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Breu M, Sandesjö F, Milos RI, Svoboda J, Salzer J, Schneider L, Reichelt JB, Bertolini A, Blaschek A, Fink K, Höftberger R, Lycke J, Rostásy K, Seidl R, Siegert S, Wickström R, Kornek B. Rituximab treatment in pediatric-onset multiple sclerosis. Eur J Neurol 2024; 31:e16228. [PMID: 38375947 DOI: 10.1111/ene.16228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/05/2023] [Accepted: 01/15/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND PURPOSE Rituximab (RTX) is frequently used off-label in multiple sclerosis. However, studies on the risk-benefit profile of RTX in pediatric-onset multiple sclerosis are scarce. METHODS In this multicenter retrospective cohort study, patients with pediatric-onset multiple sclerosis from Sweden, Austria and Germany, who received RTX treatment were identified by chart review. Annualized relapse rates, Expanded Disability Status Scale scores and magnetic resonance imaging parameters (new T2 lesions and contrast-enhancing lesions) were assessed before and during RTX treatment. The proportion of patients who remained free from clinical and disease activity (NEDA-3) during RTX treatment was calculated. Side effects such as infusion-related reactions, infections and laboratory abnormalities were assessed. RESULTS Sixty-one patients received RTX during a median (interquartile range) follow-up period of 20.9 (35.6) months. The annualized relapse rate decreased from 0.6 (95% confidence interval [CI] 0.38-0.92) to 0.03 (95% CI 0.02-0.14). The annual rate of new T2 lesions decreased from 1.25 (95% CI 0.70-2.48) to 0.08 (95% CI 0.03-0.25) and annual rates of new contrast-enhancing lesions decreased from 0.86 (95% CI 0.30-3.96) to 0. Overall, 70% of patients displayed no evidence of disease activity (NEDA-3). Adverse events were observed in 67% of patients. Six patients discontinued treatment due to ongoing disease activity or adverse events. CONCLUSION Our study provides class IV evidence that RTX reduces clinical and radiological activity in pediatric-onset multiple sclerosis.
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Affiliation(s)
- Markus Breu
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Fredrik Sandesjö
- Neuropediatric Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ruxandra-Iulia Milos
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Jan Svoboda
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jonatan Salzer
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Lisa Schneider
- Division of Infectious Diseases, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Julian Benedikt Reichelt
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Annikki Bertolini
- Department of Pediatric Neurology, University Witten/Herdecke, Children's Hospital Datteln, Datteln, Germany
| | - Astrid Blaschek
- Paediatric Neurology and Developmental Medicine, Ludwig Maximilian University of Munich, Dr. von Hauner Children's Hospital, Munich, Germany
| | - Katharina Fink
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kevin Rostásy
- Department of Pediatric Neurology, University Witten/Herdecke, Children's Hospital Datteln, Datteln, Germany
| | - Rainer Seidl
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Sandy Siegert
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ronny Wickström
- Neuropediatric Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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Murley C, Pettersson E, Hillert J, Machado A, Friberg E. Coronavirus disease 2019 infection among working-aged people with multiple sclerosis and the impact of disease-modifying therapies. Mult Scler J Exp Transl Clin 2024; 10:20552173241248293. [PMID: 38680165 PMCID: PMC11055478 DOI: 10.1177/20552173241248293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 04/03/2024] [Indexed: 05/01/2024] Open
Abstract
Background The risk of coronavirus disease 2019 among people with multiple sclerosis with different disease-modifying therapies is not well established. Objective To investigate the occurrence of coronavirus disease 2019 and the remaining symptoms among people with multiple sclerosis and the associations with different disease-modifying therapies. Methods Individuals aged 20-50 listed in the Swedish Multiple Sclerosis Registry were invited to participate in a survey in 2021. Information on reported coronavirus disease 2019 infection and remaining symptoms were linked to individual-level register data. The risks by disease-modifying therapy of having coronavirus disease 2019 or having remaining symptoms were estimated with logistic regression. Results Of the 4393 participants, 1030 (23.4%) self-reported coronavirus disease 2019 (749 confirmed and 281 suspected). The observed odds for coronavirus disease 2019 did not differ by disease-modifying therapy (p-values <0.05). The majority reporting coronavirus disease 2019 had fully recovered (68.5%), 4.2% were currently/recently sick, and 27.0% had symptoms remaining after 2 months. The most frequently reported remaining symptoms involved one's sense of smell or taste (37.0%), fatigue (20.0%), and breathing (12.0%). No statistically significant associations were observed between having remaining symptoms and the disease-modifying therapy. Conclusion Despite the initial concerns of differing infection risks by MS treatments, we observed no differences in coronavirus disease 2019 occurrence or remaining symptoms among those who had coronavirus disease 2019. Nonetheless, exercising caution in interpreting our findings, it remains implicit that people with multiple sclerosis are particularly susceptible to infection and that lingering symptoms may persist beyond the initial infection.
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Affiliation(s)
- Chantelle Murley
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Emma Pettersson
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jan Hillert
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Alejandra Machado
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Emilie Friberg
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Yamout B, Al-Jumah M, Sahraian MA, Almalik Y, Khaburi JA, Shalaby N, Aljarallah S, Bohlega S, Dahdaleh M, Almahdawi A, Khoury SJ, Koussa S, Slassi E, Daoudi S, Aref H, Mrabet S, Zeineddine M, Zakaria M, Inshasi J, Gouider R, Alroughani R. Consensus recommendations for diagnosis and treatment of Multiple Sclerosis: 2023 revision of the MENACTRIMS guidelines. Mult Scler Relat Disord 2024; 83:105435. [PMID: 38245998 DOI: 10.1016/j.msard.2024.105435] [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: 10/26/2023] [Revised: 12/21/2023] [Accepted: 01/06/2024] [Indexed: 01/23/2024]
Abstract
With evolving diagnostic criteria and the advent of new oral and parenteral therapies for Multiple Sclerosis (MS), most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and time and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of MS therapies is critical to maximize patient benefit. The current guidelines review the current diagnostic criteria for MS and the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, progressive MS, pediatric cases and pregnant women. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.
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Affiliation(s)
- B Yamout
- Neurology Institute and Multiple Sclerosis Center, Harley Street Medical Center, Abu Dhabi, United Arab Emirates.
| | - M Al-Jumah
- InterHealth hospital, Multiple Sclerosis Center, Riyadh, Saudi Arabia
| | - M A Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Y Almalik
- Division of Neurology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - J Al Khaburi
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - N Shalaby
- Neurology Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | | | - S Bohlega
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - A Almahdawi
- Consultant Neurologist, Neurology Unit, Baghdad Teaching Hospital, Medical City Complex, Iraq
| | - S J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - S Koussa
- Multiple Sclerosis Center, Geitaoui Lebanese University Hospital, Beirut, Lebanon
| | - E Slassi
- Hôpital Cheikh Khalifa Ibn Zaid, Casablanca, Morocco
| | - S Daoudi
- Hospital Center Nedir Mohamed, Faculty of Medicine, University Mouloud Mammeri Tizi-Ouzou, Algeria
| | - H Aref
- Neurology Department, Ain Shams University, Cairo, Egypt
| | - S Mrabet
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - M Zeineddine
- Middle East and North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS), Beirut, Lebanon
| | | | - J Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - R Gouider
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - R Alroughani
- Amiri Hospital, Arabian Gulf Street, Sharq, Kuwait
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Teni FS, Machado A, Fink K, Gyllensten H, Hillert J, Friberg E. Recent trends in disease-modifying therapy use and associated sickness absence and disability pension among people with multiple sclerosis in Sweden. Mult Scler 2024; 30:419-431. [PMID: 38243631 PMCID: PMC10935615 DOI: 10.1177/13524585231225929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/20/2023] [Accepted: 12/23/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Disease-modifying therapies (DMTs) have led to improved health and work productivity among people with multiple sclerosis (PwMS). OBJECTIVES To describe trajectories of recent DMT use and their association with sickness absence and/or disability pension (SADP) among PwMS in Sweden. METHODS A longitudinal register-based study was conducted among 1395 PwMS with treatment start in 2014/2015. While DMT use over 5 years was assessed using sequence analysis resulting in four clusters, a 7-year (Y-2 toY4) trend of SADP was analyzed using zero-inflated negative binomial regression. RESULTS Four clusters of DMT use trajectories were identified: long-term non-high-efficacy (483, 34.6%), long-term high-efficacy (572, 41%), escalation (221, 15.8%), and discontinuation (119, 8.5%). Progressive MS and higher expanded disability status scale scores were associated with the escalation, long-term high-efficacy, or discontinuation clusters. PwMS in the long-term high-efficacy and escalation clusters had higher likelihood of being on SADP. However, PwMS initiating high-efficacy DMTs demonstrated steeper decline in SADP than others. CONCLUSION Using sequence analysis, this study showed recent DMT use trajectories among PwMS where initiation of high-efficacy DMTs has become more common. The trend of SADP was stable and lower in those using non-high-efficacy DMTs and larger improvements were shown in those initiating high-efficacy DMTs.
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Affiliation(s)
- Fitsum Sebsibe Teni
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Alejandra Machado
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Katharina Fink
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Gyllensten
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Hillert
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Emilie Friberg
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Carlsson O, Jonsson DI, Brundin L, Iacobaeus E. Relapses and Serious Infections in Patients with Neuromyelitis Optica Spectrum Disorder Treated with Rituximab: A Swedish Single-Center Study. J Clin Med 2024; 13:355. [PMID: 38256489 PMCID: PMC10816065 DOI: 10.3390/jcm13020355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare immune-mediated relapsing-remitting disease of the central nervous system. The usage of rituximab, as relapse-preventive therapy, in NMOSD is common. We performed a single-center retrospective cohort study to assess the risk of relapses and severe infectious events (SIEs) in rituximab-treated NMOSD patients. This study included 24 aquaporin-4 IgG+ (AQP4+), 8 myelin-oligodendrocyte-protein IgG+ (MOG+), and 10 double-seronegative NMOSD patients. Relapses were observed in 50% of all patients during a mean treatment time of 4.0 (range: 0.5-8.25) years. The incidence risk ratio (IRR) of relapse was three times higher in MOG+ compared to AQP4+ patients (IRR: 3.0, 95% confidence interval (CI); 1.2-7.7). SIEs occurred in 40% of all patients during follow-up. AQP4+ patients conferred an increased risk of SIEs compared to MOG+ patients (IRR; 5.3, 95% CI; 1.2-24.3). Incomplete CD19+ B-lymphocyte suppression was not correlated with relapse risk (hazard ratio; 1.9, 95% CI; 0.7-5.2), and there was no correlation between IgG-levels and SIE risk (odds ratio; 2.0, 95% CI; 0.8-4.8). In conclusion, considerable risks of both relapses and SIEs were observed in NMOSD patients exposed to rituximab, which underlines the need for close clinical vigilance of disease activity and infections during treatment.
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Affiliation(s)
- Olof Carlsson
- Department of Clinical Neuroscience, Karolinska Institute, 171 64 Solna, Sweden; (O.C.); (D.I.J.); (L.B.)
- Department of Neurology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Dagur Ingi Jonsson
- Department of Clinical Neuroscience, Karolinska Institute, 171 64 Solna, Sweden; (O.C.); (D.I.J.); (L.B.)
- Department of Neurophysiology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Lou Brundin
- Department of Clinical Neuroscience, Karolinska Institute, 171 64 Solna, Sweden; (O.C.); (D.I.J.); (L.B.)
- Department of Neurology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Ellen Iacobaeus
- Department of Clinical Neuroscience, Karolinska Institute, 171 64 Solna, Sweden; (O.C.); (D.I.J.); (L.B.)
