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Alroughani R, Al-Hashel J, Ahmed SF. Substantial and comparable suppression of disease activity following early initiation of cladribine tablets, ocrelizumab or alemtuzumab as first pharmacologic treatment for relapsing multiple sclerosis: A real world study. Clin Neurol Neurosurg 2024; 240:108249. [PMID: 38513425 DOI: 10.1016/j.clineuro.2024.108249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 03/13/2024] [Accepted: 03/16/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND We describe the efficacy and safety of recent high efficacy disease DMTs in DMT-naive patients with highly active RMS. METHODS This was a retrospective, cross sectional study from the Kuwait national MS registry. Patients with RMS who received alemtuzumab, cladribine tablets or ocrelizumab as their first DMT for RMS, with ≥2 year of follow up were included. The primary endpoint was the change in relapse rate from treatment initiation to 1 year; changes in disability (Expanded Disability Status Scale [EDSS]), radiologic activity, the proportion with no evidence of disease activity-3 (NEDA-3), and the frequency of adverse events were secondary endpoints. RESULTS Among 123 RRMS patients, 59 received ocrelizumab, 32 received cladribine tablets and 32 received alemtuzumab. About two-thirds (65%) were women. Substantial and similar (p>0.05) reductions occurred at the end of follow-up in annual relapse rate (by 93.2% for ocrelizumab, 87.5% for cladribine tablets, and 90.6% for alemtuzumab). The proportion with new T2 of gadolinium-enhancing MRI lesions across the three groups was reduced from 85-100% to 7-13%. Rates of confirmed disability progression were low (ocrelizumab 6.9%, cladribine tablets 3.1%, alemtuzumab 0%; p=0.280); disability was reduced in 15%, 22% and 38%, respectively. NEDA-3 was observed in 89.8%, 87.5%, and 84.4, respectively (p=0.784). No new or unexpected safety issues occurred. CONCLUSION Ocrelizumab, cladribine tablets and alemtuzumab reduced relapse rates and MRI activity, and prevented disease progression, when are initiated early in DMT-naive RMS patients. These data support the early use of high-efficacy DMTs for people with highly active RMS.
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Affiliation(s)
| | - Jasem Al-Hashel
- Department of Neurology, Ibn Sina Hospital, Safat, Kuwait; Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait
| | - Samar Farouk Ahmed
- Department of Neurology, Ibn Sina Hospital, Safat, Kuwait; Department of Neurology and Psychiatry, Minia University, Egypt.
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de Seze J, Dive D, Ayrignac X, Castelnovo G, Payet M, Rayah A, Gobbi C, Vermersch P, Zecca C. Narrative Review on the Use of Cladribine Tablets as Exit Therapy for Stable Elderly Patients with Multiple Sclerosis. Neurol Ther 2024:10.1007/s40120-024-00603-y. [PMID: 38587749 DOI: 10.1007/s40120-024-00603-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
The number of ageing people with relapsing multiple sclerosis (RMS) is increasing. The efficacy of disease-modifying therapies (DMTs) for RMS declines with age. Also, older persons with MS may be more susceptible to infections, hospitalisations and malignancy. Aging people with MS have higher rates of comorbidities versus aged-matched controls, increasing the individual risk of disability. We review the therapeutic properties of cladribine tablets (CladT) in ageing people with RMS, with regard to their utility for allowing these individuals to cease continuous administration of a DMT (i.e. to act as an "exit therapy"). CladT is thought to be an immune reconstitution therapy, in that two short courses of oral treatment 1 year apart provide suppression of MS disease activity in responders that far outlasts the duration of treatment and post-treatment reductions in lymphocyte counts. Post hoc analyses, long-term follow-up of populations with RMS in randomised trials, and real-world evidence suggest that the efficacy of CladT is probably independent of age, although more data in the elderly are still needed. No clear adverse signals for lymphopenia or other adverse safety signals have emerged with increasing age, although immunosenescence in the setting of age-related "inflammaging" may predispose elderly patients to a higher risk of infections. Updating vaccination status is recommended, especially against pneumococci and herpes zoster for older patients, to minimise the risk of these infections. CladT may be a useful alternative treatment for ageing people with MS who often bear a burden of multiple comorbidities and polypharmacy and who are more exposed to the adverse effects of continuous immunosuppressive therapy.
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Affiliation(s)
- Jerome de Seze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France.
| | - Dominique Dive
- Department of Neurology, Liège University Hospital, Liège, Belgium
| | - Xavier Ayrignac
- Department of Neurology, University of Montpellier, INM, INSERM, Montpellier University Hospital, Montpellier, France
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Marianne Payet
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Amel Rayah
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Claudio Gobbi
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Patrick Vermersch
- University of Lille, INSERM U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Chiara Zecca
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
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Ciron J, Bourre B, Castelnovo G, Guennoc AM, De Sèze J, Ben-Amor AF, Savarin C, Vermersch P. Holistic, Long-Term Management of People with Relapsing Multiple Sclerosis with Cladribine Tablets: Expert Opinion from France. Neurol Ther 2024:10.1007/s40120-024-00589-7. [PMID: 38488979 DOI: 10.1007/s40120-024-00589-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/09/2024] [Indexed: 03/17/2024] Open
Abstract
Cladribine tablets (CladT) has been available for therapeutic use in France since March 2021 for the management of highly active relapsing multiple sclerosis (RMS). This high-efficacy disease-modifying therapy (DMT) acts as an immune reconstitution therapy. In contrast to most high-efficacy DMTs, which act via continuous immunosuppression, two short courses of oral treatment with CladT at the beginning of years 1 and 2 of treatment provide long-term control of MS disease activity in responders to treatment, without the need for any further pharmacological treatment for several years. Although the labelling for CladT does not provide guidance beyond the initial treatment courses, real-world data on the therapeutic use of CladT from registries of previous clinical trial participants and patients treated in routine practice indicate that MS disease activity is controlled for a period of years beyond this time for a substantial proportion of patients. Moreover, this clinical experience has provided useful information on how to initiate and manage treatment with CladT. In this article we, a group of expert neurologists from France, provide recommendations on the initiation of CladT in DMT-naïve patients, how to switch from existing DMTs to CladT for patients with continuing MS disease activity, how to manage patients during the first 2 years of treatment and finally, how to manage patients with or without MS disease activity in years 3, 4 and beyond after initiating treatment with CladT. We believe that optimisation of the use of CladT beyond its initial courses of treatment will maximise the benefits of this treatment, especially early in the course of MS when suppression of focal inflammation in the CNS is a clinical priority to limit MS disease progression.
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Affiliation(s)
- Jonathan Ciron
- Department of Neurology, Centre de Ressources et de Compétences Sclérose en Plaques (CRC-SEP), Toulouse University Hospital, Hôpital Pierre-Paul Riquet, Toulouse, France
- INSERM UMR1291, CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse III, Toulouse, France
| | | | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | | | - Jérôme De Sèze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Ali Frederic Ben-Amor
- Knowlepsy Investment, Marseille Innovation, Technopôle de Château-Gombert, Marseille, France
| | - Carine Savarin
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France.
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Brochet B, Solari A, Lechner-Scott J, Piehl F, Langdon D, Hupperts R, Selmaj K, Patti F, Brieva L, Maida EM, Alexandri N, Smyk A, Nolting A, Keller B, Montalban X, Kubala Havrdova E. Improvements in quality of life over 2 years with cladribine tablets in people with relapsing multiple sclerosis: The CLARIFY-MS study. Mult Scler 2023; 29:1808-1818. [PMID: 37978852 PMCID: PMC10687821 DOI: 10.1177/13524585231205962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) negatively affects health-related quality of life (HRQoL). OBJECTIVE To evaluate HRQoL in people with highly active relapsing MS treated with cladribine tablets (CladT; 3.5 mg/kg cumulative dose over 2 years) in CLARIFY-MS. METHODS Changes in the MS quality of life (MSQoL)-54 scores were analysed using a repeated mixed-effects linear model. Subgroup analyses were performed for participants who were pretreatment-naïve and those pretreated with disease-modifying therapies (DMTs) before initiating CladT. Safety and tolerability of CladT were also assessed. RESULTS MSQoL-54 physical (mean change = 4.86; 95% confidence interval (CI) = 3.18, 6.53) and mental health (4.80; 95% CI = 3.13, 6.46) composite scores (primary endpoints) showed significant improvement at Month 24 versus Baseline (p < 0.0001). Changes in the MSQoL-54 scores were consistent across the pretreatment-naïve and DMT-pretreated subgroups. No new severe or opportunistic infections occurred. Most post-baseline lymphopenia events were Grade 1-2 in severity. Transient Grade-3 lymphopenia was observed in 19.7% (95/482) of participants. Grade-4 lymphopenia was not observed. CONCLUSIONS CladT treatment significantly improved the mean MSQoL-54 physical and mental health composite scores over 2 years. CladT efficacy in HRQoL, relapse rates and Expanded Disability Status Scale scores demonstrates its multidimensional effects in MS treatment.
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Affiliation(s)
- Bruno Brochet
- INSERM U 1215, University of Bordeaux, Bordeaux, France
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Jeannette Lechner-Scott
- University of Newcastle, Newcastle, NSW, Australia/Division of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Dawn Langdon
- Department of Psychology, Royal Holloway, University of London, Egham, UK
| | - Raymond Hupperts
- Zuyderland Medisch Centrum Sittard, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, University of Catania, and Azienda Ospedaliero Universitaria Policlinico “G. Rodolico” – San Marco, University of Catania, Italy
| | - Luis Brieva
- IRBlLeida, Hospital Arnau de Vilanova, Lérida, Spain
| | | | | | | | | | | | - Xavier Montalban
- Department of Neurology-Neuroimmunology Centre of Multiple Sclerosis of Catalonia (Cemcat), University Hospital Vall d’Hebron, Barcelona, Spain
| | - Eva Kubala Havrdova
- Department of Neurology and Center for Clinical Neuroscience, First Medical Faculty, Charles University, Prague, Czech Republic
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Rau D, Müller B, Übler S. Evaluation of Patient-Reported Outcomes in Patients with Relapsing Multiple Sclerosis Treated with Cladribine Tablets in the CLAWIR Study: 12-Month Interim Analysis. Adv Ther 2023; 40:5547-5556. [PMID: 37776477 PMCID: PMC10611608 DOI: 10.1007/s12325-023-02682-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/08/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Patient-reported outcomes (PROs) provide an insightful method of assessing the subjective impact of therapies for those affected by multiple sclerosis (MS), a chronic neurologic disease notable for symptoms of fatigue and reduced physical function. The ongoing CLAWIR study aims to assess the effect of cladribine tablets (3.5 mg/kg cumulative dose over 2 years) in patients with highly active relapsing MS focusing on PROs of fatigue, physical function, treatment satisfaction, and work productivity. Here, we report on a pre-planned analysis at 12 months after treatment initiation with cladribine tablets. METHODS CLAWIR is a 2-year, multicenter, prospective, observational study of patients with relapsing MS newly initiating cladribine tablets. The following PROs were analyzed: PRO Measurement Information System (PROMIS®) Fatigue MS (v1.0) and Physical Function MS (v2.1), Treatment Satisfaction Questionnaire for Medication (TSQM, v1.4), and Work Productivity and Activity Impairment MS Questionnaire (WPAI-MS). Data were analyzed descriptively. RESULTS In total, 128 patients were eligible for analysis: 95 females (74.2%); median (range) age 34.5 (29, 44) years; 34 patients (26.6%) were treatment-naïve, and 89 (69.5%) were early switchers from platform therapies (the remaining 5 patients [3.9%] switched from a high-efficacy disease-modifying therapy). PROMIS® Fatigue MS mean (± standard deviation [SD]) T-scores decreased from 54.6 (± 9.59) at baseline to 51.8 (± 10.30) at 12 months, indicating an alleviation of fatigue, whereas PROMIS® Physical Function MS mean T-scores remained stable over time [baseline: 49.4 (± 10.69); 12 months: 50.3 (± 10.88)]. TSQM v1.4 mean scores indicated an improvement over time, increasing from 52.2 (± 27.79) at baseline to 81.4 (± 17.06) at 12 months for global satisfaction. WPAI-MS scores also showed an improvement across all four domains over 12 months. CONCLUSION This real-world study demonstrates the effect of cladribine tablets over 12 months on PROs of fatigue, physical function, treatment satisfaction, and work productivity. TRIAL REGISTRATION The CLAWIR study is registered at the German Federal Institute for Drugs and Medical Devices with the internal NIS number 7469.
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Affiliation(s)
- Daniela Rau
- Nervenfachärztliche Gemeinschaftspraxis Ulm, Ulm, Germany
| | - Beate Müller
- Merck Healthcare Germany GmbH (an Affiliate of Merck KGaA, Darmstadt, Germany), Waldstraße 3, 64331, Weiterstadt, Germany
| | - Susanne Übler
- Merck Healthcare Germany GmbH (an Affiliate of Merck KGaA, Darmstadt, Germany), Waldstraße 3, 64331, Weiterstadt, Germany.
