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Jan Z, Mollazadeh S, Abnous K, Taghdisi SM, Danesh A, Ramezani M, Alibolandi M. Targeted Delivery Platforms for the Treatment of Multiple Sclerosis. Mol Pharm 2022; 19:1952-1976. [PMID: 35501974 DOI: 10.1021/acs.molpharmaceut.1c00892] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Multiple sclerosis (MS) is a neurodegenerative condition of the central nervous system (CNS) that presents with varying levels of disability in patients, displaying the significance of timely and effective management of this complication. Though several treatments have been developed to protect nerves, comprehensive improvement of MS is still considered an essential bottleneck. Therefore, the development of innovative treatment methods for MS is one of the core research areas. In this regard, nanoscale platforms can offer practical and ideal approaches to the diagnosis and treatment of various diseases, especially immunological disorders such as MS, to improve the effectiveness of conventional therapies. It should be noted that there is significant progress in the development of neuroprotective strategies through the implementation of various nanoparticles, monoclonal antibodies, peptides, and aptamers. In this study, we summarize different particle systems as well as targeted therapies, such as antibodies, peptides, nucleic acids, and engineered cells for the treatment of MS, and discuss their potential in the treatment of MS in the preclinical and clinical stages. Future advances in targeted delivery of medical supplies may offer new strategies for complete recovery as well as practical treatment of progressive forms of MS.
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Affiliation(s)
- Zeinab Jan
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Science, 7GJP+VPQ Mashhad, Iran
| | - Samaneh Mollazadeh
- Natural Products and Medicinal Plants Research Center, North Khorasan University of Medical Sciences, F82C+G8V Bojnurd, Iran
| | - Khalil Abnous
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, 7GJP+VPQ Mashhad, Iran
| | - Seyed Mohammad Taghdisi
- Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, 7GJP+VPQ Mashhad, Iran
| | - Abolghasem Danesh
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Science, 7GJP+VPQ Mashhad, Iran
| | - Mohammad Ramezani
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, 7GJP+VPQ Mashhad, Iran
| | - Mona Alibolandi
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, 7GJP+VPQ Mashhad, Iran
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2
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Rammohan K, Coyle PK, Sylvester E, Galazka A, Dangond F, Grosso M, Leist TP. The Development of Cladribine Tablets for the Treatment of Multiple Sclerosis: A Comprehensive Review. Drugs 2021; 80:1901-1928. [PMID: 33247831 PMCID: PMC7708385 DOI: 10.1007/s40265-020-01422-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cladribine is a purine nucleoside analog initially developed in the 1970s as a treatment for various blood cancers. Due to the molecule’s ability to preferentially reduce T and B lymphocytes, it has been developed into an oral formulation for the treatment of multiple sclerosis (MS). The unique proposed mechanism of action of cladribine allows for the therapy to be delivered orally over two treatment-week cycles per year, one cycle at the beginning of the first month and one cycle at the beginning of the second month of years 1 and 2, with the potential for no further cladribine treatment required in years 3 and 4. This review summarizes the clinical development program for cladribine tablets in patients with MS, including the efficacy endpoints and results from the 2-year phase III CLARITY study in patients with relapsing–remitting MS (RRMS), the 2-year CLARITY EXTENSION study, and the phase III ORACLE-MS study in patients with a first clinical demyelinating event at risk for developing MS. Efficacy results from the phase II ONWARD study, in which cladribine tablets were administered as an add-on to interferon-β therapy in patients with RRMS, are also summarized. A review of all safety data, including lymphopenia, infections, and malignancies, is provided based on data from all trials in patients with MS, including the initial parenteral formulation studies. Based on these data, cladribine tablets administered at 3.5 mg/kg over 2 years have been approved across the globe for various forms of relapsing MS. The development of cladribine tablets for the treatment of multiple sclerosis: a comprehensive review (MP4 279143 kb)
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Affiliation(s)
- Kottil Rammohan
- Multiple Sclerosis Center, University of Miami, Miami, FL, USA.