- Department of Neurology, Karolinska University Hospital, 171 76 Stockholm, Sweden
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Gonzalez-Lorenzo M, Ridley B, Minozzi S, Del Giovane C, Peryer G, Piggott T, Foschi M, Filippini G, Tramacere I, Baldin E, Nonino F. Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD011381. [PMID: 38174776 PMCID: PMC10765473 DOI: 10.1002/14651858.cd011381.pub3] [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: 01/05/2024]
Abstract
BACKGROUND Different therapeutic strategies are available for the treatment of people with relapsing-remitting multiple sclerosis (RRMS), including immunomodulators, immunosuppressants and biological agents. Although each one of these therapies reduces relapse frequency and slows disability accumulation compared to no treatment, their relative benefit remains unclear. This is an update of a Cochrane review published in 2015. OBJECTIVES To compare the efficacy and safety, through network meta-analysis, of interferon beta-1b, interferon beta-1a, glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab, pegylated interferon beta-1a, daclizumab, laquinimod, azathioprine, immunoglobulins, cladribine, cyclophosphamide, diroximel fumarate, fludarabine, interferon beta 1-a and beta 1-b, leflunomide, methotrexate, minocycline, mycophenolate mofetil, ofatumumab, ozanimod, ponesimod, rituximab, siponimod and steroids for the treatment of people with RRMS. SEARCH METHODS CENTRAL, MEDLINE, Embase, and two trials registers were searched on 21 September 2021 together with reference checking, citation searching and contact with study authors to identify additional studies. A top-up search was conducted on 8 August 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) that studied one or more of the available immunomodulators and immunosuppressants as monotherapy in comparison to placebo or to another active agent, in adults with RRMS. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data. We considered both direct and indirect evidence and performed data synthesis by pairwise and network meta-analysis. Certainty of the evidence was assessed by the GRADE approach. MAIN RESULTS We included 50 studies involving 36,541 participants (68.6% female and 31.4% male). Median treatment duration was 24 months, and 25 (50%) studies were placebo-controlled. Considering the risk of bias, the most frequent concern was related to the role of the sponsor in the authorship of the study report or in data management and analysis, for which we judged 68% of the studies were at high risk of other bias. The other frequent concerns were performance bias (34% judged as having high risk) and attrition bias (32% judged as having high risk). Placebo was used as the common comparator for network analysis. Relapses over 12 months: data were provided in 18 studies (9310 participants). Natalizumab results in a large reduction of people with relapses at 12 months (RR 0.52, 95% CI 0.43 to 0.63; high-certainty evidence). Fingolimod (RR 0.48, 95% CI 0.39 to 0.57; moderate-certainty evidence), daclizumab (RR 0.55, 95% CI 0.42 to 0.73; moderate-certainty evidence), and immunoglobulins (RR 0.60, 95% CI 0.47 to 0.79; moderate-certainty evidence) probably result in a large reduction of people with relapses at 12 months. Relapses over 24 months: data were reported in 28 studies (19,869 participants). Cladribine (RR 0.53, 95% CI 0.44 to 0.64; high-certainty evidence), alemtuzumab (RR 0.57, 95% CI 0.47 to 0.68; high-certainty evidence) and natalizumab (RR 0.56, 95% CI 0.48 to 0.65; high-certainty evidence) result in a large decrease of people with relapses at 24 months. Fingolimod (RR 0.54, 95% CI 0.48 to 0.60; moderate-certainty evidence), dimethyl fumarate (RR 0.62, 95% CI 0.55 to 0.70; moderate-certainty evidence), and ponesimod (RR 0.58, 95% CI 0.48 to 0.70; moderate-certainty evidence) probably result in a large decrease of people with relapses at 24 months. Glatiramer acetate (RR 0.84, 95%, CI 0.76 to 0.93; moderate-certainty evidence) and interferon beta-1a (Avonex, Rebif) (RR 0.84, 95% CI 0.78 to 0.91; moderate-certainty evidence) probably moderately decrease people with relapses at 24 months. Relapses over 36 months findings were available from five studies (3087 participants). None of the treatments assessed showed moderate- or high-certainty evidence compared to placebo. Disability worsening over 24 months was assessed in 31 studies (24,303 participants). Natalizumab probably results in a large reduction of disability worsening (RR 0.59, 95% CI 0.46 to 0.75; moderate-certainty evidence) at 24 months. Disability worsening over 36 months was assessed in three studies (2684 participants) but none of the studies used placebo as the comparator. Treatment discontinuation due to adverse events data were available from 43 studies (35,410 participants). Alemtuzumab probably results in a slight reduction of treatment discontinuation due to adverse events (OR 0.39, 95% CI 0.19 to 0.79; moderate-certainty evidence). Daclizumab (OR 2.55, 95% CI 1.40 to 4.63; moderate-certainty evidence), fingolimod (OR 1.84, 95% CI 1.31 to 2.57; moderate-certainty evidence), teriflunomide (OR 1.82, 95% CI 1.19 to 2.79; moderate-certainty evidence), interferon beta-1a (OR 1.48, 95% CI 0.99 to 2.20; moderate-certainty evidence), laquinimod (OR 1.49, 95 % CI 1.00 to 2.15; moderate-certainty evidence), natalizumab (OR 1.57, 95% CI 0.81 to 3.05), and glatiramer acetate (OR 1.48, 95% CI 1.01 to 2.14; moderate-certainty evidence) probably result in a slight increase in the number of people who discontinue treatment due to adverse events. Serious adverse events (SAEs) were reported in 35 studies (33,998 participants). There was probably a trivial reduction in SAEs amongst people with RRMS treated with interferon beta-1b as compared to placebo (OR 0.92, 95% CI 0.55 to 1.54; moderate-certainty evidence). AUTHORS' CONCLUSIONS We are highly confident that, compared to placebo, two-year treatment with natalizumab, cladribine, or alemtuzumab decreases relapses more than with other DMTs. We are moderately confident that a two-year treatment with natalizumab may slow disability progression. Compared to those on placebo, people with RRMS treated with most of the assessed DMTs showed a higher frequency of treatment discontinuation due to AEs: we are moderately confident that this could happen with fingolimod, teriflunomide, interferon beta-1a, laquinimod, natalizumab and daclizumab, while our certainty with other DMTs is lower. We are also moderately certain that treatment with alemtuzumab is associated with fewer discontinuations due to adverse events than placebo, and moderately certain that interferon beta-1b probably results in a slight reduction in people who experience serious adverse events, but our certainty with regard to other DMTs is lower. Insufficient evidence is available to evaluate the efficacy and safety of DMTs in a longer term than two years, and this is a relevant issue for a chronic condition like MS that develops over decades. More than half of the included studies were sponsored by pharmaceutical companies and this may have influenced their results. Further studies should focus on direct comparison between active agents, with follow-up of at least three years, and assess other patient-relevant outcomes, such as quality of life and cognitive status, with particular focus on the impact of sex/gender on treatment effects.
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Affiliation(s)
- Marien Gonzalez-Lorenzo
- Laboratorio di Metodologia delle revisioni sistematiche e produzione di Linee Guida, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ben Ridley
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Cochrane Italy, Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Guy Peryer
- School of Health Sciences, University of East Anglia (UEA), Norwich, UK
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, Queens University, Kingston, Ontario, Canada
| | - Matteo Foschi
- Department of Neuroscience, Multiple Sclerosis Center - Neurology Unit, S.Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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7
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Sancho-López A, Ruiz-Antorán B, Iglesias Hernangómez T, Ramírez-García A, Gómez-Estévez I, Sanabria-Cabrera J, Llop Rius R, Pedrós C, Campodonico D, Jiménez-Jorge S, García Luque A, Costa Frossad França L, Montané E, Aldea-Perona A, Téllez Lara N, Bosch Ferrer M, Rodriguez Jiménez C, Bonilla-Toyos E, Sabín Muñoz J, Avendaño-Solá C, Blasco Quilez MR. The Need for the Closer Monitoring of Novel Drugs in MS: A Siponimod Retrospective Cohort Study (Realhes Study). J Clin Med 2023; 12:6471. [PMID: 37892611 PMCID: PMC10607533 DOI: 10.3390/jcm12206471] [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: 09/07/2023] [Revised: 09/29/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Severe cases of lymphopenia have been reported during siponimod clinical trials, which may negatively impact its benefit/risk profile. OBJECTIVE We aimed to evaluate the incidence of lymphopenia following the initiation of siponimod treatment in clinical practice. The secondary objectives included the analysis of factors predisposing to and the clinical relevance of lymphopenia events. METHODS In this multicenter retrospective cohort study, information collected from the medical records of 129 patients with MS from 15 tertiary hospitals in Spain who initiated treatment with Siponimod were followed-up for at least 3 months, including at least one lymphocyte count evaluation per patient. RESULTS Of the 129 patients, 121 (93.6%) reported lymphopenia events, including 110 (85.3%) with grade ≤ 3 and 11 (8.5%) with grade 4 lymphopenia, higher than those reported in the pivotal clinical trial (73.3% and 3.3% for grade ≤ 3 and grade 4 lymphopenia, respectively). The study included an unexpectedly high proportion of male subjects (72.9%), which might have led to an underestimation of the actual magnitude of the risk. CONCLUSIONS In this study, the incidence and severity of lymphopenia after starting siponimod treatment were higher than those reported in previous clinical trials. Therefore, our results reinforce the need for the closer monitoring of novel MS drugs in clinical practice, as well as larger and longer follow-up studies to properly characterize this risk.
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Affiliation(s)
- Arantxa Sancho-López
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, 28222 Majadahonda, Spain; (A.S.-L.); (A.R.-G.); (C.A.-S.)
| | - Belén Ruiz-Antorán
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, 28222 Majadahonda, Spain; (A.S.-L.); (A.R.-G.); (C.A.-S.)
| | | | - Almudena Ramírez-García
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, 28222 Majadahonda, Spain; (A.S.-L.); (A.R.-G.); (C.A.-S.)
| | - Irene Gómez-Estévez
- Department of Neurology, Hospital Clinico San Carlos, IdISSC, 28040 Madrid, Spain;
- Department of Medicine, Facultad de Medicina, Universidad Complutense de Madrid (UCM), 28040 Madrid, Spain
| | - Judith Sanabria-Cabrera
- Clinical Pharmacology Department, Hospital Universitario Virgen de la Victoria, IBIMA_Plataforma BIONAND, Universidad de Málaga, 29071 Malaga, Spain; (J.S.-C.); (E.B.-T.)
- Platform for Clinical Research and Clinical Trials IBIMA, Plataforma ISCIII de Investigación Clínica, 28029 Madrid, Spain
| | - Roser Llop Rius
- Clinical Pharmacology Department, Hospital Universitari de Bellvitge, 08907 l’Hospitalet de Llobregat, Spain;
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Barcelona University, 08007 l’Hospitalet de Llobregat, Spain
| | - Consuelo Pedrós
- Unidad de Farmacología Clínica, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
| | - Diana Campodonico
- Clinical Pharmacology Department, Hospital Universitario La Princesa, 28006 Madrid, Spain;
| | - Silvia Jiménez-Jorge
- CTU-HUVR (Clinical Trials Unit-Hospital Universitario Virgen del Rocío), 41013 Sevilla, Spain;
| | - Amelia García Luque
- Department of Clinical Pharmacology, Defense Central Hospital, 28047 Madrid, Spain;
- Department of Biomedical Sciences (Pharmacology Section), University of Alcalá (IRYCIS), 28801 Madrid, Spain
| | | | - Eva Montané
- Clinical Pharmacology Department, Hospital Universitario Germans Trias i Pujol, 08916 Barcelona, Spain;
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain;
| | - Ana Aldea-Perona
- Clinical Pharmacology Department, Hospital del Mar Barcelona, Clinical Research Unit Research Hospital del Mar Research Institute, Universitat Pompeu Fabra (UPF), 08002 Barcelona, Spain;
| | - Nieves Téllez Lara
- Neurology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain;
| | - Montserrat Bosch Ferrer
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain;
- Department of Clinical Pharmacology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Clinical Pharmacology Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain
| | - Consuelo Rodriguez Jiménez
- Clinical Trials Unit, Pharmacology Department, Complejo Hospitalario Universitario e Canarias, 38320 Santa Cruz de Tenerife, Spain;
| | - Elvira Bonilla-Toyos
- Clinical Pharmacology Department, Hospital Universitario Virgen de la Victoria, IBIMA_Plataforma BIONAND, Universidad de Málaga, 29071 Malaga, Spain; (J.S.-C.); (E.B.-T.)