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Petrou P, Achiron A, Cohen EG, Garty M, Magalashvili D, Karmon Y, Milo R, Regev K, Vaknin-Dembinsky A, Wilf-Yarkoni A, Karussis D. Practical recommendations on treatment of multiple sclerosis with Cladribine: an Israeli Experts Group Viewpoint. J Neurol 2023; 270:5188-5195. [PMID: 37436562 DOI: 10.1007/s00415-023-11846-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/13/2023]
Abstract
Cladribine tablets (Mavenclad®) were approved by the European Union in 2017 as high-efficacy therapy for highly active relapsing-remitting multiple sclerosis. In Israel, Mavenclad® was approved in 2018. Real-life experience has confirmed the efficacy of cladribine tablets over at least 4 years from the initial course. During the last years, several questions were raised concerning the management of people with MS who show disease activity during years 3 and 4 post-cladribine initiation and what treatment decisions are needed beyond year 4. A few expert boards have tried to provide insight based on research data and to suggest recommendations on the therapeutic dilemmas and treatment decisions with cladribine. However, there is currently no widely accepted consensus about these issues. The vast clinical experience gained in Israel in the past 5 years in several MS centers across the country allows for a broad perspective of the outcomes with long-term cladribine use. This article summarizes previously published recent recommendations and describes the insights of Israeli neurology key opinion leaders that convened for an advisory board meeting on January 29th, 2023, with the aim of reaching a consensus regarding cladribine long-term treatment and follow-up.
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Affiliation(s)
| | | | | | | | | | | | - Ron Milo
- Barzilai Medical Center, Ashkelon, Israel
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Song Y, Wang Y, Wong SL, Yang D, Sundar M, Tundia N. Real-world treatment patterns and effectiveness of cladribine tablets in patients with relapsing forms of multiple sclerosis in the United States. Mult Scler Relat Disord 2023; 79:105052. [PMID: 37832254 DOI: 10.1016/j.msard.2023.105052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/14/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Real-world evidence on the use of cladribine tablets (CladT) for relapsing forms of multiple sclerosis (RMS) in the United States is emerging. The objective of this study was to assess the real-world treatment patterns and effectiveness of CladT in RMS. METHODS Adults with RMS initiating CladT were selected from the Symphony Integrated Dataverse. Baseline and follow-up periods were the 12 months before and 24 months after CladT initiation (index date). Switching to another disease-modifying therapy (DMT) and number of CladT courses were described during follow-up. Annualized relapse rate (ARR), MS disease severity, Expanded Disability Status Scale-Derived Disability Indicators (EDSS-DDI), corticosteroid use, and healthcare resource utilization (HRU) were described during Years 1 and 2 of follow-up and compared with baseline. RESULTS A total of 539 CladT-treated patients were included (mean age: 49.9 years; 77.6 % female). Over the 2-year follow-up, 91 % and 59 % of patients had one and two CladT courses, respectively, and 7 % of patients had evidence of switching to another DMT. ARR, MS disease severity score, and corticosteroid use decreased significantly during follow-up compared with baseline, while EDSS-DDI remained stable. All-cause and MS-related HRU decreased during follow-up. CONCLUSION CladT-treated patients with RMS had low switch rates, reduced ARR, disease severity, corticosteroid use, and HRU.
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Affiliation(s)
| | - Yan Wang
- Analysis Group, Los Angeles, CA, USA
| | - Schiffon L Wong
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | | | | | - Namita Tundia
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA.
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Brownlee W, Amin A, Ashton L, Herbert A. Real-world use of cladribine tablets (completion rates and treatment persistence) in patients with multiple sclerosis in England: The CLARENCE study. Mult Scler Relat Disord 2023; 79:104951. [PMID: 37639781 DOI: 10.1016/j.msard.2023.104951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/28/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Treatment with cladribine tablets, a high-efficacy disease-modifying therapy (DMT), has been available in England since 2017 for patients with highly active relapsing multiple sclerosis (MS). Real-world data on treatment completion, persistence and switching in patients treated with cladribine tablets are beginning to emerge, but only small single and multicentre cohorts have reported so far. This longitudinal retrospective observational study (CLARENCE) evaluated a large cohort (>1900) of patients with highly active relapsing MS, receiving cladribine tablets across England, to determine rates of treatment completion, persistence and switching in the real world. METHODS Using data obtained from Blueteq® forms, a compulsory requirement for DMT reimbursement in England, we evaluated rates of treatment completion (defined as the proportion of patients who received the full 2-year course of cladribine tablets), treatment persistence (defined as the proportion of patients who did not switch and/or discontinue treatment before receiving the full 2-year course) and treatment switch (defined as the proportion of patients who switched treatment from cladribine tablets to another DMT at any point after their first course). The change in Expanded Disability Status Scale (EDSS) score between Years 1 and 2 of treatment was also determined. All data were analysed descriptively. RESULTS Blueteq® forms were completed for 1934 MS patients treated with cladribine tablets; of these patients, 691 (36%) were treatment naïve. The median EDSS score (range) at treatment initiation with cladribine tablets was 2.5 (0, 8.5). At time of analysis (September 2021, last follow-up point), a total of 1020 (53%) patients had completed the full 2-year course of cladribine tablets. At the same time point, 1762 (91%) patients were considered as treatment persistent (i.e., the patient had completed either 1 course of tablets with <18 months of follow-up data or the full 2-year course of cladribine tablets). Overall, 78 (4%) patients switched to another DMT at any point after their first course, which included 33 (1.7%) patients who switched after completing the full 2-year course. In terms of their disability, 469 (84%) patients had stable EDSS scores between Years 1 and 2 of treatment. CONCLUSION In this large real-world study of patients receiving cladribine tablets across England, high rates of treatment persistence and low rates of switching were observed, with only 1.7% of patients receiving the full 2-year course and switching treatment. The majority (84%) of evaluable patients showed stable disability between Years 1 and 2 of treatment. These findings complement earlier data from clinical trials and real-world studies, confirming the effectiveness of cladribine tablets for patients with highly active relapsing MS.
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Affiliation(s)
- Wallace Brownlee
- Queen Square MS Centre, UCL Institute of Neurology and NIHR UCL Hospitals Biomedical Research Centre, London, UK.
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Butzkueven H, Hillert J, Soilu-Hänninen M, Ziemssen T, Kuhle J, Wergeland S, Magyari M, Berger JR, Moore N, Aydemir A, Bezemer I, Sabidó M. The CLARION study: first report on safety findings in patients newly initiating treatment with cladribine tablets or fingolimod for multiple sclerosis. Curr Med Res Opin 2023; 39:1367-1374. [PMID: 37675878 DOI: 10.1080/03007995.2023.2256220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVES As part of the CLARION study: (1) characterize the incidence of severe infections, herpes zoster, and malignancies in patients newly initiating cladribine or fingolimod for relapsing multiple sclerosis (MS); (2) estimate the incidence of severe lymphopenia among cladribine users; and (3) describe prior/subsequent disease-modifying therapy (DMT) in both cohorts. METHODS Patients were identified from seven participating MS registries/data sources. The incidence rate (IR) of each outcome per 1000 patient-years and its 95% confidence interval (95%CI) were estimated for cohorts using Poisson regression. RESULTS By cut-off date (01-April-2020), 742 cladribine and 867 fingolimod users were included. Mean follow-up was ∼1 year. The IR for severe infections from all contributing sources (except Denmark) was: cladribine, 7.37 (2.76,19.6); fingolimod, 6.55 (2.46,17.4). The corresponding IR for herpes zoster was 5.51 (1.78,17.1) and 3.27 (0.82,13.1), respectively, while values for opportunistic infections were 0 (0,6.76) and 1.63 (0.23,11.6), respectively. There were no events of progressive multifocal leukoencephalopathy in either cohort. The IR of severe lymphopenia was 63.9 (40.7,100.1) in 349 cladribine users from contributing sources. The IR of malignancies (cut-off date 01-April-2022) was 3.55 (1.59,7.90) for the cladribine cohort (n = 1035) and 3.55 (1.48,8.52) for the fingolimod cohort (n = 843) from three MS registries/data sources. In the combined data sources, 36.8% of cladribine and 27.4% of fingolimod users were DMT-naïve; after initiation of study treatment, 2.5% and 20.2% switched to another DMT, respectively. CONCLUSION No new safety signal was observed in patients treated with cladribine tablets, although results are limited by a relatively short duration of follow-up.
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Affiliation(s)
- Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- The Alfred Hospital, Melbourne, VIC, Australia
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Merja Soilu-Hänninen
- Turku University Hospital Neurocenter and Division of Clinical Neurosciences, University of Turku, Turku, Finland
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, Dresden University of Technology, Dresden, Germany
| | - Jens Kuhle
- Multiple Sclerosis Center and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital and University of Basel, Basel, Switzerland
| | - Stig Wergeland
- Norwegian MS Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Melinda Magyari
- Danish Multiple Sclerosis Center and the Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Joseph R Berger
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas Moore
- Bordeaux PharmacoEpi (BPE), Université de Bordeaux, Bordeaux, France
| | - Aida Aydemir
- EMD Serono Research & Development Institute, Inc, Billerica, MA, USA, an affiliate of Merck KGaA
| | - Irene Bezemer
- Global Epidemiology, IQVIA, Amsterdam, The Netherlands
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Clavelou P, Castelnovo G, Pourcher V, De Sèze J, Vermersch P, Ben-Amor AF, Savarin C, Defer G. Expert Narrative Review of the Safety of Cladribine Tablets for the Management of Relapsing Multiple Sclerosis. Neurol Ther 2023; 12:1457-1476. [PMID: 37382841 PMCID: PMC10444734 DOI: 10.1007/s40120-023-00496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/11/2023] [Indexed: 06/30/2023] Open
Abstract
Cladribine tablets (CladT) is a highly active oral disease-modifying therapy (DMT) for the management of relapsing multiple sclerosis (RMS). CladT acts as an immune reconstitution therapy, in that two short courses of treatment 1 year apart have been shown to suppress disease activity for a prolonged period in most patients, without need for continued DMT. Each course of CladT induces a profound reduction in B lymphocytes that recovers over months, and serious lymphopenia (Grade 3-4) is uncommon. Smaller reductions in levels of T lymphocytes occur slightly later: on average, these remain within the normal range and repopulate progressively. A larger effect occurs on CD8 vs. CD4 cells. Reactivation of latent or opportunistic infections (e.g. varicella zoster, tuberculosis) is mostly associated with very low lymphocyte counts (< 200/mm3). Screening and managing pre-existing infections, vaccinating non-exposed patients and delaying the 2nd year of treatment with CladT to allow lymphocytes to recover to > 800/mm3 (if necessary) are important for avoiding infections and higher-grade lymphopenia. There was no demonstrable or apparent effect of CladT on the efficacy of vaccinations, including against Covid-19. Adverse events consistent with drug-induced liver injury (DILI) represent a rare but potentially serious complication of CladT therapy in spontaneous adverse event reporting; patients should be screened for liver dysfunction before starting treatment. Ongoing hepatic monitoring is not required, but CladT must be withdrawn if signs and symptoms of DILI develop. There was a numerical imbalance for malignancies when comparing cladribine to placebo in the clinical programme, particularly in short-term data, but recent evidence shows that the risk of malignancy with CladT is similar to the background rate in the general population and to that with other DMTs. Overall, CladT is well tolerated with a favorable safety profile appropriate for the management of RMS.
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Affiliation(s)
- Pierre Clavelou
- Department of Neurology, Clermont-Ferrand University Hospital, 58 Rue Montalembert, 63003, Clermont-Ferrand Cedex 1, France.
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Valérie Pourcher
- Department of Infectious and Tropical Diseases, Pitié-Salpêtrière Hospital, APHP, Sorbonne Université, INSERM 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique Paris, Paris, France
| | - Jerome De Sèze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Ali-Frederic Ben-Amor
- Global Medical Affairs Neurology and Immunology, Ares Trading SA (An affiliate of Merck KGaA, Darmstadt, Germany), Eysins, Switzerland
| | - Carine Savarin
- Neurology Department, Medical Affairs (An affiliate of Merck KGaA, Darmstadt, Germany), Merck Santé, Lyon, France
| | - Gilles Defer
- Department of Neurology, Caen University Hospital, Caen, France
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Inshasi J, Farouk S, Shatila A, Hassan A, Szolics M, Thakre M, Kayed D, Krieger D, Almadani A, Alsaadi T, Benedetti B, Mifsud V, Jacob A, Sayegh S, Boshra A, Alroughani R. Multicentre Observational Study of Treatment Satisfaction with Cladribine Tablets in the Management of Relapsing Multiple Sclerosis in the Arabian Gulf: The CLUE Study. Neurol Ther 2023; 12:1309-1318. [PMID: 37289421 PMCID: PMC10310633 DOI: 10.1007/s40120-023-00497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/10/2023] [Indexed: 06/09/2023] Open
Abstract
INTRODUCTION Inconvenient administration and side effects of some disease-modifying therapies (DMTs) for relapsing multiple sclerosis (RMS) can deter adherence. We evaluated treatment satisfaction with cladribine tablets (CladT) for RMS in the Arabian Gulf. METHODS This was a non-interventional, multicentre, prospective observational study in non-pregnant/lactating adults (aged ≥ 18 years) with RMS eligible for 1st treatment with CladT (EU labelling). The primary outcome was overall treatment satisfaction at 6 months (Treatment Satisfaction Questionnaire for Medication [TSQM]-14, v. 1.4), Global Satisfaction subscale. Secondary endpoints were TSQM-14 scores for convenience, satisfaction with side effects and satisfaction with effectiveness. Patients provided written informed consent. RESULTS Of 63 patients screened, 58 received CladT and 55 completed the study. Mean age was 33 ± 9 years; mean weight 73 ± 17 kg; 31% male/69% female; mostly from the United Arab Emirates (52%) or Kuwait (30%). All had RMS (mean 0.9 ± 1.1 relapses in the past year), mean Expanded Disability Status Scale (EDSS) 1.4 ± 1.2; 36% were DMT-naïve. Mean [95% CI] score was high for overall treatment satisfaction (77.8 [73.0-82.6]), ease of use (87.4 [83.7-91.0]), tolerability (94.2 [91.0-97.3]) and effectiveness (76.2 [71.6-80.7]). Scores were similar irrespective of DMT history, age, gender, relapse history or EDSS. No relapses or serious treatment-emergent adverse events (TEAE) occurred. Two severe TEAE occurred (fatigue, headache) and 16% reported lymphopenia (two cases of grade 3 lymphopenia). Absolute lymphocyte counts at baseline and 6 months were 2.2 ± 0.8 × 109/L and 1.3 ± 0.3 × 109/L, respectively. CONCLUSIONS Treatment satisfaction, ease of use, tolerability and patient-perceived effectiveness for CladT were high, irrespective of baseline demographics, disease characteristics and prior treatment.