| | - Patricia K Coyle
- Multiple Sclerosis Comprehensive Care Center, Stony Brook University, Stony Brook, NY, USA
| | | | | | - Fernando Dangond
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Megan Grosso
- EMD Serono, Inc., Rockland, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Thomas P Leist
- Comprehensive MS Center, Jefferson University, Philadelphia, PA, USA
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Wang W, Tan X, Jiang J, Cai Y, Feng F, Zhang L, Li W. Targeted biological effect of an affitoxin composed of an HPV16E7 affibody fused with granzyme B (ZHPV16E7-GrB) against cervical cancer in vitro and in vivo. Curr Cancer Drug Targets 2020; 21:CCDT-EPUB-112118. [PMID: 33292132 DOI: 10.2174/1568009620666201207145720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/17/2020] [Accepted: 10/25/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND High risk type 16 of human papillomavirus (HPV16) is associated with 50% of cervical cancer, for which reliable targeted therapies are lacking. HPV early protein 7 (E7) is an oncoprotein responsible for cell malignant transformation. In our previous work, a highly specific affibody targeting HPV16E7 (ZHPV16E7) was developed. OBJECTIVE In order to improve the targeted therapeutic effect, the present study prepared an affitoxin consisting of ZHPV16E7 fused with granzyme B (GrB), namely, ZHPV16E7-GrB, and evaluated its targeting action in vitro and in vivo. METHODS The ZHPV16E7-GrB fusion protein was produced in a prokaryotic expression system. The targeted binding properties of the ZHPV16E7-GrB to the HPV16E7 were confirmed by immunofluorescence assay (IFA) in cervical cancer cell lines, by immunohistochemical assay (IHA) in cervical cancer tissue from clinical specimens and by near-infrared imaging in tumour-bearing mice. The anti-tumour effect on both cervical cancer cells in vitro and tumour-bearing mice in vivo were further evaluated. RESULTS A 34-kDa ZHPV16E7-GrB fusion protein was produced in E. coli and displayed corresponding immunoreactivity. IFA revealed that ZHPV16E7-GrB bound specifically to HPV16-positive TC-1 and SiHa cells. IHA showed that ZHPV16E7-GrB also bound specifically to HPV16-positive clinical tissue specimens. In addition, the near-infrared imaging results showed that ZHPV16E7-GrB was enriched in tumour tissues. Moreover, both the ZHPV16E7-GrB affitoxin and ZHPV16E7 affibody (without GrB) significantly reduced the proliferation of cervical cancer cells in vitro and tumour-bearing mice in vivo, and the antiproliferative effect of ZHPV16E7-GrB was higher than that of the ZHPV16E7 affibody. CONCLUSIONS The affitoxin by coupling the affibody with GrB is a promising targeted therapeutic agent with the dual advantages of the targeted affibody and the GrB cytotoxin.
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Affiliation(s)
- Wenhuan Wang
- Wenzhou Key Laboratory of Gynecology and Obstetrics, Wenzhou People's Hospital, Wenzhou, Zhejiang Province. China
| | - Xiaochun Tan
- Department of Microbiology and Immunology, Wenzhou Medical University, Wenzhou, Zhejiang Province. China
| | - Jie Jiang
- Department of Microbiology and Immunology, Wenzhou Medical University, Wenzhou, Zhejiang Province. China
| | - Yiqi Cai
- Department of Microbiology and Immunology, Wenzhou Medical University, Wenzhou, Zhejiang Province. China
| | - Fangfang Feng
- Department of Microbiology and Immunology, Wenzhou Medical University, Wenzhou, Zhejiang Province. China
| | - Lifang Zhang
- Department of Microbiology and Immunology, Wenzhou Medical University, Wenzhou, Zhejiang Province. China
| | - Wenshu Li
- Department of Microbiology and Immunology, Wenzhou Medical University, Wenzhou, Zhejiang Province. China
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Protein A affinity chromatography of Chinese hamster ovary (CHO) cell culture broths containing biopharmaceutical monoclonal antibody (mAb): Experiments and mechanistic transport, binding and equilibrium modeling. J Chromatogr B Analyt Technol Biomed Life Sci 2018. [DOI: 10.1016/j.jchromb.2018.02.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Cuesta-Mateos C, Alcaraz-Serna A, Somovilla-Crespo B, Muñoz-Calleja C. Monoclonal Antibody Therapies for Hematological Malignancies: Not Just Lineage-Specific Targets. Front Immunol 2018; 8:1936. [PMID: 29387053 PMCID: PMC5776327 DOI: 10.3389/fimmu.2017.01936] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022] Open
Abstract
Today, monoclonal antibodies (mAbs) are a widespread and necessary tool for biomedical science. In the hematological cancer field, since rituximab became the first mAb approved by the Food and Drug Administration for the treatment of B-cell malignancies, a number of effective mAbs targeting lineage-specific antigens (LSAs) have been successfully developed. Non-LSAs (NLSAs) are molecules that are not restricted to specific leukocyte subsets or tissues but play relevant pathogenic roles in blood cancers including the development, proliferation, survival, and refractoriness to therapy of tumor cells. In consequence, efforts to target NLSAs have resulted in a plethora of mAbs-marketed or in development-to achieve different goals like neutralizing oncogenic pathways, blocking tumor-related chemotactic pathways, mobilizing malignant cells from tumor microenvironment to peripheral blood, modulating immune-checkpoints, or delivering cytotoxic drugs into tumor cells. Here, we extensively review several novel mAbs directed against NLSAs undergoing clinical evaluation for treating hematological malignancies. The review focuses on the structure of these antibodies, proposed mechanisms of action, efficacy and safety profile in clinical studies, and their potential applications in the treatment of hematological malignancies.
