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Hellgren J, Ahlström I, Strandberg MC, Jonsson MF, Hansson O, Janelidze S, Svenningsson A, Källén K. Comparison of CSF biomarkers in multiple sclerosis patients treated with natalizumab and rituximab. Mult Scler Relat Disord 2025; 99:106479. [PMID: 40345115 DOI: 10.1016/j.msard.2025.106479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2025] [Revised: 04/28/2025] [Accepted: 04/29/2025] [Indexed: 05/11/2025]
Abstract
BACKGROUND Patients with relapsing remitting multiple sclerosis (RRMS) treated with the high-efficacy drugs natalizumab (NTZ) or rituximab (RTX) generally show no evidence of disease activity. Currently, there is no head-to-head comparison between NTZ and RTX of neurodegenerative and neuroinflammatory biomarkers in cerebrospinal fluid (CSF). OBJECTIVES To compare CSF biomarkers in a stable RRMS cohort treated with NTZ or RTX. A secondary objective was to explore potential associations between CSF biomarkers, fatigue, and cognition. METHODS This Swedish multicentre cross-sectional study assessed kappa-free light chain (k-FLC) index, oligoclonal bands (OCBs), glial fibrillary acidic protein (GFAP) and neurofilament light (NfL) in CSF of 30 RRMS patients on NTZ or RTX for at least 24 months. A longitudinal comparison of biomarkers was performed for IgG Indices. Fatigue and cognition outcomes were explored in relation to CSF biomarkers. RESULTS GFAP level was significantly higher in the NTZ group compared to RTX (mean difference (CI): 2 716 (155; 5278) ng/L, p=0.047). NfL concentration did not differ between the groups. OCBs and k-FLC index were present and elevated in 97 % and 87 % of participants, respectively. IgG-index was significantly reduced only for NTZ. No significant associations were found between fatigue, cognition and the biomarkers. CONCLUSION Our results support that intrathecal inflammatory activity is still ongoing in patients with NTZ and RTX. Cross-sectional GFAP might indicate a lower risk for long-term disability in the RTX group. Our data should be interpreted with caution because of small sample size, making it difficult to control for multiple confounders.
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Affiliation(s)
- Johan Hellgren
- Clinical Sciences Helsingborg Unit, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Neurology Section, Department of Specialised Medicine, Helsingborg General Hospital, Helsingborg, Sweden.
| | - Isabella Ahlström
- Clinical Sciences Helsingborg Unit, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Maria Compagno Strandberg
- Neurology Lund Unit, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Neurology, Rehabilitation medicine, Memory disorders and Geriatrics, Skånes University Hospital, Lund, Sweden
| | | | - Oskar Hansson
- Clinical Memory Research Unit, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Shorena Janelidze
- Clinical Memory Research Unit, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences, Karolinska Institutet, Stockholm, Sweden; Department of Neurology, Danderyd Hospital, Stockholm, Sweden
| | - Kristina Källén
- Clinical Sciences Helsingborg Unit, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Filippini G, Kruja J, Del Giovane C. Rituximab for people with multiple sclerosis. Cochrane Database Syst Rev 2025; 3:CD013874. [PMID: 40066932 PMCID: PMC11895426 DOI: 10.1002/14651858.cd013874.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/15/2025]
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. This updates the 2021 version of the review. OBJECTIVES To assess the benefits and harms of rituximab as 'first choice' and 'switching' treatment for adults with any form of MS. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and three trials registers on 31 December 2023, together with reference checking and contacting study authors to identify unpublished studies. 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 any form of MS. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. We used RoB 1 to assess risk of bias in RCTs and ROBINS-I in NRSIs. We assessed the certainty of evidence for critical and important prioritised outcomes using GRADE: 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' treatment, relapsing or progressive MS, comparison with placebo or another DMT, and RCTs or NRSIs. MAIN RESULTS In this update, the number of study participants increased from 16,429 (15 studies) to 37,443 (28 studies; 13 new studies: 1 RCT and 12 NRSIs). The studies were conducted worldwide; most originated from high-income countries (25 studies). Public institutions funded 22 (79%) of the studies. Most studies investigated the effects of rituximab on people with relapsing MS (19 studies; 27,500 (73%) participants). We identified 12 ongoing