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Affiliation(s)
- Jihad Inshasi
- Rashid Hospital and Dubai Medical College and Dubai Health Authority (DHA), P.O. Box 4545, Dubai, UAE.
| | - Samar Farouk
- Ibn Sina Hospital, Kuwait, Kuwait
- Faculty of Medicine, Minia University, Minia, Egypt
| | | | - Ali Hassan
- Tawam Hospital, Abu Dhabi, UAE
- College of Medicine and Health Science, United Arab Emirates University, Abu Dhabi, UAE
| | - Miklos Szolics
- Tawam Hospital, Abu Dhabi, UAE
- College of Medicine and Health Science, United Arab Emirates University, Abu Dhabi, UAE
| | | | | | | | - Abubaker Almadani
- Rashid Hospital and Dubai Medical College and Dubai Health Authority (DHA), P.O. Box 4545, Dubai, UAE
| | | | | | | | - Anu Jacob
- Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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Brownlee WJ, Haghikia A, Hayward B, Waser N, Kayaniyil S, Khan Z, Duncan J, Millar S, Harty GT. Comparative effectiveness of cladribine tablets versus fingolimod in the treatment of highly active multiple sclerosis: A real-world study. Mult Scler Relat Disord 2023; 76:104791. [PMID: 37343465 DOI: 10.1016/j.msard.2023.104791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/01/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Cladribine tablets and fingolimod have similar marketing authorisations in Europe for the treatment of patients with highly active relapsing multiple sclerosis (HA-RMS). In the absence of direct head-to-head studies, real-world data are important to assess the comparative effectiveness of these oral disease-modifying therapies (DMTs). The primary objective of the present study was to compare relapse rates between patients who received either cladribine tablets or fingolimod. METHODS This multicentre retrospective study conducted in the United Kingdom and Germany assessed non-inferiority in relapse rates of cladribine tablets versus fingolimod in HA-RMS patients over a 12-month period. Eligible patients who initiated treatment with cladribine tablets or fingolimod at least 12 months prior to the screening date were sampled consecutively until the target sample size was reached. Patients were censored at discontinuation of study treatment, commencement of another DMT, death, loss to follow-up, or at 12 months post-baseline, whichever happened earliest. The primary analytic timeframe for physician-confirmed relapse outcomes was the study effectiveness period (nine months of follow-up after an initial 12 weeks of treatment). Propensity score analysis was applied based on the inverse probability of treatment weighting approach. RESULTS The primary analytic cohort consisted of 1,095 HA-RMS patients: 610 (55.7%) receiving cladribine tablets and 485 (44.3%) receiving fingolimod. Fewer patients discontinued cladribine tablets and/or switched to another DMT compared with fingolimod (0.2% versus 3.5%, respectively). The primary endpoint, adjusted annualised relapse rate (ARR), was 0.10 (95% confidence interval [CI]: 0.07-0.14) for cladribine tablets and 0.14 (95% CI: 0.10-0.20) for fingolimod. The adjusted ARR ratio of cladribine tablets versus fingolimod was 0.68 (95% CI: 0.42-1.11). Given the entire 95% CI was less than the non-inferiority margin of 1.2, cladribine tablets was non-inferior to fingolimod. CONCLUSIONS In this real-world retrospective cohort study, cladribine tablets demonstrated comparable effectiveness to fingolimod at one year following treatment initiation. The full treatment dosage of cladribine tablets is completed over two years and so these results may be conservative.
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Affiliation(s)
- Wallace J Brownlee
- Queen Square MS Centre, University College London Institute of Neurology and National Institute for Health and Care Research (NIHR) University College London Hospitals Biomedical Research Centre, London, UK
| | - Aiden Haghikia
- Ruhr-University Bochum & St. Josef-Hospital, Bochum, Germany
| | - Brooke Hayward
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | - Nathalie Waser
- ICON plc, 3455 North Service Rd, Burlington, Ontario L7N 3G2, Canada
| | - Sheena Kayaniyil
- ICON plc, 3455 North Service Rd, Burlington, Ontario L7N 3G2, Canada
| | - Zaeem Khan
- ICON plc, 3455 North Service Rd, Burlington, Ontario L7N 3G2, Canada
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Aerts S, Khan H, Severijns D, Popescu V, Peeters LM, Van Wijmeersch B. Safety and effectiveness of cladribine tablets for multiple sclerosis: Results from a single-center real-world cohort. Mult Scler Relat Disord 2023; 75:104735. [PMID: 37192586 DOI: 10.1016/j.msard.2023.104735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/24/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Cladribine tablets are a highly effective immune reconstitution therapy licensed for treating relapsing multiple sclerosis (RMS) in Europe since 2017. Currently, there is a high demand for real-world data from different clinical settings on the effectiveness and safety profile of cladribine in MS. METHODS Within this report, we retrospectively evaluated the outcomes of RMS patients who received cladribine between August 2018 and November 2021 at our Belgian institute. Patients with data for three effectiveness endpoints, more specifically, relapses, MRI observations, and confirmed disability worsening were incorporated into the analysis of 'no evidence of disease activity' (NEDA-3) re-baselined at 3 months. Safety endpoints included lymphopenia, liver transaminases, and adverse events (AEs) during follow-up. Descriptive statistics and time-to-event analysis were performed, including subgroup analysis by pre-treatment. RESULTS Of the 84 RMS patients included in this study (age 42 [33-50], 64.3% female, diagnosis duration 6 [2-11] years, baseline EDSS 2.5 [1.5-3.6]), 14 (16.7%) patients experienced relapses, while disability progression and brain MRI activity occurred in 8.5% (6/71) and 6.3% (5/79). This resulted in 72.6% (n = 69, standard error 6%) retaining NEDA-3 status at the mean follow-up time of 22.6 ± 11.5 months. During the first year after cladribine initiation, disease activity prevailed more in patients with ≥2 prior DMTs and those switching from fingolimod, although both trends were not statistically significant. In terms of safety, 67.9% reported at least one AE during follow-up, the most frequent being fatigue (64.9%) and skin-related problems (38.6%). CONCLUSION Overall, our research results confirm cladribine's safety and effectiveness among RMS patients in real-world conditions. After the re-baseline, we observed high rates of NEDA-3-retention, and no new safety signals were noted.
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Affiliation(s)
- Sofie Aerts
- Universitair MS Centrum (UMSC) Hasselt-Pelt, Boemerangstraat 2, Pelt 3900, Belgium; UHasselt, Biomedical Research Institute (BIOMED), Agoralaan, Diepenbeek 3590, Belgium; Noorderhart, Revalidatie en MS, Boemerangstraat 2, Pelt 3900, Belgium; UHasselt, Rehabilitation Research Center, Agoralaan, Diepenbeek 3590, Belgium.
| | - Hamza Khan
- Universitair MS Centrum (UMSC) Hasselt-Pelt, Boemerangstraat 2, Pelt 3900, Belgium; UHasselt, Biomedical Research Institute (BIOMED), Agoralaan, Diepenbeek 3590, Belgium; UHasselt, Data Science Institute, Agoralaan, Diepenbeek 3590, Belgium; The D-Lab, Department of Precision Medicine, GROW - School for Oncology, Maastricht University, Universiteitssingel 40, Maastricht 6229 ER, the Netherlands
| | - Deborah Severijns
- Universitair MS Centrum (UMSC) Hasselt-Pelt, Boemerangstraat 2, Pelt 3900, Belgium; Noorderhart, Revalidatie en MS, Boemerangstraat 2, Pelt 3900, Belgium; UHasselt, Rehabilitation Research Center, Agoralaan, Diepenbeek 3590, Belgium
| | - Veronica Popescu
- Universitair MS Centrum (UMSC) Hasselt-Pelt, Boemerangstraat 2, Pelt 3900, Belgium; UHasselt, Biomedical Research Institute (BIOMED), Agoralaan, Diepenbeek 3590, Belgium; Noorderhart, Revalidatie en MS, Boemerangstraat 2, Pelt 3900, Belgium
| | - Liesbet M Peeters
- Universitair MS Centrum (UMSC) Hasselt-Pelt, Boemerangstraat 2, Pelt 3900, Belgium; UHasselt, Biomedical Research Institute (BIOMED), Agoralaan, Diepenbeek 3590, Belgium; UHasselt, Data Science Institute, Agoralaan, Diepenbeek 3590, Belgium
| | - Bart Van Wijmeersch
- Universitair MS Centrum (UMSC) Hasselt-Pelt, Boemerangstraat 2, Pelt 3900, Belgium; UHasselt, Biomedical Research Institute (BIOMED), Agoralaan, Diepenbeek 3590, Belgium; Noorderhart, Revalidatie en MS, Boemerangstraat 2, Pelt 3900, Belgium; UHasselt, Rehabilitation Research Center, Agoralaan, Diepenbeek 3590, Belgium
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Zanetta C, Rocca MA, Meani A, Martinelli V, Ferrè L, Moiola L, Filippi M. Effectiveness and safety profile of cladribine in an Italian real-life cohort of relapsing-remitting multiple sclerosis patients: a monocentric longitudinal observational study. J Neurol 2023:10.1007/s00415-023-11700-7. [PMID: 37027018 PMCID: PMC10080181 DOI: 10.1007/s00415-023-11700-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION Cladribine is approved for the treatment of active relapsing MS (RRMS), but its positioning in MS therapeutic scenario still needs to be fully elucidated. METHODS This is a monocentric, observational, real-world study on RRMS patients treated with cladribine. Relapses, magnetic resonance imaging (MRI) activity, disability worsening, and loss of no-evidence-of-disease-activity-3 (NEDA-3) status were assessed as outcomes. White blood cell, lymphocyte counts and side effects were also evaluated. Patients were analyzed overall and in subgroups according to the last treatment before cladribine. The relationship between baseline characteristics and outcomes was tested to identify predictors of response. RESULTS Among the 114 patients included, 74.9% were NEDA-3 at 24 months. We observed a reduction of relapses and MRI activity, along with a stabilization of disability. A higher number of gadolinium-enhancing lesions at baseline was the only risk factor for loss of NEDA-3 during follow-up. Cladribine was more efficacious in switchers from first-line therapies or naïves. Grade I lymphopenia was more frequent at month 3 and 15. No grade IV lymphopenia cases were observed. Independent predictors of grade III lymphopenia were a lower baseline lymphocyte count and a higher number of previous treatments. Sixty-two patients presented at least one side effect and globally 111 adverse events were recorded, none of them was serious. CONCLUSIONS Our study confirms previous data on cladribine effectiveness and safety. Cladribine is more effective when placed early in the treatment algorithm. Real-world data on larger populations with longer follow-up are needed to confirm our findings.
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Affiliation(s)
- Chiara Zanetta
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria A Rocca
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Meani
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Martinelli
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Laura Ferrè
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lucia Moiola
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Giovannoni G, Boyko A, Correale J, Edan G, Freedman MS, Montalban X, Rammohan K, Stefoski D, Yamout B, Leist T, Aydemir A, Borsi L, Verdun di Cantogno E. Long-term follow-up of patients with relapsing multiple sclerosis from the CLARITY/CLARITY Extension cohort of CLASSIC-MS: An ambispective study. Mult Scler 2023; 29:719-730. [PMID: 37012898 PMCID: PMC10176755 DOI: 10.1177/13524585231161494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND CLASSIC-MS evaluated the long-term efficacy of cladribine tablets in patients with relapsing multiple sclerosis. OBJECTIVE Report long-term mobility and disability beyond treatment courses received in CLARITY/CLARITY Extension. METHODS This analysis represents CLASSIC-MS patients who participated in CLARITY with/without participation in CLARITY Extension, and received ⩾1 course of cladribine tablets or placebo (N = 435). Primary objective includes evaluation of long-term mobility (no wheelchair use in the 3 months prior to first visit in CLASSIC-MS and not bedridden at any time since last parent study dose (LPSD), i.e. Expanded Disability Status Scale (EDSS) score <7). Secondary objective includes long-term disability status (no use of an ambulatory device (EDSS < 6) at any time since LPSD). RESULTS At CLASSIC-MS baseline, mean ± standard deviation EDSS score was 3.9 ± 2.1 and the median time since LPSD was 10.9 (range = 9.3-14.9) years. Cladribine tablets-exposed population: 90.6% (N = 394), including 160 patients who received a cumulative dose of 3.5 mg/kg over 2 years. Patients not using a wheelchair and not bedridden: exposed, 90.0%; unexposed, 77.8%. Patients with no use of an ambulatory device: exposed, 81.2%; unexposed, 75.6%. CONCLUSION With a median 10.9 years' follow-up after CLARITY/CLARITY Extension, findings suggest the sustained long-term mobility and disability benefits of cladribine tablets.
