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Nieto González N, Rassu G, Cossu M, Catenacci L, Sorrenti ML, Cama ES, Serri C, Giunchedi P, Gavini E. A thermosensitive chitosan hydrogel: An attempt for the nasal delivery of dimethyl fumarate. Int J Biol Macromol 2024; 278:134908. [PMID: 39181356 DOI: 10.1016/j.ijbiomac.2024.134908] [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: 05/20/2024] [Revised: 07/26/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024]
Abstract
Dimethyl fumarate (DMF) is a drug that is orally administered for the treatment of relapsing-remitting multiple sclerosis. However, DMF causes gastrointestinal side effects and flushing in 43 % of patients, which significantly contributes to treatment discontinuation. To reduce side effects and increase patient compliance, the aim of this study was to develop a thermosensitive chitosan/glycerophosphate hydrogel for the nasal administration of DMF. A binary system of DMF with hydroxypropyl-β-cyclodextrin (HP-β-CD) was made and included in the hydrogel precursor solution. The precursor solution (drug content, DMF stability, thermogelling properties, viscosity), and the resulting thermosensitive hydrogel (mucoadhesion, in vitro DMF permeation) were characterized. HP-β-CD was able to interact with DMF and improve its water solubility. The leader thermosensitive nasal solution, G1 solution, was loaded with approximately 92 % DMF, which remained stable for 21 days. The G1 solution formed a hydrogel in approximately 2-1 min; it had a pH of 6.8 ± 0.06 and caused no significant change in the osmolality of the simulated nasal medium. The G1 hydrogel showed good mucoadhesive properties and released DMF that permeated in vitro in a controlled manner. As a result, G1 is a potential new approach to exploit the intranasal administration of DMF for treating multiple sclerosis.
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Affiliation(s)
- Noelia Nieto González
- PhD Program in Chemical Science and Technology, Department of Chemical, Physical, Mathematical and Natural Sciences, University of Sassari, via Vienna 2, 07100 Sassari, Italy
| | - Giovanna Rassu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, via Muroni 23a, 07100 Sassari, Italy.
| | - Massimo Cossu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, via Muroni 23a, 07100 Sassari, Italy
| | - Laura Catenacci
- Department of Drug Sciences, University of Pavia, Via Taramelli 12, 27100 Pavia, Italy
| | - Milena L Sorrenti
- Department of Drug Sciences, University of Pavia, Via Taramelli 12, 27100 Pavia, Italy
| | - Eleonora Sofia Cama
- Department of Drug Sciences, University of Pavia, Via Taramelli 12, 27100 Pavia, Italy
| | - Carla Serri
- Department of Medicine, Surgery and Pharmacy, University of Sassari, via Muroni 23a, 07100 Sassari, Italy
| | - Paolo Giunchedi
- Department of Medicine, Surgery and Pharmacy, University of Sassari, via Muroni 23a, 07100 Sassari, Italy
| | - Elisabetta Gavini
- Department of Medicine, Surgery and Pharmacy, University of Sassari, via Muroni 23a, 07100 Sassari, Italy
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Ghezzi A. Old and New Strategies in the Treatment of Pediatric Multiple Sclerosis: A Personal View for a New Treatment Approach. Neurol Ther 2024; 13:949-963. [PMID: 38822947 PMCID: PMC11263277 DOI: 10.1007/s40120-024-00633-6] [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: 04/18/2024] [Accepted: 05/14/2024] [Indexed: 06/03/2024] Open
Abstract
Up to 10 years ago the most common approach to the treatment of pediatric MS (ped-MS) was to start with IFNB or GA (so-called first-line therapies or moderate-efficacy disease-modifying therapies [ME-DMTs]) and to switch to more aggressive treatments (or high-efficacy disease-modifying therapies [HE-DMTs]) in non-responder patients. The use of HE-DMTs as first choice was recommended in selected cases with an active, aggressive form of MS. Indications for the treatment of ped-MS were essentially derived from data of observational studies. Recently, results of three randomized clinical trials have been published as well as data from many observational studies evaluating the effect of new and more active DMTs, with clear evidence that HE-DMTs are more effective than ME-DMTs. Therefore, the paradigm of treatment for patients with MS onset before 18 years of age should be changed, offering treatment with HE-DMTs as first option, because of their superior effectiveness to prevent relapses and disease progression. HE-DMTs present an overall reassuring safety profile and obtain better adherence to treatment.