studies. Rituximab as 'first choice' for active relapsing MS None of the included studies compared rituximab to placebo. One RCT compared rituximab to dimethyl fumarate, with 24 months' follow-up. Rituximab may reduce the recurrence of relapse (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.04 to 0.57; 195 participants; low-certainty evidence). The evidence is very uncertain on disability worsening and SAEs. Rituximab may result in little to no difference in upper respiratory tract infections (rate ratio (RR) 1.03, 95% CI 0.79 to 1.34; low-certainty evidence). The evidence is very uncertain for urinary tract, skin, and viral infections. HRQoL, cancer, and mortality were not reported. One NRSI compared rituximab to other DMTs, with 24 months' follow-up. Disability worsening was not reported. Compared with interferon beta or glatiramer acetate, rituximab likely delays relapse (hazard ratio (HR) 0.14, 95% CI 0.05 to 0.39; 1 study, 335 participants; moderate-certainty evidence). Compared with dimethyl fumarate and natalizumab, rituximab may delay relapse (dimethyl fumarate: HR 0.29, 95% CI 0.08 to 1.00; 1 study, 206 participants; low-certainty evidence; natalizumab: HR 0.24, 95% CI 0.06 to 1.00; 1 study, 170 participants; low-certainty evidence). The evidence for relapse is very uncertain when comparing rituximab to fingolimod. The effect on SAEs is uncertain due to very few events in all the comparison groups. No deaths were reported. HRQoL, common infections, and cancer were not reported. Rituximab as 'first choice' for primary progressive MS One RCT compared rituximab to placebo, with 24 months' follow-up. Rituximab likely results in little or no difference in disability worsening (OR 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate-certainty evidence). The evidence is very uncertain on relapse, SAEs, common infections, cancer, and mortality. HRQoL was not reported. None of the included studies compared rituximab as 'first choice' treatment to other DMTs for primary or secondary progressive MS. Rituximab as 'switching' treatment for relapsing MS One small RCT compared rituximab to placebo, with 12 months' follow-up. Disability worsening was not reported. Rituximab may reduce recurrence of relapses (OR 0.38, 95% CI 0.16 to 0.93; 1 study, 104 participants; low-certainty evidence). The evidence is very uncertain regarding SAEs, common infections, cancer, and mortality. HRQoL was not reported. Twelve NRSIs compared rituximab to other DMTs, with 24 months' follow-up. The evidence on disability worsening is very uncertain in comparison with interferons or glatiramer acetate, natalizumab, alemtuzumab, and ocrelizumab. Rituximab likely delays time to relapse in comparison with interferons or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 study, 1383 participants; moderate-certainty evidence), fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 study, 256 participants; moderate-certainty evidence), and may result in little or no difference compared with natalizumab (HR 0.96, 95% CI 0.83 to 1.10; 3 studies, 1922 participants; low-certainty evidence). The evidence is very uncertain on relapse in comparison with alemtuzumab. There is uncertainty regarding SAEs when comparing rituximab to natalizumab and fingolimod. Rituximab likely increases serious common infections when compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 study, 5477 participants; moderate-certainty evidence) and natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 studies, 5001 participants; moderate-certainty evidence). The evidence for common infections is very uncertain when comparing rituximab to fingolimod and ocrelizumab. Rituximab may slightly reduce the risk of cancer compared with natalizumab (HR 0.79, 95% CI 0.62 to 0.99; 2 studies, 6202 participants; low-certainty evidence), whereas the evidence is very uncertain in comparison with fingolimod. The effect of rituximab on mortality is very uncertain due to very few events in all the comparison groups. HRQoL was not reported. AUTHORS' CONCLUSIONS For preventing relapses in relapsing MS, rituximab as 'first choice' and 'switching' treatment compares favourably with a wide range of approved DMTs. The protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab on primary progressive MS. There is limited evidence for long-term adverse events of rituximab in people with MS. Evidence for serious adverse events, cancer, and mortality was of very low certainty due to few events. There is an increased risk of serious (hospital-treated) infections with rituximab compared with other DMTs, although the absolute risk is low. High-quality (prospectively registered) NRSIs should be conducted to draw more reliable conclusions about the potential benefits and harms of rituximab in people with MS.