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Affiliation(s)
- Carlos Cuesta-Mateos
- Servicio de Inmunología, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa, Madrid, Spain
- IMMED S.L., Immunological and Medicinal Products, Madrid, Spain
| | - Ana Alcaraz-Serna
- Servicio de Inmunología, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa, Madrid, Spain
| | - Beatriz Somovilla-Crespo
- Department of Immunology and Oncology, Centro Nacional de Biotecnología, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - Cecilia Muñoz-Calleja
- Servicio de Inmunología, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa, Madrid, Spain
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Abstract
Daclizumab (Zinbryta®; previously known as daclizumab high-yield process) is a therapeutic monoclonal antibody that has recently been approved for the treatment of relapsing forms of multiple sclerosis (MS) in adults. Daclizumab is a humanized IgG1 monoclonal antibody directed against CD25, the alpha subunit of the high-affinity interleukin-2 receptor. As demonstrated in the phase III DECIDE trial, once-monthly subcutaneous daclizumab was superior to once-weekly intramuscular interferon (IFN) β-1a in reducing the clinical relapse rate and radiological measures of disease in patients with relapsing-remitting MS. In addition, daclizumab has demonstrated efficacy in reducing disability progression and in improving health-related quality of life in patients with relapsing MS. Ongoing open-label clinical trials indicate that daclizumab's efficacy is maintained in the longer term (3 years or more). Daclizumab appears to be generally well tolerated, with adverse events of interest (including hepatic, infectious and cutaneous events) generally manageable with regular monitoring and/or standard therapies. The place of daclizumab in MS treatment remains to be fully determined. However, based on available evidence, daclizumab provides a useful alternative option to other currently available disease-modifying therapies in the treatment of relapsing MS.
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Sanchez MAR, Porter B. The role of the MS clinical nurse specialist in the management of disease-modifying drugs. ACTA ACUST UNITED AC 2015. [DOI: 10.12968/bjnn.2015.11.6.272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Miguel Angel Robles Sanchez
- Multiple Sclerosis Clinical Nurse Specialist, Multiple Sclerosis Neuroimmunology Unit, Biomedical Research Institute of Girona, Spain
| | - Bernadette Porter
- Consultant Nurse Multiple Sclerosis, University College London Hospitals NHS Foundation
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8
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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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Curtin F, Perron H, Kromminga A, Porchet H, Lang AB. Preclinical and early clinical development of GNbAC1, a humanized IgG4 monoclonal antibody targeting endogenous retroviral MSRV-Env protein. MAbs 2015; 7:265-75. [PMID: 25427053 PMCID: PMC4623301 DOI: 10.4161/19420862.2014.985021] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/15/2014] [Accepted: 10/31/2014] [Indexed: 11/19/2022] Open
Abstract
Monoclonal antibodies (mAbs) play an increasing important role in the therapeutic armamentarium against multiple sclerosis (MS), an inflammatory and degenerative disorder of the central nervous system. Most of the mAbs currently developed for MS are immunomodulators blocking the inflammatory immune process. In contrast with mAbs targeting immune function, GNbAC1, a humanized IgG4 mAb, targets the multiple sclerosis associated retrovirus envelope (MSRV-Env) protein, an upstream factor in the pathophysiology of MS. MSRV-Env protein is of endogenous retroviral origin, expressed in MS brain lesions, and it is pro-inflammatory and toxic to the remyelination process, by preventing the differentiation of oligodendrocyte precursor cells. We present the preclinical and early clinical development results of GNbAC1. The specificity of GNbAC1 for its endogenous retroviral target is described. Efficacy of different mAb versions of GNbAC1 were assessed in MSRV-Env induced experimental allergic encephalitis (EAE), an animal model of MS. Because the target MSRV-Env is not expressed in animals, no relevant animal model exists for a proper in vivo toxicological program. An off-target 2-week toxicity study in mice was thus performed, and it showed an absence of safety risk. Additional in vitro analyses showed an absence of complement or antibody-dependent cytotoxicity as well as a low level of cross-reactivity to human tissues. The first-in-man clinical study in 33 healthy subjects and a long-term clinical study in 10 MS patients showed that GNbAC1 is well tolerated in humans without induction of immunogenicity and that it induces a pharmacodynamic response on MSRV biomarkers. These initial results suggest that the mAb GNbAC1 could be a safe long-term treatment for patients with MS with a unique therapeutic mechanism of action.