- Platform for Clinical Research and Clinical Trials IBIMA, Plataforma ISCIII de Investigación Clínica, 28029 Madrid, Spain
| | - Julia Sabín Muñoz
- Neurology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, 28222 Majadahonda, Spain; (J.S.M.); (M.R.B.Q.)
| | - Cristina Avendaño-Solá
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, 28222 Majadahonda, Spain; (A.S.-L.); (A.R.-G.); (C.A.-S.)
| | - María Rosario Blasco Quilez
- Neurology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, 28222 Majadahonda, Spain; (J.S.M.); (M.R.B.Q.)
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Greenberg B, Giovannoni G. A place for biosimilars in the changing multiple sclerosis treatment landscape. Mult Scler Relat Disord 2023; 77:104841. [PMID: 37467536 DOI: 10.1016/j.msard.2023.104841] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/02/2023] [Accepted: 06/16/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The treatment paradigm for multiple sclerosis (MS), particularly relapsing-remitting MS, is heavily reliant on biologic disease-modifying therapies (DMTs). However, the current cost of treatment acts as a significant barrier to access for patients. Over the next few years exclusivity periods for key biologic medicines used in MS are likely to end, opening the door for biosimilar medicines to enter the market. METHODS In this review, we discuss what biosimilar medicines are, and how the existing experience with biosimilar medicines across multiple therapy areas can inform the assimilation of biosimilar medicines into the MS treatment landscape in Europe and the US. RESULTS There is currently a lack of knowledge and awareness around the distinctions and similarities between small molecules, non-biological complex drugs, and biological medicines, as well as the different categories of follow-on successor medicines. These include biosimilar medicines that offer a matching efficacy and safety profile to the reference biologic. Understanding and recognition of the stringency of the approval pathways required for drug categories such as biosimilars are key in building confidence in treatment outcomes. For example, biosimilar medicines are sometimes perceived only as 'copies' of their reference biologic despite undergoing an extensive approval process requiring that no clinically meaningful differences are observed between the biosimilar medicine and the reference medicine. For MS, introduction of biosimilar medicines in the future will enable more people with MS to receive effective treatment, and also expand access to biologic DMTs in MS. Experiences from the use of biosimilars in multiple therapy areas have shown us that this can result in cost-saving benefits for a healthcare system. Introduction of biosimilar medicines in other therapy areas has also demonstrated the importance of appropriate, accurate education and information for their successful integration into clinical practice. CONCLUSION In order to realize optimized treatment outcomes in MS in coming years and to find the appropriate place for biosimilar medicines in the changing MS landscape, it is essential that clinicians and people with MS understand the fundamentals of biosimilars, their potential benefits and consistency of treatment provided by a biosimilar medicine, given the matching efficacy and safety profile to its reference medicine. As evidenced in other therapy areas, biosimilar medicines may reduce key barriers to access by providing a cost-effective alternative to the MS treatment arsenal, while providing the same treatment outcomes as reference biologics.
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Affiliation(s)
- Benjamin Greenberg
- Department of Neurology and Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Rd, Bethnal Green, London E1 4NS, United Kingdom
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9
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Roos I, Hughes S, McDonnell G, Malpas CB, Sharmin S, Boz C, Alroughani R, Ozakbas S, Buzzard K, Skibina O, van der Walt A, Butzkueven H, Lechner-Scott J, Kuhle J, Terzi M, Laureys G, Van Hijfte L, John N, Grammond P, Grand’Maison F, Soysal A, Jensen AV, Rasmussen PV, Svendsen KB, Barzinji I, Nielsen HH, Sejbæk T, Prakash S, Stilund MLM, Weglewski A, Issa NM, Kant M, Sellebjerg F, Gray O, Magyari M, Kalincik T. Rituximab vs Ocrelizumab in Relapsing-Remitting Multiple Sclerosis. JAMA Neurol 2023; 80:789-797. [PMID: 37307006 PMCID: PMC10262062 DOI: 10.1001/jamaneurol.2023.1625] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/23/2023] [Indexed: 06/13/2023]
Abstract
Importance Ocrelizumab, a humanized monoclonal antibody targeted against CD20+ B cells, reduces the frequency of relapses by 46% and disability worsening by 40% compared with interferon beta 1a in relapsing-remitting multiple sclerosis (MS). Rituximab, a chimeric monoclonal anti-CD20 agent, is often prescribed as an off-label alternative to ocrelizumab. Objective To evaluate whether the effectiveness of rituximab is noninferior to ocrelizumab in relapsing-remitting MS. Design, Setting, and Participants This was an observational cohort study conducted between January 2015 and March 2021. Patients were included in the treatment group for the duration of study therapy and were recruited from the MSBase registry and Danish MS Registry (DMSR). Included patients had a history of relapsing-remitting MS treated with ocrelizumab or rituximab, a minimum 6 months of follow-up, and sufficient data to calculate the propensity score. Patients with comparable baseline characteristics were 1:6 matched with propensity score on age, sex, MS duration, disability (Expanded Disability Status Scale), prior relapse rate, prior therapy, disease activity (relapses, disability accumulation, or both), magnetic resonance imaging lesion burden (missing values imputed), and country. Exposure Treatment with ocrelizumab or rituximab after 2015. Main outcomes and Measures Noninferiority comparison of annualized rate of relapses (ARRs), with a prespecified noninferiority margin of 1.63 rate ratio. Secondary end points were relapse and 6-month confirmed disability accumulation in pairwise-censored groups. Results Of the 6027 patients with MS who were treated with ocrelizumab or rituximab, a total of 1613 (mean [SD] age; 42.0 [10.8] years; 1089 female [68%]) fulfilled the inclusion criteria and were included in the analysis (898 MSBase, 715 DMSR). A total of 710 patients treated with ocrelizumab (414 MSBase, 296 DMSR) were matched with 186 patients treated with rituximab (110 MSBase, 76 DMSR). Over a pairwise censored mean (SD) follow-up of 1.4 (0.7) years, the ARR ratio was higher in patients treated with rituximab than in those treated with ocrelizumab (rate ratio, 1.8; 95% CI, 1.4-2.4; ARR, 0.20 vs 0.09; P < .001). The cumulative hazard of relapses was higher among patients treated with rituximab than those treated with ocrelizumab (hazard ratio, 2.1; 95% CI, 1.5-3.0). No difference in the risk of disability accumulation was observed between groups. Results were confirmed in sensitivity analyses. Conclusion In this noninferiority comparative effectiveness observational cohort study, results did not show noninferiority of treatment with rituximab compared with ocrelizumab. As administered in everyday practice, rituximab was associated with a higher risk of relapses than ocrelizumab. The efficacy of rituximab and ocrelizumab administered at uniform doses and intervals is being further evaluated in randomized noninferiority clinical trials.
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Affiliation(s)
- Izanne Roos
- Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Charles B. Malpas
- Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Sifat Sharmin
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | | | - Katherine Buzzard
- Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Box Hill Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Olga Skibina
- Department of Neurology, Box Hill Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Anneke van der Walt
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Helmut Butzkueven
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, University Newcastle, Newcastle, New South Wales, Australia
- Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Jens Kuhle
- Departments of Medicine, Biomedicine, and Clinical Research, Neurologic Clinic and Policlinic, University Hospital and University of Basel, Basel, Switzerland
| | - Murat Terzi
- Medical Faculty, 19 Mayis University, Samsun, Turkey
| | - Guy Laureys
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | | | - Nevin John
- Department of Neurology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | | | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | - Ana Voldsgaard Jensen
- Danish Multiple Sclerosis Center, Rigshospitalet Glostrup, Copenhagen University Hospital, Denmark
| | | | | | | | - Helle Hvilsted Nielsen
- The Multiple Sclerosis Clinic, Department of Neurology, Odense University Hospital, Odense C, Denmark
| | - Tobias Sejbæk
- Department of Neurology, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | | | | | - Arkadiusz Weglewski
- Neurology Department Herlev Hospital, Denmark
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Matthias Kant
- Hospital of Southern Jutland, University of Southern Denmark, Aabenraa, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Rigshospitalet Glostrup, Copenhagen University Hospital, Denmark
| | - Orla Gray
- South Eastern HSC Trust, Belfast, United Kingdom
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Rigshospitalet Glostrup, Copenhagen University Hospital, Denmark
| | - Tomas Kalincik
- Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Katsarogiannis E, Landtblom AM, Kristoffersson A, Wikström J, Semnic R, Berntsson SG. Absence of Oligoclonal Bands in Multiple Sclerosis: A Call for Differential Diagnosis. J Clin Med 2023; 12:4656. [PMID: 37510771 PMCID: PMC10380970 DOI: 10.3390/jcm12144656] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Immunoglobulin gamma (IgG) oligoclonal bands (OCB) in the cerebrospinal fluid (CSF) are absent in a small group of multiple sclerosis (MS) patients. According to previous research, OCB-negative MS patients differ genetically but not clinically from OCB-positive MS patients. However, whether OCB-negative MS is a unique immunological and clinical entity remains unclear. The absence of OCB poses a significant challenge in diagnosing MS. (1) Objective: The objective of this study was twofold: (1) to determine the prevalence of OCB-negative MS patients in the Uppsala region, and (2) to assess the frequency of misdiagnosis in this patient group. (2) Methods: We conducted a retrospective study using data from the Swedish MS registry (SMSreg) covering 83% of prevalent MS cases up to 20 June 2020 to identify all MS patients in the Uppsala region. Subsequently, we collected relevant information from the medical records of all OCB-negative MS cases, including age of onset, gender, presenting symptoms, MRI features, phenotype, Expanded Disability Status Scale (EDSS) scores, and disease-modifying therapies (DMTs). (3) Results: Out of 759 MS patients identified, 69 had an OCB-negative MS diagnosis. Upon re-evaluation, 46 patients had a typical history and MRI findings of MS, while 23 had unusual clinical and/or radiologic features. An alternative diagnosis was established for the latter group, confirming the incorrectness of the initial MS diagnosis. The average EDSS score was 2.0 points higher in the MS group than in the non-MS group (p = 0.001). The overall misdiagnosis rate in the cohort was 33%, with 22% of misdiagnosed patients having received DMTs. (4) Conclusions: Our results confirm that the absence of OCB in the CSF should raise suspicion of possible misdiagnosis in MS patients and prompt a diagnostic reassessment.