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Affiliation(s)
- Angelo Ghezzi
- Dipartimento di Scienze della Salute, Università Piemonte Orientale A. Avogadro, Via Solaroli 17, 28100, Novara, Italy.
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Freedman MS, Coyle PK, Hellwig K, Singer B, Wynn D, Weinstock-Guttman B, Markovic-Plese S, Galazka A, Dangond F, Korich J, Reder AT. Twenty Years of Subcutaneous Interferon-Beta-1a for Multiple Sclerosis: Contemporary Perspectives. Neurol Ther 2024; 13:283-322. [PMID: 38206453 PMCID: PMC10951191 DOI: 10.1007/s40120-023-00565-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/06/2023] [Indexed: 01/12/2024] Open
Abstract
Multiple sclerosis (MS) is a chronic, progressive, inflammatory disorder of the central nervous system. Relapsing-remitting MS (RRMS), the most common form of the disease, is characterized by transient neurological dysfunction with concurrent accumulation of disability. Over the past three decades, disease-modifying therapies (DMTs) capable of reducing the frequency of relapses and slowing disability worsening have been studied and approved for use in patients with RRMS. The first DMTs were interferon-betas (IFN-βs), which were approved in the 1990s. Among them was IFN-β-1a for subcutaneous (sc) injection (Rebif®), which was approved for the treatment of MS in Europe and Canada in 1998 and in the USA in 2002. Twenty years of clinical data and experience have supported the efficacy and safety of IFN-β-1a sc in the treatment of RRMS, including pivotal trials, real-world data, and extension studies lasting up to 15 years past initial treatment. Today, IFN-β-1a sc remains an important therapeutic option in clinical use, especially around pregnancy planning and lactation, and may also be considered for aging patients, in which MS activity declines and long-term immunosuppression associated with some alternative therapies is a concern. In addition, IFN-β-1a sc is used as a comparator in many clinical studies and provides a framework for research into the mechanisms by which MS begins and progresses.
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Affiliation(s)
- Mark S Freedman
- Department of Medicine, University of Ottawa, Ottawa, ON, K1H 8L6, Canada.
- The Ottawa Hospital Research Institute, 501 Smyth, Ottawa, ON, K1H 8L6, Canada.
| | - Patricia K Coyle
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, New York, NY, 11794, USA
| | - Kerstin Hellwig
- Katholisches Klinikum Bochum, Ruhr University, 44787, Bochum, Germany
| | - Barry Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, 3009 N. Ballas Road, Suite 105B, St. Louis, MO, 63131, USA
| | - Daniel Wynn
- Neurology MS Center, Consultants in Neurology, Ltd, 1535 Lake Cook Road, Suite 601, Northbrook, IL, 60062, USA
| | - Bianca Weinstock-Guttman
- Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, 14215, USA
- Jacobs MS Center for Treatment and Research, Buffalo, NY, 14202, USA
- Pediatric MS Center, NY State MS Consortium, 1010 Main Street, Buffalo, NY, 14203, USA
| | - Silva Markovic-Plese
- Division of Neuroimmunology, Department of Neurology, Thomas Jefferson University, 900 Walnut St, Rm 305-B, Philadelphia, PA, 19107, USA
| | | | - Fernando Dangond
- EMD Serono Research & Development Institute Inc., an affiliate of Merck GKaA, Billerica, MA, 01821, USA
| | - Julie Korich
- EMD Serono Inc., an affiliate of Merck KGaA, Rockland, MA, 02370, USA
| | - Anthony T Reder
- Department of Neurology A-205, University of Chicago Medicine, MC-2030, 5841 S Maryland Ave, Chicago, IL, 60637, USA
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4
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Puthenparampil M, Gaggiola M, Miscioscia A, Mauceri VA, De Napoli F, Zanotelli G, Anglani M, Nosadini M, Sartori S, Perini P, Rinaldi F, Gallo P. Alemtuzumab following natalizumab is more effective in adult-onset than paediatric-onset multiple sclerosis. Ther Adv Neurol Disord 2023; 16:17562864231177196. [PMID: 37808246 PMCID: PMC10559704 DOI: 10.1177/17562864231177196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Paediatric-onset multiple sclerosis (POMS) therapeutic approach derives from of adult-onset multiple sclerosis (AOMS) tailored algorithms. Objectives To evaluate in a common clinical scenario the efficacy and safety of alemtuzumab (ALZ) in POMS and AOMS. Methods All patients switching from natalizumab (NTZ) to ALZ for safety concerns (high anti-John Cunningham Virus Antibody Index value, anti-JCV Index) were enrolled in this single-centre, retrospective, case-control open-label study. Results Ten POMS and 27 AOMS were followed up for 51.3 months. After month 12, we found a lower risk of clinical or radiological relapses among AOMS patients and among patients with older age at ALZ (both p < 0.05). Survival analysis revealed an increased risk of relapse in POMS compared with AOMS (logrank p = 0.00498) and patients starting ALZ before age 22.75 years than the elder ones (logrank p = 0.0018). Survival analysis did not disclose any difference between AOMS and POMS (logrank p = 0.27) in terms of progression independent of any relapse activity (PIRA). In addition, no evidence of relapse-associated worsening was observed. Autoimmune events were reported by 5 AOMS and no POMS (29.4% versus 0.0%, p = 0.057), and survival analysis was not significant (logrank p = 0.0786). Conclusion ALZ seems more effective in AOMS than in POMS following NTZ. These findings underrate ALZ effectiveness when shifting from NTZ in POMS.
