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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] [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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Sgarlata E, Chisari CG, Toscano S, Finocchiaro C, Lo Fermo S, Millefiorini E, Patti F. Changes in John Cunningham Virus Index in Multiple Sclerosis Patients Treated with Different Disease-Modifying Therapies. Curr Neuropharmacol 2022; 20:1978-1987. [PMID: 34766895 PMCID: PMC9886813 DOI: 10.2174/1570159x19666211111123202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Progressive Multifocal Leukoencephalopathy (PML) is an opportunistic infection caused by John Cunningham virus (JCV) reactivation, potentially associated with natalizumab (NTZ) treatment for Multiple Sclerosis (MS). The anti-JCV antibodies titre (JCV index) increases during NTZ treatment; however, the effects of other disease-modifying therapies (DMTs) on the JCV index have not been fully explored. OBJECTIVE The aim of the study was to evaluate changes in the JCV index during treatment with several DMTs. METHODS This longitudinal study evaluated the JCV index before starting DMT (T0) and during treatment with DMT (T1). RESULTS A total of 260 participants (65.4 % females, mean age 43 ± 11.3 ) were enrolled: 68 (26.2 %) treated with fingolimod (FTY), 65 (25 %) rituximab or ocrelizumab (RTX/OCR), 37 (14.2 %) dimethyl-fumarate (DMF), 29 (11.2 %) cladribine (CLD), 23 (8.8 %) teriflunomide (TFM), 20 (7.7 %) interferon or glatiramer acetate (IFN/GA), and 18 (6.9 %) alemtuzumab (ALM). At T1, the percentage of patients with JCV index <0.90 was found to be significantly increased in the ALM group (16.7 % versus 66.7 %, p = 0.05), while the percentage of patients with JCV index >1.51 was found to be significantly reduced in the RTX/OCR group (51.6 % versus 37.5 %, p = 0.04). In the FTY group, a significant reduction in the percentage of patients with JCV index <0.90 was also found (23.5 % versus 1.4 %, p = 0.0006). The mean JCV index was reduced in the RTX/OCR and ALM groups, while a significant increase was observed in the FTY group. CONCLUSION DMTs with a T and/or B depleting mechanism of action induced a significant reduction in the JCV index. These results may suggest new possible sequencing strategies potentially maximizing disease control while reducing the PML risk.
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Affiliation(s)
| | | | | | | | | | | | - Francesco Patti
- Address correspondence to this author at the Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy; Tel: 0953782783; E-mail:
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Butzkueven H, Moore N, Aydemir A, Sõnajalg J, Bezemer I, Korhonen P, Sabidó M. The CLARION study design and status update: a long-term, registry-based study evaluating adverse events of special interest in patients with relapsing multiple sclerosis newly started on cladribine tablets. Curr Med Res Opin 2022; 38:1167-1176. [PMID: 35357268 DOI: 10.1080/03007995.2022.2059977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the design of the CLARION post-approval safety study (EU PAS Register number, EUPAS24484) and provide a status update, including characteristics of patients included up to 1 May 2021. METHODS CLARION aims to further evaluate adverse events of special interest in patients who are newly initiating treatment with cladribine tablets for relapsing multiple sclerosis (MS). The study population consists of two cohorts: patients newly initiating cladribine tablets (cladribine cohort) and patients newly initiating oral fingolimod tablets (comparator fingolimod cohort), with an aim to include 8000 patients (4000 patients per cohort). The study relies on secondary use of data from pre-existing MS registries/data sources (except in Germany, where primary data collection is performed). The study is projected to last 15 years, with an anticipated 5-year inclusion period. Study outcomes are: malignancies; severe infections; tuberculosis; progressive multifocal leukoencephalopathy; other opportunistic infections; herpes zoster; severe lymphopenia (Grade ≥ 3); and treatment discontinuation. RESULTS As of 1 May 2021, 2393 patients were included in CLARION from seven participating MS registries/data sources (cladribine cohort, n = 1266; fingolimod cohort, n = 1127). The majority of patients are female (cladribine cohort, 72.5%; fingolimod cohort, 68.0%), with mean age at onset of MS of 31.5 years for the cladribine cohort and 30.9 years for the fingolimod cohort. The majority of patients in both cohorts had relapsing MS (cladribine cohort, 92.1%; fingolimod cohort, 93.5%). CONCLUSION By providing further information on adverse events of special interest during long-term follow-up, CLARION will assist neurologists and patients regarding treatment decision-making for management of relapsing MS.