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Affiliation(s)
| | - Anne-Marie Landtblom
- Department of Medical Sciences, Neurology, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Anna Kristoffersson
- Department of Medical Sciences, Neurology, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Johan Wikström
- Department of Surgical Sciences, Neuroradiology, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Robert Semnic
- Department of Surgical Sciences, Neuroradiology, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Shala G Berntsson
- Department of Medical Sciences, Neurology, Uppsala University, SE-751 85 Uppsala, Sweden
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11
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Techa-Angkoon P, Siritho S, Tisavipat N, Suansanae T. Current evidence of rituximab in the treatment of multiple sclerosis. Mult Scler Relat Disord 2023; 75:104729. [PMID: 37148577 DOI: 10.1016/j.msard.2023.104729] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/15/2023] [Accepted: 04/22/2023] [Indexed: 05/08/2023]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system. The immunopathology of MS involves both T and B lymphocytes. Rituximab is one of the anti-CD20 monoclonal antibody therapies which deplete B-cells. Although some anti-CD20 therapies have been approved by the Food and Drug Administration for treatment of MS, rituximab is used off-label. Several studies have shown that rituximab has a good efficacy and safety in MS, including certain specific patient conditions such as treatment-naïve patients, treatment-switching patients, and the Asian population. However, there are still questions about the optimal dose and duration of rituximab in MS due to the different dosing regimens used in each study. Moreover, many biosimilars have become available at a lower cost with comparable physicochemical properties, pharmacokinetics, pharmacodynamics, efficacy, safety, and immunogenicity. Thus, rituximab may be considered as a potential therapeutic option for patients without access to standard treatment. This narrative review summarized the evidence of both original and biosimilars of rituximab in MS treatment including pharmacokinetics, pharmacodynamics, clinical efficacy, safety, and dosing regimen.
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Affiliation(s)
- Phanutgorn Techa-Angkoon
- Division of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Sasitorn Siritho
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Siriraj Neuroimmunology Center, Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Bumrungrad International Hospital, Bangkok, Thailand
| | | | - Thanarat Suansanae
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Ratchathewi, Bangkok 10400, Thailand.
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Zhou Q, Yin D, Ma J, Chen S. The therapeutic effect of ofatumumab in autoimmune encephalitis: A case series. J Neuroimmunol 2023; 377:578062. [PMID: 36898305 DOI: 10.1016/j.jneuroim.2023.578062] [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: 02/01/2023] [Revised: 02/16/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023]
Abstract
The management of autoimmune encephalitis (AE) with immunotherapy is non-standardized, especially in refractory AE. Ofatumumab (OFA), an anti-CD20 antibody, has not been reported in the treatment of AE. This study presented three AE cases that received the OFA treatment. OFA was administered subcutaneously at a dose of 20 mg two or three times within three weeks. There were some mild adverse effects, including low-grade fever and dizziness. They had favorable responses (reduced antibody titer and clinical symptom improvement). Their symptoms were stable and even improved during a three-month follow-up. Thus, OFA injection is demonstrated to be safe and effective in treating AE. This is the first report about OFA treatment in AE, depicting its potential as a therapeutic option.
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Affiliation(s)
- Qinming Zhou
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dou Yin
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianfang Ma
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Sheng Chen
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Co-innovation Center of Neuroregeneration, Nantong University, Nantong, China.
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13
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Hemmer B, Wiendl H, Roth K, Wessels H, Höfler J, Hornuss C, Liedert B, Selmaj K. Efficacy and Safety of Proposed Biosimilar Natalizumab (PB006) in Patients With Relapsing-Remitting Multiple Sclerosis: The Antelope Phase 3 Randomized Clinical Trial. JAMA Neurol 2023; 80:298-307. [PMID: 36689214 PMCID: PMC9871944 DOI: 10.1001/jamaneurol.2022.5007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/10/2022] [Indexed: 01/24/2023]
Abstract
Importance Proposed biosimilar natalizumab (biosim-NTZ) PB006 is the first biosimilar monoclonal antibody therapy developed for multiple sclerosis (MS) treatment. Objective To evaluate matching efficacy, safety, and immunogenicity between biosim-NTZ and reference natalizumab (ref-NTZ) in patients with relapsing-remitting MS (RRMS). Design, Setting, and Participants The Antelope trial was a phase 3, parallel-group, randomized, active-controlled study, conducted between October 2019 and March 2021, with last patient follow-up visit on August 23, 2021. The study took place in 48 centers in 7 countries. Of 531 patients with RRMS aged 18 to 60 years screened, 266 were excluded before randomization in line with study criteria. Eligible participants had 1 or more documented relapse within the previous year and either 1 or more gadolinium-enhancing T1-weighted or 9 or more T2-weighted brain lesions, Kurtzke Expanded Disability Status Scale score of 0 to 5.0 (inclusive), and John Cunningham virus index of 1.5 or less at screening. One patient withdrew consent before dosing. Interventions Intravenous infusions every 4 weeks of biosim-NTZ, 300 mg, or ref-NTZ, 300 mg (1:1 randomization), from week 0 to week 44 (end-of-study visit: week 48). At week 24, the ref-NTZ group was rerandomized and 30 patients were switched to biosim-NTZ for the remainder of the study. Main Outcomes and Measures The primary end point was the cumulative number of new active lesions on magnetic resonance imaging (new gadolinium-enhancing T1-weighted lesions and new/enlarging T2-weighted lesions without double counting) over 24 weeks. Additional end points included further magnetic resonance imaging parameters, annualized relapse rate, and Kurtzke Expanded Disability Status Scale score. Safety, tolerability, and immunogenicity assessments included adverse events, laboratory evaluations, and positivity for anti-John Cunningham virus antibodies and antinatalizumab antibodies. Results A total of 264 participants (mean [SD] age, 36.7 [9.38] years; 162 [61.4%] female) received treatment with biosim-NTZ (n = 131) or ref-NTZ (n = 133). At week 24, the model-based mean difference in cumulative number of new active lesions between biosim-NTZ and ref-NTZ treatment groups was 0.17 (least square means [SE]: biosim-NTZ, 0.34 [0.34]; ref-NTZ, 0.45 [0.28]; 95% CI, -0.61 to 0.94 within the prespecified margins of ±2.1). No significant differences between treatment groups were observed across secondary efficacy end points, safety, tolerability, or immunogenicity assessments. Conclusions and Relevance Biosim-NTZ matched ref-NTZ in efficacy, safety, and immunogenicity for patients with RRMS in the tested setting. This phase 3 trial supports proposed biosim-NTZ as a biosimilar alternative to ref-NTZ for treating RRMS. Trial Registration ClinicalTrials.gov Identifier: NCT04115488.
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Affiliation(s)
- Bernhard Hemmer
- Department of Neurology, Technical University of Munich, Klinikum rechts der Isar, Munich & Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | | | | | | | | | | | - Krzysztof Selmaj
- Department of Neurology, University of Warmia & Mazury, Olsztyn, and Center of Neurology, Lodz, Poland
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Treatment Courses of Patients Newly Diagnosed with Multiple Sclerosis in 2012-2018. J Clin Med 2023; 12:jcm12020595. [PMID: 36675522 PMCID: PMC9866399 DOI: 10.3390/jcm12020595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Treatment options for multiple sclerosis (MS) are now numerous, but it is unclear which Disease-Modifying Treatment (DMT) is the optimal choice for a given patient. Treatment switches are common, both because of side effects and because of lack of efficacy. There are few data available on the treatment courses of patients newly diagnosed with MS in the current DMT era. All patients newly diagnosed with MS in 2012-2018 at North Karelia Central Hospital were identified (N = 55), and those with complete follow-up data available (N = 43) were included. The minimum follow-up from diagnosis was 44 months with a maximum of 9 years. Seven patients (16%) had no DMT at any time during the follow-up. Treatment was most often initiated with interferon or glatiramer acetate (69%), but 72% of these treatments were discontinued. After cladribine, teriflunomide and fingolimod showed the best treatment persistence. Patients who experienced their first MS symptoms at ≥40 years of age all continued with their initial treatment category until the end of the follow-up. In a third of the patients who had received a DMT, at the end of the follow-up, the treatment had been escalated to fingolimod, cladribine or natalizumab. Only 13 patients (28%) continued with their initial DMT until the end of the follow-up.
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Teni FS, Machado A, Murley C, He A, Fink K, Gyllensten H, Glaser A, Alexanderson K, Hillert J, Friberg E. Trajectories of disease-modifying therapies and associated sickness absence and disability pension among 1923 people with multiple sclerosis in Sweden. Mult Scler Relat Disord 2023; 69:104456. [PMID: 36529068 DOI: 10.1016/j.msard.2022.104456] [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: 08/29/2022] [Revised: 11/07/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is limited information on the trajectories of disease-modifying therapy (DMT) use and their association with sickness absence and/or disability pension (SADP) among people with multiple sclerosis (PwMS). The objective of the study was to identify trajectories of DMT use over 10 years among PwMS, identify sociodemographic and clinical factors associated with the trajectories, and to assess the association between identified trajectories and SADP days. METHODS A longitudinal register-based study was conducted, on a prospective data set linked across six nationwide registers, assessing treatment courses of PwMS with DMTs for the 10 years following multiple sclerosis (MS) onset. The study included 1923 PwMS with MS onset in 2007-2010, when aged 19-56 years. In each 6-month-period, their treatment was categorized as before treatment, high-efficacy, non-high-efficacy, or no DMT. Sequence analysis was performed to identify sequences of the treatment categories and cluster them into different DMT trajectories. Cluster belonging, in relation to demographic and clinical characteristics, was assessed through log-multinomial regression analysis. The association of trajectories/cluster-belonging with SADP net days was assessed using generalized estimating equation (GEE) models. RESULTS Cluster analyses identified 4 trajectories of DMT use: long-term non-high-efficacy DMTs (38.6%), escalation to high-efficacy DMTs (31.2%), delayed start and escalation to high-efficacy DMTs (15.4%), and discontinued/ no DMT (14.2%). Age, MS type, expanded disability status scale (EDSS) score and the number of DMT switches were associated with cluster belonging. The youngest age group (18-25) were more likely to be in the escalation to high-efficacy cluster. People with primary progressive MS were more likely to be in the delayed start or discontinued/ no DMT cluster. Higher EDSS scores were associated to being in the other three clusters than in the long-term non-high-efficacy DMTs cluster. Higher number of DMT switches were associated with being in the escalation to high-efficacy DMTs cluster but less likely to be in the delayed start or discontinued/ no DMT clusters. Descriptive analyses showed a trend of fewer mean SADP days among PwMS using non-high-efficacy DMT than the other clusters about 9 years after onset. PwMS in the escalation to high-efficacy and discontinued/no DMT clusters had more SADP days. PwMS in the delayed start and escalation to high-efficacy DMTs cluster, started with fewer SADP days which increased over time. SADP days adjusted through GEE models showed trends comparable with the descriptive analysis. CONCLUSION This study described the long-term real-world trajectories of DMT use among PwMS in Sweden using sequence analysis and showed the association of the trajectories with SADP days as well as sociodemographic and clinical characteristics.
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Affiliation(s)
- Fitsum Sebsibe Teni
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm 171 77, Sweden.
| | - Alejandra Machado
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Chantelle Murley
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Anna He
- Department of Clinical Neuroscience, Division of Neurology, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Katharina Fink
- Department of Clinical Neuroscience, Division of Neurology, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Hanna Gyllensten
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, Gothenburg 405 30, Sweden
| | - Anna Glaser
- Department of Clinical Neuroscience, Division of Neurology, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Kristina Alexanderson
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Division of Neurology, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Emilie Friberg
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm 171 77, Sweden
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Ridley B, Minozzi S, Gonzalez-Lorenzo M, Del Giovane C, Filippini G, Peryer G, Foschi M, Nonino F, Tramacere I, Baldin E. Immunomodulators and immunosuppressants for progressive multiple sclerosis: a network meta‐analysis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022; 2022:CD015443. [PMCID: PMC9632686 DOI: 10.1002/14651858.cd015443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: We will perform a network meta‐analysis to assess the relative effectiveness and safety of immunomodulatory and immunosuppressive treatments for people with multiple sclerosis in progressive forms of the condition.