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Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alexey Boyko
- Department of Neurology, Neurosurgery and Medical Genetics, Federal Center of Brain Research and Neurotechnologies, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Jorge Correale
- Department of Neurology, FLENI Institute, Buenos Aires, Argentina
| | - Gilles Edan
- Department of Neurology, University Hospital of Rennes, Rennes, France
| | - Mark S Freedman
- Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Xavier Montalban
- Department of Neurology-Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Kottil Rammohan
- MS Research Center, School of Medicine, University of Miami, Miami, FL, USA
| | - Dusan Stefoski
- Department of Neurological Sciences, Rush Medical College, Chicago, IL, USA
| | - Bassem Yamout
- Neurology Institute, Harley Street Medical Center, Abu Dhabi, UAE/American University of Beirut Medical Center, Beirut, Lebanon
| | - Thomas Leist
- Division of Clinical Neuroimmunology, Comprehensive MS Center, Jefferson University, Philadelphia, PA, USA
| | - Aida Aydemir
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
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Sorensen PS, Pontieri L, Joensen H, Heick A, Rasmussen PV, Schäfer J, Ratzer R, Pihl CE, Sellebjerg F, Magyari M. Real-world experience of cladribine treatment in relapsing-remitting multiple sclerosis: A Danish nationwide study. Mult Scler Relat Disord 2023; 70:104491. [PMID: 36623393 DOI: 10.1016/j.msard.2022.104491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cladribine is a nucleoside analogue interfering with synthesis and repair of DNA. Treatment with cladribine leads to a preferential reduction in lymphocytes, resulting in profound depletion of B-cells with a rapid recovery of naïve B-cells, while T-cell show a lesser but long-lasting depletion It is approved for treatment of relapsing multiple sclerosis (MS). Cladribine tablets 3.5 mg/kg bodyweight are administered in two yearly treatment courses, each including two treatment series lasting 4 or 5 days, one at the start of the first month and the other at the start of the second month. OBJECTIVE To describe treatment patterns of cladribine in a real-world setting. METHODS Registry based observational cohort study with prospectively enrolled cases from December 2017 through June 2021. The data source is The Danish Multiple Sclerosis Registry, which is a near complete nationwide population-based registry. Outcomes were length of the treatment, preceding and following treatments, treatment response, and safety data. RESULTS In total 268 patients had started therapy with cladribine tablets, 89 men and 179 women, with a median age of 40 years (interquartile range (IQR) 32-48. The disease course was relapsing-remitting MS in 97.8% of the patients, and at treatment start the median time from disease onset was 8.1 years (IQR 4.2-14.5) and EDSS 2.5 (IQR 1.5-3.5). Thirty-four patients (12.7%) were treatment naïve while 56 (20.9%) had received one previous disease-modifying therapy (DMT), 67 (25.0%) two, and 111 (41.4%) three or more previous DMTs. In total, 214 (80.0%) patients had completed the full treatment of two courses of cladribine, while 54 (20.0%) had received only one course of cladribine tablets. The median follow-up time after cladribine initiation was 34.7 months (IQR 23.3-43.7). Compared with an annualized relapse rate (ARR) of 0.67 (95% CI [0.56, 0.79]) in the year prior to start of cladribine, ARR was reduced to 0.11 (95% CI [0.08, 0.15]) in year 0-2 after 3-month re-baseline with cladribine (84.8% reduction). Adverse events, reported in 44 (16.4%) of the patients, were mild or moderate, and herpes zoster was only reported in 2 patients. In total, 30 (11.2%) patients discontinued cladribine treatment, of whom 7 (2.6%) discontinued because of adverse effects and 12 (4.5%) discontinued because of disease activity. CONCLUSION In this nationwide review of all Danish patients starting therapy with cladribine tablets in a real-world setting, cladribine treatment was safe, and the therapeutic response was as expected from previous clinical trials. A prolonged observation period is necessary to assess the long-term benefit and risk of cladribine.
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Affiliation(s)
- Per Soelberg Sorensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Luigi Pontieri
- The Danish Multiple Sclerosis Registry, Department of Neurology, Rigshospitalet, Glostrup, Denmark
| | - Hanna Joensen
- The Danish Multiple Sclerosis Registry, Department of Neurology, Rigshospitalet, Glostrup, Denmark
| | - Alex Heick
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | | | - Jakob Schäfer
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Rikke Ratzer
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Caroline Ellinore Pihl
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; The Danish Multiple Sclerosis Registry, Department of Neurology, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Boyko AN, Dolgushin MB, Karalkina MA. [New neuroimaging methods in assessing the activity of neuroinflammation in multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:8-14. [PMID: 37560828 DOI: 10.17116/jnevro20231230728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
The review presents current data on the use of positron emission tomography and single-photon emission computed tomography in multiple sclerosis (MS) to assess the activity of the pathological process, including neuroinflammation, demyelination, activation of microglia, neurodegeneration and local blood flow disorders. These methodologies are a new approach for studying the mechanisms of action and evaluating the clinical effect of disease modifying therapy of MS, especially those capable of penetrating into brain tissue. Among them, the most attention is attracted by cladribine tablets acting on the mechanism of immune reconstitution therapy, most likely with the modulation of immune reactions directly in the brain tissue.
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Affiliation(s)
- A N Boyko
- Federal Center of Brain and Neurotechnologies of the Federal Medical Biological Agency, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M B Dolgushin
- Federal Center of Brain and Neurotechnologies of the Federal Medical Biological Agency, Moscow, Russia
| | - M A Karalkina
- Federal Center of Brain and Neurotechnologies of the Federal Medical Biological Agency, Moscow, Russia
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Oreja-Guevara C, Brownlee W, Celius EG, Centonze D, Giovannoni G, Hodgkinson S, Kleinschnitz C, Havrdova EK, Magyari M, Selchen D, Vermersch P, Wiendl H, Van Wijmeersch B, Salloukh H, Yamout B. Expert opinion on the long-term use of cladribine tablets for multiple sclerosis: Systematic literature review of real-world evidence. Mult Scler Relat Disord 2023; 69:104459. [PMID: 36565573 DOI: 10.1016/j.msard.2022.104459] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/20/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment with cladribine tablets (CladT), an immune reconstitution therapy for relapsing multiple sclerosis (RMS), involves two short courses of treatment in Year 1 and Year 2. Most patients achieve sustained efficacy with CladT, but a small proportion may experience new disease activity (DA). Following completion of the indicated dose, physicians may have questions relating to the long-term management of these patients. Since the EU approval of CladT over 5 years ago, real-world evidence (RWE) is increasing and may provide some insights and guidance for clinical practice. We describe a systematic literature review (SLR) of RWE and provide expert opinions relating to six questions regarding the long-term use of CladT. METHODS Pertinent clinical questions were developed by a steering committee (SC) of 14 international multiple sclerosis (MS) experts regarding breakthrough DA in Year 1, new DA after 2 years or more of treatment, long-term management of stable patients, and whether additional courses of CladT may be required or safe. An SLR was performed in EMBASE and PubMed using the population, intervention, comparators, outcomes, study design (PICOS) framework to identify relevant studies within the last 15 years. Searches of key congress proceedings for the last 2-3 years were also performed. Following review of the results and RWE, the SC drafted and agreed on expert opinion statements for each question. RESULTS A total of 35 publications reporting RWE for CladT were included in this review. In the real world, breakthrough DA in Year 1 is of low incidence (1.1-21.9%) but can occur, particularly in patients switching from anti-lymphocyte trafficking agents. In most patients, this DA did not lead to treatment discontinuation. Reported rates of DA after the full therapeutic effect of CladT has been achieved (end of Year 2, 3 or 4) range from 12.0 to 18.7% in the few studies identified. No RWE was identified to support management decisions for stable patients in Year 5 or later. Views among the group were also diverse on this question and voting on expert opinion statements was required. Only two studies reported the administration of additional courses of CladT, but detailed safety outcomes were not provided. CONCLUSIONS RWE for the long-term use of CladT in the treatment of RMS is increasing, however, gaps in knowledge remain. Where possible, the RWE identified through the SLR informed expert statements, but, where RWE is still lacking, these were based solely on experiences and opinion, providing some guidance on topics and questions that occur in daily clinical practice. More real-world studies with longer-term follow-up periods are needed and highly anticipated.
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Affiliation(s)
- Celia Oreja-Guevara
- Neurology, Hospital Clínico San Carlos, IdISSC, Madrid, Spain; Department of Medicine, Faculty of Medicine, Universidad Complutense de Madrid, Spain
| | - Wallace Brownlee
- Queen Square MS Centre, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Elisabeth G Celius
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Diego Centonze
- Department of Systems Medicine, Tor Vergata University, Rome, Italy; Unit of Neurology, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Suzanne Hodgkinson
- Department of Neurology, Liverpool Hospital, and UNSW Sydney, New South Wales, Australia
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational and Behavioural Neurosciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Melinda Magyari
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Daniel Selchen
- Division of Neurology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster, Germany
| | | | - Hashem Salloukh
- Ares Trading SA, Eysins, Switzerland (An Affiliate of Merck KGaA)
| | - Bassem Yamout
- Neurology Institute, Harley Street Medical Center, Abu Dhabi, UAE; American University of Beirut, Lebanon.
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Habek M, Drulovic J, Brecl Jakob G, Barbov I, Radulovic L, Rajda C, Rejdak K, Turčáni P. Treatment with Cladribine Tablets Beyond Year 4: A Position Statement by Southeast European Multiple Sclerosis Centers. Neurol Ther 2023; 12:25-37. [PMID: 36394714 DOI: 10.1007/s40120-022-00422-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022] Open
Abstract
Based on the results of the pivotal CLARITY study, cladribine tablets were approved for use in the European Union in 2017 as a high-efficacy therapy for highly active relapsing-remitting multiple sclerosis (MS). Cladribine tablets are used as an induction therapy: half of the total dose is given in year 1 and the other half in year 2. In the CLARITY Extension trials, repeating the dose routinely in years 3 and 4, was not associated with significantly improved disease control. However, there is very limited evidence on how to manage people with MS (pwMS) beyond year 4, which is increasingly important because more and more patients are now ≥ 4 years after cladribine treatment. Overall, postapproval data show that treatment with two cladribine cycles effectively controls disease activity in the long term. However, there is general agreement that some pwMS with suboptimal response could benefit from retreatment. This study reviews the practical aspects of using cladribine tablets, summarizes the evidence from clinical trials and real-world studies on the safety and efficacy of cladribine, and proposes a treatment algorithm developed by expert consensus for pwMS previously treated with cladribine. In brief, we propose that additional courses of cladribine tablets should be considered in patients with minimal (no relapses, 1-2 new lesions) or moderate (1 relapse, 3-4 new lesions) disease activity, while significant disease activity (> 1 relapse, > 3 new lesions) or progression should warrant a switch to another high-efficacy treatment (HET). More evidence is needed to improve the treatment guidelines for pwMS who previously received cladribine.
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20
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Brill L, Rechtman A, Shifrin A, Rozenberg A, Afanasiev S, Zveik O, Haham N, Levin N, Vaknin-Dembinsky A. Longitudinal humoral response in MS patients treated with cladribine tablets after receiving the second and third doses of SARS-CoV-2 mRNA vaccine. Mult Scler Relat Disord 2022; 63:103863. [PMID: 35667316 PMCID: PMC9088160 DOI: 10.1016/j.msard.2022.103863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/19/2022] [Accepted: 05/08/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) patients receive immunomodulatory treatments which can influence their ability to maintain vaccine specific serological response overtime. MS patients treated with cladribine tablets developed a positive serology response following two doses of mRNA COVID-19 vaccine. However, there is only limited data regarding the effect of cladribine tablets on long-term humoral response after the second and the third booster. METHODS Serology response to SARS-CoV-2 was tested in healthy controls (HCs) and MS patients treated with cladribine tablets 6 and 9-12 months after the second dose, and 1 and 3-6 months following the third booster-dose of the BTN162b2 mRNA vaccine. RESULTS Thirty-five out of 36 MS patients treated with cladribine tablets and 100% (46/46) of HCs had a positive serology response up to 10 months after the second vaccine dose. In addition, all cladribine tablets -treated MS patients (22/22) and HCs (24/24) had a positive robust serology response following the third vaccine with a positive humoral response sustain up to 6 months. One month after the third vaccine dose IgG levels were significantly lower in patients treated with cladribine tablets compared to HCs (15,598+11,313 vs 26,394+11,335, p<0.01). Six-month post second vaccine and 3-6 months post third vaccine there was no difference in IgG levels between the groups (1088.0 ± 1072.0 vs 1153.0 ± 997.1, p = 0.79; 5234+4097 vs 11,198+14,679, p = 0.4). CONCLUSION AND RELEVANCE MS patients treated with cladribine tablets have sustained positive vaccine specific serology response following the second and third SARS-CoV-2 vaccine dose.
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Affiliation(s)
- Livnat Brill
- Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center. Faculty of Medicine, Hebrew University of Jerusalem. Jerusalem, Israel
| | - Ariel Rechtman
- Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center. Faculty of Medicine, Hebrew University of Jerusalem. Jerusalem, Israel
| | - Alla Shifrin
- Department of Neurology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
| | - Ayal Rozenberg
- Department of Neurology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
| | - Svetlana Afanasiev
- Department of Neurology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
| | - Omri Zveik
- Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center. Faculty of Medicine, Hebrew University of Jerusalem. Jerusalem, Israel
| | - Nitzan Haham
- Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center. Faculty of Medicine, Hebrew University of Jerusalem. Jerusalem, Israel
| | - Neta Levin
- Functional Imaging Unit, Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Adi Vaknin-Dembinsky
- Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center. Faculty of Medicine, Hebrew University of Jerusalem. Jerusalem, Israel
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21
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Brill L, Rechtman A, Zveik O, Haham N, Levin N, Shifrin A, Rozenberg A, Vaknin-Dembinsky A. Effect of cladribine on COVID-19 serology responses following two doses of the BNT162b2 mRNA vaccine in patients with multiple sclerosis. Mult Scler Relat Disord 2022; 57:103343. [PMID: 35158452 PMCID: PMC8539216 DOI: 10.1016/j.msard.2021.103343] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND multiple sclerosis (MS) patients are treated with immunomodulatory treatments that can influence their ability to develop a protective antibody response to the SARS-CoV-2 vaccine. Vaccine efficacy is important for treatment decision and for patients' reassurance. The main objective is to assess antibody response to SARS-CoV-2 vaccine in MS patients treated with cladribine. METHODS Serology response was tested in 97 participants, 67 MS patients and 30 healthy controls (HCs), using two independent methods, 2-3 weeks following the second dose of the BNT162b2 vaccine. RESULTS HCs (n = 30) and MS patients treated with cladribine (n = 32) had 100% positive serology response against the SARS-CoV-2 spike protein following the second vaccine dose (mean S1/S2-IgG and RBD-IgG:284.5 ± 104.9, 13,041±9411 AU/mL and 226.3 ± 121.4, 10,554±11,405 AU/mL respectively). Comparable findings were observed for untreated MS patients, and interferon beta-1a-treated MS patients (mean S1/S2-IgG: 282.1 ± 100.1, 276.9 ± 94.31 AU/mL respectively). No correlation was found between lymphocyte counts, treatment duration, or time between cladribine dose and vaccination, and serology response or antibody titers. CONCLUSION AND RELEVANCE Cladribine treated MS patients are able to produce antibodies to the SARS-CoV-2 mRNA vaccine. In the era of the COVID-19 pandemic, it is reassuring and important for both patients and physicians and will allow to develop consensus guidelines.