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Affiliation(s)
- Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Nicholas Moore
- Bordeaux PharmacoEpi (BPE), Université de Bordeaux, Bordeaux, France
| | - Aida Aydemir
- Global Biostatistics, EMD Serono Research & Development Institute, Inc, Billerica, MA, USA (an affiliate of Merck KGaA)
| | | | - Irene Bezemer
- Global Epidemiology and Outcomes Research, IQVIA, Amsterdam, The Netherlands
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Fuchs TA, Wattengel BA, Carter MT, El-Solh AA, Lesse AJ, Mergenhagen KA. Outcomes of multiple sclerosis patients admitted with COVID-19 in a large veteran cohort. Mult Scler Relat Disord 2022; 64:103964. [PMID: 35724529 PMCID: PMC9188116 DOI: 10.1016/j.msard.2022.103964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/03/2022] [Accepted: 06/10/2022] [Indexed: 11/03/2022]
Abstract
Background Given concerns over immune function, the decision whether to continue disease modifying therapy (DMT) in multiple sclerosis (MS) patients during the COVID-19 pandemic has been challenging, complicated by the risk of MS disease progression in the absence of treatment. Methods This retrospective analysis of patients treated for COVID-19 infection at veteran affairs healthcare systems across the United States, investigated 30-day all-cause mortality after first positive COVID-19 in patients with and without MS. We examined mortality risk impact of disease modifying therapy for MS, accounting for other relevant factors known to be associated with COVID-19 mortality. Patients were propensity score matched in a 1:20 fashion based on MS diagnosis. Results 49,737 COVID-19 inpatient cases were identified, of which 258 were diagnosed with MS. In the propensity score matched cohort, MS patients taking DMT (excluding those receiving anti-CD20 antibodies) had a lower odds of 30 day mortality (OR: 0.18 [95%CI: 0.00988-0.94] p=0.041). Similarly, in the unmatched cohort, patients on DMT had a lower risk of death (OR: 0.16 [95%CI: 0.01-0.82] p=0.023). There was no statistically significant difference in mortality between those with and without MS. In the propensity matched cohort, age over 65, heart failure, chronic kidney disease (CKD), and diabetes increased the risk of mortality while vaccination reduced the risk of mortality. Conclusion Veteran patients with MS hospitalized for COVID-19 were less likely to die when taking DMTs (excluding those receiving anti-CD20 antibodies), accounting for other relevant factors. Results suggest that, in relation to the COVID-19 pandemic, not only is it safe to continue most DMTs in people with MS, but it may be beneficial given the decreased risk of COVID-19 mortality and decreased risk of MS disease progression.
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Affiliation(s)
- Tom A Fuchs
- Jacobs Multiple Sclerosis Center, Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States
| | - Bethany A Wattengel
- Veteran Affairs Western New York Healthcare System, Department of Pharmacy, Buffalo, NY, United States
| | - Michael T Carter
- Veteran Affairs Western New York Healthcare System, Department of Pharmacy, Buffalo, NY, United States
| | - Ali A El-Solh
- Veteran Affairs Western New York Healthcare System, Department of Research and Development, Buffalo, NY, United States
| | - Alan J Lesse
- Department of Infectious Diseases, Veteran Affairs Western New York Healthcare System, Buffalo, NY
| | - Kari A Mergenhagen
- Veteran Affairs Western New York Healthcare System, Department of Pharmacy, Buffalo, NY, United States.