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Affiliation(s)
| | - Ben Ridley
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Silvia Minozzi
- Department of EpidemiologyLazio Regional Health ServiceRomeItaly
| | | | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM)BernSwitzerland,Department of Medical and Surgical SciencesUniversity of Modena and Reggio EmiliaModenaItaly
| | - Graziella Filippini
- Scientific Director’s OfficeFondazione IRCCS, Istituto Neurologico Carlo BestaMilanItaly
| | - Guy Peryer
- School of Health SciencesUniversity of East Anglia (UEA)NorwichUK
| | - Matteo Foschi
- Department of Neuroscience, AUSL RomagnaSanta Maria delle Croci HospitalRavennaItaly
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific DirectorateFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
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Mirmosayyeb O, Shaygannejad V, Ebrahimi N, Ghoshouni H, Ghajarzadeh M. The prevalence of cancer in patients with multiple sclerosis (MS) who received rituximab: a systematic review and meta-analysis. Neurologia 2022:S2173-5808(22)00090-6. [PMID: 36055575 DOI: 10.1016/j.nrleng.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/29/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To estimate the pooled prevalence of cancer in patients with multiple sclerosis (MS) cases who were under treatment with rituximab. METHODS We searched PubMed, Scopus, EMBASE, Web of Science, and google scholar along with gray literature up to April 2021. The search strategy included the MeSH and text words as (("CD20 Antibody" AND Rituximab) OR "Rituximab CD20 Antibody" OR Mabthera OR "IDEC-C2B8 Antibody" OR "IDEC C2B8 Antibody" OR IDEC-C2B8 OR "IDEC C2B8" OR GP2013 OR Rituxan OR rituximab) AND ((Sclerosis AND multiple) OR (sclerosis AND disseminated) OR "disseminated sclerosis" OR "multiple sclerosis" OR "acute fulminating"). RESULTS The literature search revealed 3577 articles, after deleting duplicates 2066 remained. For the meta-analysis, 22 studies were included. Totally, 15599 patients were enrolled while 133 cancers were detected. The pooled prevalence of cancer in MS patients under treatment with rituximab is 1in 100,000 (I2 = 99.9%, p < 0.001). CONCLUSION The results of this systematic review and meta-analysis show that the pooled prevalence of cancer in MS patients who received rituximab is 1 in 100,000 cases.
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Affiliation(s)
- O Mirmosayyeb
- Department of Neurology, School of Medicine, Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - V Shaygannejad
- Department of Neurology, School of Medicine, Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - N Ebrahimi
- Department of Neurology, School of Medicine, Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - H Ghoshouni
- Department of Neurology, School of Medicine, Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - M Ghajarzadeh
- Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran.
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18
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Safety and efficacy of rituximab versus dimethyl fumarate in patients with relapsing-remitting multiple sclerosis or clinically isolated syndrome in Sweden: a rater-blinded, phase 3, randomised controlled trial. Lancet Neurol 2022; 21:693-703. [DOI: 10.1016/s1474-4422(22)00209-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/24/2022] [Accepted: 05/03/2022] [Indexed: 12/15/2022]
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19
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Ovchinnikov A, Findling O. An overview of pivotal trials and real-world evidence for CD20-depleting therapy in multiple sclerosis : Immunotherapy with rituximab, ocrelizumab, and ofatumumab. Wien Med Wochenschr 2022; 172:359-364. [PMID: 35723820 PMCID: PMC9208251 DOI: 10.1007/s10354-022-00939-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 05/04/2022] [Indexed: 11/28/2022]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system leading to demyelination and neurodegeneration of brain tissue. For a long time, research focused on T cells as the primary mechanism of disease. Driven by reports on the clinical results of B cell-depleting therapies, this therapeutic approach has come into focus in the last decade, and new highly effective treatments have been developed and are now complementing the therapeutic landscape. This review provides an overview of the development of B cell-depleting therapies and shows the advantages and disadvantages of current developments. In addition, we discuss basic considerations for CD20-depleted MS patients in the face of the COVID-19 pandemic.
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Affiliation(s)
- Arkady Ovchinnikov
- Department of Neurology, Kantonsspital Aarau, Tellstr. 25, 5001, Aarau, Switzerland
| | - Oliver Findling
- Department of Neurology, Kantonsspital Aarau, Tellstr. 25, 5001, Aarau, Switzerland.
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20
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Krämer J, Wiendl H. What Have Failed, Interrupted, and Withdrawn Antibody Therapies in Multiple Sclerosis Taught Us? Neurotherapeutics 2022; 19:785-807. [PMID: 35794296 PMCID: PMC9294122 DOI: 10.1007/s13311-022-01246-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2022] [Indexed: 12/13/2022] Open
Abstract
In the past two decades, monoclonal antibodies (mAbs) have revolutionized the treatment of multiple sclerosis (MS). However, a remarkable number of mAbs failed due to negative study results were withdrawn because of unexpected serious adverse events (SAEs) or due to studies being halted for other reasons. While trials with positive outcomes are usually published in prestigious journals, negative trials are merely published as abstracts or not at all. This review summarizes MS mAbs that have either failed in phase II-III trials, have been interrupted for various reasons, or withdrawn from the market since 2015. The main conclusions that can be drawn from these 'negative' experiences are as follows. mAbs that have been proven to be safe in other autoimmune conditions, will not have the same safety profile in MS due to immunopathogenetic differences in these diseases (e.g., daclizumab). Identification of SAEs in clinical trials is difficult highlighting the importance of phase IV studies. Memory B cells are central players in MS immunopathogenesis (e.g., tabalumab). The pathophysiological mechanisms of disease progression are independent of leukocyte 'outside-in' traffic which drives relapses in MS. Therefore, therapies for progressive MS must be able to sufficiently cross the blood-brain barrier. Sufficiently long trial duration and multicomponent outcome measures are important for clinical studies in progressive MS. The success of trials on remyelination-promoting therapies mainly depends on the sufficient high dose of mAb, the optimal readout for 'proof of concept', time of treatment initiation, and appropriate selection of patients. Failed strategies are highly important to better understand assumed immunopathophysiological mechanisms and optimizing future trial designs.
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Affiliation(s)
- Julia Krämer
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
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21
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Abstract
BACKGROUND Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off-label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high-income countries where on-label disease-modifying treatments (DMTs) are available. OBJECTIVES: To assess beneficial and adverse effects of rituximab as 'first choice' and as 'switching' for adults with MS. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and trial registers for completed and ongoing studies on 31 January 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) and controlled non-randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with MS. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. We used the Cochrane Collaboration's tool for assessing risk of bias. We rated the certainty of evidence using GRADE for: disability worsening, relapse, serious adverse events (SAEs), health-related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching', relapsing or progressive MS, comparison versus placebo or another DMT, and RCTs or NRSIs. MAIN RESULTS We included 15 studies (5 RCTs, 10 NRSIs) with 16,429 participants of whom 13,143 were relapsing MS and 3286 progressive MS. The studies were one to two years long and compared rituximab as 'first choice' with placebo (1 RCT) or other DMTs (1 NRSI), rituximab as 'switching' against placebo (2 RCTs) or other DMTs (2 RCTs, 9 NRSIs). The studies were conducted worldwide; most originated from high-income countries, six from the Swedish MS register. Pharmaceutical companies funded two studies. We identified 14 ongoing studies. Rituximab as 'first choice' for relapsing MS Rituximab versus placebo: no studies met eligibility criteria for this comparison. Rituximab versus other DMTs: one NRSI compared rituximab with interferon beta or glatiramer acetate, dimethyl fumarate, natalizumab, or fingolimod in active relapsing MS at 24 months' follow-up. Rituximab likely results in a large reduction in relapses compared with interferon beta or glatiramer acetate (hazard ratio (HR) 0.14, 95% confidence interval (CI) 0.05 to 0.39; 335 participants; moderate-certainty evidence). Rituximab may reduce relapses compared with dimethyl fumarate (HR 0.29, 95% CI 0.08 to 1.00; 206 participants; low-certainty evidence) and natalizumab (HR 0.24, 95% CI 0.06 to 1.00; 170 participants; low-certainty evidence). It may make little or no difference on relapse compared with fingolimod (HR 0.26, 95% CI 0.04 to 1.69; 137 participants; very low-certainty evidence). The study reported no deaths over 24 months. The study did not measure disability worsening, SAEs, HRQoL, and common infections. Rituximab as 'first choice' for progressive MS One RCT compared rituximab with placebo in primary progressive MS at 24 months' follow-up. Rituximab likely results in little to no difference in the number of participants who have disability worsening compared with placebo (odds ratio (OR) 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate-certainty evidence). Rituximab may result in little to no difference in recurrence of relapses (OR 0.60, 95% CI 0.18 to 1.99; 439 participants; low-certainty evidence), SAEs (OR 1.25, 95% CI 0.71 to 2.20; 439 participants; low-certainty evidence), common infections (OR 1.14, 95% CI 0.75 to 1.73; 439 participants; low-certainty evidence), cancer (OR 0.50, 95% CI 0.07 to 3.59; 439 participants; low-certainty evidence), and mortality (OR 0.25, 95% CI 0.02 to 2.77; 439 participants; low-certainty evidence). The study did not measure HRQoL. Rituximab versus other DMTs: no studies met eligibility criteria for this comparison. Rituximab as 'switching' for relapsing MS One RCT compared rituximab with placebo in relapsing MS at 12 months' follow-up. Rituximab may decrease recurrence of relapses compared with placebo (OR 0.38, 95% CI 0.16 to 0.93; 104 participants; low-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to placebo on SAEs (OR 0.90, 95% CI 0.28 to 2.92; 104 participants; very low-certainty evidence), common infections (OR 0.91, 95% CI 0.37 to 2.24; 104 participants; very low-certainty evidence), cancer (OR 1.55, 95% CI 0.06 to 39.15; 104 participants; very low-certainty evidence), and mortality (OR 1.55, 95% CI 0.06 to 39.15; 104 participants; very low-certainty evidence). The study did not measure disability worsening and HRQoL. Five NRSIs compared rituximab with other DMTs in relapsing MS at 24 months' follow-up. The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to interferon beta or glatiramer acetate on disability worsening (HR 0.86, 95% CI 0.52 to 1.42; 1 NRSI, 853 participants; very low-certainty evidence). Rituximab likely results in a large reduction in relapses compared with interferon beta or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 NRSI, 1383 participants; moderate-certainty evidence); and fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 NRSI, 256 participants; moderate-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to natalizumab on relapses (HR 1.0, 95% CI 0.2 to 5.0; 1 NRSI, 153 participants; very low-certainty evidence). Rituximab likely increases slightly common infections compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 NRSI, 5477 participants; moderate-certainty evidence); and compared with natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 NRSIs, 5001 participants; moderate-certainty evidence). Rituximab may increase slightly common infections compared with fingolimod (OR 1.26, 95% CI 0.90 to 1.77; 3 NRSIs, 5187 participants; low-certainty evidence). It may make little or no difference compared with ocrelizumab (OR 0.02, 95% CI 0.00 to 0.40; 1 NRSI, 472 participants; very low-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab on mortality compared with fingolimod (OR 5.59, 95% CI 0.22 to 139.89; 1 NRSI, 136 participants; very low-certainty evidence) and natalizumab (OR 6.66, 95% CI 0.27 to 166.58; 1 NRSI, 153 participants; very low-certainty evidence). The included studies did not measure SAEs, HRQoL, and cancer. AUTHORS' CONCLUSIONS For preventing relapses in relapsing MS, rituximab as 'first choice' and as 'switching' may compare favourably with a wide range of approved DMTs. A protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab for progressive MS. The evidence is uncertain about the effect of rituximab on SAEs. They are relatively rare in people with MS, thus difficult to study, and they were not well reported in studies. There is an increased risk of common infections with rituximab, but absolute risk is small. Rituximab is widely used as off-label treatment in people with MS; however, randomised evidence is weak. In the absence of randomised evidence, remaining uncertainties on beneficial and adverse effects of rituximab for MS might be clarified by making real-world data available.