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Affiliation(s)
- Marco Puthenparampil
- Multiple Sclerosis Centre, Clinica Neurologica, Dipartimento di Neuroscienze, Università degli Studi di Padova, Via Giustiniani 5, 35128 Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Marta Gaggiola
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Alessandro Miscioscia
- Department of Neurosciences, University of Padua, Padova, Italy
- Padua Neuroscience Centre, University of Padua, Padova, Italy
| | - Valentina Annamaria Mauceri
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Federica De Napoli
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Giovanni Zanotelli
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | | | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute ‘Città della Speranza’, Padova, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute ‘Città della Speranza’, Padova, Italy
| | - Paola Perini
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Francesca Rinaldi
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
| | - Paolo Gallo
- Department of Neurosciences, University of Padua, Padova, Italy
- Multiple Sclerosis Centre, Azienda Ospedaliera di Padova, Padova, Italy
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Gold R, Barnett M, Chan A, Feng H, Fujihara K, Giovannoni G, Montalbán X, Shi FD, Tintoré M, Xue Q, Yang C, Zhou H. Clinical use of dimethyl fumarate in multiple sclerosis treatment: an update to include China, using a modified Delphi method. Ther Adv Neurol Disord 2023; 16:17562864231180734. [PMID: 37465201 PMCID: PMC10350766 DOI: 10.1177/17562864231180734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/20/2023] [Indexed: 07/20/2023] Open
Abstract
Dimethyl fumarate (DMF) is a widely used oral disease-modifying therapy for multiple sclerosis (MS). Its efficacy and safety profiles are supported by over a decade of experience. Differences exist between Asia and Europe/United States in the prevalence and characteristics of MS; most data for DMF are derived from populations outside Asia. DMF was recently (2021) approved for use in China. The objectives of this review were to evaluate the evidence for DMF's profile, to provide an update to healthcare providers on current knowledge surrounding its use and to assess the relevance of existing data to use in China. This study used a modified Delphi method based on the insights of a scientific Steering Committee (SC), with a structured literature review conducted to assess the data of DMF. The literature review covered all papers in English (from 01 January 2011 to 21 February 2022) that include 'dimethyl fumarate' and 'multiple sclerosis', and their MeSH terms, on PubMed, supplemented by EMBASE and Citeline searches. Papers were categorized by topic and assessed for relevance and quality, before being used to formulate statements summarizing the literature on each subject. SC members voted on/revised statements, requiring ⩾80% agreement and ⩽10% disagreement for inclusion. Statements not reaching this level were discussed further until agreement was reached or until there was agreement to remove the statement. A total of 1030 papers were retrieved and used to formulate the statements and evidence summaries considered by the SC members. A total of 45 statements were agreed by the SC members. The findings support the positive efficacy and safety profile of DMF in treating patients with MS. Limited Chinese patient data are an ongoing consideration; however, based on current evidence, the statements are considered applicable to both the global and Chinese populations. DMF is a valuable addition to address unmet MS treatment needs in China. Registration: Not applicable.
