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Tonev D, Momchilova A. Oxidative Stress and the Nuclear Factor Erythroid 2-Related Factor 2 (Nrf2) Pathway in Multiple Sclerosis: Focus on Certain Exogenous and Endogenous Nrf2 Activators and Therapeutic Plasma Exchange Modulation. Int J Mol Sci 2023; 24:17223. [PMID: 38139050 PMCID: PMC10743556 DOI: 10.3390/ijms242417223] [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: 10/26/2023] [Revised: 11/18/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
The pathogenesis of multiple sclerosis (MS) suggests that, in genetically susceptible subjects, T lymphocytes undergo activation in the peripheral compartment, pass through the BBB, and cause damage in the CNS. They produce pro-inflammatory cytokines; induce cytotoxic activities in microglia and astrocytes with the accumulation of reactive oxygen species, reactive nitrogen species, and other highly reactive radicals; activate B cells and macrophages and stimulate the complement system. Inflammation and neurodegeneration are involved from the very beginning of the disease. They can both be affected by oxidative stress (OS) with different emphases depending on the time course of MS. Thus, OS initiates and supports inflammatory processes in the active phase, while in the chronic phase it supports neurodegenerative processes. A still unresolved issue in overcoming OS-induced lesions in MS is the insufficient endogenous activation of the Nuclear Factor Erythroid 2-Related Factor 2 (Nrf2) pathway, which under normal conditions plays an essential role in mitochondria protection, OS, neuroinflammation, and degeneration. Thus, the search for approaches aiming to elevate endogenous Nrf2 activation is capable of protecting the brain against oxidative damage. However, exogenous Nrf2 activators themselves are not without drawbacks, necessitating the search for new non-pharmacological therapeutic approaches to modulate OS. The purpose of the present review is to provide some relevant preclinical and clinical examples, focusing on certain exogenous and endogenous Nrf2 activators and the modulation of therapeutic plasma exchange (TPE). The increased plasma levels of nerve growth factor (NGF) in response to TPE treatment of MS patients suggest their antioxidant potential for endogenous Nrf2 enhancement via NGF/TrkA/PI3K/Akt and NGF/p75NTR/ceramide-PKCζ/CK2 signaling pathways.
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Affiliation(s)
- Dimitar Tonev
- Department of Anesthesiology and Intensive Care, University Hospital “Tzaritza Yoanna—ISUL”, Medical University of Sofia, 1527 Sofia, Bulgaria
| | - Albena Momchilova
- Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Science, 1113 Sofia, Bulgaria;
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Bresciani G, Manai F, Davinelli S, Tucci P, Saso L, Amadio M. Novel potential pharmacological applications of dimethyl fumarate-an overview and update. Front Pharmacol 2023; 14:1264842. [PMID: 37745068 PMCID: PMC10512734 DOI: 10.3389/fphar.2023.1264842] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Dimethyl fumarate (DMF) is an FDA-approved drug for the treatment of psoriasis and multiple sclerosis. DMF is known to stabilize the transcription factor Nrf2, which in turn induces the expression of antioxidant response element genes. It has also been shown that DMF influences autophagy and participates in the transcriptional control of inflammatory factors by inhibiting NF-κB and its downstream targets. DMF is receiving increasing attention for its potential to be repurposed for several diseases. This versatile molecule is indeed able to exert beneficial effects on different medical conditions through a pleiotropic mechanism, in virtue of its antioxidant, immunomodulatory, neuroprotective, anti-inflammatory, and anti-proliferative effects. A growing number of preclinical and clinical studies show that DMF may have important therapeutic implications for chronic diseases, such as cardiovascular and respiratory pathologies, cancer, eye disorders, neurodegenerative conditions, and systemic or organ specific inflammatory and immune-mediated diseases. This comprehensive review summarizes and highlights the plethora of DMF's beneficial effects and underlines its repurposing opportunities in a variety of clinical conditions.
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Affiliation(s)
- Giorgia Bresciani
- Section of Pharmacology, Department of Drug Sciences, University of Pavia, Pavia, Italy
| | - Federico Manai
- Department of Biology and Biotechnology L. Spallanzani, University of Pavia, Pavia, Italy
| | - Sergio Davinelli
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, Campobasso, Italy
| | - Paolo Tucci
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Luciano Saso
- Department of Physiology and Pharmacology Vittorio Erspamer, Sapienza University, Rome, Italy
| | - Marialaura Amadio
- Section of Pharmacology, Department of Drug Sciences, University of Pavia, Pavia, Italy
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Askari VR, Baradaran Rahimi V, Shafiee-Nick R. Low Doses of β-Caryophyllene Reduced Clinical and Paraclinical Parameters of an Autoimmune Animal Model of Multiple Sclerosis: Investigating the Role of CB 2 Receptors in Inflammation by Lymphocytes and Microglial. Brain Sci 2023; 13:1092. [PMID: 37509022 PMCID: PMC10377147 DOI: 10.3390/brainsci13071092] [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: 06/09/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Multiple Sclerosis (MS) is a prevalent inflammatory disease in which the immune system plays an essential role in the damage, inflammation, and demyelination of central nervous system neurons (CNS). The cannabinoid receptor type 2 (CB2) agonists possess anti-inflammatory effects against noxious stimuli and elevate the neuronal survival rate. We attempted to analyze the protective impact of low doses of β-Caryophyllene (BCP) in experimental autoimmune encephalomyelitis (EAE) mice as a chronic MS model. Immunization of female C57BL/6 mice was achieved through two subcutaneous injections into different areas of the hind flank with an emulsion that consisted of myelin Myelin oligodendrocyte glycoprotein (MOG)35-55 (150 µg) and complete Freund's adjuvant (CFA) (400 µg) with an equal volume. Two intraperitoneal (i.p.) injections of pertussis toxin (300 ng) were performed on the animals on day zero (immunizations day) and 48 h (2nd day) after injection of MOG + CFA. The defensive effect of low doses of BCP (2.5 and 5 mg/kg/d) was investigated in the presence and absence of a CB2 receptor antagonist (1 mg/kg, AM630) in the EAE model. We also examined the pro/anti-inflammatory cytokine levels and the polarization of brain microglia and spleen lymphocytes in EAE animals. According to our findings, low doses of BCP offered protective impacts in the EAE mice treatment in a CB2 receptor-dependent way. In addition, according to results, BCP decreased the pathological and clinical defects in EAE mice via modulating adaptive (lymphocytes) and innate (microglia) immune systems from inflammatory phenotypes (M1/Th1/Th17) to anti-inflammatory (M2/Th2/Treg) phenotypes. Additionally, BCP elevated the anti-inflammatory cytokine IL-10 and reduced blood inflammatory cytokines. BCP almost targeted the systemic immune system more than the CNS immune system. Thus, a low dose of BCP can be suggested as a therapeutic effect on MS treatment with potent anti-inflammatory effects and possibly lower toxicity.
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Affiliation(s)
- Vahid Reza Askari
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran
| | - Vafa Baradaran Rahimi
- Department of Cardiovascular Diseases, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran
| | - Reza Shafiee-Nick
- Department of Pharmacology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran
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Bittner S, Pape K, Klotz L, Zipp F. Implications of immunometabolism for smouldering MS pathology and therapy. Nat Rev Neurol 2023:10.1038/s41582-023-00839-6. [PMID: 37430070 DOI: 10.1038/s41582-023-00839-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 07/12/2023]
Abstract
Clinical symptom worsening in patients with multiple sclerosis (MS) is driven by inflammation compartmentalized within the CNS, which results in chronic neuronal damage owing to insufficient repair mechanisms. The term 'smouldering inflammation' summarizes the biological aspects underlying this chronic, non-relapsing and immune-mediated mechanism of disease progression. Smouldering inflammation is likely to be shaped and sustained by local factors in the CNS that account for the persistence of this inflammatory response and explain why current treatments for MS do not sufficiently target this process. Local factors that affect the metabolic properties of glial cells and neurons include cytokines, pH value, lactate levels and nutrient availability. This Review summarizes current knowledge of the local inflammatory microenvironment in smouldering inflammation and how it interacts with the metabolism of tissue-resident immune cells, thereby promoting inflammatory niches within the CNS. The discussion highlights environmental and lifestyle factors that are increasingly recognized as capable of altering immune cell metabolism and potentially responsible for smouldering pathology in the CNS. Currently approved MS therapies that target metabolic pathways are also discussed, along with their potential for preventing the processes that contribute to smouldering inflammation and thereby to progressive neurodegenerative damage in MS.
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Affiliation(s)
- Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
| | - Katrin Pape
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
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Occhiuto CJ, Moerland JA, Leal AS, Gallo KA, Liby KT. The Multi-Faceted Consequences of NRF2 Activation throughout Carcinogenesis. Mol Cells 2023; 46:176-186. [PMID: 36994476 PMCID: PMC10070161 DOI: 10.14348/molcells.2023.2191] [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: 12/16/2022] [Revised: 02/22/2023] [Accepted: 02/22/2023] [Indexed: 03/31/2023] Open
Abstract
The oxidative balance of a cell is maintained by the Kelch-like ECH-associated protein 1 (KEAP1)/nuclear factor erythroid 2-related factor 2 (NRF2) pathway. This cytoprotective pathway detoxifies reactive oxygen species and xenobiotics. The role of the KEAP1/NRF2 pathway as pro-tumorigenic or anti-tumorigenic throughout stages of carcinogenesis (including initiation, promotion, progression, and metastasis) is complex. This mini review focuses on key studies describing how the KEAP1/NRF2 pathway affects cancer at different phases. The data compiled suggest that the roles of KEAP1/NRF2 in cancer are highly dependent on context; specifically, the model used (carcinogen-induced vs genetic), the tumor type, and the stage of cancer. Moreover, emerging data suggests that KEAP1/NRF2 is also important for regulating the tumor microenvironment and how its effects are amplified either by epigenetics or in response to co-occurring mutations. Further elucidation of the complexity of this pathway is needed in order to develop novel pharmacological tools and drugs to improve patient outcomes.