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Affiliation(s)
- Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Jera Kruja
- Neurology, UHC Mother Theresa, University of Medicine, Tirana, Albania
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
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22
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Landtblom A, Berntsson SG, Boström I, Iacobaeus E. Multiple sclerosis and COVID-19: The Swedish experience. Acta Neurol Scand 2021; 144:229-235. [PMID: 34028810 PMCID: PMC8222873 DOI: 10.1111/ane.13453] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/16/2021] [Accepted: 04/22/2021] [Indexed: 12/13/2022]
Abstract
The COVID-19 pandemic has brought challenges for healthcare management of patients with multiple sclerosis (MS). Concerns regarding vulnerability to infections and disease-modifying therapies (DMTs) and their complications have been raised. Recent published guidelines on the use of DMTs in relation to COVID-19 in MS patients have been diverse between countries with lack of evidence-based facts. In Sweden, there exists a particular interest in anti-CD20 therapy as a possible risk factor for severe COVID-19 due to the large number of rituximab-treated patients off-label in the country. Rapid responses from the Swedish MS Association (SMSS) and the Swedish MS registry (SMSreg) have resulted in national guidelines on DMT use for MS patients and implementation of a COVID-19 module in the SMSreg. Recently updated guidelines also included recommendations on COVID-19 vaccination with regard to the different DMTs. Social distancing policies forced implementation of telemedicine consultation to replace in-person consultations as part of regular MS health care. Patient-reported outcome measures (PROMs) in SMSreg have been useful in this respect. This paper reports our experiences on the progress of national MS health care during the COVID-19 pandemic, in addition to offering an overview of the present scientific context.
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Affiliation(s)
- Anne‐Marie Landtblom
- Department of Neuroscience Uppsala University Uppsala Sweden
- Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden
| | | | - Inger Boström
- Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden
| | - Ellen Iacobaeus
- Department of Clinical Neuroscience Division of Neurology Karolinska Institute and Karolinska University Hospital Stockholm Sweden
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Brancati S, Gozzo L, Longo L, Vitale DC, Drago F. Rituximab in Multiple Sclerosis: Are We Ready for Regulatory Approval? Front Immunol 2021; 12:661882. [PMID: 34295328 PMCID: PMC8290177 DOI: 10.3389/fimmu.2021.661882] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/15/2021] [Indexed: 12/19/2022] Open
Abstract
Despite the availability of a lot of effective disease-modifying drugs, multiple sclerosis (MS) (in particular the progressive forms) still represents an important unmet medical need, because of issues in terms of effectiveness, duration of response, safety, and patient compliance. An increasing body of evidence from randomized clinical trials and real-world data suggest that rituximab is a highly effective alternative in both relapsing and progressive MS, with a low discontinuation rate, related to a good benefit/risk profile, and a good compliance. To date, the use of rituximab in patients with multiple sclerosis is not in accordance with the authorized product information (off-label use). However, the use of this medicine is widespread in several countries, and in some cases, it is the most commonly used disease-modifying drug for MS subtypes. This use could be officially recognized by national regulatory authorities, according to specific procedures, to ensure equal access for patients to a safe and effective option.
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Affiliation(s)
- Serena Brancati
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Lucia Gozzo
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Laura Longo
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Daniela Cristina Vitale
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Filippo Drago
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
- Centre for Research and Consultancy in HTA and Drug Regulatory Affairs (CERD), University of Catania, Catania, Italy
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24
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Coyle PK, Gocke A, Vignos M, Newsome SD. Vaccine Considerations for Multiple Sclerosis in the COVID-19 Era. Adv Ther 2021; 38:3550-3588. [PMID: 34075554 PMCID: PMC8169434 DOI: 10.1007/s12325-021-01761-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/24/2021] [Indexed: 02/06/2023]
Abstract
People with multiple sclerosis (MS) are at risk for infections that can result in amplification of baseline symptoms and possibly trigger clinical relapses. Vaccination can prevent infection through the activation of humoral and cellular immune responses. This is particularly pertinent in the era of emerging novel vaccines against severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease 2019 (COVID-19). MS disease-modifying therapies (DMTs), which affect the immune system, may impact immune responses to COVID-19 vaccines in people with MS. The objective of this article is to provide information on immune system responses to vaccinations and review previous studies of vaccine responses in people with MS to support the safety and importance of receiving currently available and emerging COVID-19 vaccines. Immunological studies have shown that coordinated interactions between T and B lymphocytes of the adaptive immune system are key to successful generation of immunological memory and production of neutralizing antibodies following recognition of vaccine antigens by innate immune cells. CD4+ T cells are essential to facilitate CD8+ T cell and B cell activation, while B cells drive and sustain T cell memory. Data suggest that some classes of DMT, including type 1 interferons and glatiramer acetate, may not significantly impair the response to vaccination. DMTs-such as sphingosine-1-phosphate receptor modulators, which sequester lymphocytes from circulation; alemtuzumab; and anti-CD20 therapies, which rely on depleting populations of immune cells-have been shown to attenuate responses to conventional vaccines. Currently, three COVID-19 vaccines have been granted emergency use authorization in the USA on the basis of promising interim findings of ongoing trials. Because analyses of these vaccines in people with MS are not available, decisions regarding COVID-19 vaccination and DMT choice should be informed by data and expert consensus, and personalized with considerations for disease burden, risk of infection, and other factors.
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Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | | | - Megan Vignos
- Biogen, Cambridge, MA, USA.
- US Medical MS Franchise and Interferons, Biogen, 133 Boston Post Rd, Weston, MA, 20493, USA.
| | - Scott D Newsome
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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25
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Filippini G, Kruja J, He D, Del Giovane C. Rituximab for people with multiple sclerosis. Hippokratia 2021. [DOI: 10.1002/14651858.cd013874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Graziella Filippini
- Scientific Director’s Office; Carlo Besta Foundation and Neurological Institute; Milan Italy
| | - Jera Kruja
- Neurology; UHC Mother Theresa; Tirana Albania
| | - Dian He
- Department of Neurology; Affiliated Hospital of Guizhou Medical University; Guiyang China
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM); University of Bern; Bern Switzerland
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Kågström S, Fält A, Berglund A, Piehl F, Olsson T, Lycke J. Reduction of the risk of PML in natalizumab treated MS patients in Sweden: An effect of improved PML risk surveillance. Mult Scler Relat Disord 2021; 50:102842. [PMID: 33610957 DOI: 10.1016/j.msard.2021.102842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/01/2021] [Accepted: 02/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Natalizumab (NTZ) treatment of multiple sclerosis (MS) has been associated with increased risk of progressive multifocal leukoencephalopathy (PML). The aim of the present study was to evaluate the impact of PML risk assessment on PML incidence in NTZ treated MS patients. METHODS By using information from the population-based Swedish MS registry a retrospective cohort was established of patients treated with NTZ between 2006-2018. The effect on PML incidence before and after utilizing a risk management plan, including JC virus (JCV) serology, was analyzed. RESULTS In December 2018, 804 PML cases associated with NTZ therapy of MS had been reported globally, including 9 cases from Sweden. The estimated PML incidence 2018 in Sweden and globally was 0.7 (0.3-1.4) and 4.15 (3.9-4.4) per 1,000 person years, respectively. In Sweden, JCV serology was introduced 2012 for PML risk assessment and the cumulative risk of PML was significantly lower 2012-2018 compared to the period 2006-2011 (p=0.042). The mean NTZ exposure time was 60.1 months (SD 37.2) in the first period (2006-2011) and 32.6 months (SD 22.0) in the second period (2012-2018). The number of patients treated with NTZ decreased, and the number of patients at increased risk of PML was 1.9 % at the end of the study period. CONCLUSION Since 2006 the incidence of PML associated with NTZ treatment of MS has decreased in Sweden. Our findings suggest that this reduction is due to an effective adoptation and adherence to the established risk management plan that implies switching patients at increased PML risk from NTZ to other highly efficacious therapies. A less pronounced decline in PML incidence has recently been observed in France, but not globally.
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Affiliation(s)
- Stina Kågström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Anna Fält
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Anders Berglund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Gklinos P, Papadopoulou M, Stanulovic V, Mitsikostas DD, Papadopoulos D. Monoclonal Antibodies as Neurological Therapeutics. Pharmaceuticals (Basel) 2021; 14:ph14020092. [PMID: 33530460 PMCID: PMC7912592 DOI: 10.3390/ph14020092] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 02/08/2023] Open
Abstract
Over the last 30 years the role of monoclonal antibodies in therapeutics has increased enormously, revolutionizing treatment in most medical specialties, including neurology. Monoclonal antibodies are key therapeutic agents for several neurological conditions with diverse pathophysiological mechanisms, including multiple sclerosis, migraines and neuromuscular disease. In addition, a great number of monoclonal antibodies against several targets are being investigated for many more neurological diseases, which reflects our advances in understanding the pathogenesis of these diseases. Untangling the molecular mechanisms of disease allows monoclonal antibodies to block disease pathways accurately and efficiently with exceptional target specificity, minimizing non-specific effects. On the other hand, accumulating experience shows that monoclonal antibodies may carry class-specific and target-associated risks. This article provides an overview of different types of monoclonal antibodies and their characteristics and reviews monoclonal antibodies currently in use or under development for neurological disease.
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Affiliation(s)
- Panagiotis Gklinos
- Department of Neurology, KAT General Hospital of Attica, 14561 Athens, Greece;
| | - Miranta Papadopoulou
- Center for Clinical, Experimental Surgery & Translational Research, Biomedical Research Foundation of the Academy of Athens (BRFAA), 11527 Athens, Greece;
| | - Vid Stanulovic
- Global Pharmacovigilance, R&D Sanofi, 91385 Chilly-Mazarin, France;
| | - Dimos D. Mitsikostas
- 1st Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, 11521 Athens, Greece;
| | - Dimitrios Papadopoulos
- Laboratory of Molecular Genetics, Hellenic Pasteur Institute, 129 Vasilissis Sophias Avenue, 11521 Athens, Greece
- Salpetriere Neuropsychiatric Clinic, 149 Papandreou Street, Metamorphosi, 14452 Athens, Greece
- Correspondence:
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Findling O, Sellner J. Second-generation immunotherapeutics in multiple sclerosis: can we discard their precursors? Drug Discov Today 2020; 26:416-428. [PMID: 33248250 DOI: 10.1016/j.drudis.2020.11.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/18/2020] [Accepted: 11/17/2020] [Indexed: 12/27/2022]
Abstract
Options for disease-modifying therapies in multiple sclerosis have increased over the past two decades. Among these innovations are interferon-β, glatiramer acetate, fumaric acid and dihydroorotate dehydrogenase inhibitors, an antibody targeting the migration of immune cells, a compound that traps immune cells in lymphoid organs by sphingosine 1-phosphate receptor (S1PR) modulation and immune-reconstitution therapies. Second-generation drugs such as pegylated interferon-β, advanced CD20 depleting antibodies, more-specific S1PR modulators and new formulations have been developed to achieve higher efficacy while exhibiting fewer side effects. In this review, we address the shortcomings of the parent drugs, present the pros and cons of the second-generation therapies and summarize upcoming developments in the field of immunotherapy for multiple sclerosis.
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Affiliation(s)
- Oliver Findling
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland; Department of Neurology, University Hospital Tulln, Karl-Landsteiner-University, Tulln, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria; Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany.