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Affiliation(s)
- Ralf Gold
- Department of Neurology, Ruhr University Bochum, Bochum 44791, Germany
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney and Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew Chan
- Department of Neurology, Inselspital (Bern University Hospital), University of Bern, Bern, Switzerland
| | - Huiyu Feng
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Gavin Giovannoni
- Department of Neurology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Xavier Montalbán
- Neurology Department, Multiple Sclerosis Center of Catalonia (Cemcat), Vall d’Hebron University Hospital, Barcelona, Spain
| | - Fu-Dong Shi
- Department of Neurology, Institute of Neuroimmunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Mar Tintoré
- Neurology Department, Multiple Sclerosis Center of Catalonia (Cemcat), Vall d’Hebron University Hospital, Barcelona, Spain
| | - Qun Xue
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chunsheng Yang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Capasso N, Virgilio E, Covelli A, Giovannini B, Foschi M, Montini F, Nasello M, Nilo A, Prestipino E, Schirò G, Sperandei S, Clerico M, Lanzillo R. Aging in multiple sclerosis: from childhood to old age, etiopathogenesis, and unmet needs: a narrative review. Front Neurol 2023; 14:1207617. [PMID: 37332984 PMCID: PMC10272733 DOI: 10.3389/fneur.2023.1207617] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/15/2023] [Indexed: 06/20/2023] Open
Abstract
Multiple sclerosis (MS) primarily affects adult females. However, in the last decades, rising incidence and prevalence have been observed for demographic extremes, such as pediatric-onset MS (POMS; occurring before 18 years of age) and late-onset MS (corresponding to an onset above 50 years). These categories show peculiar clinical-pathogenetic characteristics, aging processes and disease courses, therapeutic options, and unmet needs. Nonetheless, several open questions are still pending. POMS patients display an important contribution of multiple genetic and environmental factors such as EBV, while in LOMS, hormonal changes and pollution may represent disease triggers. In both categories, immunosenescence emerges as a pathogenic driver of the disease, particularly for LOMS. In both populations, patient and caregiver engagement are essential from the diagnosis communication to early treatment of disease-modifying therapy (DMTs), which in the elderly population appears more complex and less proven in terms of efficacy and safety. Digital technologies (e.g., exergames and e-training) have recently emerged with promising results, particularly in treating and following motor and cognitive deficits. However, this offer seems more feasible for POMS, being LOMS less familiar with digital technology. In this narrative review, we discuss how the aging process influences the pathogenesis, disease course, and therapeutic options of both POMS and LOMS. Finally, we evaluate the impact of new digital communication tools, which greatly interest the current and future management of POMS and LOMS patients.
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Affiliation(s)
- Nicola Capasso
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
| | - Eleonora Virgilio
- Neurology Unit, Department of Translational Medicine, AOU Maggiore della Carità Novara, University of Eastern Piedmont, Novara, Italy
| | - Antonio Covelli
- Department of Neurology, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Beatrice Giovannini
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matteo Foschi
- Department of Neuroscience, MS Center, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy
| | - Federico Montini
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Nasello
- Neurology Unit, Department of Neurosciences, Mental Health and Sensory organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Annacarmen Nilo
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Elio Prestipino
- UOSC Neuro-Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Giuseppe Schirò
- Section of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Silvia Sperandei
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Roberta Lanzillo
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
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Skarlis C, Markoglou N, Gontika M, Bougea A, Katsavos S, Artemiadis A, Chrousos G, Dalakas M, Stefanis L, Anagnostouli M. First-line disease modifying treatments in pediatric-onset multiple sclerosis in Greece: therapy initiation at more advanced age is the main cause of treatment failure, in a retrospective observational study, with a cohort from a single Multiple Sclerosis Center. Neurol Sci 2023; 44:693-701. [PMID: 36197577 PMCID: PMC9842569 DOI: 10.1007/s10072-022-06431-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Long-term immunomodulatory therapy of pediatric onset-multiple sclerosis (POMS) is based mainly on published case series and internationally agreed guidelines. Relevant studies in the Greek population are absent from the literature. The purpose of this study is to present data on the efficacy and safety of the 1st line immunomodulatory drugs in the treatment of POMS patients. MATERIALS AND METHODS The present study included 27 patients meeting the IPMSSG criteria for POMS and who are monitored at the outpatient clinic of the Multiple Sclerosis and Demyelinating Diseases Unit (MSDDU), of the 1st Neurological Department, University Hospital of Aeginition. All patients received 1st line immunomodulatory drugs as initial therapy. Clinical, laboratory, and imaging parameters of the disease were recorded before and after treatment. RESULTS Post-treatment, a significant reduction of the relapse number (mean ± SD: 2.0 ± 1.0 vs 1.2 ± 1.6, p = 0.002), EDSS progression (mean ± SD: 1.5 ± 0.8 vs 0.9 ± 0.7, p = 0.005) and ARR (mean ± SD: 1.5 ± 0.7 vs 0.4 ± 0.5, p = 0.0001) was observed, while no changes were observed in the EDSS score, (mean ± SD: 1.8 ± 0.6 vs 1.9. 0.6, p = 0.60). Advanced age at treatment initiation increased the risk for drug discontinuation before 24 months of therapy (HR = 0.6, 95% CI (0.35-0.99), p = 0.04). CONCLUSIONS Most pediatric patients are forced to switch to either more efficacious 1st line or 2nd line drugs. Additionally, our study suggests that older age at the time of the 1st line treatment initiation, contributes to earlier drug discontinuation.