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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
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
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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 2025; 40:41-47. [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] [MESH Headings] [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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Marijam A, Vroom N, Bhavsar A, Posiuniene I, Lecrenier N, Vroling H. Systematic Literature Review on the Incidence of Herpes Zoster in Populations at Increased Risk of Disease in the EU/EEA, Switzerland, and the UK. Infect Dis Ther 2024; 13:1083-1104. [PMID: 38656653 PMCID: PMC11098998 DOI: 10.1007/s40121-024-00963-w] [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: 01/04/2024] [Accepted: 03/15/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Older adults and patients with underlying conditions such as immunocompromised (IC) populations (e.g., due to medical conditions or immunosuppressive medication) are at increased risk for herpes zoster (HZ). The first HZ recombinant vaccine for IC patients was approved in 2020. Limited evidence exists to inform decision-makers on HZ incidence in high-risk patients in Europe. This systematic literature review (SLR) assessed HZ incidence across 14 high-risk populations in the European Union/European Economic Area, Switzerland, and the United Kingdom. METHODS An SLR (Embase, Medline, 2002-2022, observational studies) was performed to identify HZ incidence (i.e., primary outcomes: rate or cumulative; secondary: relative incidence) in type 1 and 2 diabetes mellitus (DM); chronic obstructive pulmonary disease and asthma; depression; rheumatic disorders (RD); multiple sclerosis (MS); inflammatory bowel diseases (IBD); psoriasis; lupus; human immunodeficiency virus (HIV); solid organ transplantation (SOT); solid organ malignancy (SOM); hematologic malignancy (HM); and stem cell transplantation (SCT). RESULTS Of 776 unique records screened, 59 studies were included (24 reported incidence rate per 1000 person-years; two, cumulative incidence per 1000 persons; and 33, relative incidence). The highest incidence rates were reported for SOT (12.1-78.8) and SCT (37.2-56.1); HM (2.9-32.0); RD (0.41-21.5); lupus (11.0-16.5); IC mixed population (11.3-15.5); HIV/AIDS (11.8-13.0); chronic respiratory diseases (4.7-11.4); SOM (8.8-11.0); IBD (7.0-10.8); DM (4.3-9.4); depression (7.2-7.6); MS (5.7-6.3); and psoriasis (5.3-6.1). In many high-risk populations, HZ incidence was higher for older age groups, women, and some treatments. CONCLUSIONS The HZ incidence rate in Europe increased with age and varied across high-risk populations, with high rates for solid organ and stem cell transplants, cancer, and rheumatoid arthritis. Most studies were retrospective with methodological differences affecting generalizability and comparability. Future studies should stratify data by IC population, age, sex, severity, medication, and study timeframe.
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Affiliation(s)
| | - Nikki Vroom
- Pallas Health Research & Consultancy, A P95 Company, Rotterdam, The Netherlands
| | | | | | | | - Hilde Vroling
- Pallas Health Research & Consultancy, A P95 Company, Rotterdam, The Netherlands
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5
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Li KH, Kaker M, Lau J, Noonan K, Zhang S, McDermott CL, Lockhart CM. The landscape of real-world evidence of rituximab utilization and clinical outcomes in patients with cancer, rheumatoid arthritis, and multiple sclerosis: A scoping review. J Manag Care Spec Pharm 2024; 30:480-489. [PMID: 38701025 PMCID: PMC11068653 DOI: 10.18553/jmcp.2024.30.5.480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND Rituximab (RTX) is an anti-CD20 monoclonal antibody that is used to treat various conditions in cancer, rheumatoid arthritis (RA), and multiple sclerosis (MS). Although RTX has been used in the United States for almost 3 decades, questions remain regarding its real-world utilization and effectiveness. OBJECTIVE To describe the state of observational research and real-world evidence evaluating RTX in oncology, RA, and off-label use in MS. METHODS A broad search was conducted in MEDLINE, Embase, and CINAHL covering the period of January 2010 to June 2022. Two reviewers independently screened all identified records for each disease category (cancer, RA, MS) beginning with title review, followed by abstract, and full-text review to identify relevant publications to include in the final analysis. Data were extracted and summarized for each disease based on overall trends, similarities, and differences across included studies and stratified by disease state. RESULTS A total of 260 studies met eligibility criteria, with 79 studies for the RA cohort, 144 for cancer, and 37 for MS. Across all disease cohorts, most studies (n = 189; 72.7%) were retrospective. 171 (65.8%) studies used hospital or electronic health record data as their data source and 65 (23.2%) used registry databases. Most studies (n = 153; 58.8%) assessed the effectiveness of RTX measured by disease-specific endpoints, followed by safety (n = 60; 23.1%), treatment patterns (n = 32; 12.3%), and descriptive analyses assessing treatment adherence and economic burden of disease (n = 16; 6.2%). Although safety was not the primary outcome for most studies, the majority of studies across all disease states still reported some form of safety measure. Conclusive statements on RTX's benefit varied across disease states, with MS having the most (n = 30; 81.1%) studies suggesting the drug's positive benefit. There were limited studies assessing RTX use, associated economic burden, and biosimilar switching. CONCLUSIONS The findings underscore the need for health care providers to better understand the treatment landscape and utilization of RTX, particularly in terms of patient selection, timing of initiation, and long-term outcomes. Real-world evidence can help support health care decisions and treatment using rituximab.