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Affiliation(s)
- Livnat Brill
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center, Jerusalem, Israel
| | - Ariel Rechtman
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center, Jerusalem, Israel
| | - Omri Zveik
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center, Jerusalem, Israel
| | - Nitzan Haham
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center, Jerusalem, Israel
| | - Netta Levin
- Functional Imaging Unit, Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Alla Shifrin
- Department of Neurology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
| | - Ayal Rozenberg
- Department of Neurology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
| | - Adi Vaknin-Dembinsky
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology and the Agnes-Ginges Center for Neurogenetics, Hadassah- Medical Center, Jerusalem, Israel.
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22
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Brochet B, Hupperts R, Langdon D, Solari A, Piehl F, Lechner-Scott J, Montalban X, Selmaj K, Valis M, Rejdak K, Havrdova EK, Patti F, Alexandri N, Nolting A, Keller B. Treatment satisfaction, safety, and tolerability of cladribine tablets in patients with highly active relapsing multiple sclerosis: CLARIFY-MS study 6-month interim analysis. Mult Scler Relat Disord 2022; 57:103385. [PMID: 35158476 DOI: 10.1016/j.msard.2021.103385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/24/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
Abstract
Background Multiple sclerosis (MS) is a chronic disabling disease that is associated with negative effects on health-related quality of life (HRQoL) due to reduced physical and psychosocial functioning. Cladribine tablets 10 mg (3.5 mg/kg cumulative dose over 2 years) have been approved for the treatment of adult patients with highly active relapsing multiple sclerosis (RMS). The ongoing CLARIFY-MS study (NCT03369665; EudraCT number: 2017-002632-17) aims to assess the effect of cladribine tablets 3.5 mg/kg on HRQoL of patients with highly active RMS. Objective To report on the design of the CLARIFY-MS study, baseline patient characteristics, and results of a pre-planned interim analysis focusing on treatment satisfaction, safety, and tolerability that includes all data reported till 6 months after start of treatment. Methods The CLARIFY-MS study is a 2-year, open-label, single-arm, prospective, multicenter, phase IV study. Eligible patients with highly active RMS were assigned to receive cladribine tablets 3.5 mg/kg over 2 years. Treatment satisfaction was assessed using the Treatment Satisfaction Questionnaire for Medication (TSQM, v1.4; scale range from 0 to 100, higher values indicating higher satisfaction). Safety assessments, including occurrence of treatment-emergent adverse events (TEAEs; any adverse event reported after drug administration), serious adverse events (SAEs), and lymphocyte counts, were summarized descriptively. Results A total of 482 patients from 85 sites in Europe were treated with cladribine tablets. Mean patient age was 37.4 years, 338 (70.1%) were women, median EDSS was 2.5, and 345 (71.6%) were prior users of disease-modifying therapy (DMT). During the first 6 months after the start of treatment, and before reaching the full dose of cladribine tablets, mean TSQM global satisfaction score for the overall population was 70.4 (standard deviation, ± 18.48). The side effects score was 91.9 (± 17.68), convenience scored 86.6 (± 13.57), and effectiveness was 65.8 (± 21.14). A total of 275 patients (57.1%) reported at least one TEAE and 9 patients (1.9%) had a SAE. The majority of observed lymphopenia cases were of grade 1 or 2; 33 (6.8%) of the total study cohort had grade 3 lymphopenia, and no grade 4 lymphopenia was reported. Conclusion Patients reported high treatment satisfaction (TSQM) with cladribine tablets in this pre-planned interim analysis at 6 months. Few serious, and no unexpected, adverse events were reported, and there were no instances of grade 4 lymphopenia over the first 6 months. These preliminary data indicate good tolerability and convenience of administration of cladribine tablets in patients with highly active RMS.
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Affiliation(s)
- Bruno Brochet
- INSERM U 1215, University of Bordeaux, Bordeaux, France.
| | - Raymond Hupperts
- Zuyderland Medisch Centrum Sittard, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Dawn Langdon
- Department of Psychology, Royal Holloway, University of London, Egham, United Kingdom
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jeannette Lechner-Scott
- University of Newcastle, Newcastle, NSW, Australia; Division of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Xavier Montalban
- Department of Neurology-Neuroimmunology Centre of Multiple Sclerosis of Catalonia (Cemcat), University Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Martin Valis
- Charles University and University Hospital, Hradec Králové, Czech Republic
| | | | - Eva K Havrdova
- Charles University, First Medical Faculty, Prague, Czech Republic
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, University of Catania, and Azienda Ospedaliero Universitaria Policlinico "G Rodolico"- San Marco, University of Catania, Catania, Italy
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23
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Grothe C, Steffen F, Bittner S. Humoral immune response and lymphocyte levels after complete vaccination against COVID-19 in a cohort of multiple sclerosis patients treated with cladribine tablets. J Cent Nerv Syst Dis 2021; 13:11795735211060118. [PMID: 34880703 PMCID: PMC8647228 DOI: 10.1177/11795735211060118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/28/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients with multiple sclerosis (MS) receiving immunomodulatory drugs were excluded from clinical trials on COVID-19 vaccines. Therefore, data regarding the efficacy of COVID-19 vaccines to induce humoral immunity in MS patients treated with B- and T-cell depleting agents is urgently warranted. Cladribine tablets are a high-efficacy disease-modifying treatment that exerts its therapeutic effect via sustained but transient lymphocyte depletion. AIM We report humoral responses in a German cohort of MS patients treated with cladribine tablets. METHODS This retrospective analysis included patients ≥18 years who were treated with cladribine tablets for relapsing MS in the first or second year and were fully vaccinated against COVID-19. Two weeks after the second vaccination at the earliest, blood samples were obtained for the assessment of anti-SARS-CoV-2 IgG antibodies, lymphocyte counts, B-cells, CD4+ T-cells, and CD8+ T-cells. Anti-SARS-CoV-2 IgG antibodies were quantified with the LIAISON® SARS-CoV-2 TrimericS IgG assay. Positivity was defined at a cutoff value of 33.8 BAU/mL. RESULTS In total, 38 patients (73.7% female, aged 23-66 years) were included in the analysis. Ten patients (26.3%) were treatment-naïve before initiating treatment with cladribine tablets. Most patients (84.2%) received mRNA vaccines. The time between the last dose of cladribine tablets and vaccination ranged between 2 and 96 weeks. Six patients (15.8%) were vaccinated within 4 weeks of their last cladribine dose. All patients achieved positive anti-SARS-CoV-2 IgG antibody levels. Humoral immune response was independent of age, time of vaccination in relation to the last cladribine dose, lymphocyte counts as well as B- and T-cell counts. CONCLUSIONS Treatment with cladribine tablets did not impair humoral response to COVID-19 vaccination. Time since last cladribine dose, age, prior therapy, lymphocyte count as well as B- and T-cell counts had no effect on seropositivity of anti-SARS-CoV-2 IgG antibodies.
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Affiliation(s)
| | - Falk Steffen
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Stefan Bittner
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
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24
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Inshasi JS, Alfahad S, Alsaadi T, Hassan A, Zein T, Mifsud VA, Nouri SI, Shakra M, Shatila AO, Szolics M, Thakre M, Kumar A, Boshra A. Position of Cladribine Tablets in the Management of Relapsing-Remitting Multiple Sclerosis: An Expert Narrative Review From the United Arab Emirates. Neurol Ther 2021; 10:435-454. [PMID: 33891277 PMCID: PMC8062252 DOI: 10.1007/s40120-021-00243-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/16/2021] [Indexed: 11/06/2022] Open
Abstract
The use of immune reconstitution therapies (IRT) in patients with relapsing-remitting multiple sclerosis (RRMS) is associated with a prolonged period of freedom from relapses in the absence of continuously applied therapy. Cladribine tablets is a disease-modifying treatment (DMT) indicated for highly active relapsing multiple sclerosis (MS) as defined by clinical or imaging features. Treatment with cladribine tablets is effective and well tolerated in patients with active MS disease and have a low burden of monitoring during and following treatment. In this article, an expert group of specialist neurologists involved in the care of patients with MS in the United Arab Emirates provides their consensus recommendations for the practical use of cladribine tablets according to the presenting phenotype of patients with RRMS. The IRT approach may be especially useful for patients with highly active MS insufficiently responsive to treatment with a first-line DMT, those who are likely to adhere poorly to a continuous therapeutic regimen, treatment-naïve patients with high disease activity at first presentation, or patients planning a family who are prepared to wait until at least 6 months after the end of treatment. Information available to date does not suggest an adverse interaction between cladribine tablets and COVID-19 infection. Data are unavailable at this time regarding the efficacy of COVID-19 vaccination in patients treated with cladribine tablets. Robust immunological responses to COVID-19 infection or to other vaccines have been observed in patients receiving this treatment, and treatment with cladribine tablets per se should not represent a barrier to this vaccination.
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Affiliation(s)
- Jihad S Inshasi
- Neurology Department, Rashid Hospital and Dubai Medical College, Dubai Health Authority (DHA), PO Box 4545, Dubai, UAE.
| | - Sarmed Alfahad
- Neurology Department, Neurospinal Hospital, Baghdad Medical College, Dubai, UAE
| | - Taoufik Alsaadi
- Neurology Department, American Center for Psychiatry and Neurology, Dubai, UAE
| | - Ali Hassan
- Neurology Medical Clinic, Tawam Hospital, Abu Dhabi, UAE
| | - Tayseer Zein
- Neurology Department, AlQassami Hospital, Sharjah, UAE
| | | | | | - Mustafa Shakra
- Department of Neurology, Sheikh Khalifa Medical City, Abu Dhabi, UAE
| | | | - Miklos Szolics
- Neurology Medical Clinic, Tawam Hospital, Abu Dhabi, UAE
| | - Mona Thakre
- Neurology Department, Al Zahra Hospital, Dubai, UAE
| | - Ajit Kumar
- Neurology Department, NMC Specialty Hospital, Al Nahda, Dubai, UAE
| | - Amir Boshra
- Merck Serono Middle East FZ Ltd, Dubai, UAE
- Merck KgaA, Darmstadt, Germany
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25
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Giovannoni G, Singer BA, Issard D, Jack D, Vermersch P. Durability of no evidence of disease activity-3 (NEDA-3) in patients receiving cladribine tablets: The CLARITY extension study. Mult Scler 2021; 28:1219-1228. [PMID: 34634968 PMCID: PMC9189728 DOI: 10.1177/13524585211049392] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: No evidence of disease activity (NEDA-3) is a patient-centric outcome
increasingly used as the goal of multiple sclerosis treatment. Objective: Determine treatment durability of cladribine tablets beyond 2 years
considering the variable bridging interval of 0.1–116.0 weeks between
CLARITY and CLARITY Extension. Methods: Between CLARITY and CLARITY Extension, patients transitioned from cladribine
tablets 3.5 mg/kg to placebo (CP3.5 group, n = 98) or
continued further treatment with cladribine tablets 3.5 mg/kg (CC7.0 group,
n = 186). Treatment assignment was randomized and
blinded in both CLARITY and CLARITY Extension. Results: The 2-year NEDA-3 in CLARITY Extension (encompassing both years of CLARITY
Extension) was 29.6% in the CP3.5 group and 32.8% in the CC7.0 group. There
was no evidence that treatment effect differed with varying bridging
intervals. For patients in the CP3.5 group with a bridging interval of
⩽48 weeks, 1 year NEDA-3 (the first year of CLARITY Extension) was 44.4%
(28/63) compared with 31.4% (11/35) in patients with a bridging interval of
>48 weeks. Conclusion: Treatment with cladribine tablets in CLARITY, followed by either placebo or
cladribine tablets in CLARITY Extension, produced sustained benefits for
NEDA-3 and its constituent elements for a follow up period up to 6 years
from CLARITY baseline.