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Affiliation(s)
- Charalampos Skarlis
- Research Immunogenetics Laboratory, 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, Aeginition University Hospital, Athens, Greece
| | - Nikolaos Markoglou
- Research Immunogenetics Laboratory, 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, Aeginition University Hospital, Athens, Greece
| | - Maria Gontika
- Research Immunogenetics Laboratory, 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, Aeginition University Hospital, Athens, Greece
| | - Anastasia Bougea
- 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, NKUA, Aeginition University Hospital, Vassilisis Sofias Ave 72-74, 11528 Athens, Greece
| | - Serafeim Katsavos
- Research Immunogenetics Laboratory, 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, Aeginition University Hospital, Athens, Greece
| | - Artemios Artemiadis
- Research Immunogenetics Laboratory, 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, Aeginition University Hospital, Athens, Greece
| | - George Chrousos
- Aghia Sophia Children’s Hospital, University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair On Adolescent Health Care, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Marinos Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece ,Department of Neurology, Thomas Jefferson University, Philadelphia, PA USA
| | - Leonidas Stefanis
- 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, NKUA, Aeginition University Hospital, Vassilisis Sofias Ave 72-74, 11528 Athens, Greece
| | - Maria Anagnostouli
- Research Immunogenetics Laboratory, 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, Aeginition University Hospital, Athens, Greece ,1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, NKUA, Aeginition University Hospital, Vassilisis Sofias Ave 72-74, 11528 Athens, Greece ,Multiple Sclerosis and Demyelinating Diseases Unit, 1st, Department of Neurology, Medical School, National and Kapodistrian University of Athens, Aeginition University Hospital, Athens, Greece
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8
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Specific Aspects of Immunotherapy for Multiple Sclerosis in Switzerland—A Structured Commentary, Update 2022. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2022. [DOI: 10.3390/ctn7010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Multiple sclerosis (MS), particularly relapsing MS (RMS), has become a treatable disease in recent decades, and immunotherapies are now able to influence long-term disease course. A wide range of disease-modifying drugs are available, which makes the choice of therapy in individual cases considerably more complex. Due to specific regulatory aspects (partly diverging approvals by Swissmedic compared to the European Medicines Agency (EMA), and an independent evaluation process for the Federal Office of Public Health (FOPH) specialities list (SL)), we issued a consensus recommendation regarding specific aspects of immunotherapy for MS in Switzerland in 2019. Here, we present revised recommendations with an update on newly approved drugs and new safety aspects, also in reference to the risk of COVID-19 infection and vaccination.