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Key Words
- ADCC, antibody-dependent cell-mediated cytotoxicity
- AE, adverse events
- AUC, area under the curve
- BLAST, Basic Local Alignment Search Tool
- CDC, complement-dependent cytotoxicity
- CDR, complementarity-determining regions
- Cmax, maximal concentration
- Cmin, minimal concentration
- HERV-W
- HERV-W, human endogenous retrovirus type W
- HLA, human leukocyte antigen
- MOG, myelin oligodendrocyte glycoprotein
- MS, multiple sclerosis
- MSRV
- MSRV, multiple sclerosis associated retrovirus
- MSRV-Env, multiple sclerosis associated retrovirus envelope protein
- PBMC, peripheral blood mononuclear cell
- SAE, serious adverse event
- SU, surface domain
- Syncytin
- TLR4, Toll-like receptor 4
- ch-GNbAC1, chimeric version of mAb GNbAC1
- drug safety
- human endogenous retrovirus
- mAb, monoclonal antibody
- monoclonal antibody
- mu-GNbAC1, murine version of mAb GNbAC1
- multiple sclerosis
- neurotoxicity
- toxicology
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MESH Headings
- Animals
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/immunology
- Antibody Specificity
- Encephalomyelitis, Autoimmune, Experimental/drug therapy
- Encephalomyelitis, Autoimmune, Experimental/immunology
- Encephalomyelitis, Autoimmune, Experimental/pathology
- Endogenous Retroviruses/immunology
- Female
- Gene Products, env/immunology
- HEK293 Cells
- Humans
- Immunoglobulin G/administration & dosage
- Immunoglobulin G/adverse effects
- Immunoglobulin G/immunology
- Male
- Mice
- Multiple Sclerosis/drug therapy
- Multiple Sclerosis/immunology
- Multiple Sclerosis/pathology
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Affiliation(s)
- François Curtin
- GeNeuro SA; Plan-les-Ouates/Geneva, Switzerland
- Division of Clinical Pharmacology and Toxicology; University of Geneva; Geneva, Switzerland
| | | | - Arno Kromminga
- Institute of Immunology; University Kiel; Kiel, Germany
- IPM Biotech; Hamburg, Germany
| | - Hervé Porchet
- GeNeuro SA; Plan-les-Ouates/Geneva, Switzerland
- Department of Pharmacology; University of Pretoria; Pretoria, South Africa
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Zaheer F, Berger JR. Treatment-related progressive multifocal leukoencephalopathy: current understanding and future steps. Ther Adv Drug Saf 2014; 3:227-39. [PMID: 25083238 DOI: 10.1177/2042098612453849] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disorder of the brain caused by a ubiquitous polyomavirus, JC virus. PML is almost always associated with some underlying immunosuppression and acquired immune deficiency syndrome has been the most common predisposing disorder. Recently, different pharmacological agents have been demonstrated to increase the risk of PML. Therapies that predispose people to PML can be classified into three categories: therapies that uniquely increase the risk for the disorder, such as the monoclonal antibodies natalizumab and efalizumab; therapies that appear to increase the risk in individuals already at risk of PML due to pre-existing conditions, such as rituximab and mycophenolate mofetil; and therapies with a mechanism of action that might suggest a potential for increased PML risk and/or with which rare cases of PML have been observed. Unlike the latter two classes, therapeutic agents uniquely increasing the risk of PML are associated with a much greater prevalence of the disorder and a latent interval from the time of drug initiation to the development of PML. PML development with pharmacological agents has provided new insight into the pathogenesis of this devastating disorder. This review focuses on the risks of PML with multiple pharmacological agents, the proposed pathogenesis with these agents, and potential risk mitigation strategies.