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Patti F, Chisari CG, Toscano S, Arena S, Finocchiaro C, Cimino V, Milone G. Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis Patients: Monocentric Case Series and Systematic Review of the Literature. J Clin Med 2022; 11:jcm11040942. [PMID: 35207216 PMCID: PMC8875789 DOI: 10.3390/jcm11040942] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 02/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory and immune-mediated disease of the central nervous system (CNS), commonly affecting young adults and potentially associated with life-long disability. About 14 disease-modifying treatments (DMTs) are currently approved for the treatment of MS. However, despite the use of highly effective therapies, some patients exhibit a highly active disease with an aggressive course from onset and a higher risk of long-term disability accrual. In the last few years, several retrospective studies, clinical trials, meta-analyses and systematic reviews have investigated autologous hematopoietic stem cell transplantation (AHSCT) as a possible therapeutic option in order to address this unmet clinical need. These studies demonstrated that AHSCT is a highly efficacious and relatively safe therapeutic option for the treatment of highly active MS. Particularly, over recent years, the amount of evidence has grown, with significant improvements in the development of patient selection criteria, choice of the most suitable transplant technique and clinical experience. In this paper, we present six patients who received AHSCT in our MS center and we systematically reviewed recent evidence about the long-term efficacy and safety of AHSCT and the placement of AHSCT in the rapidly evolving therapeutic armamentarium for MS.
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Affiliation(s)
- Francesco Patti
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Clara Grazia Chisari
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Simona Toscano
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Sebastiano Arena
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Chiara Finocchiaro
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Vincenzo Cimino
- IRCCS Centro Neurolesi “Bonino Pulejo”, 98124 Messina, Italy;
| | - Giuseppe Milone
- Hematology and Bone Marrow Transplant Unit, Azienda Policlinico-Vittorio Emanuele, 95124 Catania, Italy;
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Clark KC, Wang D, Kumar P, Mor S, Kulubya E, Lazar S, Wang A. The Molecular Mechanisms Through Which Placental Mesenchymal Stem Cell-Derived Extracellular Vesicles Promote Myelin Regeneration. Adv Biol (Weinh) 2022; 6:e2101099. [PMID: 35023637 PMCID: PMC9225676 DOI: 10.1002/adbi.202101099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/30/2021] [Indexed: 02/03/2023]
Abstract
Multiple sclerosis (MS) is a debilitating degenerative disease characterized by an immunological attack on the myelin sheath leading to demyelination and axon degeneration. Mesenchymal stem/stromal cells (MSCs) and secreted extracellular vesicles (EVs) have become attractive targets as therapies to treat neurodegenerative diseases such as MS due to their potent immunomodulatory and regenerative properties. The placenta is a unique source of MSCs (PMSCs), demonstrates "fetomaternal" tolerance during pregnancy, and serves as a novel source of MSCs for the treatment of neurodegenerative diseases. PMSCs and PMSC-EVs have been shown to promote remyelination in animal models of MS, however, the molecular mechanisms by which modulation of autoimmunity and promotion of myelination occurs have not been well elucidated. The current review will address the molecular mechanisms by which PMSC-EVs can promote remyelination in MS.