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9
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Diagnose and treat paediatric-onset multiple sclerosis promptly to delay physical worsening and cognitive decline. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00938-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Vermersch P, Scaramozza M, Levin S, Alroughani R, Deiva K, Pozzilli C, Lyons J, Mokliatchouk O, Pultz J, N’Dure F, Liu S, Badwan R, Branco F, Hood-Humphrey V, Franchimont N, Hanna J, Maghzi AH. Effect of Dimethyl Fumarate vs Interferon β-1a in Patients With Pediatric-Onset Multiple Sclerosis: The CONNECT Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2230439. [PMID: 36169959 PMCID: PMC9520348 DOI: 10.1001/jamanetworkopen.2022.30439] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE With few approved multiple sclerosis therapies in the pediatric population, there is a need for further approved treatment options. Limited data exist for dimethyl fumarate (DMF) treatment in pediatric-onset multiple sclerosis (POMS). OBJECTIVE To compare the efficacy, safety, and tolerability of DMF vs intramuscular interferon β-1a (IFNβ-1a) in POMS. DESIGN, SETTING, AND PARTICIPANTS The CONNECT study was an active-controlled, open-label, rater-blinded 96-week randomized clinical trial in patients with POMS aged 10 to less than 18 years treated between August 2014 and November 2020. Data were analyzed from January through October 2021. INTERVENTIONS Patients were randomized to DMF or IFNβ-1a. MAIN OUTCOMES AND MEASURES The primary end point was the proportion of patients free of new or newly enlarging (N or NE) T2 hyperintense lesions at week 96 among trial completers. Secondary end points included number of N or NE T2 lesions, proportion of patients free of relapse, annualized relapse rate (ARR), and safety. The estimated proportion of participants who were relapse free up to week 96 was calculated based on the Kaplan-Meier method. Adjusted ARR was obtained from a negative binomial regression adjusted for baseline relapse rate, baseline Expanded Disability Status Scale (EDSS) score, and age group. RESULTS Among 150 patients with POMS in the intention-to-treat (ITT) population (median [range] age, 15 [10-17] years; 101 [67.3%] female patients), 78 individuals received DMF and 72 individuals received IFNβ-1a. At week 96, the proportion of patients with no N or NE T2 hyperintense lesions among 103 trial completers was 16.1% (95% CI, 8.0%-27.7%) for DMF vs 4.9% (95% CI, 0.6%-16.5%) for IFNβ-1a, and in a sensitivity analysis among the ITT population, the proportions were 10 patients receiving DMF (12.8%) vs 2 patients receiving IFNβ-1a (2.8%). The estimated proportion of patients who remained relapse free at week 96 was 66.2% for DMF vs 52.3% for IFNβ-1a. Adjusted ARR (95% CI) at week 96 was 0.24 (95% CI, 0.15-0.39) for DMF vs 0.53 (95% CI, 0.33-0.84) for IFNβ-1a; the rate ratio for DMF vs IFNβ-1a was 0.46 (95% CI, 0.26-0.80; P = .006). The number of treatment-emergent adverse events (TEAEs; 74 patients [94.9%] vs 69 patients [95.8%]), serious TEAEs (18 patients [23.1%] vs 21 patients [29.2%]), and treatment discontinuations due to TEAEs (5 patients [6.4%] vs 8 patients [11.1%]) was similar for DMF vs IFNβ-1a. CONCLUSIONS AND RELEVANCE This study found that more pediatric patients with POMS treated with DMF were free of new or newly enlarging T2 lesions and that the adjusted ARR was lower among these patients compared with those treated with interferon β-1a. DMF was well tolerated. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02283853.
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Affiliation(s)
- Patrick Vermersch
- University Lille, Inserm, Centre Hospitalier Universitaire de Lille, Fédératif Hospitalo-Universitaire Precise, Lille, France
| | | | | | | | - Kumaran Deiva
- Assistance Publique-Hôpitaux de Paris, Pediatric Neurology Department, University Hospitals Paris Saclay, Bicêtre Hospital, Le Kremlin Bicêtre, France
- French Reference Network of Rare Inflammatory Brain and Spinal Diseases, Le Kremlin Bicêtre, France
| | - Carlo Pozzilli
- Sant’ Andrea Multiple Sclerosis Center, Sapienza University, Rome, Italy
| | | | | | - Joe Pultz
- Biogen, Cambridge, Massachusetts
- Now with CR Medicon, Orange, Connecticut
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11
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Bou-Fakhredin R, De Franceschi L, Motta I, Cappellini MD, Taher AT. Pharmacological Induction of Fetal Hemoglobin in β-Thalassemia and Sickle Cell Disease: An Updated Perspective. Pharmaceuticals (Basel) 2022; 15:ph15060753. [PMID: 35745672 PMCID: PMC9227505 DOI: 10.3390/ph15060753] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 12/04/2022] Open
Abstract
A significant amount of attention has recently been devoted to the mechanisms involved in hemoglobin (Hb) switching, as it has previously been established that the induction of fetal hemoglobin (HbF) production in significant amounts can reduce the severity of the clinical course in diseases such as β-thalassemia and sickle cell disease (SCD). While the induction of HbF using lentiviral and genome-editing strategies has been made possible, they present limitations. Meanwhile, progress in the use of pharmacologic agents for HbF induction and the identification of novel HbF-inducing strategies has been made possible as a result of a better understanding of γ-globin regulation. In this review, we will provide an update on all current pharmacological inducer agents of HbF in β-thalassemia and SCD in addition to the ongoing research into other novel, and potentially therapeutic, HbF-inducing agents.