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Affiliation(s)
- Kevin H. Li
- University of Washington School of Pharmacy, Seattle
| | | | - Jerry Lau
- phactMI, Rutgers University, New Brunswick, NJ
| | | | - Stephanie Zhang
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill
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Hellgren J, Strandberg MC, Källén K, Svenningsson A. A comparative study of fatigue and processing speed in patients with multiple sclerosis treated with natalizumab or rituximab. Mult Scler J Exp Transl Clin 2024; 10:20552173241252566. [PMID: 38807848 PMCID: PMC11131408 DOI: 10.1177/20552173241252566] [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: 10/19/2023] [Accepted: 04/17/2024] [Indexed: 05/30/2024] Open
Abstract
Background Fatigue is the most debilitating symptom in patients with multiple sclerosis (MS). Natalizumab and rituximab are the most used MS disease modifying therapies in Sweden, but comparative data on the effect on fatigue is sparse. Objective Primary objective was to compare fatigue levels between patients on natalizumab and rituximab. As secondary objective, we assessed processing speed, an attention domain quality, between treatment groups. Method In this Swedish multicentre cross-sectional study, patients with relapsing-remitting MS and >24 months treatment duration were identified in the Swedish MS-registry. Fatigue was assessed using the Fatigue Scale for Motor and Cognitive functions (FSMC) and processing speed using Symbol Digit Modalities Test (SDMT). Results 128 patients were enrolled (natalizumab: 56, rituximab: 72). No significant differences in FSMC were found when adjusting for potential confounders (p = 0.936), with age having the biggest impact, correlating with increased fatigue. Individuals on natalizumab performed significantly better on SDMT at cross-section (natalizumab 64.7, rituximab 56.2; p = 0.003), with an improvement from treatment initiation, compared to rituximab (change: natalizumab 8.9, rituximab -1.0; p = 0.002). Conclusion We found no difference in fatigue levels between natalizumab and rituximab cohorts. Patients treated with natalizumab showed significantly better results on SDMT than patients on rituximab.
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Affiliation(s)
- Johan Hellgren
- Clinical Sciences Helsingborg Unit, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Neurology Section, Department of Specialised Medicine, Helsingborg General Hospital, Helsingborg, Sweden
| | - Maria Compagno Strandberg
- Neurology Lund Unit, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Rehabilitation medicine, Memory disorders and Geriatrics, Skånes University Hospital, Lund, Sweden
| | - Kristina Källén
- Clinical Sciences Helsingborg Unit, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Neurology Section, Department of Specialised Medicine, Helsingborg General Hospital, Helsingborg, Sweden
- Department of Neurology, Rehabilitation medicine, Memory disorders and Geriatrics, Skånes University Hospital, Lund, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital AB, Stockholm, Sweden
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Nabizadeh F, Ahmadabad MA, Mohamadi M, Mirmosayyeb O, Maleki T, Kazemzadeh K, Seyedmirzaei H. Efficacy and safety of rituximab in multiple sclerosis: a systematic review and meta-analysis. Acta Neurol Belg 2023; 123:2115-2127. [PMID: 37428437 DOI: 10.1007/s13760-023-02329-4] [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: 01/19/2023] [Accepted: 06/28/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE We aimed to synthesize all available observational studies and clinical trials of rituximab to estimate the safety and efficacy of this monoclonal antibody in people with multiple sclerosis (MS). METHODS The four databases including PubMed, Scopus, Embase, and Web of Science were comprehensively searched in April 2022. We defined PICO as follows. Problem or study population (P): patients with MS; intervention (I): Rituximab; comparison (C): none; outcome (O): efficacy and safety. RESULTS After two-step screening, a total of 27 studies entered into our qualitative and quantitative synthesis. Our analysis showed a significant decrease in EDSS score in all patients with MS after treatment (SMD: - 0.44, 95% CI - 0.85, - 0.03). In addition, the ARR was reduced after using rituximab compared to the pre-treatment period (SMD: - 0.65, 95% CI - 1.55, 0.24) but it was not significant. The most common side effect after rituximab with a pooled prevalence of 28.63% (95% CI 16.61%, 42.33%). Furthermore, the pooled prevalence of infection was 24% in patients with MS (95% CI 13%, 36%). In the end, the pooled prevalence of malignancies after rituximab treatment was 0.39% (95% CI 0.02%, 1.03%). CONCLUSION Our findings illustrated an acceptable safety for this treatment. However, further studies with randomized design, long follow-up, and large sample sizes are needed to confirm the safety and efficacy of rituximab in patients with MS.