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Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA
| | - Delphine Issard
- Department of Biostatistics, Cytel Inc., Geneva, Switzerland
| | - Dominic Jack
- Global Medical Affairs, Neurology and Immunology, Merck Serono Ltd, Feltham, UK (an affiliate of Merck KGaA)
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
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26
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Giovannoni G, Comi G, Rammohan K, Rieckmann P, Dangond F, Keller B, Jack D, Vermersch P. Long-Term Disease Stability Assessed by the Expanded Disability Status Scale in Patients Treated with Cladribine Tablets 3.5 mg/kg for Relapsing Multiple Sclerosis: An Exploratory Post Hoc Analysis of the CLARITY and CLARITY Extension Studies. Adv Ther 2021; 38:4975-85. [PMID: 34370275 DOI: 10.1007/s12325-021-01865-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/16/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION In the Cladribine Tablets Treating Multiple Sclerosis Orally (CLARITY) study, cladribine tablets significantly reduced relapse rates and improved findings on magnetic resonance imaging versus placebo in patients with relapsing multiple sclerosis. In the CLARITY Extension study, treatment with cladribine tablets for 2 years followed by placebo for 2 years produced similar clinical benefits to 4 years of cladribine tablets. The objective of this exploratory post hoc analysis was to evaluate long-term disease stability (assessed by the Expanded Disability Status Scale [EDSS] score) after treatment with cladribine tablets. METHODS Patients enrolled into CLARITY Extension who were previously randomized to cladribine tablets 3.5 mg/kg in the CLARITY study were included in this post hoc analysis. Two treatment groups were investigated-patients randomized to cladribine tablets 3.5 mg/kg in CLARITY and thereafter randomized to placebo in CLARITY Extension (the CP3.5 group) or to cladribine tablets 3.5 mg/kg in CLARITY Extension (the CC7 group). In each treatment group, EDSS scores at 6-month intervals, EDSS score improvement/worsening each year, and time to 3- and 6-month confirmed EDSS progression were assessed from CLARITY baseline over 5 years of follow-up (including a variable bridging interval between studies). All analyses are descriptive, and no statistical comparisons were performed for between-treatment group differences. RESULTS The median (95% confidence interval [CI]) EDSS score for patients in the CP3.5 group at 5 years was 2.5 (2.0-3.5) compared with 3.0 (2.5-3.5) at baseline. In the CC7 group, median EDSS score (95% CI) at 5 years was 2.0 (2.0-3.0) compared with 2.5 (2.5-3.0) at baseline. During year 5 for the CP3.5 group, and based on changes in minimum score each year, EDSS score stability was observed in 53.9% of patients, improvement in 21.3%, and worsening in 24.7%. In the CC7 group, EDSS score remained stable in 66.1%, improved in 18.1%, and worsened in 15.8% of patients. Over 70% of patients in both treatment groups did not show 3- or 6-month confirmed EDSS progression at 5 years from CLARITY baseline. CONCLUSIONS These findings confirm long-term beneficial effects on disability afforded by either the recommended dose of cladribine tablets over 4 years (cumulative dose, 3.5 mg/kg) or a higher cumulative dose. TRIAL REGISTRATION ClinicalTrials.gov NCT00213135 (CLARITY); NCT00641537 (CLARITY Extension).
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Stangel M, Becker V, Elias-Hamp B, Havla J, Grothe C, Pul R, Rau D, Richter S, Schmidt S. Oral pulsed therapy of relapsing multiple sclerosis with cladribine tablets - expert opinion on issues in clinical practice. Mult Scler Relat Disord 2021; 54:103075. [PMID: 34261026 DOI: 10.1016/j.msard.2021.103075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Oral cladribine is the first oral pulsed therapy licensed for relapsing multiple sclerosis (RMS). Three years after the introduction into the European market, we evaluated practical aspects in the use of cladribine tablets, incorporating the experience gained in routine clinical practice and real-world studies. METHODS Based on a structured review process, a panel of nine neurologists experienced in MS therapy discussed salient statements regarding the use of cladribine tables. For each statement the level of evidence was determined according to the levels of evidence recommended by the Centre for Evidence-Based Medicine, Oxford. The strength of each expert statement was then evaluated by means of a linear scale from 1 (very strong rejection) to 9 (very strong approval). Votes were collected by a formalized blinded process. Consent was considered to be reached if at least 75% of the experts agreed on a particular statement (i.e. voted for 7-9 points on the linear scale). RESULTS . Statements include efficacy in early RMS, risk of side effects and infections, vaccination, pregnancy, and monitoring requirements. CONCLUSION The consented recommendations summarize the practical experience inthe use of cladribine tablets in a real-world setting. These may provide guidance for unanswered questions arising with the introduction of new treatments such as cladribine tablets.
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Affiliation(s)
- Martin Stangel
- Klinik für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
| | - Veit Becker
- Neurologische Praxis Eppendorf, Kümmellstr. 1, D-20249 Hamburg, Germany.
| | - Birte Elias-Hamp
- Birte Elias-Hamp, Praxis für Neurologie und Psychiatrie, Bengelsdorfstr. 5, D-22179 Hamburg, Germany.
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, and Data Integration for Future Medicine (DIFUTURE) consortium, LMU Hospital, Ludwig-Maximilians Universität München, Munich, Germany.
| | - Christoph Grothe
- GFO-Kliniken Troisdorf, Wilhelm-Busch-Straße 9, D-53840 Troisdorf, Germany.
| | - Refik Pul
- Klinik für Neurologie am Universitätsklinikum in Essen, Hufelandstr. 55, D-45147 Essen, Germany.
| | - Daniela Rau
- Nervenfachärztliche Gemeinschaftspraxis in Ulm, Pfauengasse 8, D-89073 Ulm, Germany.
| | - Stephan Richter
- MIND-MVZ Stuttgart, Charlottenstr. 14, D-70182 Stuttgart, Germany.
| | - Stephan Schmidt
- Neurologische Gemeinschaftspraxis Bonn, Gesundheitszentrum St. Johannes, Kölnstr. 54, D-53111 Bonn, Germany.
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Jack D, Damian D, Nolting A, Galazka A. COVID-19 in patients with multiple sclerosis treated with cladribine tablets: An update. Mult Scler Relat Disord 2021; 51:102929. [PMID: 33813097 PMCID: PMC7997846 DOI: 10.1016/j.msard.2021.102929] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/23/2021] [Indexed: 11/30/2022]
Abstract
Background We previously summarized outcomes for 46 cladribine tablets (CladT)-treated patients with multiple sclerosis (MS) and confirmed or suspected COVID-19, as reported to the Merck KGaA Global Patient Safety Database. This report updates on these findings, to 15 January 2021, for a total of 272 reported cases of COVID-19 among CladT recipients. Methods Case definitions: confirmed (COVID-19 diagnostic test was positive); suspected (no confirmatory test performed/reported). Cases fulfilling the criteria of hospitalized, medically significant, or fatal were designated as serious and outcomes were classified per usual pharmacovigilance practice. Results The evaluable cohort comprised 261 patients (confirmed COVID-19, n=160; suspected, n=101); an additional 11 patients had symptoms compatible with COVID-19 but were not evaluated further given their negative diagnostic tests. Median time to onset of COVID-19 from the most recent preceding CladT treatment course was 162 days (n=139). Outcomes were: recovered/recovering, n=133 (51%); not recovered/not resolved, n=19 (7%); died, n=1 (0.4%); and not reported/missing/pending, n=108 (41%). Of the total cohort, 40 (15%) experienced serious COVID-19. Conclusion Our results suggest that CladT-treated patients with MS are generally not at greater risk of serious disease and/or a severe outcome with COVID-19 compared with the general population and other patients with MS who acquired COVID-19.
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Affiliation(s)
| | - Doris Damian
- EMD Serono Research & Development Institute Inc., Billerica, MA, United States
| | | | - Andrew Galazka
- Merck, Aubonne, Switzerland, a division of Merck KGaA, Darmstadt, Germany
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Lizak N, Hodgkinson S, Butler E, Lechner-Scott J, Slee M, McCombe PA, Shaw C, Skibina O, Vucic S, Shuey N, Barnett MH, Parratt J, Butzkueven H, Jack D, Fabris J, Kalincik T. Real-world effectiveness of cladribine for Australian patients with multiple sclerosis: An MSBase registry substudy. Mult Scler 2021; 27:465-474. [PMID: 32530363 PMCID: PMC7897790 DOI: 10.1177/1352458520921087] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 02/24/2020] [Accepted: 03/31/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND/OBJECTIVE Observational clinical data from cladribine-treated patients with relapsing forms of multiple sclerosis (MS) were recorded in the Australian MS registry powered by the MSBase registry platform (5-year follow-up) and analysed to complement information from the pivotal cladribine clinical trials in MS. METHODS A cohort of 90 cladribine-treated patients with follow-up data reported by treating physicians and recorded in the Australian MSBase registry (database lock February 2016) were examined. Clinical data included Expanded Disability Status Scale (EDSS) scores, relapses and other disease-modifying drugs (DMDs) administered before and after cladribine treatment. RESULTS Mean age on starting cladribine was 47 years; mean age at MS onset was 34 years, and median baseline EDSS score was 5.25. Disability trajectories in patients with sufficient follow-up suggested an overall increasing trend prior to cladribine treatment which was reduced during the 2-year post-treatment. Approximately 80% of patients were EDSS progression-free, 65% remained relapse-free after 2 years and median time to next DMD was 1.7 years. CONCLUSION These observational data suggest a disease-modifying effect in this cohort of relapsing MS patients characterised by older and more disabled patients. Since these data represent a single-arm cohort, clinical trials and larger comparative post-marketing studies are needed to validate and extend these findings.
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Affiliation(s)
- Nathaniel Lizak
- CORe, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia/The Alfred Hospital, Melbourne, VIC, Australia
| | - Suzanne Hodgkinson
- Ingham Institute for Applied Medical Research, UNSW Medicine, Liverpool, NSW, Australia/Liverpool Hospital, Sydney, NSW, Australia
| | - Ernest Butler
- Monash Medical Centre, Monash University, Melbourne, VIC, Australia
| | - Jeannette Lechner-Scott
- Hunter New England Health and Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW, Australia
| | - Mark Slee
- Flinders University, Adelaide, SA, Australia
| | - Pamela Ann McCombe
- Royal Brisbane and Women’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Cameron Shaw
- Geelong Hospital, Geelong, VIC, Australia/Deakin University, Melbourne, VIC, Australia
| | | | | | - Neil Shuey
- St Vincent’s Hospital, Melbourne, VIC, Australia
| | | | - John Parratt
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Helmut Butzkueven
- Central Clinical School, Monash University, Melbourne, VIC, Australia/Eastern Hospital, Melbourne, VIC, Australia
| | | | - Jessica Fabris
- Merck Serono Australia Pty Ltd, Frenchs Forest, NSW, Australia
| | - Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
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Bartosik-Psujek H, Kaczyński Ł, Górecka M, Rolka M, Wójcik R, Zięba P, Kaczor M. Cladribine tablets versus other disease-modifying oral drugs in achieving no evidence of disease activity (NEDA) in multiple sclerosis-A systematic review and network meta-analysis. Mult Scler Relat Disord 2021; 49:102769. [PMID: 33516133 DOI: 10.1016/j.msard.2021.102769] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/04/2020] [Accepted: 01/13/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Assuming full control of the relapsing-remitting multiple sclerosis (RRMS) is the main target for practitioners. Disease control could be defined as no clinical relapse, absence of 3-month confirmed disability progression expressed on the Expanded Disability Status Scale (EDSS), as well as no disease activity on magnetic resonance imaging (MRI). NEDA-3 (no evidence of disease activity) is a composite endpoint used primarily in clinical trials, comprising these 3 measurements of disease activity. The aim of this study is to compare cladribine tablets (CT) with oral disease-modifying drugs (DMDs) - fingolimod (FTY), dimethyl fumarate (DMF), and teriflunomide (TERI) - with regard to NEDA-3 and its clinical (relapse and disability progression) and MRI (no new T1 Gd+ lesions or no new T2 lesions or no enlargement of existing lesions) components occurrence during a 24-month follow-up. METHODS In June 2018, a systematic review of MEDLINE, Embase and Cochrane database was performed. Due to the lack of head-to-head trials directly comparing cladribine tablets to oral drugs of interest, an indirect network meta-analysis (NMA) was applied, with placebo as a common comparator. NMA was performed with Bayesian approach and Markov chain Monte Carlo (MCMC) method for estimating posterior distributions. Additional data used in the analysis were taken from conference abstracts or post hoc analyses of pooled data from the clinical studies. RESULTS Six randomised clinical trials (RCTs) presenting NEDA, with active treatment compared to placebo, were included in the NMA: CLARITY (CT), FREEDOMS and FREEDOMS II (FTY), CONFIRM and DEFINE (DMF) and TEMSO (TERI). The rate of NEDA-3 was significantly higher in cladribine tablets vs DMF: OR (odds ratio)=1.76 (95% CrI [credible intervals]: 1.02-3.03) and TERI: OR=2.78 (95% CrI: 1.60-4.83), but not vs FTY. For the MRI NEDA results were as follows - cladribine tablets vs DMF: OR=1.87 (95% CrI: 1.18-2.97); cladribine tablets vs TERI: OR=6.59 (95% CrI: 4.32-10.09); cladribine tablets vs FTY: OR=1.58 (95% CrI: 1.10-2.29). The comparison of clinical NEDA did not reach significance vs either DMF or TERI and evaluation vs FTY was not possible because of lack of data. CONCLUSIONS Cladribine in the form of tablets was significantly more effective in achieving NEDA-3 than DMF and TERI, but there was no significant difference vs FTY. Cladribine tablets was more effective than all oral comparators considering the MRI NEDA. For clinical NEDA, the superiority vs DMF and vs TERI was not confirmed, and vs FTY evaluation was not possible.