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Affiliation(s)
- Christopher J. Occhiuto
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA
- College of Human Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Jessica A. Moerland
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Ana S. Leal
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Kathleen A. Gallo
- Department of Physiology, Michigan State University, East Lansing, MI 48824, USA
| | - Karen T. Liby
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824, USA
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Kohle F, Dalakas MC, Lehmann HC. Repurposing MS immunotherapies for CIDP and other autoimmune neuropathies: unfulfilled promise or efficient strategy? Ther Adv Neurol Disord 2023; 16:17562864221137129. [PMID: 36620728 PMCID: PMC9810996 DOI: 10.1177/17562864221137129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/19/2022] [Indexed: 01/03/2023] Open
Abstract
Despite advances in the treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and other common autoimmune neuropathies (AN), still-many patients with these diseases do not respond satisfactorily to the available treatments. Repurposing of disease-modifying therapies (DMTs) from other autoimmune conditions, particularly multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD), is a promising strategy that may accelerate the establishment of novel treatment choices for AN. This approach appears attractive due to homologies in the pathogenesis of these diseases and the extensive post-marketing experience that has been gathered from treating MS and NMOSD patients. The idea is also strengthened by a number of studies that explored the efficacy of DMTs in animal models of AN but also in some CIDP patients. We here review the available preclinical and clinical data of approved MS therapeutics in terms of their applicability to AN, especially CIDP. Promising therapeutic approaches appear to be B cell-directed and complement-targeting strategies, such as anti-CD20/anti-CD19 agents, Bruton's tyrosine kinase inhibitors and anti-C5 agents, as they exert their effects in the periphery. This is a major advantage because, in contrast to MS, their action in the periphery is sufficient to exert significant immunomodulation.
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Affiliation(s)
- Felix Kohle
- Department of Neurology, Faculty of Medicine,
University of Cologne and University Hospital Cologne, Cologne,
Germany
| | - Marinos C. Dalakas
- Department of Neurology, Thomas Jefferson
University, Philadelphia, PA, USA,Neuroimmunology Unit, National and Kapodistrian
University of Athens Medical School, Athens, Greece
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Manai F, Govoni S, Amadio M. The Challenge of Dimethyl Fumarate Repurposing in Eye Pathologies. Cells 2022; 11:cells11244061. [PMID: 36552824 PMCID: PMC9777082 DOI: 10.3390/cells11244061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/28/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Dimethyl fumarate (DMF) is a small molecule currently approved and used in the treatment of psoriasis and multiple sclerosis due to its immuno-modulatory, anti-inflammatory, and antioxidant properties. As an Nrf2 activator through Keap1 protein inhibition, DMF unveils a potential therapeutical use that is much broader than expected so far. In this comprehensive review we discuss the state-of-art and future perspectives regarding the potential repositioning of this molecule in the panorama of eye pathologies, including Age-related Macular Degeneration (AMD). The DMF's mechanism of action, an extensive analysis of the in vitro and in vivo evidence of its beneficial effects, together with a search of the current clinical trials, are here reported. Altogether, this evidence gives an overview of the new potential applications of this molecule in the context of ophthalmological diseases characterized by inflammation and oxidative stress, with a special focus on AMD, for which our gene-disease (KEAP1-AMD) database search, followed by a protein-protein interaction analysis, further supports the rationale of DMF use. The necessity to find a topical route of DMF administration to the eye is also discussed. In conclusion, the challenge of DMF repurposing in eye pathologies is feasible and worth scientific attention and well-focused research efforts.
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Affiliation(s)
- Federico Manai
- Department of Biology and Biotechnology “L. Spallanzani”, University of Pavia, 27100 Pavia, Italy
| | - Stefano Govoni
- Department of Drug Sciences, Section of Pharmacology, University of Pavia, 27100 Pavia, Italy
| | - Marialaura Amadio
- Department of Drug Sciences, Section of Pharmacology, University of Pavia, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-0382-987888
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Matteo P, Federico D, Emanuela M, Giulia R, Tommaso B, Alfredo G, Anna C, Annamaria O. New and Old Horizons for an Ancient Drug: Pharmacokinetics, Pharmacodynamics, and Clinical Perspectives of Dimethyl Fumarate. Pharmaceutics 2022; 14:pharmaceutics14122732. [PMID: 36559226 PMCID: PMC9788528 DOI: 10.3390/pharmaceutics14122732] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
(1) Background: In their 60-year history, dimethyl fumarate and other salts of fumaric acid have been used for the treatment of psoriasis and other immune-mediated diseases for their immune-modulating properties. Over the years, new mechanisms of action have been discovered for this evergreen drug that remains a first-line treatment for several different inflammatory diseases. Due to its pleiotropic effects, this molecule is still of great interest in varied conditions, not exclusively inflammatory diseases. (2) Methods: The PubMed database was searched using combinations of the following keywords: dimethyl fumarate, pharmacokinetics, pharmacodynamics, adverse effects, psoriasis, multiple sclerosis, and clinical indications. This article reviews and updates the pharmacokinetics, mechanisms of action, and clinical indications of dimethyl fumarate. (3) Conclusions: The pharmacology of dimethyl fumarate is complex, fascinating, and not fully known. Progressive insights into the molecule's mechanisms of action will make it possible to maximize its clinical efficacy, reduce concerns about adverse effects, and find other possible areas of application.
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Affiliation(s)
- Paolinelli Matteo
- Department of Clinical and Molecular Sciences-Dermatological Clinic, Polytechnic Marche University, 60121 Ancona, Italy
- Correspondence:
| | - Diotallevi Federico
- Department of Clinical and Molecular Sciences-Dermatological Clinic, Polytechnic Marche University, 60121 Ancona, Italy
| | - Martina Emanuela
- Department of Clinical and Molecular Sciences-Dermatological Clinic, Polytechnic Marche University, 60121 Ancona, Italy
| | - Radi Giulia
- Department of Clinical and Molecular Sciences-Dermatological Clinic, Polytechnic Marche University, 60121 Ancona, Italy
| | | | | | - Campanati Anna
- Department of Clinical and Molecular Sciences-Dermatological Clinic, Polytechnic Marche University, 60121 Ancona, Italy
| | - Offidani Annamaria
- Department of Clinical and Molecular Sciences-Dermatological Clinic, Polytechnic Marche University, 60121 Ancona, Italy
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Fernández-Ginés R, Encinar JA, Hayes JD, Oliva B, Rodríguez-Franco MI, Rojo AI, Cuadrado A. An inhibitor of interaction between the transcription factor NRF2 and the E3 ubiquitin ligase adapter β-TrCP delivers anti-inflammatory responses in mouse liver. Redox Biol 2022; 55:102396. [PMID: 35839629 PMCID: PMC9283934 DOI: 10.1016/j.redox.2022.102396] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 11/18/2022] Open
Abstract
It is widely accepted that activating the transcription factor NRF2 will blast the physiological anti-inflammatory mechanisms, which will help combat pathologic inflammation. Much effort is being put in inhibiting the main NRF2 repressor, KEAP1, with either electrophilic small molecules or disrupters of the KEAP1/NRF2 interaction. However, targeting β-TrCP, the non-canonical repressor of NRF2, has not been considered yet. After in silico screening of ∼1 million compounds, we now describe a novel small molecule, PHAR, that selectively inhibits the interaction between β-TrCP and the phosphodegron in transcription factor NRF2. PHAR upregulates NRF2-target genes such as Hmox1, Nqo1, Gclc, Gclm and Aox1, in a KEAP1-independent, but β-TrCP dependent manner, breaks the β-TrCP/NRF2 interaction in the cell nucleus, and inhibits the β-TrCP-mediated in vitro ubiquitination of NRF2. PHAR attenuates hydrogen peroxide induced oxidative stress and, in lipopolysaccharide-treated macrophages, it downregulates the expression of inflammatory genes Il1b, Il6, Cox2, Nos2. In mice, PHAR selectively targets the liver and greatly attenuates LPS-induced liver inflammation as indicated by a reduction in the gene expression of the inflammatory cytokines Il1b, TNf, and Il6, and in F4/80-stained liver resident macrophages. Thus, PHAR offers a still unexplored alternative to current NRF2 activators by acting as a β-TrCP/NRF2 interaction inhibitor that may have a therapeutic value against undesirable inflammation.