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Guarnaccia JB, Cabot A, Garten LL, Napoli S, Hasbani MJ. Teriflunomide levels in women whose male sexual partner is on teriflunomide for relapsing multiple sclerosis. Mult Scler Relat Disord 2022; 57:103347. [PMID: 35158456 DOI: 10.1016/j.msard.2021.103347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/05/2021] [Accepted: 10/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND For small molecules such as teriflunomide, used to treat relapsing multiple sclerosis (MS), that are potentially embryotoxic, there is a theoretical risk of transmission of the medication from males on the drug to female sexual partners. However, that risk has been undefined up to now. METHODS Teriflunomide concentrations were assayed concomitantly in ten sexually active couples, not using barrier methods of contraception, in whom the male partner with MS was on treatment with teriflunomide 14 mg daily for at least two months. These results were compared by male and female age, teriflunomide concentrations and reported average number of incidences of sexual intercourse per month. The threshold level of detection of teriflunomide was 0.020 µg/ml in females. RESULTS The average age of the cohort was 46.70 for males and 47.10 for females. Four of ten females had detectible teriflunomide concentrations (mean 0.046 µg/ml (range 0.22-0.077, standard deviation 0.025). Male age and both female teriflunomide positive threshold and female teriflunomide concentration were inversely correlated (r = 0.67, R2=0.45, p = 0.034) for the former and (r = 0.62, R2=0.39, p = 0.05, ns) for the latter. No significant correlations were observed for female age, male teriflunomide concentrations, or reported mean monthly episodes of sexual intercourse. CONCLUSION This limited study suggests that the small risk that low levels of teriflunomide can be transmitted from male to female partners via sexual intercourse is related to male age. This supports the recommendations found in the United States Product Insert (USPI) stating that men taking teriflunomide who do not wish to father a child, and their female partners, should use reliable contraception. Men wishing to father a child should discontinue use of teriflunomide and undergo an accelerated elimination procedure to reduce the plasma concentrations of the medication to less than 0.02 mg/L (0.02 µg/ml1.
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Affiliation(s)
| | - Ann Cabot
- MS Specialty Care Program, Concord Hospital, NH, United States
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8
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Toscano S, Chisari CG, Patti F. Multiple Sclerosis, COVID-19 and Vaccines: Making the Point. Neurol Ther 2021; 10:627-649. [PMID: 34625925 PMCID: PMC8500471 DOI: 10.1007/s40120-021-00288-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/22/2021] [Indexed: 12/15/2022] Open
Abstract
On 11 March 2020, the World Health Organization declared the coronavirus disease 19 (COVID-19) outbreak a pandemic. In this context, several studies and clinical trials have been conducted since then, and many are currently ongoing, leading to the development of several COVID-19 vaccines with different mechanisms of action. People affected by multiple sclerosis (MS) have been considered high-risk subjects in most countries and prioritized for COVID-19 vaccination. However, the management of MS during the COVID-19 pandemic has represented a new challenge for MS specialists, particularly because of the initial lack of guidelines and differing recommendations. Despite an initial hesitation in prescribing disease-modifying drugs (DMDs) in naïve and already treated patients with MS, most national neurology associations and organizations agree on not stopping treatment. However, care is needed especially for patients treated with immune-depleting drugs, which also require some attentions in programming vaccine administration. Many discoveries and new research results have accumulated in a short time on COVID-19, resulting in a need for summarizing the existing evidence on this topic. In this review, we describe the latest research results on the immunological aspects of SARS-CoV-2 infection speculating about their impact on COVID-19 vaccines' mechanisms of action and focused on the management of MS during the COVID pandemic according to the most recent guidelines and recommendations. Finally, the efficacy of COVID-19 and other well-known vaccines against infectious disease in patients with MS on DMDs is discussed.
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Affiliation(s)
- Simona Toscano
- Department G. F. Ingrassia, Section of Neurosciences, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy
| | - Clara G Chisari
- Department G. F. Ingrassia, Section of Neurosciences, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy
| | - Francesco Patti
- Department G. F. Ingrassia, Section of Neurosciences, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy.