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Zhong M, van der Walt A, Campagna MP, Stankovich J, Butzkueven H, Jokubaitis V. The Pharmacogenetics of Rituximab: Potential Implications for Anti-CD20 Therapies in Multiple Sclerosis. Neurotherapeutics 2020; 17:1768-1784. [PMID: 33058021 PMCID: PMC7851267 DOI: 10.1007/s13311-020-00950-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 12/13/2022] Open
Abstract
There are a broad range of disease-modifying therapies (DMTs) available in relapsing-remitting multiple sclerosis (RRMS), but limited biomarkers exist to personalise DMT choice. All DMTs, including monoclonal antibodies such as rituximab and ocrelizumab, are effective in preventing relapses and preserving neurological function in MS. However, each agent harbours its own risk of therapeutic failure or adverse events. Pharmacogenetics, the study of the effects of genetic variation on therapeutic response or adverse events, could improve the precision of DMT selection. Pharmacogenetic studies of rituximab in MS patients are lacking, but pharmacogenetic markers in other rituximab-treated autoimmune conditions have been identified. This review will outline the wider implications of pharmacogenetics and the mechanisms of anti-CD20 agents in MS. We explore the non-MS rituximab literature to characterise pharmacogenetic variants that could be of prognostic relevance in those receiving rituximab, ocrelizumab or other monoclonal antibodies for MS.
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Affiliation(s)
- Michael Zhong
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia.
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia.
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Maria Pia Campagna
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Jim Stankovich
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
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Novi G, Bovis F, Fabbri S, Tazza F, Gazzola P, Maietta I, Currò D, Bruschi N, Roccatagliata L, Boffa G, Lapucci C, Pesce G, Cellerino M, Solaro C, Laroni A, Capello E, Mancardi G, Sormani M, Inglese M, Uccelli A. Tailoring B cell depletion therapy in MS according to memory B cell monitoring. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/5/e845. [PMID: 32753406 PMCID: PMC7413707 DOI: 10.1212/nxi.0000000000000845] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 06/05/2020] [Indexed: 11/15/2022]
Abstract
Objective We wanted to evaluate efficacy on inflammatory parameters of rituximab (RTX)-personalized reinfusion scheme using a memory B cell–based treatment regimen. Methods This is a prospective, uncontrolled, open-label study including patients with MS treated with RTX in 2 Italian MS units. All patients were treated with RTX induction, followed by maintenance infusion at the dosage of 375 mg/m2, according to memory B cell repopulation (0.05% of peripheral-blood mononuclear cells [PBMCs] for the first 2 years, 0.1% of PBMC for the third year). MS activity was assessed as clinical or MRI activity. Results One hundred two patients were included in the analysis. Mean follow-up was 2.40 years (range 0.57–7.15 years). The annualized relapse rate (ARR) was 0.67 in the year before RTX start and decreased to 0.01 in the 3 years after RTX initiation (global ARR). The proportion of patient with MS activity (i.e., relapse or MRI activity) was 63.16% in the year before RTX start and decreased to 8.7% (0–6 months), 1.3% (6–12 months), 0% (12–24 months), and 0% (24–36 months). Annualized RTX infusion rates were 1.67 (95% confidence interval [CI]: 1.43–1.94), 0.76 (95% CI: 0.58–0.98), and 0.78 (95% CI: 0.52–1.12) for the first 3 years after RTX initiation, respectively. Patients were reinfused with a mean infusion interval of 367 days (range 181–839 days). Conclusion The results of this study show that the memory B cell–based RTX reinfusion protocol is able to reduce the mean number of RTX reinfusions with persistent reduction of disease activity. Classification of evidence This study provides Class IV evidence that for patients with MS, a memory B cell–based RTX reinfusion protocol can reduce the mean number of RTX reinfusions with persistent reduction of disease activity.
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Affiliation(s)
- Giovanni Novi
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy.
| | - Francesca Bovis
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Sabrina Fabbri
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Francesco Tazza
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Paola Gazzola
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Ilaria Maietta
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Daniela Currò
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Nicolò Bruschi
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Luca Roccatagliata
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Giacomo Boffa
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Caterina Lapucci
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Giampaola Pesce
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Maria Cellerino
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Claudio Solaro
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Alice Laroni
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Elisabetta Capello
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Gianluigi Mancardi
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Mariapia Sormani
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Matilde Inglese
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
| | - Antonio Uccelli
- From the Department of Neuroscience (G.N.), Ospedale Policlinico San Martino-IRCCS; Department of Health Sciences (DISSAL) (F.B., I.M., L.R., M.S.), University of Genova, Italy; Ospedale A. Micone (S.F., P.G.), Genova; Department of Neuroscience (F.T., N.B., G.B., C.L., M.C., A.L., E.C., G.M.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova; Ospedale Policlinico San Martino-IRCCS (F.T., N.B., L.R., A.L., E.C., M.S., M.I., A.U.), Genova, Italy; Ospedale San Paolo (D.C.), Savona; Autoimmunity Laboratory DiMI (G.P.), University of Genova, Italy; Monsignor Luigi Novarese Rehabilitation Center (C.S.), Moncrivello, Vercelli; Istituti Clinici Scientifici Maugeri (G.M.), IRCCS, Pavia; and Department of Neuroscience (M.I., A.U.), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) and Center of Excellence for Biomedical Research (CEBR), University of Genova, Italy
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Delate T, Hansen ML, Gutierrez AC, Le KN. Indications for Rituximab Use in an Integrated Health Care Delivery System. J Manag Care Spec Pharm 2020; 26:832-838. [PMID: 32584674 PMCID: PMC10391100 DOI: 10.18553/jmcp.2020.26.7.832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rituximab is a top-selling biologic that was first approved by the FDA in 1997 for a non-Hodgkin lymphoma orphan indication. It has since been approved for additional orphan indications, with rheumatoid arthritis as the only FDA-approved, nonorphan indication. Evidence suggests that rituximab is frequently used off-label, but information on its use over time and indications for use in the United States is limited. OBJECTIVE To assess incident rituximab use over time in an integrated health care delivery system. METHODS This was a cross-sectional, retrospective study. Data were collected from administrative databases and manual chart reviews. Patients who received their first rituximab infusion between October 1, 2009, and December 31, 2017, and who were not a part of a clinical trial were included. Indication for use (FDA-approved orphan/nonorphan, off-label) was determined. Proportions of use were assessed over time. Multivariable logistic regression modeling was performed to assess factors associated with receiving rituximab for an FDA-approved indication. RESULTS A total of 1,674 patients were included. The majority (66.4%) of patients had an FDA-approved indication, with lymphoma being the most common approved indication (66.4%). The most common indication for off-label use was neurologic conditions (72.7%), predominantly demyelinating diseases. Off-label indication use increased from 1.2% in 2009 to 55.6% in 2017. Factors associated with rituximab use for an FDA-approved indication included increased age (adjusted odds ratio [AOR] = 1.05, 95% CI = 1.04-1.07) and increased burden of chronic disease (chronic disease score: AOR = 1.07, 95% CI = 1.02-1.12; Charlson Comorbidity Index score: AOR = 3.52, 95% CI = 3.03-4.10). CONCLUSIONS Off-label use of rituximab grew dramatically over the course of the study. With the recent FDA approval of the rituximab biosimilar and its expected lower price, off-label use will likely continue to rise. Opportunities for cost savings and to ensure appropriate use of these medications should be evaluated. DISCLOSURES This study was funded by Kaiser Permanente. All authors except Hansen are employed by Kaiser Permanente. Hansen has nothing to disclose. Preliminary results were presented at the Mountain States Conference for Residents and Preceptors in May 2019 in Salt Lake City, UT, and at an encore presentation October 2019 at the American College of Clinical Pharmacy Annual Meeting in New York, NY.
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Affiliation(s)
- Thomas Delate
- Drug Use Management, Kaiser Permanente National Pharmacy, Aurora, Colorado, and Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Margaret L. Hansen
- Neurology Department, Wexner Medical Center, The Ohio State University, Columbus
| | | | - Kim N. Le
- Drug Use Management, Kaiser Permanente National Pharmacy, Downey, California
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Pirttisalo AL, Sipilä JOT, Viitala M, Soilu-Hänninen M. Trends and characteristics of infection-related hospital admissions in multiple sclerosis patients in Southwest Finland in 2009-2018. Mult Scler Relat Disord 2020; 44:102328. [PMID: 32619965 DOI: 10.1016/j.msard.2020.102328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/20/2020] [Accepted: 06/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) patients are at increased risk for infections. The aim of this study was to investigate the trends in hospital admissions of patients with MS and to identify the factors predisposing to infection-related admissions. METHODS Hospital admissions with MS as a primary or an auxiliary diagnosis in the hospital district of Southwest Finland in 2009-2018 were searched and MS patients with infection admissions compared with other MS patients in the hospital district. Data were derived from hospital registries, patient charts and the Finnish MS register. Group comparisons were performed using Pearson´s chi-squared test, Fisher´s exact test or Wilcoxon rank sum test. Overdispersion-adjusted Poisson regression was used to analyze the annual admission numbers and multivariable logistic regression to examine the predictors of infection-related admissions. RESULTS 1380 hospital admissions for 532 patients were identified. The annual number of admissions decreased by 8.9% annually (p<0.001). Proportion of infection-related admissions declined from 26.5% to 19.5% (p = 0.049). The patients with infection admissions were on average 8.2 years older (p<0.001), more often male (p<0.001), had on average 5.3 years longer disease duration (p<0.001), more disability (median EDSS 5.0 vs. 2.0; p<0.001), more often progressive disease (p<0.001) and more comorbidities (p = 0.006) than other MS patients. Disease modifying therapies (DMTs) were used less often by patients with infection admissions (p<0.001). Infection admissions were not associated with the number of recent relapses. In-hospital mortality was higher in the infection-related admissions (3.57% vs 0.29%; p<0.001). Only 14.3% of patients with over two infection admissions had a DMT during the study period. CONCLUSION Hospital admissions, with or without an infection, have become more infrequent in MS patients of Southwest Finland over the decade from 2009 to 2018. Infection-related admissions were associated with lesser use of DMTs, older age, male gender and disability.
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Affiliation(s)
- Anna-Leena Pirttisalo
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland; Department of Clinical Neurosciences, University of Turku, Turku, Finland.
| | - Jussi O T Sipilä
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland; Department of Clinical Neurosciences, University of Turku, Turku, Finland; Department of Neurology, Siun sote, North Karelia Central Hospital, Joensuu, Finland
| | - Matias Viitala
- Department of Mathematics and Statistics, University of Turku, Turku, Finland; StellarQ LTD, Turku, Finland
| | - Merja Soilu-Hänninen
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland; Department of Clinical Neurosciences, University of Turku, Turku, Finland
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Hellgren J, Risedal A, Källén K. Rituximab in multiple sclerosis at general hospital level. Acta Neurol Scand 2020; 141:491-499. [PMID: 31990978 DOI: 10.1111/ane.13225] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/09/2020] [Accepted: 01/20/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The use of rituximab (RTX) in multiple sclerosis (MS) is a rapidly increasing choice of disease-modifying therapy. Efficacy outside specialized university hospital-based care is not yet systematically investigated. Our aim was to evaluate off-label RTX treatment for MS at a general hospital in Sweden. MATERIALS AND METHODS Subjects with definite MS with at least one rituximab infusion were eligible for inclusion in this retrospective, observational study. Effect was evaluated by monitoring clinical disability, annual relapse rate, new lesions on MRI, and safety by the incidence and severity of adverse events. RESULTS Among the 83 included subjects, 15 had clinical worsening of disease during the median 23.5 (1-76) months of follow-up after RTX initiation: 7/66 with relapsing-remitting multiple sclerosis (RRMS) and 8/17 with progressive subtypes (PMS). Cumulative survival without worsening was 86% in RRMS and 30% in PMS. The annual relapse rate before RTX vs follow-up dropped from 0.38 to 0.05 (P < .00001). Subjects with new enhancing lesions on MRI during the first year before RTX initiation vs the year after dropped from 0.94 to 0.024 (P < .00001) and was only seen in RRMS (1.05-0.31, P = .00003). Adverse events were mainly mild. Thirty-six out of 53 non-infusion-related adverse events were infections, of which four were serious, including a case of pneumonia with concomitant late-onset neutropenia. CONCLUSIONS Rituximab was as effective and safe when given at a general hospital outpatient clinic compared with results from previous university hospital-based studies. Vigilance is required concerning severe adverse events.