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Affiliation(s)
- Raquel Fernández-Ginés
- Instituto de Investigaciones Biomédicas "Alberto Sols" UAM-CSIC, Instituto de Investigación Sanitaria La Paz (IdiPaz) and Department of Biochemistry, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), ISCIII, Madrid, Spain
| | - José Antonio Encinar
- Institute of Research, Development and Innovation in Biotechnology of Elche (IDiBE) and Molecular and Cell Biology Institute (IBMC), Miguel Hernández University (UMH), 03202, Elche, Alicante, Spain
| | - John D Hayes
- Jacqui Wood Cancer Centre, Division of Cellular Medicine, James Arrott Drive, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, Scotland, United Kingdom
| | - Baldo Oliva
- Structural Bioinformatics Group (GRIB-IMIM), Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Maria Isabel Rodríguez-Franco
- Instituto de Química Médica, Consejo Superior de Investigaciones Científicas (IQM-CSIC), C/ Juan de la Cierva 3, E-28006, Madrid, Spain
| | - Ana I Rojo
- Instituto de Investigaciones Biomédicas "Alberto Sols" UAM-CSIC, Instituto de Investigación Sanitaria La Paz (IdiPaz) and Department of Biochemistry, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), ISCIII, Madrid, Spain
| | - Antonio Cuadrado
- Instituto de Investigaciones Biomédicas "Alberto Sols" UAM-CSIC, Instituto de Investigación Sanitaria La Paz (IdiPaz) and Department of Biochemistry, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), ISCIII, Madrid, Spain.
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Moreno-Morente G, Hurtado-Pomares M, Terol Cantero MC. Bibliometric Analysis of Research on the Use of the Nine Hole Peg Test. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10080. [PMID: 36011713 PMCID: PMC9407738 DOI: 10.3390/ijerph191610080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 06/15/2023]
Abstract
Manual dexterity is essential for performing daily life tasks, becoming a primary means of interaction with the physical, social, and cultural environment. In this respect, the Nine Hole Peg Test (NHPT) is considered a gold standard for assessing manual dexterity. Bibliometrics is a discipline that focuses on analyzing publications to describe, evaluate, and predict the status and development trends in certain fields of scientific research. We performed a bibliometric analysis to track research results and identify global trends regarding the use of the NHPT. The bibliographic data were retrieved from the Web of Science database and then analyzed using the Bibliometrix R package, resulting in the retrieval of a total of 615 publications from 1988 to 2021. Among the 263 journals investigated, the most prolific were the Multiple Sclerosis Journal, Clinical Rehabilitation, and Multiple Sclerosis and Related Disorders. North America and Europe were the areas with the highest production of publications, with the United States (n = 104) ranking first in terms of the number of publications, followed by the United Kingdom (n = 62) and Italy (n = 62). The analysis of keywords revealed that there were two main lines of research, with one related to the study of recovery and disability of the upper limbs caused by certain diseases and another related to the study of reliability and validity. Structured information can be useful to understand the research trajectory and the uses of this tool.
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Affiliation(s)
- Gema Moreno-Morente
- Department of Surgery and Pathology, Miguel Hernández University, 03550 Alicante, Spain
| | - Miriam Hurtado-Pomares
- Department of Surgery and Pathology, Miguel Hernández University, 03550 Alicante, Spain
- Grupo de Investigación en Terapia Ocupacional (InTeO), Miguel Hernández University, 03550 Alicante, Spain
| | - M. Carmen Terol Cantero
- Department of Behavioral Sciences and Health, Miguel Hernández University, 03550 Alicante, Spain
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11
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Sattarnezhad N, Healy BC, Baharnoori M, Diaz-Cruz C, Stankiewicz J, Weiner HL, Chitnis T. Comparison of dimethyl fumarate and interferon outcomes in an MS cohort. BMC Neurol 2022; 22:252. [PMID: 35820822 PMCID: PMC9277810 DOI: 10.1186/s12883-022-02761-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background To compare the effectiveness of dimethyl fumarate (DMF) with subcutaneous interferon beta-1a (IFNβ-1a) in controlling disease activity in patients with relapsing–remitting Multiple Sclerosis (MS). Methods Clinical and imaging data from patients treated with either IFNβ-1a or DMF for at least one year were reviewed. The proportion of patients with at least one clinical relapse within 3–15 months after treatment onset, the proportion of patients with new T2 or gadolinium-enhancing lesions, and the proportion of subjects who achieved no evidence of disease activity (NEDA) status were assessed. Results Three hundred sixteen (98 on IFNβ-1a, 218 on DMF) subjects were included. Baseline demographics were comparable between groups except for age, disease duration, and the number of previous treatments being higher and relapse rate in the prior year being lower in the DMF-treated group. The proportion of patients having a clinical relapse (24.5% vs. 9.6%; OR = 3.04; P < 0.001) or a new MRI lesion (28.6% vs. 8.7%; OR = 4.19, P < 0.001) at 15 months were higher on IFNβ-1a. 79.9% of the patients achieved NEDA status at 15 months on DMF (vs. 51.1% for IFNβ-1a; OR = 0.26, P < 0.001). Further adjustment for demographics, disease characteristics, treatment and relapse history, and subgroup analyses confirmed these findings. Conclusion DMF was associated with less clinical and radiological disease activity compared to IFNβ-1a. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02761-8.
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Affiliation(s)
- Neda Sattarnezhad
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Brian C Healy
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Moogeh Baharnoori
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Camilo Diaz-Cruz
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - James Stankiewicz
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Howard L Weiner
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Tanuja Chitnis
- Harvard Medical School, Boston, Massachusetts, 02115, USA. .,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA.
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Cavalcanti F, Gonzalez-Rey E, Delgado M, Falo CP, Mestre L, Guaza C, O’Valle F, Lufino MMP, Xaus J, Mascaró C, Lunardi S, Sacilotto N, Dessanti P, Rotllant D, Navarro X, Herrando-Grabulosa M, Buesa C, Maes T. Efficacy of Vafidemstat in Experimental Autoimmune Encephalomyelitis Highlights the KDM1A/RCOR1/HDAC Epigenetic Axis in Multiple Sclerosis. Pharmaceutics 2022; 14:pharmaceutics14071420. [PMID: 35890315 PMCID: PMC9323733 DOI: 10.3390/pharmaceutics14071420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023] Open
Abstract
Lysine specific demethylase 1 (LSD1; also known as KDM1A), is an epigenetic modulator that modifies the histone methylation status. KDM1A forms a part of protein complexes that regulate the expression of genes involved in the onset and progression of diseases such as cancer, central nervous system (CNS) disorders, viral infections, and others. Vafidemstat (ORY-2001) is a clinical stage inhibitor of KDM1A in development for the treatment of neurodegenerative and psychiatric diseases. However, the role of ORY-2001 targeting KDM1A in neuroinflammation remains to be explored. Here, we investigated the effect of ORY-2001 on immune-mediated and virus-induced encephalomyelitis, two experimental models of multiple sclerosis and neuronal damage. Oral administration of ORY-2001 ameliorated clinical signs, reduced lymphocyte egress and infiltration of immune cells into the spinal cord, and prevented demyelination. Interestingly, ORY-2001 was more effective and/or faster acting than a sphingosine 1-phosphate receptor antagonist in the effector phase of the disease and reduced the inflammatory gene expression signature characteristic ofEAE in the CNS of mice more potently. In addition, ORY-2001 induced gene expression changes concordant with a potential neuroprotective function in the brain and spinal cord and reduced neuronal glutamate excitotoxicity-derived damage in explants. These results pointed to ORY-2001 as a promising CNS epigenetic drug able to target neuroinflammatory and neurodegenerative diseases and provided preclinical support for the subsequent design of early-stage clinical trials.
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Affiliation(s)
- Fernando Cavalcanti
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
| | - Elena Gonzalez-Rey
- Institute of Parasitology and Biomedicine López-Neyra, IPBLN-CSIC, PTS-Granada, 18016 Granada, Spain; (E.G.-R.); (M.D.)
| | - Mario Delgado
- Institute of Parasitology and Biomedicine López-Neyra, IPBLN-CSIC, PTS-Granada, 18016 Granada, Spain; (E.G.-R.); (M.D.)
| | - Clara P. Falo
- Institute of Parasitology and Biomedicine López-Neyra, IPBLN-CSIC, PTS-Granada, 18016 Granada, Spain; (E.G.-R.); (M.D.)
| | - Leyre Mestre
- Department of Functional and Systems Neurobiology, Cajal Institute (CSIC), 28034 Madrid, Spain; (L.M.); (C.G.)
| | - Carmen Guaza
- Department of Functional and Systems Neurobiology, Cajal Institute (CSIC), 28034 Madrid, Spain; (L.M.); (C.G.)
| | - Francisco O’Valle
- Department of Pathology, School of Medicine, IBIMER and IBS-Granada, Granada University, 18071 Granada, Spain;
| | - Michele M. P. Lufino
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
| | - Jordi Xaus
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
| | - Cristina Mascaró
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
| | - Serena Lunardi
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
| | - Natalia Sacilotto
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
| | - Paola Dessanti
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
| | - David Rotllant
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
| | - Xavier Navarro
- Departament de Biologia Cellular, Fisiologia i Immunologia, Institut de Neurociències, Universitat Autònoma de Barcelona, and Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), 08193 Barcelona, Spain; (X.N.); (M.H.-G.)
| | - Mireia Herrando-Grabulosa
- Departament de Biologia Cellular, Fisiologia i Immunologia, Institut de Neurociències, Universitat Autònoma de Barcelona, and Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), 08193 Barcelona, Spain; (X.N.); (M.H.-G.)
| | - Carlos Buesa
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
| | - Tamara Maes
- Oryzon Genomics S.A., Carrer Sant Ferran 74, 08940 Cornellà de Llobregat, Spain; (F.C.); (M.M.P.L.); (J.X.); (C.M.); (N.S.); (P.D.); (D.R.); (C.B.)