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Affiliation(s)
- Fardin Nabizadeh
- Neuroscience Research Group (NRG), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Mona Asghari Ahmadabad
- Neuroscience Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Mobin Mohamadi
- Neuroscience Research Group (NRG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Omid Mirmosayyeb
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Tahereh Maleki
- School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Kimia Kazemzadeh
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Homa Seyedmirzaei
- School of Medicine, Tehran University of Medical Science, Tehran, Iran
- Interdisciplinary Neuroscience Research Program (INRP), Tehran University of Medical Sciences, Tehran, Iran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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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: 5] [Impact Index Per Article: 2.5] [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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Aungsumart S, Apiwattanakul M. Clinical and fringe benefits of rituximab in multiple sclerosis treatment in a poor resource setting: Case series and cost analysis. Mult Scler Relat Disord 2023; 73:104673. [DOI: 10.1016/j.msard.2023.104673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/20/2023] [Accepted: 03/26/2023] [Indexed: 03/28/2023]
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10
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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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Peng Y, Deng X, Yang SS, Nie W, Tang YD. Progress in Mechanism of Astragalus membranaceus and Its Chemical Constituents on Multiple Sclerosis. Chin J Integr Med 2023; 29:89-95. [PMID: 35809178 DOI: 10.1007/s11655-022-3535-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 12/24/2022]
Abstract
The primary chemical components of Astragalus membranaceus include polysaccharides, saponins, flavonoids, and amino acids. Recent studies have shown that Astragalus membranaceus has multiple functions, including improving immune function and exerting antioxidative, anti-radiation, anti-tumor, antibacterial, antiviral, and hormone-like effects. Astragalus membranaceus and its extracts are widely used in clinical practice because they have obvious therapeutic effects against various autoimmune diseases and relatively less adverse reaction. Multiple sclerosis (MS) is an autoimmune disease of central nervous system (CNS), which mainly caused by immune disorder that leads to inflammatory demyelination, inflammatory cell infiltration, and axonal degeneration in the CNS. In this review, the authors analyzed the clinical manifestations of MS and experimental autoimmune encephalomyelitis (EAE) and focused on the efficacy of Astragalus membranaceus and its chemical components in the treatment of MS/EAE.
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Affiliation(s)
- Yong Peng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan Province, 412000, China.
| | - Xiang Deng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan Province, 412000, China
| | - Shan-Shan Yang
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan Province, 412000, China
| | - Wei Nie
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan Province, 412000, China
| | - Yan-Dan Tang
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan Province, 412000, China
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Rossi L, Dinoto A, Bratina A, Baldini S, Pasquin F, Bosco A, Sartori A, Manganotti P. Neutropenia complicating anti-CD20 treatment in patients with multiple sclerosis: A retrospective case series and a systematic review of reported cases. Mult Scler Relat Disord 2022; 68:104090. [PMID: 35994977 DOI: 10.1016/j.msard.2022.104090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/18/2022] [Accepted: 08/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neutropenia is an infrequent complication of treatment with CD20 depleting agents and may require the administration of granulocyte-colony stimulating factors (G-CSF), which have been associated with an increased relapse risk in patients with multiple sclerosis (PwMS). The management of this side effect is still matter of debate. METHODS Aim of this study is to evaluate the clinical features and the management of neutropenia occurring in anti-CD20 treated PwMS through a single-center case series and a systematic review of the literature, performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS A total of 19 patients were included (3 from our clinical experience, 16 from the systematic review). Median age was 38 years-old (25-69) and nearly 70% were female, most of these patients had already received a median of 3 (0-4) previous treatments. Neutropenia occurred in 11 patients treated with ocrelizumab and 8 with rituximab, after a median of 2 (1-7) infusions and 9.5 (1-42) months from the first infusion. Most of these patients had late-onset neutropenia, that occurred after a median time of 90 days (2-156). About 70% of patients were symptomatic and most were treated with G-CSF or antibiotics. No relapses after G-CSF were reported. In those who did not suspend anti-CD20 (68.8%), neutropenia reoccurred in 18.2% of cases. Finally, switching between rituximab and ocrelizumab seem not to affect the occurrence of neutropenia. CONCLUSION Our data provides practical evidence regarding the occurrence and the management of neutropenia during treatment with anti-CD20 in PwMS.
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Affiliation(s)
- Lucrezia Rossi
- Neurology Unit, Department of Medical, Surgical and Health Sciences, Cattinara University Hospital, ASUGI, University of Trieste, Strada di Fiume,447 - 34149, Trieste, Italy
| | - Alessandro Dinoto
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Alessio Bratina
- Neurology Unit, Department of Medical, Surgical and Health Sciences, Cattinara University Hospital, ASUGI, University of Trieste, Strada di Fiume,447 - 34149, Trieste, Italy
| | - Sara Baldini
- Neurology Unit, Department of Medical, Surgical and Health Sciences, Cattinara University Hospital, ASUGI, University of Trieste, Strada di Fiume,447 - 34149, Trieste, Italy
| | - Fulvio Pasquin
- Neurology Unit, Department of Medical, Surgical and Health Sciences, Cattinara University Hospital, ASUGI, University of Trieste, Strada di Fiume,447 - 34149, Trieste, Italy
| | - Antonio Bosco
- Neurology Unit, Department of Medical, Surgical and Health Sciences, Cattinara University Hospital, ASUGI, University of Trieste, Strada di Fiume,447 - 34149, Trieste, Italy
| | - Arianna Sartori
- Neurology Unit, Department of Medical, Surgical and Health Sciences, Cattinara University Hospital, ASUGI, University of Trieste, Strada di Fiume,447 - 34149, Trieste, Italy.
