only previous exposure to natalizumab (p = 0.049) and duration of fingolimod treatment (p < 0.001) significantly correlated with the annualized relapse rate. Previous exposure to natalizumab (p = 0.028) and duration of treatment with fingolimod (p < 0.001) were confirmed by restricting the analysis to the first 12 months of treatment with fingolimod, but were no longer statistically significant by analysing only patients (n = 51) with at least 12 months of treatment with fingolimod (0.32; C.I. 95% 0.08-0.55 vs. 0.22; C.I. 95% 0.11-0.32; p = NS). No differences were observed in neuroradiological outcomes and disability progression in patients exposed to natalizumab and not exposed. The rate of discontinuation due to adverse events was 11.3%, with no differences between the two groups. CONCLUSIONS Our study confirms efficacy and side effects of fingolimod in a second-line clinical practice cohort. Prior natalizumab exposure and duration of treatment with fingolimod are independent predictors of annualized relapse rate during the first 12 months of treatment with fingolimod, but not in the long-term, and may be influenced by the 3 months washout period between the two drugs.
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Affiliation(s)
- Assunta Bianco
- Institute of Neurology, Catholic University, Rome, Italy
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Alroughani R, Almulla A, Lamdhade S, Thussu A. Multiple sclerosis reactivation postfingolimod cessation: is it IRIS? BMJ Case Rep 2014; 2014:bcr-2014-206314. [PMID: 25320259 DOI: 10.1136/bcr-2014-206314] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Although few recent studies have reported efficacy and safety data among patients with multiple sclerosis (MS) switching between immunotherapies, data on the mechanism of rebound activity postwithdrawal of fingolimod in patients with MS is scarce. A 36-year-old woman developed severe reactivation of her disease within 7 weeks of fingolimod's withdrawal despite the absence of breakthrough disease during the 8-week natalizumab washout period previously. The clinical presentation and radiological features were described indicating the diagnostic challenge given the potential risk of developing progressive multifocal leucoencephalopathy. The severe reactivation postwithdrawal of fingolimod could be due to the immune reconstitution inflammatory syndrome (IRIS) given the abrupt rise in lymphocyte count. Patients who discontinued fingolimod might be at risk of developing IRIS resulting in disease reactivation in the washout period.
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Affiliation(s)
- R Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Kuwait City, Kuwait Neurology Clinic, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - A Almulla
- Division of Neurology, Department of Medicine, Amiri Hospital, Kuwait City, Kuwait
| | - S Lamdhade
- Division of Neurology, Department of Medicine, Amiri Hospital, Kuwait City, Kuwait
| | - A Thussu
- Division of Neurology, Department of Medicine, Amiri Hospital, Kuwait City, Kuwait Neurology Clinic, Dasman Diabetes Institute, Kuwait City, Kuwait
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Hoepner R, Havla J, Eienbröker C, Tackenberg B, Hellwig K, Meinl I, Hohlfeld R, Gold R, Kümpfel T, Kleiter I. Predictors for multiple sclerosis relapses after switching from natalizumab to fingolimod. Mult Scler 2014; 20:1714-20. [PMID: 24842961 DOI: 10.1177/1352458514533398] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Risks of natalizumab (NAT) therapy have to be weighed against disease recurrence after stopping NAT. OBJECTIVES The objective of this paper is to identify risk factors for recurrence of relapses after switching from NAT to fingolimod (FTY) in relapsing-remitting multiple sclerosis (RRMS). METHODS Patients (n = 33) were treated with NAT for ≥1 year, and then switched to FTY within 24 weeks (mean follow-up on FTY 81.1 (SD 26.5) weeks). Annual relapse rates (ARR) and Expanded Disability Status Scale scores (EDSS) were assessed. Descriptive statistics, univariate logistic regression analysis, and receiver operating characteristic curves were conducted. RESULTS Overall, 20 patients (61%) had relapses after discontinuation of NAT and 16 (48%) during FTY therapy. The maximum incidence of relapses occurred between weeks 13-24 post-NAT. The last EDSS during the switching period predicted relapses during subsequent FTY therapy. EDSS >3 separated most powerfully between the groups (sensitivity 64%, specificity 88%) and significantly predicted relapses (relative risk 3.27, 95% CI: 1.5-7.3). Seventy-five percent of patients with EDSS ≤ 3 remained free of relapses, compared to 18% of patients with EDSS >3. CONCLUSIONS There was an increase of the ARR in the first year after switching from NAT to FTY. Last EDSS during the switching period was a predictor of relapses during FTY.
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Affiliation(s)
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University, Germany
| | | | | | | | - Ingrid Meinl
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University, GermanyMunich Cluster for Systems Neurology (SyNergy), Germany
| | - Ralf Gold
- St Josef-Hospital, Ruhr-University, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University, Germany
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Planas R, Martin R, Sospedra M. Long-term safety and efficacy of natalizumab in relapsing-remitting multiple sclerosis: impact on quality of life. PATIENT-RELATED OUTCOME MEASURES 2014; 5:25-33. [PMID: 24741337 PMCID: PMC3983075 DOI: 10.2147/prom.s41768] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Natalizumab was the first monoclonal antibody to be approved for the treatment of relapsing-remitting multiple sclerosis (RRMS) based on its short-term efficacy and overall tolerability. However, the incidence of treatment-associated progressive multifocal leukoencephalopathy (PML), an infection of the brain caused by the John Cunningham virus, jeopardized this efficacious treatment from the beginning. Eight years after licensing of natalizumab, long-term studies confirm the considerable and sustained efficacy of natalizumab, although the PML complication still threatens one of the most successful treatments available for RRMS. During these years, considerable progress has been made in identification of risk factors that allow more effective management of PML risk. In addition, long-term studies to define better when to start or stop treatment and to optimize treatment strategies after cessation of natalizumab are ongoing, and hopefully will improve management and will allow natalizumab to remain as a valuable therapeutic option for patients with highly active RRMS.
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Affiliation(s)
- Raquel Planas
- Neuroimmunology and MS Research, Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Roland Martin
- Neuroimmunology and MS Research, Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Mireia Sospedra
- Neuroimmunology and MS Research, Department of Neurology, University of Zurich, Zurich, Switzerland
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Knier B, Hemmer B, Korn T. Novel monoclonal antibodies for therapy of multiple sclerosis. Expert Opin Biol Ther 2014; 14:503-13. [DOI: 10.1517/14712598.2014.887676] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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