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Affiliation(s)
- Fariha Zaheer
- Department of Neurology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Joseph R Berger
- Department of Neurology, University of Kentucky, Kentucky Clinic Room L-445, 740 S. Limestone St., Lexington, KY 40536, USA
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Cantor JM. CD98 is a potential target for ablating B cell clonal expansion and autoantibody in multiple sclerosis. J Neuroimmunol 2014; 274:230-3. [PMID: 25002078 DOI: 10.1016/j.jneuroim.2014.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/01/2014] [Accepted: 06/17/2014] [Indexed: 01/15/2023]
Abstract
Current B cell-directed therapies for multiple sclerosis impact multiple B cell functions. CD98hc enables B cell clonal expansion and antibody production. I probed the relative importance of autoantibody secretion vs. other B cell functions in MS and targeted CD98hc as a possible therapeutic strategy. I report that the loss of CD98hc function in B cells largely prevents autoantibody production while preserving antigen-presenting and T cell-directing capacities. Mice lacking CD98hc in B cells are protected from EAE; importantly this is overcome with autoantibody-containing plasma. Thus CD98hc blockade is a possible avenue to treat MS by inhibiting clonal expansion and autoantibody.
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Affiliation(s)
- Joseph M Cantor
- Department of Medicine, University of California San Diego, MC 0726, 9500 Gilman Drive, La Jolla, CA 92093-0726, United States.
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12
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Monaco MCG, Major EO. The link between VLA-4 and JC virus reactivation. Expert Rev Clin Immunol 2014; 8:63-72. [DOI: 10.1586/eci.11.85] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Multiple sclerosis (MS) is considered as an autoimmune disorder of the CNS with neuro-inflammatory and neurodegenerative components. We review here the innovative drugs recently registered and those in clinical development for MS. Immunomodulation has been the preferred therapeutic approach for MS since the first IFN-β was registered in the 1990s. Several immunomodulators are now available, which show a high efficacy in reducing the number of relapses in patients with the relapsing-remitting form of MS (RRMS). The high efficacy of most immunomodulators is, however, associated with substantial safety risks, notably concerning infections or cancers. Recently oral drugs have been approved for RRMS; however, biologics, and notably, monoclonal antibodies are still well represented in the development pipelines. An unmet medical need remains the treatment of the primary and secondary forms of MS or chronic progressive MS (CPMS). Half a dozen immunomodulators with proven efficacy in RRMS are now undergoing evaluation in Phase III trials in the CPMS indication. Neuroprotective drugs that prevent demyelination and/or improve remyelination would be interesting for CPMS, but these drugs are currently in the early development phase and their efficacy has not been demonstrated yet.
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Affiliation(s)
- François Curtin
- GeNeuro SA, Chemin des Aulx 18, CH-1228 Plan-les-Ouates/Geneva, Switzerland
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Lugaresi A, di Ioia M, Travaglini D, Pietrolongo E, Pucci E, Onofrj M. Risk-benefit considerations in the treatment of relapsing-remitting multiple sclerosis. Neuropsychiatr Dis Treat 2013; 9:893-914. [PMID: 23836975 PMCID: PMC3699254 DOI: 10.2147/ndt.s45144] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system and mainly affects young adults. Its natural history has changed in recent years with the advent of disease-modifying drugs, which have been available since the early 1990s. The increasing number of first-line and second-line treatment options, together with the variable course of the disease and patient lifestyles and expectations, makes the therapeutic decision a real challenge. The aim of this review is to give a comprehensive overview of the main present and some future drugs for relapsing-remitting MS, including risk-benefit considerations, to enable readers to draw their own conclusions regarding the risk-benefit assessment of personalized treatment strategies, taking into account not only treatment-related but also disease-related risks. We performed a Medline literature search to identify studies on the treatment of MS with risk stratification and risk-benefit considerations. We focused our attention on studies of disease-modifying, immunomodulating, and immunosuppressive drugs, including monoclonal antibodies. Here we offer personal considerations, stemming from long-term experience in the treatment of MS and thorough discussions with other neurologists closely involved in the care of patients with the disease. MS specialists need to know not only the specific risks and benefits of single drugs, but also about drug interactions, either in simultaneous or serial combination therapy, and patient comorbidities, preferences, and fears. This has to be put into perspective, considering also the risks of untreated disease in patients with different clinical and radiological characteristics. There is no single best treatment strategy, but therapy has to be tailored to the patient. This is a time-consuming task, rich in complexity, and influenced by the attitude towards risk on the parts of both the patient and the clinical team. The broader the MS drug market becomes, the harder it will be for the clinician to help the patient decide which therapeutic strategy to opt for.