- Correspondence:
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13
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Tastan B, Arioz BI, Genc S. Targeting NLRP3 Inflammasome With Nrf2 Inducers in Central Nervous System Disorders. Front Immunol 2022; 13:865772. [PMID: 35418995 PMCID: PMC8995746 DOI: 10.3389/fimmu.2022.865772] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/04/2022] [Indexed: 12/15/2022] Open
Abstract
The NLRP3 inflammasome is an intracellular multiprotein complex that plays an essential role in the innate immune system by identifying and eliminating a plethora of endogenous and exogenous threats to the host. Upon activation of the NLRP3 complex, pro-inflammatory cytokines are processed and released. Furthermore, activation of the NLRP3 inflammasome complex can induce pyroptotic cell death, thereby propagating the inflammatory response. The aberrant activity and detrimental effects of NLRP3 inflammasome activation have been associated with cardiovascular, neurodegenerative, metabolic, and inflammatory diseases. Therefore, clinical strategies targeting the inhibition of the self-propelled NLRP3 inflammasome activation are required. The transcription factor Nrf2 regulates cellular stress response, controlling the redox equilibrium, metabolic programming, and inflammation. The Nrf2 pathway participates in anti-oxidative, cytoprotective, and anti-inflammatory activities. This prominent regulator, through pharmacologic activation, could provide a therapeutic strategy for the diseases to the etiology and pathogenesis of which NLRP3 inflammasome contributes. In this review, current knowledge on NLRP3 inflammasome activation and Nrf2 pathways is presented; the relationship between NLRP3 inflammasome signaling and Nrf2 pathway, as well as the pre/clinical use of Nrf2 activators against NLRP3 inflammasome activation in disorders of the central nervous system, are thoroughly described. Cumulative evidence points out therapeutic use of Nrf2 activators against NLRP3 inflammasome activation or diseases that NLRP3 inflammasome contributes to would be advantageous to prevent inflammatory conditions; however, the side effects of these molecules should be kept in mind before applying them to clinical practice.
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Affiliation(s)
- Bora Tastan
- Genc Laboratory, Izmir Biomedicine and Genome Center, Izmir, Turkey,Izmir International Biomedicine and Genome Institute, Dokuz Eylul University, Izmir, Turkey
| | - Burak I. Arioz
- Genc Laboratory, Izmir Biomedicine and Genome Center, Izmir, Turkey,Izmir International Biomedicine and Genome Institute, Dokuz Eylul University, Izmir, Turkey
| | - Sermin Genc
- Genc Laboratory, Izmir Biomedicine and Genome Center, Izmir, Turkey,Department of Neuroscience, Health Sciences Institute, Dokuz Eylul University, Izmir, Turkey,*Correspondence: Sermin Genc,
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14
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Resistance exercise improves learning and memory and modulates hippocampal metabolomic profile in aged rats. Neurosci Lett 2021; 766:136322. [PMID: 34737021 DOI: 10.1016/j.neulet.2021.136322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/02/2021] [Accepted: 09/16/2021] [Indexed: 12/21/2022]
Abstract
Physical activity has been considered an important non-medication intervention to preserve mnemonic processes during aging. However, how resistance exercise promotes such benefits remains unclear. A possible hypothesis is that brain-metabolic changes of regions responsible for memory consolidation is affected by muscular training. Therefore, we analyzed the memory, axiety and the metabolomic of aged male Wistar rats (19-20 months old in the 1st day of experiment) submitted to a 12-week resistance exercise protocol (EX, n = 11) or which remained without physical exercise (CTL, n = 13). Barnes maze, elevated plus maze and inhibitory avoidance tests were used to assess the animals' behaviour. The metabolomic profile was identified by nuclear magnetic resonance spectrometry. EX group had better performance in the tests of learning and spatial memory in Barnes maze, and an increase of short and long-term aversive memories formation in inhibitory avoidance. In addition, the exercised animals showed a greater amount of metabolites, such as 4-aminobutyrate, acetate, butyrate, choline, fumarate, glycerol, glycine, histidine, hypoxanthine, isoleucine, leucine, lysine, niacinamide, phenylalanine, succinate, tyrosine, valine and a reduction of ascorbate and aspartate compared to the control animals. These data indicate that the improvement in learning and memory of aged rats submitted to resistance exercise program is associated by changes in the hippocampal metabolomic profile.
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Brummer T, Ruck T, Meuth SG, Zipp F, Bittner S. Treatment approaches to patients with multiple sclerosis and coexisting autoimmune disorders. Ther Adv Neurol Disord 2021; 14:17562864211035542. [PMID: 34457039 PMCID: PMC8388232 DOI: 10.1177/17562864211035542] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/08/2021] [Indexed: 12/30/2022] Open
Abstract
The past decades have yielded major therapeutic advances in many autoimmune conditions - such as multiple sclerosis (MS) - and thus ushered in a new era of more targeted and increasingly potent immunotherapies. Yet this growing arsenal of therapeutic immune interventions has also rendered therapy much more challenging for the attending physician, especially when treating patients with more than one autoimmune condition. Importantly, some therapeutic strategies are either approved for several autoimmune disorders or may be repurposed for other conditions, therefore opening new curative possibilities in related fields. In this article, we especially focus on frequent and therapeutically relevant concomitant autoimmune conditions faced by neurologists when treating patients with MS, namely psoriasis, rheumatoid arthritis and inflammatory bowel diseases. We provide an overview of the available disease-modifying therapies, highlight possible contraindications, show pathophysiological overlaps and finally present which therapeutics can be utilized as a combinatory treatment, in order to 'kill two birds with one stone'.
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Affiliation(s)
- Tobias Brummer
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Tobias Ruck
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, Rhineland-Palatinate, Mainz 55131, Germany
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16
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Berger AA, Sottosanti ER, Winnick A, Izygon J, Berardino K, Cornett EM, Kaye AD, Varrassi G, Viswanath O, Urits I. Monomethyl Fumarate (MMF, Bafiertam) for the Treatment of Relapsing Forms of Multiple Sclerosis (MS). Neurol Int 2021; 13:207-223. [PMID: 34069538 PMCID: PMC8162564 DOI: 10.3390/neurolint13020022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/18/2021] [Accepted: 04/15/2021] [Indexed: 01/29/2023] Open
Abstract
Multiple sclerosis (MS) is a prevalent neurologic autoimmune disorder affecting two million people worldwide. Symptoms include gait abnormalities, perception and sensory losses, cranial nerve pathologies, pain, cognitive dysfunction, and emotional aberrancies. Traditional therapy includes corticosteroids for the suppression of relapses and injectable interferons. Recently, several modern therapies-including antibody therapy and oral agents-were approved as disease-modifying agents. Monomethyl fumarate (MMF, Bafiertam) is a recent addition to the arsenal available in the fight against MS and appears to be well-tolerated, safe, and effective. In this paper, we review the evidence available regarding the use of monomethyl fumarate (Bafiertam) in the treatment of relapsing-remitting MS.
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Affiliation(s)
- Amnon A. Berger
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA 02115, USA;
- Correspondence: (A.A.B.); (E.M.C.); Tel.: +1-(617)-667-7000 (A.A.B.); Fax: +1-(617)-667-5050 (A.A.B.)
| | - Emily R. Sottosanti
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA 02115, USA;
| | - Ariel Winnick
- Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva 8400100, Israel; (A.W.); (J.I.)
- School of Optometry, University of California, Berkeley, CA 94720, USA
| | - Jonathan Izygon
- Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva 8400100, Israel; (A.W.); (J.I.)
| | - Kevin Berardino
- School of Medicine, Georgetown University, Washington, DC 20007, USA;
| | - Elyse M. Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
- Correspondence: (A.A.B.); (E.M.C.); Tel.: +1-(617)-667-7000 (A.A.B.); Fax: +1-(617)-667-5050 (A.A.B.)
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
| | | | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ 85004, USA
- Valley Anesthesiology and Pain Consultants—Envision Physician Services, Phoenix, AZ 85001, USA
- Department of Anesthesiology, School of Medicine, Creighton University, Omaha, NE 68124, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
- Southcoast Health, Southcoast Health Physician Group Pain Medicine, North Dartmouth, MA 02747, USA
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de Jongh NW, Swart RM, Nicol W. Fed-batch growth of Rhizopus oryzae: Eliminating ethanol formation by controlling glucose addition. Biochem Eng J 2021. [DOI: 10.1016/j.bej.2021.107961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hoogendoorn A, Avery TD, Li J, Bursill C, Abell A, Grace PM. Emerging Therapeutic Applications for Fumarates. Trends Pharmacol Sci 2021; 42:239-254. [PMID: 33618840 PMCID: PMC7954891 DOI: 10.1016/j.tips.2021.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 02/08/2023]
Abstract
Fumarates are successfully used for the treatment of psoriasis and multiple sclerosis. Their antioxidative, immunomodulatory, and neuroprotective properties make fumarates attractive therapeutic candidates for other pathologies. The exact working mechanisms of fumarates are, however, not fully understood. Further elucidation of the mechanisms is required if these drugs are to be successfully repurposed for other diseases. Towards this, administration route, dosage, and treatment timing, frequency, and duration are important parameters to consider and optimize with clinical paradigms in mind. Here, we summarize the rapidly expanding literature on the pharmacokinetics and pharmacodynamics of fumarates, including a discussion on two recently FDA-approved fumarates VumerityTM and BafiertamTM. We review emerging applications of fumarates, focusing on neurological and cardiovascular diseases.