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Affiliation(s)
- Halina Bartosik-Psujek
- Department of Neurology, Institute of Medical Sciences, Medical College of Rzeszow University, Warzywna 1A, 35-310 Rzeszów, Poland.
| | | | | | | | - Rafał Wójcik
- Aestimo s.c., Krakowska 36/3, 31-062 Kraków, Poland
| | - Patrycja Zięba
- Merck Sp. z o.o., Aleje Jerozolimskie 142 B, 02-305 Warsaw, Poland, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Marcin Kaczor
- Jagiellonian University Medical College, Skawinska 8, 31-066 Kraków, Poland
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Cree BAC, Bowen JD, Hartung HP, Vermersch P, Hughes B, Damian D, Hyvert Y, Dangond F, Galazka A, Grosso M, Jones DL, Leist TP. Subgroup analysis of clinical and MRI outcomes in participants with a first clinical demyelinating event at risk of multiple sclerosis in the ORACLE-MS study. Mult Scler Relat Disord 2020; 49:102695. [PMID: 33578191 DOI: 10.1016/j.msard.2020.102695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/20/2020] [Accepted: 12/12/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND In the Phase 3, 96-week ORACLE-MS study, cladribine 10 mg tablets (3.5 mg/kg or 5.25 mg/kg cumulative dose over 2 years) significantly reduced the rate of conversion to clinically definite multiple sclerosis (CDMS) per the Poser criteria (henceforth referred to as CDMS), multiple sclerosis (MS) per the 2005 McDonald criteria, and the number of new or persisting T1 gadolinium-enhancing (Gd+), new or enlarging T2, and combined unique active (CUA) lesions versus placebo in participants with a first clinical demyelinating event (FCDE). Patient demographic and disease characteristics may be predictors of disease progression. The current study analyzed the effect of cladribine tablets in subgroups of participants in the ORACLE-MS study by baseline demographics and disease characteristics. METHODS This analysis retrospectively examined data collected from 616 participants enrolled in the ORACLE-MS study (placebo, n=206; cladribine tablets 3.5 mg/kg, n=206; cladribine tablets 5.25 mg/kg, n=204). Five subgroups were predetermined by baseline demographics, including sex, age (<30 or ≥30 years), classification of FCDE, and lesion characteristics, including absence or presence of T1 Gd+ lesions and number of T2 lesions (<9 or ≥9). Selected endpoints of the ORACLE-MS study were re-analyzed for these subgroups. The primary and main secondary endpoints were time to conversion to CDMS and MS (2005 McDonald criteria), respectively. Secondary magnetic resonance imaging (MRI) endpoints included cumulative T1 Gd+ and new or enlarging T2 lesions. Cox proportional hazards models were used to evaluate time to conversion to CDMS and MS (2005 McDonald criteria). This analysis focused primarily on the results for the cladribine tablets 3.5 mg/kg group because this dosage is approved for relapsing forms of MS. RESULTS In the overall intent-to-treat (ITT) population, cladribine tablets 3.5 mg/kg significantly reduced the risk of conversion to CDMS (hazard ratio [HR]=0.326; P<0.0001) and MS (2005 McDonald criteria; HR=0.485; P<0.0001) versus placebo. Similar effects of cladribine tablets on risk of conversion were observed in post hoc analyses of subgroups defined by various baseline characteristics. In both the ITT population and across subgroups, cladribine tablets 3.5 mg/kg reduced the numbers of cumulative T1 Gd+ (range of rate ratios: 0.106-0.399), new or enlarging T2 (range of rate ratios: 0.178-0.485), and CUA (range of rate ratios: 0.154-0.384) lesions versus placebo (all nominal P<0.03). Multivariate Cox proportional hazards models revealed that age (HR=0.577, nominal P<0.0001), FCDE classification (HR=0.738, nominal P=0.0043), presence of T1 Gd+ lesions (HR=0.554, nominal P<0.0001), and number of T2 lesions (HR=0.417, nominal P<0.0001) at baseline were factors associated with risk of conversion to MS (2005 McDonald criteria), whereas no baseline factors examined were associated with risk of conversion to CDMS. CONCLUSION In this post hoc analysis of the ORACLE-MS study, cladribine tablets reduced the risk of conversion to multiple sclerosis and lesion burden in participants with an FCDE in the overall ITT population and multiple subgroups defined by baseline demographics and lesion characteristics.
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Affiliation(s)
- Bruce A C Cree
- UCSF Weill Institute for Neurosciences, San Francisco, CA, USA
| | - James D Bowen
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Hans-Peter Hartung
- Department of Neurology, University Hospital of Düsseldorf, Medical Faculty, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Patrick Vermersch
- University of Lille, INSERM U1172, Lille Neurosciences and Cognition, CHU Lille, FHU Imminent, F-59000 Lille, France
| | - Bruce Hughes
- MercyOne Ruan Multiple Sclerosis Center, Des Moines, IA, USA
| | - Doris Damian
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | | | - 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
| | - Daniel L Jones
- EMD Serono, Inc., Rockland, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Thomas P Leist
- Comprehensive Multiple Sclerosis Center, Jefferson University, Philadelphia, PA, USA
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Tafazzoli A, Chavan A, Harty G, Moller J, Wong SL. Efficiency Model of Cladribine Tablets Versus Infusion-Based Disease-Modifying Drugs for Patients with Relapsing-Remitting Multiple Sclerosis. Adv Ther 2020; 37:3791-3806. [PMID: 32647909 DOI: 10.1007/s12325-020-01426-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION To develop a simulation model assessing the efficiency of using cladribine tablets versus infusion-based disease-modifying drugs (DMDs) for the treatment of relapsing-remitting multiple sclerosis (RRMS) from a facility perspective in the UK. METHODS A scheduling algorithm was developed to simulate day-case admissions and calculate the mean changes to resource use and time burden for patients in a facility that transitions from infusion-based treatments to cladribine tablets over 1 year. Model inputs and assumptions were based on previous research and expert opinion. Model validation and quality checks were performed and additional scenario analyses were also conducted. RESULTS The model successfully scheduled all infusion treatments in the base case and no patients were left off the schedule as a result of lack of capacity. Modeled base-case outcomes increased in future scenarios owing to a 35% increase in demand. The introduction of cladribine tablets reduced these impacts. Specifically, the difference in mean daily utilization was reduced in the future scenario from 13% to 3% as 8% of patients moved to cladribine tablets; annual administration costs decreased by 96% and annual time burden decreased by 90%. Results from additional scenarios showed the largest benefits from switching current infusion patients to cladribine tablets were realized in facilities having moderate to high resource utilization. CONCLUSIONS This model provides facility decision-makers the ability to assess the efficiency of using cladribine tablets rather than an infusion-based DMD. The simulation quantified the benefits gained from reducing the burden on facility resources by switching some patients with RRMS from infusion-based DMDs to cladribine tablets. Overall, modeled outcomes increased in future scenarios owing to an increase in demand, although the introduction of cladribine tablets reduced this impact.
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Affiliation(s)
- Ali Tafazzoli
- Evidence Synthesis, Modeling and Communication, Evidera, Bethesda, MD, USA
| | - Ameya Chavan
- Evidence Synthesis, Modeling and Communication, Evidera, Bethesda, MD, USA
| | - Gerard Harty
- Global Evidence and Value Development, Global Research and Development, EMD Serono, Inc, Billerica, MA, USA.
| | - Jorgen Moller
- Evidence Synthesis, Modeling and Communication, Evidera, London, UK
| | - Schiffon L Wong
- Global Evidence and Value Development, Global Research and Development, EMD Serono, Inc, Billerica, MA, USA
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AlJumah M, Alkhawajah MM, Qureshi S, Al-Thubaiti I, Ayoub O, Bohlega SA, Bushnag A, Cupler E, Daif A, El Boghdady A, Hassan A, Al Malik Y, Saeedi J, Al-Shamrany F, Shosha E, Rieckmann P. Cladribine Tablets and Relapsing-Remitting Multiple Sclerosis: A Pragmatic, Narrative Review of What Physicians Need to Know. Neurol Ther 2020; 9:11-23. [PMID: 32056129 PMCID: PMC7229040 DOI: 10.1007/s40120-020-00177-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Indexed: 12/21/2022] Open
Abstract
Immune reconstitution therapy (IRT) is an emerging management concept for multiple sclerosis, whereby a short course of treatment provides long-lasting suppression of disease activity. "Cladribine tablets 10 mg" refers to a total cumulative dose of cladribine given over 2 years (henceforth referred to as cladribine tablets 3.5 mg/kg); it is a relatively new treatment option that is hypothesised to act as an IRT acting preferentially on the adaptive immune system. A randomised, 2-year, placebo-controlled trial (CLARITY) showed that treatment with cladribine tablets reduced indices of disease activity (relapses, lesions on magnetic resonance images, disability progression) and that this effect outlasted the pharmacologic effect of the treatment on the immune system (mainly a reduction in circulating B and T cells, with little effect on components of the innate immune system such as monocytes). CLARITY Extension, a 2-year extension to this trial, demonstrated durable efficacy, also in patients who received the standard 2-year course of cladribine tablets 3.5 mg/kg and were re-randomised to placebo for a further 2 years. Relative risk reductions for relapse rate with cladribine tablets 3.5 mg/kg were similar for patients with or without prior high disease activity. Reductions in disability progression with cladribine tablets 3.5 mg/kg were higher in patients with prior high relapse rates with or without prior treatment non-response. In this review, we describe the therapeutic profile of cladribine tablets 3.5 mg/kg and provide practical information on initiating this treatment option in the most appropriate patients.
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Affiliation(s)
- Mohamed AlJumah
- King Fahad Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia.
| | | | - Shireen Qureshi
- Johns Hopkins Aramco Healthcare, Dhahran, Kingdom of Saudi Arabia
| | | | - Omar Ayoub
- King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Saeed A Bohlega
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Areej Bushnag
- International Medical Center, Jeddah, Kingdom of Saudi Arabia
| | - Edward Cupler
- King Faisal Specialist Hospital and Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Abdulkader Daif
- King Khaled University Hospital, Riyadh, Kingdom of Saudi Arabia
| | | | - Ahmed Hassan
- King Faisal Specialist Hospital and Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Yaser Al Malik
- King Saud Bin Abdulaziz University for Health Sciences (KSBU-HS), King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Jameelah Saeedi
- King Abdullah Bin Abdulaziz University Hospital, KAAUH, Riyadh, Kingdom of Saudi Arabia
| | | | - Eslam Shosha
- King Khaled Hospital, Al-Majmaah, Kingdom of Saudi Arabia
| | - Peter Rieckmann
- Bamberg Hospital and University of Erlangen, Bamberg, Germany
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Mankinen P, Lundström T, Soini E, Sumelahti ML, Ruutiainen J, Niskala U, Järvinen E. Cost Assessment Modelling of Treatments for Highly Active Relapsing Multiple Sclerosis. Adv Ther 2020; 37:800-18. [PMID: 31873868 DOI: 10.1007/s12325-019-01186-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Cost assessment modelling (CAM) of treatments in highly active relapsing multiple sclerosis was conducted. METHODS The CAM was developed using the R programming language. The PICOSTEPS health technology assessment framework was applied in the CAM. Modelled patients were 280 adults with highly active relapsing multiple sclerosis eligible for disease-modifying treatment. Intervention was cladribine tablets, a new and reimbursed oral treatment for highly active relapsing multiple sclerosis in Finland. Comparators included fingolimod, the most used oral reimbursed treatment for the highly active disease, and natalizumab, the most used intravenous treatment, and a treatment mix (80% use fingolimod, 20% use natalizumab) in Finland. Outcomes presented expected annual and cumulative drug-associated costs in the overall population and per patient. Setting was modelled public specialist care in Finland. Time was set to 4 years, without discounting. Effects covered expected drug-associated costs (screening, acquisition, administration, monitoring, adverse events, travelling, productivity). Perspective was a limited societal perspective. Sensitivity analyses regarding all PICOSTEPS components were conducted. RESULTS Cladribine tablets were projected to be cost saving in comparison to fingolimod, natalizumab and treatment mix. The respective modelled savings were €4,598,742, €16,249,701 and €6,928,934 in the overall population, and €16,424, €58,035 and €24,746 per patient, respectively, during the 4 years. The most important cost driver was drug costs, representing 96.3%, 96.0% and 83.4% of modelled costs associated with cladribine tablets, fingolimod and natalizumab, respectively. Cladribine tablets sustained their affordability in the sensitivity analyses. From the perspective of health care payer, cladribine tablets' savings were projected to be €4,514,509, €15,145,366 and €6,640,680 in the overall population, and €16,123, €54,091 and €23,717 per patient in comparison to fingolimod, natalizumab and treatment mix, respectively. CONCLUSION Based on the CAM, cladribine tablets were projected to robustly save modelled drug-associated costs in comparison to fingolimod, natalizumab and their mix in Finland.
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Comi G, Cook S, Giovannoni G, Rieckmann P, Sørensen PS, Vermersch P, Galazka A, Nolting A, Hicking C, Dangond F. Effect of cladribine tablets on lymphocyte reduction and repopulation dynamics in patients with relapsing multiple sclerosis. Mult Scler Relat Disord 2019; 29:168-174. [PMID: 30885375 DOI: 10.1016/j.msard.2019.01.038] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 01/21/2019] [Accepted: 01/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immune reconstitution therapies (IRT) for patients with multiple sclerosis are used for short, intermittent treatment periods to induce immune resetting and allow subsequent treatment-free periods. Cladribine tablets are postulated to be an IRT that causes selective and transient reductions in CD19+ B cells and T cells, followed by reconstitution of adaptive immune function. OBJECTIVE To characterize long-term lymphocyte count changes in pooled data from the 2-year CLARITY and subsequent 2-year CLARITY Extension studies, and the PREMIERE registry (Long-term CLARITY cohort). METHODS Data from patients randomized to placebo (n = 435) or cladribine tablets 10 mg (MAVENCLAD®; 3.5 mg/kg cumulative dose over 2 years, referred to as cladribine tablets 3.5 mg/kg; n = 685) in CLARITY or CLARITY Extension, including time spent in the PREMIERE registry were pooled to provide long-term follow-up data. The study investigated absolute lymphocyte counts (ALC) up to 312 weeks and B and T cell subsets up to 240 weeks after the first dose, in patients receiving placebo or cladribine tablets 3.5 mg/kg administered as two short (4 or 5 days) weekly treatments at the start of months 1 and 2 in each treatment year, followed by no further active treatment. RESULTS Treatment with cladribine tablets 3.5 mg/kg resulted in selective reductions in B and T lymphocytes. Lymphocyte recovery began soon after treatment in each of years 1 and 2. Median ALC recovered to the normal range and CD19+ B cells recovered to threshold values by week 84, approximately 30 weeks after the last dose of cladribine tablets in year 2. Median CD4+ T cell counts recovered to threshold values by week 96 (approximately 43 weeks after the last dose of cladribine tablets in year 2). Median CD8+ cell counts never dropped below the threshold value. CONCLUSION These results show the dynamics of lymphocyte count changes following treatment with cladribine tablets 3.5 mg/kg. The immune cell repopulation results provide further evidence that cladribine tablets may represent a form of IRT.