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Affiliation(s)
- Johan Hellgren
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
| | - Anette Risedal
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
- Department of Specialized Medicine Helsingborg General Hospital Helsingborg Sweden
| | - Kristina Källén
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
- Department of Specialized Medicine Helsingborg General Hospital Helsingborg Sweden
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Siddiqui MK, Singh B, Attri S, Veraart C, Harty G, Wong SL. Use of rituximab in adults with relapsing-remitting multiple sclerosis: a systematic literature review. Curr Med Res Opin 2020; 36:809-826. [PMID: 32129684 DOI: 10.1080/03007995.2020.1739009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Rituximab is used as an off-label treatment for relapsing-remitting multiple sclerosis (RRMS); however, the comparative efficacy and safety of rituximab versus currently licensed disease-modifying drugs (DMDs) for RRMS is unknown. A systematic literature review was conducted to evaluate the available data pertaining to efficacy and safety of rituximab in adult patients with RRMS and highly active relapsing multiple sclerosis (HA-RMS); data quality was critically assessed via risk of bias (RoB) assessment.Methods: Biomedical literature databases were searched until mid-2018 and key proceedings were searched from 2016 to 2018. Critical appraisal of non-randomized studies was conducted using the Cochrane RoB assessment tool; randomized controlled trials (RCTs) were appraised using comprehensive assessment criteria based on the NICE guidelines.Results: Thirty-eight unique studies based on 49 publications were identified: 25 RRMS studies (one RCT) and 13 HA-RMS studies (no RCTs). The evidence among patients with RRMS generally favored rituximab in comparison to placebo (relapse rate) and interferons/glatiramer acetate (relapse rate and disability progression), although much of the non-randomized data were descriptive and/or not statistically significant. In comparison to placebo, rituximab was associated with a greater risk of adverse events. Two-thirds of the non-randomized RRMS studies were associated with critical/serious RoB; the single RCT was associated with low RoB. Furthermore, all of the non-randomized HA-RMS studies were associated with critical/serious RoB.Conclusions: Available evidence of off-label rituximab use for the treatment of patients with RRMS suggests generally favorable efficacy versus placebo and interferons/glatiramer acetate; however, the poor quality of the included studies limits any robust conclusions.
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Bellinvia A, Prestipino E, Portaccio E, Razzolini L, Fonderico M, Fratangelo R, Tudisco L, Pastò L, Amato MP. Experience with rituximab therapy in a real-life sample of multiple sclerosis patients. Neurol Sci 2020; 41:2939-2945. [PMID: 32350672 DOI: 10.1007/s10072-020-04434-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/16/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an autoimmune, neuroinflammatory, and neurodegenerative disease of the central nervous system. B cells have recently emerged as a promising target to significantly reduce inflammatory disease activity in MS, with successful trial studies using antiCD20 therapies. However, real-life data about safety and efficacy are limited. OBJECTIVES To analyze the clinical and radiological inflammatory activity, adherence to therapy, and safety of rituximab (RTX) in an MS patients' sample, treated from 2015 to 2018 in our center PATIENTS AND METHODS: Retrospective study on prospectively collected data about relapses, disability progression, and radiological activity (new T2 lesions and Gd-enhancing lesions) were recorded and used to assess no evidence of disease activity (NEDA) at 12 months. RTX-related adverse events were recorded. RTX was administered intravenously at a dosage of 1000 mg twice 2 weeks apart, then every 6 months. RESULTS Sixty-nine patients were included. Fifty-three (76.8%) had a relapsing-remitting, two a primary progressive course, and 14 a secondary progressive course. The mean follow-up period was 16 ± 9.7 months. Thirty-five (50.7%) patients had relapses in the year prior to RTX therapy, with a mean annualized relapse rate of 0.75, significantly reduced to 0.36 at 12 months (p < 0.001). Among the 36 patients included in the study who had an MRI available at 12 months, MRI activity was reduced from 88% (n = 32) to 8.3% (n = 3) at follow-up (p < 0.001). Twelve (17.4%) patients suspended RTX during the study. CONCLUSIONS Our real-life experience confirms that off-label therapy with RTX may represent a valid, cost-effective therapeutic option in MS.
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Affiliation(s)
- Angelo Bellinvia
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Elio Prestipino
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Emilio Portaccio
- SOC Neurologia, AUSL Toscana Centro, San Giovanni di Dio Hospital, Florence, Italy
| | - Lorenzo Razzolini
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Mattia Fonderico
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Roberto Fratangelo
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Laura Tudisco
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Luisa Pastò
- SOD Neurological Rehabilitation, Careggi University Hospital, Florence, Italy
| | - Maria P Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy.
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.
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Naser Moghadasi A, Darki A, Masoumi P, Hashemi SN, Ghadiri F. Evaluating the efficacy and safety of ZytuxTM (Rituximab, AryoGen pharmed) in Iranian multiple sclerosis patients: An observational study. Mult Scler Relat Disord 2019; 36:101419. [DOI: 10.1016/j.msard.2019.101419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 08/12/2019] [Accepted: 09/25/2019] [Indexed: 01/06/2023]
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Yamout B, Sahraian M, Bohlega S, Al-Jumah M, Goueider R, Dahdaleh M, Inshasi J, Hashem S, Alsharoqi I, Khoury S, Alkhawajah M, Koussa S, Al Khaburi J, Almahdawi A, Alsaadi T, Slassi E, Daodi S, Zakaria M, Alroughani R. Consensus recommendations for the diagnosis and treatment of multiple sclerosis: 2019 revisions to the MENACTRIMS guidelines. Mult Scler Relat Disord 2019; 37:101459. [PMID: 31670208 DOI: 10.1016/j.msard.2019.101459] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 12/19/2022]
Abstract
With evolving diagnostic criteria and the advent of new oral and parenteral therapies for MS, most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and in time, and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of multiple sclerosis (MS) therapies is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, and progressive MS. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.
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Affiliation(s)
- B Yamout
- Nehme and Therese Tohme MS Center, American University of Beirut Medical Center, Beirut, Lebanon.
| | - M Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - S Bohlega
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Al-Jumah
- King Fahad Medical Cit, MOH, Riyadh, Saudi Arabia
| | - R Goueider
- Service de Neurologie, Hôpital Razi, Manouba, Tunis
| | | | - J Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - S Hashem
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - I Alsharoqi
- Dept of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain
| | - S Khoury
- Nehme and Therese Tohme MS Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Alkhawajah
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - S Koussa
- MS Center- Geitaoui Lebanese University Hospital, Beirut, Lebanon
| | - J Al Khaburi
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - A Almahdawi
- Consultant neurologist, neurology unit, Baghdad Teaching Hospital, Medical City Complex, Iraq
| | - T Alsaadi
- American Center for Psychiatry & Neurology- UAE
| | - E Slassi
- Hôpital Cheikh Khalifa Ibn Zaid, Casablanca- Morocco
| | - S Daodi
- Hospital Center Nedir Mohamed, Faculty of Medicine University Mouloud Mammeri Tizi-ouzou Algeria
| | | | - R Alroughani
- Amiri Hospital, Arabian Gulf Street, Sharq, Kuwait
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Abstract
Rituximab, a chimeric anti-CD20-antibody, attracts increasing attention as a treatment option for multiple sclerosis (MS). Apart from smaller controlled trials, an increasing number of studies in real-world populations indicate high efficacy based on clinical and neuroradiological outcomes for rituximab in relapsing-remitting MS patients. Additional evidence also demonstrates efficacy of rituximab with treatment of progressive MS phenotypes. In this topical review, we summarize and discuss current evidence on mechanisms of action, efficacy, safety, tolerance and other clinical aspects of rituximab in the treatment of MS. Finally, we will highlight current knowledge gaps and the need for comparative studies with other disease-modifying therapies in MS.
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Affiliation(s)
- Benjamin V Ineichen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Division of Neuroradiology, Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Moridi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Tobias Granberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Division of Neuroradiology, Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
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Linden J, Granåsen G, Salzer J, Svenningsson A, Sundström P. Inflammatory activity and vitamin D levels in an MS population treated with rituximab. Mult Scler J Exp Transl Clin 2019; 5:2055217319826598. [PMID: 30800416 PMCID: PMC6378455 DOI: 10.1177/2055217319826598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 12/17/2018] [Accepted: 01/06/2019] [Indexed: 01/09/2023] Open
Abstract
Background Most multiple sclerosis patients on disease-modifying treatment at Umeå University Hospital are treated with rituximab and the prevalence of vitamin D supplementation has increased over time. Follow-up studies of these off-label treatments are needed. Objective To study inflammatory activity and adverse effects in rituximab-treated multiple sclerosis patients, and associations with 25-hydroxy-vitamin D levels. Methods Retrospectively collected data on repeated estimates of relapses, disability, side effects, magnetic resonance imaging, laboratory measures including 25-hydroxy-vitamin D levels and self-perceived health. Results In 272 multiple sclerosis patients with a mean follow-up of 43 months, we identified seven possible relapses during active rituximab treatment. On magnetic resonance imaging examination, new T2 lesions were seen in 1.3% (10 out of 792 scans), and 0.25% (two out of 785 scans) showed contrast enhancement. Adjusted 25-hydroxy-vitamin D levels in samples drawn close to all magnetic resonance images with new T2 lesions were lower compared to the remainder (62 vs. 81 nmol/l; P = 0.030). Levels of 25-hydroxy-vitamin D were associated with self-perceived health (r = 0.18, P = 0.041, n = 130) and C-reactive protein (r = -0.13, P = 0.042) but not with the risk of side effects. Conclusion The inflammatory activity in this rituximab-treated multiple sclerosis population that increasingly used vitamin D supplementation was extremely low. Higher 25-hydroxy-vitamin D levels were associated with beneficial outcomes.
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Affiliation(s)
- Johan Linden
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Sweden
| | - Gabriel Granåsen
- Department of Public Health and Clinical Medicine, Umeå University, Sweden
| | - Jonatan Salzer
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Sweden
| | | | - Peter Sundström
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Sweden
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Myhr KM, Torkildsen Ø, Lossius A, Bø L, Holmøy T. B cell depletion in the treatment of multiple sclerosis. Expert Opin Biol Ther 2019; 19:261-271. [PMID: 30632834 DOI: 10.1080/14712598.2019.1568407] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. The latest development of B-cell depletion by anti-CD20 monoclonal antibodies has been a large step forward in the treatment of this devastating disease. AREAS COVERED In this manuscript, we review mechanisms of action, efficacy, safety, and tolerance of anti-CD20 therapies for MS, including rituximab, ocrelizumab, and ofatumumab. EXPERT OPINION B-cell depletion efficiently suppresses acute inflammatory disease activity in relapsing-remitting MS (RRMS), and may slowdown progression in primary progressive MS (PPMS). The treatment is generally well tolerated, with manageable adverse events related to infusion reactions and infections. Ocrelizumab, a humanized anti-CD20 monoclonal antibody, is the first therapy to be approved for the treatment of both RRMS and PPMS.
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Affiliation(s)
- Kjell-Morten Myhr
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Øivind Torkildsen
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Andreas Lossius
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,d Department of Immunology and Transfusion Medicine, Faculty of Medicine , University of Oslo and Oslo University Hospital Rikshospitalet , Oslo , Norway
| | - Lars Bø
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Trygve Holmøy
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,e Department of Clinical Medicine , University of Oslo , Oslo , Norway
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