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Affiliation(s)
- Ayla Hoogendoorn
- Vascular and Heart Health, Life Long Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia; ARC Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Australia.
| | - Thomas D Avery
- ARC Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Australia; Institute for Photonics and Advanced Sensing & Department of Chemistry, The University of Adelaide, Australia
| | - Jiahe Li
- Laboratories of Neuroimmunology, Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christina Bursill
- Vascular and Heart Health, Life Long Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia; ARC Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Australia; Faculty of Health and Medical Science, University of Adelaide, Adelaide, Australia
| | - Andrew Abell
- ARC Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Australia; Institute for Photonics and Advanced Sensing & Department of Chemistry, The University of Adelaide, Australia
| | - Peter M Grace
- Laboratories of Neuroimmunology, Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Abstract
The transcription factor NRF2 (nuclear factor erythroid 2-related factor 2) triggers homeostatic responses against a plethora of environmental or endogenous deviations in redox metabolism, inflammation, proteostasis, etc. Therefore, pharmacological activation of NRF2 is a promising therapeutic strategy for several chronic diseases that are underlined by low-grade oxidative inflammation and dysregulation of redox metabolism, such as neurodegenerative, cardiovascular, and metabolic diseases. While NRF2 activation is useful in inhibiting carcinogenesis, its inhibition is needed in constituted tumors where NRF2 provides a survival advantage in the challenging tumor niche. This review describes the electrophilic and non-electrophilic NRF2 activators with clinical projection in various chronic diseases. We also analyze the status of NRF2 inhibitors, which are for the moment in a proof-of-concept stage. Advanced in silico screening and medicinal chemistry are expected to provide new or repurposing small molecules with increased potential for fostering the development of targeted NRF2 modulators. The nuclear factor erythroid 2 (NFE2)-related factor 2 (NRF2) is rapidly degraded by proteasomes under a basal condition in a Keap1-dependent manner. ROS oxidatively modifies Keap1 to release NRF2 and allow its nuclear translocation. Here it binds to the antioxidant response element to regulate gene transcription. An alternative mechanism controlling NRF2 stability is glycogen synthase kinase 3 (GSK-3)-induced phosphorylation. Indicated in blue are NRF2-activating and NRF2-inhibiting drugs.
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Hedrich WD, Wang H. Friend or Foe: Xenobiotic Activation of Nrf2 in Disease Control and Cardioprotection. Pharm Res 2021; 38:213-241. [PMID: 33619640 DOI: 10.1007/s11095-021-02997-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/08/2020] [Indexed: 12/30/2022]
Abstract
Nuclear factor erythroid 2-related factor 2 (Nrf2) is a transcription factor that governs a highly conserved pathway central to the protection of cells against various oxidative stresses. However, the biological impact of xenobiotic intervention of Nrf2 in physiological and pathophysiological conditions remains debatable. Activation of Nrf2 in cancer cells has been shown to elevate drug resistance and increase cell survival and proliferation, while inhibition of Nrf2 sensitizes cancer cells to drug treatment. On the other hand, activation of Nrf2 in normal healthy cells has been explored as a rather successful strategy for cancer chemoprevention. Selective activation of Nrf2 in off-target cells has recently been investigated as an approach for protecting off-target tissues from untoward drug toxicity. Specifically, induction of antioxidant response element genes via Nrf2 activation in cardiac cells is being explored as a means to limit the well-documented cardiotoxicity accompanied by cancer treatment with commonly prescribed anthracycline drugs. In addition to cancers, Nrf2 has been implicated in many other diseases including Alzheimer's and Parkinson's Diseases, diabetes, and cardiovascular disease. In this review, we discuss the roles of Nrf2 and its downstream target genes in the treatment of various diseases, and its recently explored potential for increasing the benefit: risk ratio of commonly utilized cancer treatments.
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Affiliation(s)
- William D Hedrich
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, 20 Penn Street, Baltimore, Maryland, 21201, USA.,Bristol-Myers Squibb Company, Pharmaceutical Candidate Optimization, Metabolism and Pharmacokinetics, Rt. 206 and Province Line Road, Princeton, New Jersey, 08543, USA
| | - Hongbing Wang
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, 20 Penn Street, Baltimore, Maryland, 21201, USA.
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21
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Wipke BT, Hoepner R, Strassburger-Krogias K, Thomas AM, Gianni D, Szak S, Brennan MS, Pistor M, Gold R, Chan A, Scannevin RH. Different Fumaric Acid Esters Elicit Distinct Pharmacologic Responses. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/2/e950. [PMID: 33468560 PMCID: PMC7862084 DOI: 10.1212/nxi.0000000000000950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/25/2020] [Indexed: 01/29/2023]
Abstract
Objective To test the hypothesis that dimethyl fumarate (DMF, Tecfidera) elicits different biological changes from DMF combined with monoethyl fumarate (MEF) (Fumaderm, a psoriasis therapy), we investigated DMF and MEF in rodents and cynomolgus monkeys. Possible translatability of findings was explored with lymphocyte counts from a retrospective cohort of patients with MS. Methods In rodents, we evaluated pharmacokinetic and pharmacodynamic effects induced by DMF and MEF monotherapies or in combination (DMF/MEF). Clinical implications were investigated in a retrospective, observational analysis of patients with MS treated with DMF/MEF (n = 36). Results In rodents and cynomolgus monkeys, monomethyl fumarate (MMF, the primary metabolite of DMF) exhibited higher brain penetration, whereas MEF was preferentially partitioned into the kidney. In mice, transcriptional profiling for DMF and MEF alone identified both common and distinct pharmacodynamic responses, with almost no overlap between DMF- and MEF-induced differentially expressed gene profiles in immune tissues. The nuclear factor (erythroid-derived 2)-like 2 (Nrf2)-mediated oxidative stress response pathway was exclusively regulated by DMF, whereas apoptosis pathways were activated by MEF. DMF/MEF treatment demonstrated that DMF and MEF functionally interact to modify DMF- and MEF-specific responses in unpredictable ways. In patients with MS, DMF/MEF treatment led to early and pronounced suppression of lymphocytes, predominantly CD8+ T cells. In a multivariate regression analysis, the absolute lymphocyte count (ALC) was associated with age at therapy start, baseline ALC, and DMF/MEF dosage but not with previous immunosuppressive medication and sex. Furthermore, the ALC increased in a small cohort of patients with MS (n = 6/7) after switching from DMF/MEF to DMF monotherapy. Conclusions Fumaric acid esters exhibit different biodistribution and may elicit different biological responses; furthermore, pharmacodynamic effects of combinations differ unpredictably from monotherapy. The strong potential to induce lymphopenia in patients with MS may be a result of activation of apoptosis pathways by MEF compared with DMF.
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Affiliation(s)
- Brian T Wipke
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Robert Hoepner
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Katrin Strassburger-Krogias
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Ankur M Thomas
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Davide Gianni
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Suzanne Szak
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Melanie S Brennan
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Maximilian Pistor
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Ralf Gold
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Andrew Chan
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.
| | - Robert H Scannevin
- From Biogen, Inc (B.T.W., A.M.T., D.G., S.S., M.S.B., R.H.S.), Cambridge, MA; Department of Neurology (R.H., M.P., A.C.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Neurology (K.S.-K., R.G.), St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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22
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Dietrich M, Hecker C, Nasiri M, Samsam S, Issberner A, Kohne Z, Hartung HP, Albrecht P. Neuroprotective Properties of Dimethyl Fumarate Measured by Optical Coherence Tomography in Non-inflammatory Animal Models. Front Neurol 2021; 11:601628. [PMID: 33519681 PMCID: PMC7838501 DOI: 10.3389/fneur.2020.601628] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/15/2020] [Indexed: 12/26/2022] Open
Abstract
While great advances have been made in the immunomodulatory treatment of multiple sclerosis (MS), there is still an unmet need for drugs with neuroprotective potential. Dimethyl fumarate (DMF) has been suggested to exert both immunomodulatory and neuroprotective effects in MS. To investigate if DMF has neuroprotective effects independent of immunomodulation we evaluated its effects in the non-inflammatory animal models of light-induced photoreceptor loss and optic nerve crush. This might also reveal applications for DMF besides MS, such as age related macular degeneration. Retinal neurodegeneration was longitudinally assessed by in vivo retinal imaging using optical coherence tomography (OCT), and glutathione (GSH) measurements as well as histological investigations were performed to clarify the mode of action. For light-induced photoreceptor loss, one eye of C57BL/6J mice was irradiated with a LED cold light lamp while for optic nerve crush the optic nerve was clamped behind the eye bulb. The other eye served as control. GSH was measured in the optic nerve, choroid and retina and immunohistological staining of retinal microglia (Iba1) was performed. Mice were treated with 15 or 30 mg DMF/kg bodyweight or vehicle. While no protective effects were observed in optic nerve crush, in the light-induced retinal degeneration model DMF treatment significantly reduced retinal degeneration. In these mice, GSH levels in the retina and surrounding choroid were increased and histological investigations revealed less microglial activation in the outer retinal layers, suggesting both antioxidant and anti-inflammatory effects.