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Hillen J, Ward M, Slee M, Stanford T, Roughead E, Kalisch Ellett L, Pratt N. Utilisation of disease modifying treatment and diversity of treatment pathways in relapsing remitting multiple sclerosis. Mult Scler Relat Disord 2021; 57:103412. [PMID: 34856498 DOI: 10.1016/j.msard.2021.103412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is minimal information on the utilisation of Disease Modifying Treatment (DMTs) for multiple sclerosis. The appropriate and safe use of medicines is informed by utilisation studies. Outcomes can inform health interventions to improve appropriate use of medicines and post marketing surveillance activities to improve safety. OBJECTIVE To evaluate utilisation and treatment patterns of disease modifying treatments (DMTs) for relapsing remitting multiple sclerosis (RRMS). METHODS A representative sample of the Australian pharmaceutical benefits scheme data were analysed (2006-2016). Demographics of incident users and trends in incident and prevalent users were determined. Individual patient treatment pathways were determined by sequential initiation of medicines in two different periods (2006-2013 and 2014-2019). RESULTS There were 20,660 patients with at least one dispensing of a DMT for RRMS during the study period (median age 41 years, 75% female). Incident and prevalent use increased by 20% and 88%, respectively. The market was responsive to 13 new listings of DMTs over the study period. Sequential treatment was found for 66% of initiators in 2006-2013 and 28.5% of initiators in 2014-2019. Diverse treatment pathways were found, with 278 and 93 unique sequences in 2006-2013 and 2014-2019, respectively. CONCLUSION The availability of new DMTs has influenced both initial treatment choice and prevalence of users. Individualised treatment patterns and exposure to multiple medicines over time will challenge traditional pharmacovigilance systems.
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Affiliation(s)
- J Hillen
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Australia.
| | - M Ward
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Australia; Pharmacy Education, Clinical and Health Sciences, University of South Australia, Australia
| | - M Slee
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - T Stanford
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Australia
| | - E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Australia
| | - L Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Australia
| | - N Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Australia
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Jalkh G, Abi Nahed R, Macaron G, Rensel M. Safety of Newer Disease Modifying Therapies in Multiple Sclerosis. Vaccines (Basel) 2020; 9:12. [PMID: 33375365 PMCID: PMC7823546 DOI: 10.3390/vaccines9010012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022] Open
Abstract
In the past decade, the therapeutic arsenal for multiple sclerosis has expanded greatly. Newer more potent disease modifying therapies (DMTs) with varying mechanisms of actions are increasingly used early in the disease course. These newer DMTs include oral therapies (teriflunomide, dimethyl fumarate, fingolimod, siponimod, ozanimod, and cladribine) and infusion therapies (natalizumab, alemtuzumab, and ocrelizumab), and are associated with better control of disease activity and long-term outcomes in patients with MS compared to older injectable therapies (interferon beta and glatiramer acetate). However, they are associated with safety concerns and subsequent monitoring requirements. Adverse events are initially observed in phase 2 and 3 clinical trials, and further long-term data are collected in phase 3 extension studies, case series, and post-marketing reports, which highlight the need to periodically re-evaluate and adjust monitoring strategies to optimize treatment safety in an individualized approach.
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Affiliation(s)
- Georges Jalkh
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Rachelle Abi Nahed
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Ricardo A, Carnero Contentti E, Anabel SB, Adrian LP, Orlando G, Fernando H, Víctor R, Fernando G, Ignacio RJ. Decision-making on management of ms and nmosd patients during the COVID-19 pandemic: A latin american survey. Mult Scler Relat Disord 2020; 44:102310. [PMID: 32590314 PMCID: PMC7837246 DOI: 10.1016/j.msard.2020.102310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 12/29/2022]
Abstract
In this COVID-19 context, there is an urgent necessity of sharing information to enable evidence-based decision making on the clinical management. In LATAM, 60% of the experts had the possibility of monitoring their patients by telemedicine. Most neurologists postpone magnetic resonance and laboratory blood tests delay is associated with the type of MS or NMOSD treatment. Platform therapies, dimethyl-fumarate and natalizumab are considered safe options to initiate in naive patients.