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Affiliation(s)
- Giancarlo Comi
- Department of Neurology and Institute of Experimental Neurology, Università Vita-Salute San Raffaele, Ospedale San Raffaele, Milan, Italy
| | - Stuart Cook
- Rutgers, The State University of New Jersey, New Jersey Medical School, Department of Neurology & Neurosciences, Medical Science Building, 185 South Orange Avenue, MSB, H506, Newark, NJ 07101-1709, United States.
| | - Gavin Giovannoni
- Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Peter Rieckmann
- Department of Neurology, Medical Park Loipl and University of Erlangen, Erlangen, Germany
| | - Per Soelberg Sørensen
- Danish MS Center, Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Patrick Vermersch
- University of Lille, CHU Lille, LIRIC-INSERM U995, FHU Imminent, Lille, France
| | | | | | | | - Fernando Dangond
- EMD Serono Research & Development Institute Inc., Billerica, MA, United States
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Cook S, Leist T, Comi G, Montalban X, Giovannoni G, Nolting A, Hicking C, Galazka A, Sylvester E. Safety of cladribine tablets in the treatment of patients with multiple sclerosis: An integrated analysis. Mult Scler Relat Disord 2018; 29:157-167. [PMID: 30885374 DOI: 10.1016/j.msard.2018.11.021] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/09/2018] [Accepted: 11/19/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treating patients with relapsing multiple sclerosis (MS) with cladribine tablets (two times 4 or 5 days of treatment each year for 2 years) results in long-lasting efficacy, with continued stability in many patients for 4 or more years. Safety and tolerability outcomes from individual clinical studies with cladribine tablets have been reported previously. OBJECTIVE Report safety data from an integrated analysis of clinical trials and follow-up in patients with MS to further characterize the safety profile of cladribine tablets. METHODS Data for patients treated with cladribine tablets 10 mg (MAVENCLAD®; 3.5 mg/kg cumulative dose over 2 years, referred to as cladribine tablets 3.5 mg/kg) as monotherapy (n = 923) or placebo (n = 641) in Phase III clinical trials (CLARITY, CLARITY Extension and ORACLE-MS) and followed up in the PREMIERE registry were aggregated (Monotherapy Oral cohort). To better characterize rare events, additional data from earlier studies which involved the use of parenteral cladribine in patients with MS, and the ONWARD study, in which patients were given cladribine tablets in addition to interferon (IFN)-β or placebo plus IFN-β were included in an All Exposed cohort (cladribine, n = 1926; placebo, n = 802). Adjusted adverse events incidences per 100 patient-years (Adj-AE per 100 PY) were calculated for the integrated analyses. RESULTS The incidence rate of treatment-emergent adverse events (TEAEs) in the Monotherapy Oral cohort was 103.29 vs. 94.26 Adj-AEs per 100 PY for placebo. TEAEs that occurred more frequently with cladribine tablets were mainly driven by the TEAEs of lymphopenia (Adj-AE per 100 PY 7.94 vs. 1.06 for placebo) and lymphocyte count decreased (Adj-AE per 100 PY 0.78 vs. 0.10 for placebo) as anticipated due to the mode of action of cladribine. An increase in TEAE incidence rate was also observed in the cladribine tablets 3.5 mg/kg group vs. placebo for herpes zoster (Adj-AE per 100 PY 0.83 vs. 0.20, respectively). There were no cases of systemic, serious disseminated herpes zoster attributed to treatment with cladribine tablets. In general there was no increase in the risk of infections including opportunistic infections with cladribine tablets versus placebo, except for herpes zoster. Periods of severe lymphopenia (< 0.5 × 109 cells/L) were associated with an increased frequency of infections, but the nature of these was not different to that observed in the overall patient group treated with cladribine tablets 3.5 mg/kg. Within the constraints of a limited sample size, malignancy rates in the overall clinical program for cladribine in MS did not show evidence of an increase compared to placebo-treated patients and there was no increase in the incidence of malignancies over time in cladribine-treated patients. CONCLUSION The AE profile for cladribine tablets 3.5 mg/kg as a monotherapy has been well-characterized in a pooled population of patients from early to more advanced relapsing MS. There was no increased risk for infections in general except for a higher incidence of herpes zoster. Lymphopenia was amongst the most frequently observed TEAEs that occurred at a higher incidence with cladribine relative to placebo. There was also no increase in malignancy rates for cladribine relative to placebo.
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Affiliation(s)
- Stuart Cook
- Rutgers, The State University of New Jersey, New Jersey Medical School, Department of Neurology & Neurosciences, 185 South Orange Avenue, Newark, NJ 07101-1709, United States.
| | - Thomas Leist
- Division of Clinical Neuroimmunology, Jefferson University, Comprehensive MS Center, 900 Walnut Street, Philadelphia, PA 19107, United States
| | - Giancarlo Comi
- Department of Neurology and Institute of Experimental Neurology, Università Vita-Salute San Raffaele, Ospedale San Raffaele, Via Olgettina 48, Milan 20132, Italy
| | - Xavier Montalban
- Division of Neurology, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5B 1W8, Canada; Department of Neurology-Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Passeif de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Gavin Giovannoni
- Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, 4 Newark Street, London, E1 2AT, UK
| | - Axel Nolting
- Merck KGaA, Frankfurter Str. 250, 64293 Darmstadt, Germany
| | | | - Andrew Galazka
- Merck, Zone Industrielle de L'Ouriettaz, Aubonne, 1170, Switzerland, a division of Merck KGaA, Darmstadt, Germany
| | - Elke Sylvester
- Merck KGaA, Frankfurter Str. 250, 64293 Darmstadt, Germany
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Siddiqui MK, Khurana IS, Budhia S, Hettle R, Harty G, Wong SL. Systematic literature review and network meta-analysis of cladribine tablets versus alternative disease-modifying treatments for relapsing-remitting multiple sclerosis. Curr Med Res Opin 2018; 34:1361-1371. [PMID: 29149804 DOI: 10.1080/03007995.2017.1407303] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess the comparative efficacy and safety of cladribine tablets versus alternative disease modifying treatments (DMTs) in patients with active relapsing-remitting multiple sclerosis (RRMS), and in a subgroup with high disease activity (HRA + DAT), using systematic literature review (SLR) and network meta-analysis (NMA). METHODS MEDLINE, Embase, MEDLINE In-Process and CENTRAL databases were systematically searched to identify English-language publications of relevant studies of approved DMTs for RRMS. Searches were conducted from database inception to January 2017. Conference websites and trial registries were also searched. NMA considered the effects of DMTs on annualized relapse rate (ARR), confirmed disease progression (CDP), no evidence of disease activity (NEDA) and safety. RESULTS Of 10,825 articles retrieved and screened, 44 studies assessing 12 DMTs contributed to the NMA. In patients with active RRMS, cladribine tablets were associated with a significant 58% reduction in ARR versus placebo (p < .05); cladribine tablets were similar or significantly better than other DMT regimens and ranked fourth among DMTs, behind alemtuzumab, natalizumab and ocrelizumab. For CDP for 6 months and NEDA, improvements with cladribine tablets were significantly greater than those of placebo (p < .05), with no comparator DMT demonstrating significantly better results. Similar findings were reported in the HRA + DAT population. Overall adverse event risk for cladribine tablets did not differ significantly from that of placebo and most alternative DMTs. CONCLUSION In this first NMA to consider cladribine tablets, ocrelizumab and daclizumab for treatment of RRMS, cladribine tablets are a comparatively effective and safe alternative to other DMTs in both active RRMS and HRA + DAT populations.
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Hettle R, Harty G, Wong SL. Cost-effectiveness of cladribine tablets, alemtuzumab, and natalizumab in the treatment of relapsing-remitting multiple sclerosis with high disease activity in England. J Med Econ 2018; 21:676-686. [PMID: 29618273 DOI: 10.1080/13696998.2018.1461630] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AIMS Cladribine tablets were the first oral short-course treatment approved for highly active relapsing multiple sclerosis (MS). The Association of British Neurologists guidelines currently recommend two infusion therapies, alemtuzumab and natalizumab, to treat high disease activity relapsing remitting MS (HDA-RRMS). This analysis assessed the cost-effectiveness of cladribine tablets in HDA-RRMS compared with alemtuzumab and natalizumab, from the perspective of the National Health Service (NHS) in England. MATERIALS AND METHODS A cohort-based Markov model with 11 health states (10 Expanded Disability Status Scale [EDSS] plus death) was developed. Transition matrices from the British Columbia registry were used to model the natural history of EDSS. The treatment effect on EDSS was modelled using hazard ratios for 6-month confirmed disability progression from an indirect treatment comparison (ITC). Relapses and drug-related adverse events were modeled via annualized relapse rates and event probabilities, with associated costs and quality-adjusted life year (QALY) losses. Utilities were derived from trials and the literature, and costs from NHS and literature sources. Uncertainty was assessed via probabilistic and deterministic sensitivity analyses. RESULTS Cladribine tablets were dominant (i.e., less costly and more effective) vs alemtuzumab and natalizumab in pairwise comparisons, and the dominant strategy in fully incremental analyses. Incremental cost was driven largely by drug acquisition and administration costs, and incremental QALY gain largely by differences in delayed EDSS progression. Cladribine tablets had a 93% probability of being cost-effective at a threshold of GBP 30,000 per QALY gained, and remained dominant across the scenario analyses tested. The greatest influence on results was the treatment effect on disability progression derived from the ITC. LIMITATIONS Uncertainty over the efficacy of DMT beyond trial durations. In line with other comparative effectiveness analyses, the network meta-analysis informing this cost-effectiveness analysis was associated with a degree of uncertainty. No treatment switching analyses were undertaken. CONCLUSIONS Cladribine tablets are a cost-effective alternative to alemtuzumab and natalizumab in the treatment of HDA-RRMS from the perspective of the NHS in England.
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Affiliation(s)
- Robert Hettle
- a Parexel Access Consulting, Parexel International , Uxbridge , UK
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Freedman MS, Leist TP, Comi G, Cree BA, Coyle PK, Hartung HP, Vermersch P, Damian D, Dangond F. The efficacy of cladribine tablets in CIS patients retrospectively assigned the diagnosis of MS using modern criteria: Results from the ORACLE-MS study. Mult Scler J Exp Transl Clin 2017; 3:2055217317732802. [PMID: 29051829 PMCID: PMC5637982 DOI: 10.1177/2055217317732802] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/07/2017] [Indexed: 11/15/2022] Open
Abstract
Background Multiple sclerosis (MS) diagnostic criteria have changed since the ORACLE-MS study was conducted; 223 of 616 patients (36.2%) would have met the diagnosis of MS vs clinically isolated syndrome (CIS) using the newer criteria. Objective The objective of this paper is to assess the effect of cladribine tablets in patients with a first clinical demyelinating attack fulfilling newer criteria (McDonald 2010) for MS vs CIS. Methods A post hoc analysis for subgroups of patients retrospectively classified as fulfilling or not fulfilling newer criteria at the first clinical demyelinating attack was conducted. Results Cladribine tablets 3.5 mg/kg (n = 68) reduced the risk of next attack or three-month confirmed Expanded Disability Status Scale (EDSS) worsening by 74% vs placebo (n = 72); p = 0.0009 in patients meeting newer criteria for MS at baseline. Cladribine tablets 5.25 mg/kg (n = 83) reduced the risk of next attack or three-month confirmed EDSS worsening by 37%, but nominal significance was not reached (p = 0.14). In patients who were still CIS after applying newer criteria, cladribine tablets 3.5 mg/kg (n = 138) reduced the risk of conversion to clinically definite multiple sclerosis (CDMS) by 63% vs placebo (n = 134); p = 0.0003. Cladribine tablets 5.25 mg/kg (n = 121) reduced the risk of conversion by 75% vs placebo (n = 134); p < 0.0001. Conclusions Regardless of the criteria used to define CIS or MS, 3.5 mg/kg cladribine tablets are effective in patients with a first clinical demyelinating attack. ClinicalTrials.gov registration: The ORACLE-MS study (NCT00725985).
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Affiliation(s)
- Mark S Freedman
- Department of Medicine (Neurology), University of Ottawa and the Ottawa Hospital Research Institute, Canada
| | - Thomas P Leist
- Division of Clinical Neuroimmunology, Thomas Jefferson University, USA
| | - Giancarlo Comi
- Department of Neurology and Institute of Experimental Neurology, Università Vita-Salute San Raffaele, Ospedale San Raffaele, Italy
| | | | | | - Hans-Peter Hartung
- Department of Neurology, Heinrich Heine University, Medical Faculty, Germany
| | - Patrick Vermersch
- University of Lille, CHU Lille, LIRIC-INSERM U995, FHU Imminent, France
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