| | - Paolo Manganotti
- Neurology Unit, Department of Medical, Surgical and Health Sciences, Cattinara University Hospital, ASUGI, University of Trieste, Strada di Fiume,447 - 34149, Trieste, Italy
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13
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D'Amico E, Zanghì A, Parrinello NL, Romano A, Palumbo GA, Chisari CG, Toscano S, Raimondo FD, Zappia M, Patti F. Immunological Subsets Characterization in Newly Diagnosed Relapsing-Remitting Multiple Sclerosis. Front Immunol 2022; 13:819136. [PMID: 35273601 PMCID: PMC8902351 DOI: 10.3389/fimmu.2022.819136] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Using flow cytometry, we characterized myeloid, B, and T cells in patients recently diagnosed with relapsing–remitting multiple sclerosis (RRMS) naive to disease-modifying therapies (DMTs). Methods This prospective case–control study was conducted in the tertiary MS center of Catania, Italy. Demographic/clinical data and peripheral bloods were collected from 52 naive patients recently diagnosed with RRMS and sex/age-matched healthy controls (HCs) in a 2:1 ratio. We performed flow cytometry on isolated peripheral blood mononuclear cells to assess immune cell subsets differences between RMMS patients and HCs. We explored the biomarker potential of cell subsets using receiver operating characteristic (ROC) curves and relative area under the curve (AUC) analyses. Results Monocytic myeloid-derived suppressor cells (Mo-MDSCs CD14+/HLADR−/low) and inflammatory monocytes (CD14+CD16+) displayed higher frequencies in RRMS patients when compared with HCs (p <.05). A lower percentage of B-unswitched memory cells was observed in RRMS patients when compared with HCs (p = .026). T cells had a higher frequency of T-helper CD4+ cells and their subset, CD4+CD161+, in RRMS patients when compared with HCs (p <.001). ROC analyses revealed an AUC >70% for Mo-MDSCs CD14+/HLADR−/low and inflammatory CD14+CD16+, T-helper CD3+CD4+, and T-helper CD4+CD161+. Conclusions Patients with a recent RRMS diagnosis and naive to DMTs, showed peculiar myeloid, B-, and T-cell immunophenotypes.
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Affiliation(s)
- Emanuele D'Amico
- Department "G.F. Ingrassia", University of Catania, Catania, Italy.,Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Aurora Zanghì
- Department "G.F. Ingrassia", University of Catania, Catania, Italy.,Medicine Department, Neurology Unit, Sant'Elia Hospital, Caltanisetta, Italy
| | | | - Alessandra Romano
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | | | | | - Simona Toscano
- Department "G.F. Ingrassia", University of Catania, Catania, Italy
| | | | - Mario Zappia
- Department "G.F. Ingrassia", University of Catania, Catania, Italy
| | - Francesco Patti
- Department "G.F. Ingrassia", University of Catania, Catania, Italy
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14
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Rezaee M, Morowvat MH, Poursadeghfard M, Radgoudarzi A, Keshavarz K. Cost-effectiveness analysis of rituximab versus natalizumab in patients with relapsing remitting multiple sclerosis. BMC Health Serv Res 2022; 22:118. [PMID: 35090438 PMCID: PMC8796500 DOI: 10.1186/s12913-022-07495-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Multiple sclerosis (MS) is an inflammatory disease in which the myelin sheaths of the nerve cells in the brain and spinal cord, which are responsible for communication, are destroyed and cause physical signs and symptoms. According to studies, anti-CD20 monoclonal antibodies have significant results in the treatment of this disease. Thus, the aim of the present study was to determine the cost-effectiveness of rituximab against natalizumab in the patients with RRMS in southern Iran in 2020. Methods This is an economic evaluation including cost-effectiveness analysis in which the Markov model with a lifetime horizon was used. The study sample consisted of 120 patients randomly selected from among those referred to the MS Association and the Special Diseases Unit of Shiraz University of Medical Sciences. In this study, the costs were collected from a societal perspective, and the outcomes were obtained in the form of Quality Adjusted Life Years (QALY) and the mean relapse rate. The TreeAge pro 2020 and Excel 2016 software were used for data analysis. Results The comparative study of rituximab and natalizumab showed that the patients receiving rituximab had lower costs ($ 58,307.93 vs. $ 354,174.85) and more QALYs (7.77 vs. 7.65). In addition, the incidence of relapse by rituximab was lower compared to natalizumab (1.15 vs. 2.57). The probabilistic one-way sensitivity analysis showed the robustness of the results. The scatter plots also showed that rituximab was more cost-effective for the patients in 100% of the simulations for the threshold of < $ 37,641. Discussion and conclusion According to the results of this study, rituximab had higher cost-effectiveness than natalizumab. Therefore, it could be a priority for RRMS patients compared to natalizumab because it reduced treatment costs and increased effectiveness.