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Affiliation(s)
- Michael Dietrich
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Christina Hecker
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Milad Nasiri
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Sogol Samsam
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Andrea Issberner
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Zippora Kohne
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp Albrecht
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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23
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Lam YP, Lam Z, Yeung YY. Zwitterion-Catalyzed Isomerization of Maleic to Fumaric Acid Diesters. J Org Chem 2021; 86:1183-1190. [PMID: 33315398 DOI: 10.1021/acs.joc.0c02316] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fumaric acid diesters are important building blocks for organic synthesis. A class of zwitterionic organocatalysts based on an amide anion/iminium cation charge pair were found to be effective in catalyzing the isomerization of maleic acid diesters to give fumaric acid diesters. Comparison of the performance of different zwitterionic organocatalysts toward the reaction revealed that nonclassical hydrogen bonding was involved in the stabilization of the Michael adduct intermediate.
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Affiliation(s)
- Ying-Pong Lam
- Department of Chemistry and State Key Laboratory of Synthetic Chemistry, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Zachary Lam
- Department of Chemistry and State Key Laboratory of Synthetic Chemistry, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Ying-Yeung Yeung
- Department of Chemistry and State Key Laboratory of Synthetic Chemistry, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
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24
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Kourakis S, Timpani CA, de Haan JB, Gueven N, Fischer D, Rybalka E. Dimethyl Fumarate and Its Esters: A Drug with Broad Clinical Utility? Pharmaceuticals (Basel) 2020; 13:ph13100306. [PMID: 33066228 PMCID: PMC7602023 DOI: 10.3390/ph13100306] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 12/11/2022] Open
Abstract
Fumaric acid esters (FAEs) are small molecules with anti-oxidative, anti-inflammatory and immune-modulating effects. Dimethyl fumarate (DMF) is the best characterised FAE and is approved and registered for the treatment of psoriasis and Relapsing-Remitting Multiple Sclerosis (RRMS). Psoriasis and RRMS share an immune-mediated aetiology, driven by severe inflammation and oxidative stress. DMF, as well as monomethyl fumarate and diroximel fumarate, are commonly prescribed first-line agents with favourable safety and efficacy profiles. The potential benefits of FAEs against other diseases that appear pathogenically different but share the pathologies of oxidative stress and inflammation are currently investigated.
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Affiliation(s)
- Stephanie Kourakis
- College of Health and Biomedicine, Victoria University, Melbourne, VIC 8001, Australia;
| | - Cara A. Timpani
- Institute for Health and Sport, Victoria University, Melbourne, VIC 8001, Australia;
- Australian Institute for Musculoskeletal Science, Victoria University, St Albans, VIC 3021, Australia
| | - Judy B. de Haan
- Oxidative Stress Laboratory, Baker Heart and Diabetes Institute, Basic Science Domain, Melbourne, VIC 3004, Australia;
- Department of Physiology, Anatomy and Microbiology, La Trobe University, Melbourne, VIC 3083, Australia
| | - Nuri Gueven
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7005, Australia;
| | - Dirk Fischer
- Division of Developmental- and Neuropediatrics, University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland;
| | - Emma Rybalka
- Institute for Health and Sport, Victoria University, Melbourne, VIC 8001, Australia;
- Australian Institute for Musculoskeletal Science, Victoria University, St Albans, VIC 3021, Australia
- Correspondence: ; Tel.: +61-383-958-226
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25
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Casas AI, Nogales C, Mucke HAM, Petraina A, Cuadrado A, Rojo AI, Ghezzi P, Jaquet V, Augsburger F, Dufrasne F, Soubhye J, Deshwal S, Di Sante M, Kaludercic N, Di Lisa F, Schmidt HHHW. On the Clinical Pharmacology of Reactive Oxygen Species. Pharmacol Rev 2020; 72:801-828. [DOI: 10.1124/pr.120.019422] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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26
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Valencia-Sanchez C, Carter JL. An evaluation of dimethyl fumarate for the treatment of relapsing remitting multiple sclerosis. Expert Opin Pharmacother 2020; 21:1399-1405. [PMID: 32543241 DOI: 10.1080/14656566.2020.1763304] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION In recent years there has been a dramatic rise in available disease-modifying therapies for the treatment of relapsing multiple sclerosis (MS). Dimethyl fumarate (DMF) is an oral drug approved by the FDA for relapsing MS with unique immunomodulatory and cytoprotective effects. AREAS COVERED Herein, the authors provide the reader with a review of the literature obtained via a PubMed database search and provide their expert opinion on the use of DMF in clinical practice. The article details DMF's mechanism of action, long-term data on efficacy, tolerability and safety. EXPERT OPINION Since approval, growing experience with DMF in clinical practice demonstrates a combination of efficacy, ease of administration along with an acceptable safety profile. The authors believe that DMF is a valuable long-term treatment option in patients with relapsing MS. However, long-term follow up studies are needed to provide further data on progressive multifocal leukoencephalopathy (PML) risk stratification for MS patients on treatment with DMF. Indeed, despite the strong association with lymphopenia, not all patients with DMF associated PML experienced prolonged overall lymphopenia, suggesting that additional predictive metrics are still needed.
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Affiliation(s)
- Cristina Valencia-Sanchez
- Department of Neurology, Mayo Clinic Arizona, Mayo Foundation for Medical Education and Research , Scottsdale, AZ, USA
| | - Jonathan L Carter
- Department of Neurology, Mayo Clinic Arizona, Mayo Foundation for Medical Education and Research , Scottsdale, AZ, USA
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27
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Lima MT, Finelli FG, de Oliveira AVB, Kartnaller V, Cajaiba JF, Leão RAC, de Souza ROMA. Continuous-flow synthesis of dimethyl fumarate: a powerful small molecule for the treatment of psoriasis and multiple sclerosis. RSC Adv 2020; 10:2490-2494. [PMID: 35496077 PMCID: PMC9048608 DOI: 10.1039/c9ra09119j] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/16/2019] [Indexed: 11/22/2022] Open
Abstract
Dimethyl fumarate (DMF) is a methyl ester of fumaric acid and has recently gained attention due to its use as a pro-drug in different pharmaceutical preparations, besides the low price of the final molecule and no active patents being available for the synthesis of DMF, the prices of multiple sclerosis treatment are still high. In our continuous effort for the development of process intensification strategies towards the synthesis of active pharmaceutical ingredients, here we present our work on a cascade methodology for dimethyl fumarate synthesis in short reaction times and quantitative yields. Dimethyl fumarate (DMF) has recently gained attention due to its use as a pro-drug in different pharmaceutical preparations, here in we present our work on a cascade methodology in short reaction times and quantitative yields.![]()
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Affiliation(s)
- Marcelo T. Lima
- Biocatalysis and Organic Synthesis Group
- Chemistry Institute
- Federal University of Rio de Janeiro
- Brazil
- Instituto de Pesquisas de Produtos Naturais
| | - Fernanda G. Finelli
- Instituto de Pesquisas de Produtos Naturais
- Federal University of Rio de Janeiro
- Brazil
| | - Alline V. B. de Oliveira
- Núcleo de Desenvolvimento de Processos e Análises Químicas em Tempo Real (NQTR)
- Chemistry Institute
- Federal University of Rio de Janeiro
- Brazil
| | - Vinicius Kartnaller
- Núcleo de Desenvolvimento de Processos e Análises Químicas em Tempo Real (NQTR)
- Chemistry Institute
- Federal University of Rio de Janeiro
- Brazil
| | - João F. Cajaiba
- Núcleo de Desenvolvimento de Processos e Análises Químicas em Tempo Real (NQTR)
- Chemistry Institute
- Federal University of Rio de Janeiro
- Brazil
| | - Raquel A. C. Leão
- Biocatalysis and Organic Synthesis Group
- Chemistry Institute
- Federal University of Rio de Janeiro
- Brazil
| | - Rodrigo O. M. A. de Souza
- Biocatalysis and Organic Synthesis Group
- Chemistry Institute
- Federal University of Rio de Janeiro
- Brazil
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28
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Combination of Imipramine, a sphingomyelinase inhibitor, and β-caryophyllene improve their therapeutic effects on experimental autoimmune encephalomyelitis (EAE). Int Immunopharmacol 2019; 77:105923. [DOI: 10.1016/j.intimp.2019.105923] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/27/2019] [Accepted: 09/19/2019] [Indexed: 12/21/2022]
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29
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Observational designs in clinical multiple sclerosis research: Particulars, practices and potentialities. Mult Scler Relat Disord 2019; 35:142-149. [PMID: 31394404 DOI: 10.1016/j.msard.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/03/2019] [Accepted: 07/19/2019] [Indexed: 11/24/2022]
Abstract
Observational studies investigate a wide range of topics in multiple sclerosis research. This paper presents an overview of the various observational designs and their applications in clinical studies. Observational studies are well suited for making discoveries and assessing new explanations of phenomena, but less so for establishing causal relationships, due to confounding by indication (selection bias), co-morbidity, socio-economic or other factors. Whether observational findings are demonstrative, indicative or only suggestive, depends on the research question, whether and how the design fits this question, analytical techniques, and the quality of data. Observational studies may be cross-sectional vs. longitudinal, and prospective vs. retrospective. The term 'retrograde' is proposed to explicate that cross-sectional studies may obtain data that cover (long) preceding periods. Case reports and case series are usually based on accidental observations or routinely collected data. Cross-sectional studies, by simultaneously assessing clinical phenomena and external factors, enable the discovery and quantification of associations. In ecological studies the unit of analysis is population or group, and relationships on patient level cannot be established. A cohort study is a longitudinal study that investigates patients with a defining characteristic, e.g. diagnosis or specific treatment, by analyzing data acquired at various intervals. Prospective cohort studies use (some) data that are not yet available at the time the research is conceived, whereas in retrospective studies the data already exist. In a case-control study a representative group of patients with a specific clinical feature is compared with controls, and the frequencies at which an external factor, e.g. infection, has occurred in each group is compared; in a nested case-control study controls are drawn from a fully known cohort. Randomized controlled trial (RCT)-extension studies are informative because, due to RCT randomization, they are free from confounding by indication. Patient or disease registries are organised systems for the long-term collection of uniform data on a population that is defined by a particular disease, condition or exposure, with the purpose to study changes over time. In pharmacotherapeutic research, accidental observations of unexpected beneficial effects may lead to further research into a drug's efficacy in other conditions. Uncontrolled phase 1 studies investigate safety and dosing aspects. Observational studies are alternatives to RCTs when these are not feasible for ethical or practical reasons. Phase 4 observational studies play a crucial role in the evaluation of the effectiveness of treatments in daily practice, the validation of RCT-based side effect profiles, and the discovery of late occurring or rare, potentially life-threatening side effects. Combinations of multidisciplinary longitudinal data bases into large data sets enable the development of algorithms for personalized treatments. To improve the reporting of observational findings on treatment effectiveness, it is proposed that abstracts define the research question(s) the study was meant to answer, study design and analytical methods, and identify and quantify the patient population, treatment of interest, relevant outcomes and the study's strengths and limitations. The development of guidelines for Strengthening the Reporting of Observational Studies in Effectiveness Research (STROBER), as an extension of the guidelines used in epidemiology, is wanted.