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Affiliation(s)
- Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.B.-F.); (I.M.)
| | - Lucia De Franceschi
- Department of Medicine, University of Verona and Azienda Ospedaliera Universitaria Verona, 37128 Verona, Italy;
| | - Irene Motta
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.B.-F.); (I.M.)
- UOC General Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.B.-F.); (I.M.)
- UOC General Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence: (M.D.C.); (A.T.T.)
| | - Ali T. Taher
- Department of Internal Medicine, Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
- Correspondence: (M.D.C.); (A.T.T.)
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12
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Saijo N, Abe Y, Oikawa Y, Okubo Y, Endo W, Numata-Uematsu Y, Takahashi T, Uematsu M. Successful treatment with dimethyl fumarate in a child with relapsing-remitting multiple sclerosis. Brain Dev 2022; 44:353-356. [PMID: 35058083 DOI: 10.1016/j.braindev.2021.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/09/2021] [Accepted: 12/30/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Early disease control with disease-modifying drugs is important for improving the prognosis of multiple sclerosis (MS) in children. Dimethyl fumarate (DMF) is an oral disease-modifying drug for MS in adults with relatively stable disease; however, its use in young children has not been heavily documented in the current literature. We report the case of a pediatric patient with relapsing-remitting MS who was treated with DMF. CASE REPORT A 3-year-old boy with a history of common cold symptoms developed unsteadiness and somnolence. Magnetic resonance imaging revealed multiple white matter lesions. Symptoms were recurrent, and DMF was prescribed at 6 years of age due to a relapse episode with oculomotor disability and facial paralysis. However, disease progression continued, and new lesions were noted at age 7; thus, the dose of DMF was increased to 240 mg/day. No relapse has been observed for over three years; sequelae or severe side effects were absent. CONCLUSIONS DMF may be a useful oral disease-modifying drug for preventing recurrence in young children with MS.
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Affiliation(s)
- Naoya Saijo
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Yu Abe
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Yoshitsugu Oikawa
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Yukimune Okubo
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan
| | - Wakaba Endo
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan
| | | | - Toshiyuki Takahashi
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Neurology, National Hospital Organization National Yonezawa Hospital, Yonezawa, Japan
| | - Mitsugu Uematsu
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan.
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13
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Treatment of multiple sclerosis in children: A brief overview. Clin Immunol 2022; 237:108947. [PMID: 35123059 DOI: 10.1016/j.clim.2022.108947] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/29/2021] [Accepted: 01/31/2022] [Indexed: 11/20/2022]
Abstract
Multiple sclerosis (MS) is the most common autoimmune, chronic inflammatory demyelinating disorder of the central nervous system. Pediatric-onset MS (POMS), as opposed to adult-onset MS (AOMS), is a rare condition, presenting similar clinical features to AOMS, but a more active course of the disease, with higher relapse rates and greater white and grey matter damage. To date, the therapeutic approaches to treat POMS have been extrapolated from observational studies and data from trials conducted on adults, raising concerns about their efficacy and safety in the pediatric population. Herein, we discuss the most common therapeutic strategies used in POMS management, basing on the individual clinical practice and experience.