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15
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Chisari CG, Sgarlata E, Arena S, Toscano S, Luca M, Patti F. Rituximab for the treatment of multiple sclerosis: a review. J Neurol 2022; 269:159-183. [PMID: 33416999 PMCID: PMC7790722 DOI: 10.1007/s00415-020-10362-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 01/07/2023]
Abstract
In the last decades, evidence suggesting the direct or indirect involvement of B cells on multiple sclerosis (MS) pathogenesis has accumulated. The increased amount of data on the efficacy and safety of B-cell-depleting therapies from several studies has suggested the addition of these drugs as treatment options to the current armamentarium of disease modifying therapies (DMTs) for MS. Particularly, rituximab (RTX), a chimeric monoclonal antibody directed at CD20 positive B lymphocytes resulting in cell-mediated apoptosis, has been demonstrated to reduce inflammatory activity, incidence of relapses and new brain lesions on magnetic resonance imaging (MRI) in patients with relapsing-remitting MS (RRMS). Additional evidence also demonstrated that patients with progressive MS (PMS) may benefit from RTX, which also showed to be well tolerated, with acceptable safety risks and favorable cost-effectiveness profile.Despite these encouraging results, RTX is currently approved for non-Hodgkin's lymphoma, chronic lymphocytic leukemia, several forms of vasculitis and rheumatoid arthritis, while it can only be administered off-label for MS treatment. Between Northern European countries exist different rules for using not licensed drug for treating MS. The Sweden MS register reports a high rate (53.5%) of off-label RTX prescriptions in relation to other annually started DMTs to treat MS patients, while Danish and Norwegian neurologists have to use other anti-CD20 drugs, as ocrelizumab, in most of the cases.In this paper, we review the pharmacokinetics, pharmacodynamics, clinical efficacy, safety profile and cost effectiveness aspects of RTX for the treatment of MS. Particularly, with the approval of new anti-CD20 DMTs, the recent worldwide COVID-19 emergency and the possible increased risk of infection with this class of drugs, this review sheds light on the use of RTX as an alternative treatment option for MS management, while commenting the gaps of knowledge regarding this drug.
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Affiliation(s)
- Clara Grazia Chisari
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Eleonora Sgarlata
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
- Stroke Unit, Department of Medicine, Umberto I Hospital, Siracusa, Italy
| | - Sebastiano Arena
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Simona Toscano
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Maria Luca
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Francesco Patti
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy.
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16
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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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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: 34] [Impact Index Per Article: 8.5] [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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18
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Esmaeili S, Abbasi MH, Abolmaali M, Mojtahed M, Alavi SNR, Soleimani S, Mokhtari M, Hatam J, Khotbehsara ST, Motamed MR, Joghataei MT, Mirzaasgari Z, Moghaddasi M. Rituximab and risk of COVID-19 infection and its severity in patients with MS and NMOSD. BMC Neurol 2021; 21:183. [PMID: 33933026 PMCID: PMC8087518 DOI: 10.1186/s12883-021-02218-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/26/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Choosing a safe disease modifying therapy during the COVID-19 pandemic is challenging. This case series study was conducted to determine the incidence rate and the course of Covid-19 infection in MS/NMOSD patients treated with Rituximab. METHODS In this study, we designed a web-based questionnaire. Baseline information such as patient- reported walking disability, total number of Rituximab infusions received, delayed injections, occurrence of any relapse, and the use of corticosteroids during the pandemic were collected. Also, information regarding the Covid-19 pandemic such as adherence to self-isolation, any recent exposure to an infected individual and the presence of suggestive symptoms were collected. In case of positive test results, patients were grouped into 2 categories; mild to moderate and seriously ill and outcomes were evaluated as favorable (improved/ discharged) and unfavorable (expired). RESULTS Two hundred fifty-eight patients with Multiple Sclerosis were enrolled in this study, 9 of the subjects (3.4%) were confirmed positive for Covid-19, five of which required hospitalizations (55.5%), two patients required ICU admission (22.2%) and 2 two patients died (22.2%). None of these patients ever mentioned using corticosteroids during the pandemic. In comparison to MS patients who were not receiving disease modifying therapy (DMT), our study indicated a higher incidence of Covid-19 infection, higher ratio of serious illness and a higher fatality ratio. CONCLUSIONS Rituximab seems not to be safe enough during the pandemic.