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30
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Activators and Inhibitors of NRF2: A Review of Their Potential for Clinical Development. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:9372182. [PMID: 31396308 PMCID: PMC6664516 DOI: 10.1155/2019/9372182] [Citation(s) in RCA: 330] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/26/2019] [Accepted: 04/16/2019] [Indexed: 02/07/2023]
Abstract
The transcription factor NRF2 (nuclear factor erythroid 2-related factor 2) triggers the first line of homeostatic responses against a plethora of environmental or endogenous deviations in redox metabolism, proteostasis, inflammation, etc. Therefore, pharmacological activation of NRF2 is a promising therapeutic approach for several chronic diseases that are underlined by oxidative stress and inflammation, such as neurodegenerative, cardiovascular, and metabolic diseases. A particular case is cancer, where NRF2 confers a survival advantage to constituted tumors, and therefore, NRF2 inhibition is desired. This review describes the electrophilic and nonelectrophilic NRF2 activators with clinical projection in various chronic diseases. We also analyze the status of NRF2 inhibitors, which at this time provide proof of concept for blocking NRF2 activity in cancer therapy.
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31
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Jaiswal AK, Sandey M, Suryawanshi A, Cattley RC, Mishra A. Dimethyl fumarate abrogates dust mite-induced allergic asthma by altering dendritic cell function. IMMUNITY INFLAMMATION AND DISEASE 2019; 7:201-213. [PMID: 31264384 PMCID: PMC6688084 DOI: 10.1002/iid3.262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/23/2019] [Accepted: 05/25/2019] [Indexed: 12/12/2022]
Abstract
Introduction Allergic asthma is the most common inflammatory disease of upper airways. Airway dendritic cells (DCs) are key antigen presenting cells that regulate T helper 2 (Th2)‐dependent allergic inflammation. Recent studies have shown critical role of airway DCs in the induction of Th2‐mediated allergic inflammation and are attractive therapeutic targets in asthma. However, molecular signaling mechanism that regulate DCs function to Th2 immune responses are poorly understood. Here we aim to evaluate the immunomodulatory effect of dimethyl fumarate (DMF), an FDA approved small molecule drug, in the house dust mite (HDM)‐induced experimental model of allergic asthma. Methods DMF was administered intranasally in the challenge period of HDM‐induced murine model of experimental asthma. Airway inflammation, airway hyperreactivity, Th2/Th1 cytokine were assessed. The effect of DMF on DC function was further evaluated by adoptive transfer of HDM‐pulsed DMF treated DCs to wild‐type naïve mice. Results DMF treatment significantly reduced HDM‐induced airway inflammation, mucous cell metaplasia, and airway hyperactivity to inhaled methacholine. Mechanistically, DMF interferes with the migration of lung DCs to draining mediastinal lymph nodes, thereby attenuates the induction of allergic sensitization and Th2 immune response. Notably, adoptive transfer of DMF treated DCs to naïve mice with HDM challenge similarly reduces the features of allergic asthma. Conclusion This identifies a novel function of DMF on DC‐mediated adaptive immune responses in the setting of HDM‐induced airway inflammation. Taken together, our results offer a mechanistic rationale for DMF use to target DCs in local lung environment as antiasthmatic therapy.
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Affiliation(s)
- Anil K Jaiswal
- The Laboratory of Lung Inflammation, College of Veterinary Medicine, Auburn University, Auburn, Alabama.,Department of Pathobiology, College of Veterinary Medicine, Auburn University, Auburn, Alabama
| | - Maninder Sandey
- Department of Pathobiology, College of Veterinary Medicine, Auburn University, Auburn, Alabama
| | - Amol Suryawanshi
- Department of Pathobiology, College of Veterinary Medicine, Auburn University, Auburn, Alabama
| | - Russell C Cattley
- Department of Pathobiology, College of Veterinary Medicine, Auburn University, Auburn, Alabama
| | - Amarjit Mishra
- The Laboratory of Lung Inflammation, College of Veterinary Medicine, Auburn University, Auburn, Alabama.,Department of Pathobiology, College of Veterinary Medicine, Auburn University, Auburn, Alabama
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32
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Nally FK, De Santi C, McCoy CE. Nanomodulation of Macrophages in Multiple Sclerosis. Cells 2019; 8:cells8060543. [PMID: 31195710 PMCID: PMC6628349 DOI: 10.3390/cells8060543] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 12/16/2022] Open
Abstract
Multiple Sclerosis (MS) is a chronic demyelinating autoimmune disease primarily affecting young adults. Despite an unclear causal factor, symptoms and pathology arise from the infiltration of peripheral immune cells across the blood brain barrier. Accounting for the largest fraction of this infiltrate, macrophages are functionally heterogeneous innate immune cells capable of adopting either a pro or an anti-inflammatory phenotype, a phenomenon dependent upon cytokine milieu in the CNS. This functional plasticity is of key relevance in MS, where the pro-inflammatory state dominates the early stage, instructing demyelination and axonal loss while the later anti-inflammatory state holds a key role in promoting tissue repair and regeneration in later remission. This review highlights a potential therapeutic benefit of modulating macrophage polarisation to harness the anti-inflammatory and reparative state in MS. Here, we outline the role of macrophages in MS and look at the role of current FDA approved therapeutics in macrophage polarisation. Moreover, we explore the potential of particulate carriers as a novel strategy to manipulate polarisation states in macrophages, whilst examining how optimising macrophage uptake via nanoparticle size and functionalisation could offer a novel therapeutic approach for MS.
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Affiliation(s)
- Frances K Nally
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, 123 St Stephen's Green, 2 D02 YN77 Dublin, Ireland.
| | - Chiara De Santi
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, 123 St Stephen's Green, 2 D02 YN77 Dublin, Ireland.
| | - Claire E McCoy
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, 123 St Stephen's Green, 2 D02 YN77 Dublin, Ireland.
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33
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Traub J, Traffehn S, Ochs J, Häusser-Kinzel S, Stephan S, Scannevin R, Brück W, Metz I, Weber MS. Dimethyl fumarate impairs differentiated B cells and fosters central nervous system integrity in treatment of multiple sclerosis. Brain Pathol 2019; 29:640-657. [PMID: 30706542 PMCID: PMC6849574 DOI: 10.1111/bpa.12711] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 01/28/2019] [Indexed: 12/13/2022] Open
Abstract
In multiple sclerosis (MS), the effect of dimethyl fumarate (DMF) treatment is primarily attributed to its capacity to dampen pathogenic T cells. Here, we tested whether DMF also modulates B cells, which are newly recognized key players in MS, and to which extent DMF restricts ongoing loss of oligodendrocytes and axons in the central nervous system (CNS). Therefore, blood samples and brain tissue from DMF-treated MS patients were analyzed by flow cytometry or histopathological examination, respectively. Complementary mechanistic studies were conducted in inflammatory as well as non-inflammatory CNS demyelinating mouse models. In this study, DMF reduced the frequency of antigen-experienced and memory B cells and rendered remaining B cells less prone to activation and production of pro-inflammatory cytokines. Dissecting the functional consequences of these alterations, we found that DMF ameliorated a B cell-accentuated experimental autoimmune encephalomyelitis model by diminishing the capacity of B cells to act as antigen-presenting cells for T cells. In a non-inflammatory model of toxic demyelination, DMF limited oligodendrocyte apoptosis, promoted maturation of oligodendrocyte precursors and reduced axonal damage. In a CNS biopsy of a DMF-treated MS patient, we equivalently observed higher numbers of mature oligodendrocytes as well as a reduced extent of axonal damage when compared to a cohort of treatment-naïve patients. In conclusion, we showed that besides suppressing T cells, DMF dampens pathogenic B cell functions, which probably contributes to its clinical effectiveness in relapsing MS. DMF treatment may furthermore limit chronically ongoing CNS tissue damage, which may reduce long-term disability in MS apart from its relapse-reducing capacity.