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14
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Jakimovski D, Awan S, Eckert SP, Farooq O, Weinstock-Guttman B. Multiple Sclerosis in Children: Differential Diagnosis, Prognosis, and Disease-Modifying Treatment. CNS Drugs 2022; 36:45-59. [PMID: 34940954 PMCID: PMC8697541 DOI: 10.1007/s40263-021-00887-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 12/19/2022]
Abstract
Pediatric-onset multiple sclerosis (POMS) is a rare neuroinflammatory and neurodegenerative disease that has a significant impact on long-term physical and cognitive patient outcomes. A small percentage of multiple sclerosis (MS) diagnoses occur before the age of 18 years. Before treatment initiation, a careful differential diagnosis and exclusion of other similar acquired demyelinating syndromes such as anti-aquaporin-4-associated neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody spectrum disorder (MOGSD) is warranted. The recent 2017 changes to the McDonald criteria can successfully predict up to 71% of MS diagnoses and have good specificity of 95% and sensitivity of 71%. Additional measures such as the presence of T1-weighted hypointense lesions and/or contrast-enhancing lesions significantly increase the accuracy of diagnosis. In adults, early use of disease-modifying therapies (DMTs) is instrumental to a better long-term prognosis, including lower rates of relapse and disability worsening, and numerous FDA-approved therapies for adult-onset MS are available. However, unlike their adult counterparts, the development, testing, and regulatory approval of POMS treatments have been significantly slower and hindered by logistic and/or ethical considerations. Currently, only two MS DMTs (fingolimod and teriflunomide) have been tested in large phase III trials and approved by regulatory agencies for use in POMS. First-line therapies not approved by the FDA for use in children (interferon-β and glatiramer acetate) are also commonly used and result in a significant reduction in inflammatory activity when compared with non-treated POMS patients. An increasing number of POMS patients are now treated with moderate efficacy therapies such as dimethyl fumarate and high-efficacy therapies such as natalizumab, anti-CD20 monoclonal antibodies, anti-CD52 monoclonal antibodies, and/or autologous hematopoietic stem cell transplantation. These high-efficacy DMTs generally provide additional reduction in inflammatory activity when compared with the first-line medications (up to 62% of relapse-rate reduction). Therefore, a number of phase II and III trials are currently investigating their efficacy and safety in POMS patients. In this review, we discuss potential changes in the regulatory approval process for POMS patients that are recommended for DMTs already approved for the adult MS population, including smaller sample size for pharmacokinetic/pharmacodynamic studies, MRI-centered primary outcomes, and/or inclusion of teenagers in the adult trials.
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Affiliation(s)
- Dejan Jakimovski
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA ,Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY USA
| | - Samreen Awan
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA
| | - Svetlana P. Eckert
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA
| | - Osman Farooq
- Division of Pediatric Neurology, Oishei Children’s Hospital of Buffalo, Buffalo, NY USA ,Department of Neurology, Jacobs School of Medicine, State University of New York at Buffalo, Buffalo, NY USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY, 14202, USA.
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15
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Abrams AW, March A, Porat D, Bhayana K, Rensel M. Treatment Updates in Paediatric-onset Multiple Sclerosis. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A number of new disease-modifying therapies have recently been developed and approved for use in adult-onset multiple sclerosis. However, few treatment options are approved for patients with paediatric-onset multiple sclerosis. There are an increasing number of clinical trials evaluating the efficacy and safety of disease-modifying therapies in children and teens living with multiple sclerosis. Clinical trials are difficult to complete in rare diseases like paediatric-onset multiple sclerosis; however, it is critical to assess safety and monitoring in this vulnerable population by applying robust research methodology to randomized controlled clinical trials. Longer-term extension analyses are also needed to better evaluate the efficacy, dosing and long-term safety of adult disease-modifying therapy for use in paediatric-onset multiple sclerosis. Future research should focus on defining optimal first-line disease-modifying therapy in paediatric-onset multiple sclerosis as related to both efficacy and safety, improving recruitment and completion rates of clinical trials, identifying relevant biomarkers of disease activity, analysing outcome measures related to treatment response and assessing long-term safety for this unique population living with a chronic disease.
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16
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Margoni M, Rinaldi F, Perini P, Gallo P. Therapy of Pediatric-Onset Multiple Sclerosis: State of the Art, Challenges, and Opportunities. Front Neurol 2021; 12:676095. [PMID: 34079516 PMCID: PMC8165183 DOI: 10.3389/fneur.2021.676095] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/08/2021] [Indexed: 11/13/2022] Open
Abstract
Treatment of pediatric-onset multiple sclerosis (POMS) has been tailored after observational studies and data obtained from clinical trials in adult-onset multiple sclerosis (AOMS) patients. There are an increasing number of new therapeutic agents for AOMS, and many will be formally studied for use also in POMS. However, there are important efficacy and safety concerns regarding the use of these therapies in children and young adults. This review will discuss the current state of the art of POMS therapy and will focus on the newer therapies (oral and infusion disease-modifying drugs) and on those still currently under investigation.
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Affiliation(s)
- Monica Margoni
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy.,Padova Neuroscience Centre, University of Padua, Padua, Italy
| | - Francesca Rinaldi
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy
| | - Paola Perini
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy
| | - Paolo Gallo
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy.,Department of Neurosciences, Medical School, University of Padua, Padua, Italy
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