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Affiliation(s)
- Sara Esmaeili
- Cellular and Molecular Research Center, Iran university of medical sciences, Tehran, Iran
- School of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Abbasi
- Cellular and Molecular Research Center, Iran university of medical sciences, Tehran, Iran
- School of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Meysam Abolmaali
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mojtahed
- School of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | | | - Sevim Soleimani
- School of Medicine, Shahid Beheshti Medical University, Tehran, Iran
| | - Mahisa Mokhtari
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Jaber Hatam
- Department of Neurosurgery, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Mohammad Taghi Joghataei
- Cellular and Molecular Research Center, Iran university of medical sciences, Tehran, Iran
- School of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Mirzaasgari
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Moghaddasi
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
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19
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Torgauten HM, Myhr KM, Wergeland S, Bø L, Aarseth JH, Torkildsen Ø. Safety and efficacy of rituximab as first- and second line treatment in multiple sclerosis - A cohort study. Mult Scler J Exp Transl Clin 2021; 7:2055217320973049. [PMID: 33796328 PMCID: PMC7970692 DOI: 10.1177/2055217320973049] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/17/2020] [Indexed: 12/04/2022] Open
Abstract
Background Rituximab is increasingly used as off-label therapy in multiple sclerosis (MS). More data are needed on safety and efficacy of rituximab, particularly in cohorts of de novo patients and patients in early therapy escalation. Objective To investigate the safety and efficacy of off-label treatment with rituximab in an MS-cohort of predominantly de novo patients or as therapy escalation. Methods We retrieved safety and efficacy data from the Norwegian MS-registry and biobank for all MS-patients treated with rituximab at Haukeland University Hospital, Bergen, Norway, during a four year period. Results In the 365 MS-patients (320 relapsing-remitting MS (RRMS), 23 secondary progressive MS (SPMS), and 22 primary progressive MS (PPMS)), the overall annualized relapse rate (ARR) was 0.03 and annualized drug discontinuation rate (ADDR) was 0.05. NEDA-3 was achived in 79% of patients with available data (n=351). Sixty-one patients experienced infusion-related adverse events of which two were serious (CTCAE grade 3–4). Eighteen patients experienced serious non-infusion related adverse events, of which 16 were infections. Infections (n = 34; 9.3%, CTCAE grade 2-5), hypogammaglobulinemia (n = 19, 5.2%) and neutropenia (n = 16; 4.4%) were the most common non-infusion-related adverse events. Conclusion Rituximab was a safe and highly efficient disease modifying therapy in this cohort of MS-patients; however, infections and neutropenia need to be monitored.
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Affiliation(s)
- Hilde Marie Torgauten
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Stig Wergeland
- Norwegian Multiple Sclerosis Registry, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Jan H Aarseth
- Norwegian Multiple Sclerosis Registry, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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20
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Sempere AP, Berenguer-Ruiz L, Borrego-Soriano I, Burgos-San Jose A, Concepcion-Aramendia L, Volar L, Aragones M, Palazón-Bru A. Ocrelizumab in Multiple Sclerosis: A Real-World Study From Spain. Front Neurol 2021; 11:592304. [PMID: 33519676 PMCID: PMC7844090 DOI: 10.3389/fneur.2020.592304] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022] Open
Abstract
Objectives: The aim of this study was to describe the tolerability, safety, and effectiveness of ocrelizumab for primary progressive multiple sclerosis (PPMS) and relapsing multiple sclerosis (RMS) in a clinical practice setting. Methods: In this retrospective observational study, we analyzed clinical and MRI data in all patients with PPMS and RMS who had received at least one infusion of ocrelizumab in two health areas in south-eastern Spain. Patients involved in any ocrelizumab trial and those patients with a follow-up shorter than 6 months were excluded. Results: The cohort included 70 patients (42 women) who had received ocrelizumab; 30% had PPMS and 70%, RMS. At baseline, patients' mean age was 47.1 years in the PPMS group and 39.2 years in the RMS group, while the median EDSS was 3.0 and 2.5, respectively. Median follow-up was 13.6 months. The median number of treatment cycles was three. Most patients remained free from clinical and MRI activity after ocrelizumab initiation. Baseline MRI showed T1 Gd-enhancing lesions in 57% of the patients; by the first MRI control at 4–6 months, all patients except one were free of T1 Gd-enhancing lesions (69/70, 98.6% P < 0.001). The proportion of patients with NEDA was 94% in the group of RMS patients who were followed for at least 1 year. Ocrelizumab was generally well-tolerated; the most common adverse events were infusion-related reactions and infections, none of which were serious. Conclusions: Our real-world study supports the tolerability, safety, and effectiveness of ocrelizumab in clinical practice.
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Affiliation(s)
- Angel P Sempere
- Neurology Service, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.,Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
| | | | - Ines Borrego-Soriano
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
| | - Amparo Burgos-San Jose
- Pharmacy Department, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | | | - Lucian Volar
- Department of Radiology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Miguel Aragones
- Neurology Service, Hospital Marina Baixa, Villajoyosa, Spain
| | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
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