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Affiliation(s)
- Alessandra Lugaresi
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Maria di Ioia
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Daniela Travaglini
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Erika Pietrolongo
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Eugenio Pucci
- Operative Unit Neurologia ASUR Marche Area Vasta 3, Macerata, Italy
| | - Marco Onofrj
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
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Filippini G, Del Giovane C, Vacchi L, D'Amico R, Di Pietrantonj C, Beecher D, Salanti G. Immunomodulators and immunosuppressants for multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2013:CD008933. [PMID: 23744561 DOI: 10.1002/14651858.cd008933.pub2] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Different therapeutic strategies are available for treatment of multiple sclerosis (MS) including immunosuppressants, immunomodulators, and monoclonal antibodies. Their relative effectiveness in the prevention of relapse or disability progression is unclear due to the limited number of direct comparison trials. A summary of the results, including both direct and indirect comparisons of treatment effects, may help to clarify the above uncertainty. OBJECTIVES To estimate the relative efficacy and acceptability of interferon ß-1b (IFNß-1b) (Betaseron), interferon ß-1a (IFNß-1a) (Rebif and Avonex), glatiramer acetate, natalizumab, mitoxantrone, methotrexate, cyclophosphamide, azathioprine, intravenous immunoglobulins, and long-term corticosteroids versus placebo or another active agent in participants with MS and to provide a ranking of the treatments according to their effectiveness and risk-benefit balance. SEARCH METHODS We searched the Cochrane Database of Systematic Reviews, the Cochrane MS Group Trials Register, and the Food and Drug Administration (FDA) reports. The most recent search was run in February 2012. SELECTION CRITERIA Randomized controlled trials (RCTs) that studied one of the 11 treatments for use in adults with MS and that reported our pre-specified efficacy outcomes were considered for inclusion. DATA COLLECTION AND ANALYSIS Identifying search results and data extraction were performed independently by two authors. Data synthesis was performed by pairwise meta-analysis and network meta-analysis that was performed within a Bayesian framework. The body of evidence for outcomes within the pairwise meta-analysis was assessed according to GRADE, as very low, low, moderate, or high quality. MAIN RESULTS Forty-four trials were included in this review, in which 17,401 participants had been randomised. Twenty-three trials included relapsing-remitting MS (RRMS) (9096 participants, 52%), 18 trials included progressive MS (7726, 44%), and three trials included both RRMS and progressive MS (579, 3%). The majority of the included trials were short-term studies, with the median duration being 24 months. The results originated mostly from 33 trials on IFNß, glatiramer acetate, and natalizumab that overall contributed outcome data for 9881 participants (66%).From the pairwise meta-analysis, there was high quality evidence that natalizumab and IFNß-1a (Rebif) were effective against recurrence of relapses in RRMS during the first 24 months of treatment compared to placebo (odds ratio (OR) 0.32, 95% confidence interval (CI) 0.24 to 0.43; OR 0.45, 95% CI 0.28 to 0.71, respectively); they were more effective than IFNß-1a (Avonex) (OR 0.28, 95% CI 0.22 to 0.36; OR 0.19, 95% CI 0.06 to 0.60, respectively). IFNß-1b (Betaseron) and mitoxantrone probably decreased the odds of the participants with RRMS having clinical relapses compared to placebo (OR 0.55, 95% CI 0.31 to 0.99; OR 0.15, 95% CI 0.04 to 0.54, respectively) but the quality of evidence for these treatments was graded as moderate. From the network meta-analysis, the most effective drug appeared to be natalizumab (median OR versus placebo 0.29, 95% credible intervals (CrI) 0.17 to 0.51), followed by IFNß-1a (Rebif) (median OR versus placebo 0.44, 95% CrI 0.24 to 0.70), mitoxantrone (median OR versus placebo 0.43, 95% CrI 0.20 to 0.87), glatiramer acetate (median OR versus placebo 0.48, 95% CrI 0.38 to 0.75), IFNß-1b (Betaseron) (median OR versus placebo 0.48, 95% CrI 0.29 to 0.78). However, our confidence was moderate for direct comparison of mitoxantrone and IFNB-1b vs placebo and very low for direct comparison of glatiramer vs placebo. The relapse outcome for RRMS at three years' follow-up was not reported by any of the included trials.Disability progression was based on surrogate markers in the majority of included studies and was unavailable for RRMS beyond two to three years. The pairwise meta-analysis suggested, with moderate quality evidence, that natalizumab and IFNß-1a (Rebif) probably decreased the odds of the participants with RRMS having disability