Background The emergence of COVID-19 and its vertiginous spreading speed represents a unique challenge to neurologists managing multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). The need for data on the impact of the virus on these patients grows rapidly. There is an urgent necessity of sharing information to enable evidence-based decision making on the clinical management. There are no data on what physicians are doing on clinical practice in Latin American countries. Aim to investigate current management opinion of Latin American MS and/or NMOSD expert neurologists based on their experience and recommendations. Methods we developed a voluntary web-based survey based on hypothetical situations that these patients may encounter, while taking into account the potential risk of developing severe COVID-19 infection. Results 60% of the experts had the possibility of monitoring their patients by telemedicine. Most neurologists postpone magnetic resonance. Laboratory blood tests delay is associated with the type of treatment. Platform therapies, dimethyl-fumarate and natalizumab are considered safe options to initiate in naive patients. Conclusion decision-making about MS and NMOSD patients has become even more complex in order to adapt to the COVID-19 pandemic. Risks and benefits should be taken into consideration throughout the patient follow-up.
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Affiliation(s)
- Alonso Ricardo
- Centro Universitario de Esclerosis Múltiple (CUEM), Hospital Ramos Mejía, Facultad de Medicina, Universidad de Buenos Aires, Urquiza número 609, CABA, C1221 ADC, Argentina; División Neurología, Sanatorio Güemes, CABA.
| | | | - Silva Berenice Anabel
- Centro Universitario de Esclerosis Múltiple (CUEM), Hospital Ramos Mejía, Facultad de Medicina, Universidad de Buenos Aires, Urquiza número 609, CABA, C1221 ADC, Argentina
| | - López Pablo Adrian
- Neuroimmunology Unit, Department of Neuroscience, Hospital Alemán, Buenos Aires, Argentina
| | - Garcea Orlando
- Centro Universitario de Esclerosis Múltiple (CUEM), Hospital Ramos Mejía, Facultad de Medicina, Universidad de Buenos Aires, Urquiza número 609, CABA, C1221 ADC, Argentina
| | - Hamuy Fernando
- Centro Nacional de Esclerosis Múltiple Hospital IMT, Paraguay-Departamento de Neurología de Diagnóstico Codas Thompson, Paraguay
| | - Rivera Víctor
- Department of Neurology, Baylor College of Medicine, Houston, TX, 77030, United States
| | - Gracia Fernando
- Clínica de Esclerosis Múltiple, Servicio de Neurología, Hospital Santo Tomas, Panamá, Facultad de Ciencias de la Salud, Universidad Interamericana de Panamá
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Abstract
Extensive studies have suggested a central role of B cells in the autoimmune pathogenesis, as loss of B cell tolerance results in increased serum levels of autoantibodies, enhanced effector T cell response and tissue damages. Here, we provide an overview of dysregulated B cell responses in the development of autoimmunity. In addition to their presence in the target organs, autoreactive B cells can promote the formation of ectopic lymphoid structures and differentiate into plasma cells that produce large amounts of autoantibodies and cytokines. In animal models that recapitulate the key features of human autoimmune disease, mechanistic studies have indicated two categories of autoantibodies: (1) serological markers for disease diagnosis and prognosis; (2) effector molecules that induce organ hypofunction or damage directly in an epitope-specific manner, or indirectly by activating other immune cell subsets. Moreover, B cell-derived cytokines usually promote the autoreactive T cell response during autoimmune development, but there is compelling evidence that a subpopulation of B cells negatively regulates immune responses, also known as regulatory B cells via secreting anti-inflammatory cytokines (IL-10, IL-35, etc.) or a contact-dependent fashion. Although B cell depletion could eliminate most circulating B cells in the periphery, the clinical outcomes of B cell depletion therapy for autoimmune diseases vary among individuals due to differential activation or survival signals for B cells provided by tissue microenvironment. Thus, therapeutic combinations that target immune checkpoints and B cell activation may represent a promising strategy for the effective treatment of human autoimmune diseases.
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