progression at two years' follow-up, with an absolute reduction of 14% and 10%, respectively, compared to placebo. Natalizumab and IFNß-1b (Betaseron) were significantly more effective (OR 0.62, 95% CI 0.49 to 0.78; OR 0.35, 95% CI 0.17 to 0.70, respectively) than IFNß-1a (Avonex) in reducing the number of the participants with RRMS who had progression at two years' follow-up, and confidence in this result was graded as moderate. From the network meta-analyses, mitoxantrone appeared to be the most effective agent in decreasing the odds of the participants with RRMS having progression at two years' follow-up, but our confidence was very low for direct comparison of mitoxantrone vs placebo. Both pairwise and network meta-analysis revealed that none of the individual agents included in this review were effective in preventing disability progression over two or three years in patients with progressive MS.There was not a dose-effect relationship for any of the included treatments with the exception of mitoxantrone. AUTHORS' CONCLUSIONS Our review should provide some guidance to clinicians and patients. On the basis of high quality evidence, natalizumab and IFNß-1a (Rebif) are superior to all other treatments for preventing clinical relapses in RRMS in the short-term (24 months) compared to placebo. Moderate quality evidence supports a protective effect of natalizumab and IFNß-1a (Rebif) against disability progression in RRMS in the short-term compared to placebo. These treatments are associated with long-term serious adverse events and their benefit-risk balance might be unfavourable. IFNß-1b (Betaseron) and mitoxantrone probably decreased the odds of the participants with RRMS having relapses, compared with placebo (moderate quality of evidence). The benefit-risk balance with azathioprine is uncertain, however this agent might be effective in decreasing the odds of the participants with RRMS having relapses and disability progression over 24 to 36 months, compared with placebo. The lack of convincing efficacy data shows that IFNß-1a (Avonex), intravenous immunoglobulins, cyclophosphamide and long-term steroids have an unfavourable benefit-risk balance in RRMS. None of the included treatments are effective in decreasing disability progression in patients with progressive MS. It is important to consider that the clinical effects of all these treatments beyond two years are uncertain, a relevant point for a disease of 30 to 40 years duration. Direct head-to-head comparison(s) between natalizumab and IFNß-1a (Rebif) or between azathioprine and IFNß-1a (Rebif) should be top priority on the research agenda and follow-up of the trial cohorts should be mandatory.
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Affiliation(s)
- Graziella Filippini
- Neuroepidemiology Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milano, Italy.
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Comi G, Battaglia MA, Bertolotto A, Del Sette M, Ghezzi A, Malferrari G, Salvetti M, Sormani MP, Tesio L, Stolz E, Mancardi G. Italian multicentre observational study of the prevalence of CCSVI in multiple sclerosis (CoSMo study): rationale, design, and methodology. Neurol Sci 2013; 34:1297-307. [PMID: 23344741 PMCID: PMC3747324 DOI: 10.1007/s10072-012-1269-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 12/05/2012] [Indexed: 11/29/2022]
Abstract
Chronic cerebro-spinal venous insufficiency (CCSVI) has been proposed as a “congenital malformation” implicated in the pathogenesis of multiple sclerosis (MS). However, numerous studies failed to confirm its presence in MS patients. This paper presents the rationale, design, and methodology adopted in the CoSMo study, conducted with the aim of verifying whether or not CCSVI is linked to MS. The primary endpoint of the CoSMo study is to compare the prevalence of CCSVI in patients with MS versus patients affected by other neurodegenerative diseases (OND) and healthy volunteers. CoSMo is a multicenter, blinded, prevalence study recruiting 2,000 adult subjects, involving 43 MS centers across Italy. Assessment of the presence or absence of CCSVI is performed by color-coded duplex (CCD) sonography and two out of the five criteria according to Zamboni are necessary for the diagnosis of CCSVI. Local CCD examination carried out by a certified sonologist and the central image readings performed by experts in the field are blinded. An advanced protocol is also described in this paper. The application of a rigorous methodological design will definitively confirm whether an association exists between CCSVI and MS. Should an association be observed, this study also further examines the link between CCSVI and the severity of MS. The addition of subgroups without MS and OND also provides information on whether CCSVI is specific to MS only. Results from the CoSMo study will play a crucial role in the possible studies concerning the potential treatment of CCSVI in MS.
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Affiliation(s)
- Giancarlo Comi
- Division of Neurology and Neurophysiology Service, Ospedale "San Raffaele", Milan, Italy
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Engineering aggregation resistance in IgG by two independent mechanisms: lessons from comparison of Pichia pastoris and mammalian cell expression. J Mol Biol 2012; 417:309-35. [PMID: 22306407 DOI: 10.1016/j.jmb.2012.01.027] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/16/2012] [Accepted: 01/20/2012] [Indexed: 11/22/2022]
Abstract
Aggregation is an important concern for therapeutic antibodies, since it can lead to reduced bioactivity and increase the risk of immunogenicity. In our analysis of immunoglobulin G (IgG) molecules of identical amino acid sequence but produced either in mammalian cells (HEK293) or in the yeast Pichia pastoris (PP), dramatic differences in their aggregation susceptibilities were encountered. The antibodies produced in Pichia were much more resistant to aggregation under many conditions, a phenomenon found to be mainly caused by two factors. First, the mannose-rich glycan of the IgG from Pichia, while slightly thermally destabilizing the IgG, strongly inhibited its aggregation susceptibility, compared to the complex mammalian glycan. Second, on the Pichia-produced IgGs, amino acids belonging to the α-factor pre-pro sequence were left at the N-termini of both chains. These additional residues proved to considerably increase the temperature of the onset of aggregation and reduced the aggregate formation after extended incubation at elevated temperatures. The attachment of these residues to IgGs produced in cell culture confirmed their beneficial effect on the aggregation resistance. Secretion of IgGs with native N-termini in the yeast system became possible after systematic engineering of the precursor proteins and the processing site. Taken together, the present results will be useful for the successful production of full-length IgGs in Pichia, give indications on how to engineer aggregation-resistant IgGs and shed new light on potential biophysical effects of tag sequences in general.
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Uettwiller F, Rigal E, Hoarau C. Infections associated with monoclonal antibody and fusion protein therapy in humans. MAbs 2011; 3:461-6. [PMID: 21822056 DOI: 10.4161/mabs.3.5.16553] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Monoclonal antibodies (mAbs), especially those that interact with immune or hematologic leukocyte membrane targets, have changed the outcome of numerous diseases. However, mAbs can block or reduce immune cells and cytokines, and can lead to increased risk of infection. Some of these risks are predictable and can be explained by their mechanisms of action. Others have been observed only after the mAbs were licensed and used extensively in patients. In this review, we focus on infectious complications that occur upon treatment with mAbs or Fc-containing fusion proteins targeting leukocyte membrane proteins, including CD52, CD20, tumor necrosis factor, VLA4, CD11a and CTLA4. We report their known infectious risks and the recommendations for their use. Although most of these drugs are clinically safe when the indications are respected, we emphasize the need for regular updating of pharmacovigilance data.
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Affiliation(s)
- Florence Uettwiller
- Allergology and Clinical Immunology Unit, Pediatric Unit, Clocheville Hospital, "CDIG" François Rabelais University, Tours, France
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Workman G, Sage EH. Identification of a sequence in the matricellular protein SPARC that interacts with the scavenger receptor stabilin-1. J Cell Biochem 2011; 112:1003-8. [PMID: 21308731 DOI: 10.1002/jcb.23015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
SPARC (osteonectin/BM-40), a secreted matricellular protein that promotes cellular deadhesion and motility in wound healing, carcinogenesis, and inflammation, binds to the scavenger receptor stabilin-1 in alternatively activated macrophages and undergoes endocytosis and clearance from the extracellular space. Both SPARC and stabilin-1 are expressed by endothelial cells during inflammation, but their interaction in this context is unknown. We have identified a binding site on SPARC for stabilin-1 by a solid-state peptide array coupled with a modified enzyme-linked immunosorbent assay. A monoclonal antibody that recognizes the identified binding site was also characterized that could be an inhibitor for the SPARC-stabilin-1 interaction in macrophages or endothelial cells.
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Affiliation(s)
- Gail Workman
- Department of Vascular Biology, Benaroya Research Institute, Seattle, Washington 98101, USA
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Abstract
After infection, most antigen-specific memory T cells reside in nonlymphoid tissues. Tissue-specific programming during priming leads to directed migration of T cells to the appropriate tissue, which promotes the development of tissue-resident memory in organs such as intestinal mucosa and skin. Mechanisms that regulate the retention of tissue-resident memory T cells include transforming growth factor-β (TGF-β)-mediated induction of the E-cadherin receptor CD103 and downregulation of the chemokine receptor CCR7. These pathways enhance protection in internal organs, such as the nervous system, and in the barrier tissues--the mucosa and skin. Memory T cells that reside at these surfaces provide a first line of defense against subsequent infection, and defining the factors that regulate their development is critical to understanding organ-based immunity.
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Affiliation(s)
- Brian S Sheridan
- Center for Integrated Immunology and Vaccine Research, Department of Immunology, University of Connecticut Health Center, Farmington, Connecticut, USA.
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