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Affiliation(s)
- Jan Traub
- Institute of Neuropathology, University Medical Center, Göttingen, Germany.,Department of Neurology, University Medical Center, Göttingen, Germany
| | - Sarah Traffehn
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Jasmin Ochs
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | | | - Schirin Stephan
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | | | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Imke Metz
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Martin S Weber
- Institute of Neuropathology, University Medical Center, Göttingen, Germany.,Department of Neurology, University Medical Center, Göttingen, Germany
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34
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Abstract
Multiple sclerosis treatment faces tremendous changes owing to the approval of new medications, some of which are available as oral formulations. Until now, the four orally available medications, fingolimod, dimethylfumarate (BG-12), teriflunomide, and cladribine have received market authorization, whereas laquinimod is still under development. Fingolimod is a sphingosine-1-phosphate inhibitor, which is typically used as escalation therapy and leads to up to 60% reduction of the annualized relapse rate, but might also have neuroprotective properties. In addition, there are three more specific S1P agonists in late stages of development: siponimod, ponesimod, and ozanimod. Dimethylfumarate has immunomodulatory and cytoprotective functions and is used as baseline therapy. Teriflunomide, the active metabolite of the rheumatoid arthritis medication leflunomide, targets the dihydroorotate dehydrogenase, thus inhibiting the proliferation of lymphocytes by depletion of pyrimidines. Here we will review the mechanisms of action, clinical trial data, as well as data about safety and tolerability of the compounds.
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Affiliation(s)
- Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
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35
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Asendorf T, Henderson R, Schmidli H, Friede T. Sample size re‐estimation for clinical trials with longitudinal negative binomial counts including time trends. Stat Med 2018; 38:1503-1528. [DOI: 10.1002/sim.8061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 11/16/2018] [Accepted: 11/19/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Thomas Asendorf
- Department of Medical StatisticsUniversity Medical Center Göttingen Göttingen Germany
| | - Robin Henderson
- School of Mathematics, Statistics and PhysicsNewcastle University Newcastle upon Tyne UK
| | - Heinz Schmidli
- Statistical Methodology GroupNovartis Pharma AG Basel Switzerland
| | - Tim Friede
- Department of Medical StatisticsUniversity Medical Center Göttingen Göttingen Germany
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Keleku-Lukwete N, Suzuki M, Yamamoto M. An Overview of the Advantages of KEAP1-NRF2 System Activation During Inflammatory Disease Treatment. Antioxid Redox Signal 2018; 29:1746-1755. [PMID: 28899203 DOI: 10.1089/ars.2017.7358] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Inflammation can be defined as a protective immune response against harmful exogenous and endogenous stimuli. Nevertheless, prolonged or autoimmune inflammatory responses are likely to cause pathological states that are associated with a production of inflammation-associated molecules along with reactive oxygen species (ROS). Kelch-like ECH-associated protein 1-nuclear factor erythroid 2-related factor 2 (KEAP1-NRF2) signaling provides a cell protection mechanism against oxidative insults when endogenous stress defense mechanisms are imbalanced. Understanding the roles of the KEAP1-NRF2 system in inflammation caused by various types of stimuli may aid in the development of new therapies. Recent Advances: There have been tremendous advances in understanding the mechanism by which the KEAP1-NRF2 pathway abrogates inflammation. In addition to the well-established ROS-dependent pathway, recent studies have provided evidence of the direct repression of the transcription of pro-inflammatory cytokine genes, such as IL1b and IL6 (encoding Interleukin-1β and Interleukin-6, respectively). Further, the expanding functions of NRF2 have elicited interest in the development of therapeutic modalities for inflammatory diseases, including multiple sclerosis and sickle cell disease. Critical Issues and Future Directions: Despite progress in the understanding of molecular mechanisms supporting the roles that NRF2 plays during inflammation, the relationship between NRF2 and other transcription factors and mediators of inflammation still remains ambiguous. Further studies are required to address the effects of functional polymorphisms in KEAP1 and NRF2 that modify susceptibility to specific disease-related inflammation. Comprehensive analyses in the future should explore tissue- or cell-type specific NRF2 activation to elaborate effects of NRF2 induction. Antioxid. Redox Signal. 00, 000-000.
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Affiliation(s)
- Nadine Keleku-Lukwete
- 1 Department of Medical Biochemistry, Tohoku University Graduate School of Medicine , Sendai, Japan
| | - Mikiko Suzuki
- 2 Center for Radioisotope Sciences, Tohoku University Graduate School of Medicine , Sendai, Japan
| | - Masayuki Yamamoto
- 1 Department of Medical Biochemistry, Tohoku University Graduate School of Medicine , Sendai, Japan
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Hosseini A, Masjedi A, Baradaran B, Hojjat‐Farsangi M, Ghalamfarsa G, Anvari E, Jadidi‐Niaragh F. Dimethyl fumarate: Regulatory effects on the immune system in the treatment of multiple sclerosis. J Cell Physiol 2018; 234:9943-9955. [DOI: 10.1002/jcp.27930] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 10/24/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Arezoo Hosseini
- Drug Applied Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Ali Masjedi
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Mohammad Hojjat‐Farsangi
- Immune and Gene therapy Lab Department of Oncology‐Pathology Cancer Center Karolinska (CCK), Karolinska University Hospital Solna and Karolinska Institute Stockholm Sweden
- Department of Immunology School of Medicine, Bushehr University of Medical Sciences Bushehr Iran
| | - Ghasem Ghalamfarsa
- Cellular and Molecular Research Center, Yasuj University of Medical Sciences Yasuj Iran
| | - Enayat Anvari
- Department of Physiology Faculty of Medicine, Ilam University of Medical Sciences Ilam Iran
| | - Farhad Jadidi‐Niaragh
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
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Montes Diaz G, Hupperts R, Fraussen J, Somers V. Dimethyl fumarate treatment in multiple sclerosis: Recent advances in clinical and immunological studies. Autoimmun Rev 2018; 17:1240-1250. [DOI: 10.1016/j.autrev.2018.07.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 12/30/2022]
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Affiliation(s)
- Brian Raymer
- Medicine Design, Pfizer Worldwide Research and Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
| | - Samit K. Bhattacharya
- Medicine Design, Pfizer Worldwide Research and Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
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Cuadrado A, Manda G, Hassan A, Alcaraz MJ, Barbas C, Daiber A, Ghezzi P, León R, López MG, Oliva B, Pajares M, Rojo AI, Robledinos-Antón N, Valverde AM, Guney E, Schmidt HHHW. Transcription Factor NRF2 as a Therapeutic Target for Chronic Diseases: A Systems Medicine Approach. Pharmacol Rev 2018; 70:348-383. [DOI: 10.1124/pr.117.014753] [Citation(s) in RCA: 329] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Abstract
Multiple sclerosis treatment faces tremendous changes as a result of the approval of new medications. The new medications have differing safety considerations and risks after long-term treatment, which are important for treating physicians to optimize and individualize multiple sclerosis care. Since the approval of the first multiple sclerosis capsule, fingolimod, the armamentarium of multiple sclerosis therapy has grown with the orally available medications dimethyl fumarate and teriflunomide. Fingolimod is mainly associated with cardiac side effects, dimethyl fumarate with bowel symptoms. Several reports about progressive multifocal leukoencephalopathy as a result of dimethyl fumarate or fingolimod therapy raised the awareness of fatal opportunistic infections. Alemtuzumab, a CD52-depleting antibody, is highly effective in reducing relapses but leads to secondary immunity with mainly thyroid disorders in about 30% of patients. Development of secondary B-cell-mediated disease might also be a risk of this antibody. The follow-up drug of the B-cell-depleting antibody rituximab, ocrelizumab, is mainly associated with infusion-related reactions; long-term data are scarce. The medication daclizumab high yield process, acting via the activation of CD56bright natural killer cells, can induce the elevation of liver function enzymes, but also fulminant liver failure has been reported. Therefore, daclizumab has been retracted from the market. Long-term data on the purine nucleoside cladribine in MS therapy, recently authorized in the European Union, have been acquired during the long-term follow-up of the cladribine studies. The small molecule laquinimod is currently under development. We review data of clinical trials and their extensions regarding long-term efficacy and side effects, which might be associated with long-term treatment.
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Affiliation(s)
- Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, Bochum, 44791, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, Bochum, 44791, Germany.
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Fleischer V, Friedrich M, Rezk A, Bühler U, Witsch E, Uphaus T, Bittner S, Groppa S, Tackenberg B, Bar-Or A, Zipp F, Luessi F. Treatment response to dimethyl fumarate is characterized by disproportionate CD8+ T cell reduction in MS. Mult Scler 2017; 24:632-641. [PMID: 28436295 DOI: 10.1177/1352458517703799] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The effect of dimethyl fumarate (DMF) on circulating lymphocyte subsets and their contribution as predictors of clinical efficacy have not yet been investigated in multiple sclerosis (MS). OBJECTIVE To evaluate lymphocytes and lymphocyte subsets (analyzed 6 months after DMF start) in MS patients with and without disease activity after 1 year of treatment in a retrospective study. METHODS Peripheral blood lymphocyte subsets were analyzed by flow cytometry. Untreated MS patients ( n = 40) were compared to those 6 months after onset of DMF treatment ( n = 51). Clinical and magnetic resonance imaging (MRI) disease activity of DMF-treated patients were assessed in the first year under treatment. RESULTS Stable patients showed significantly lower lymphocytes, CD4+ and CD8+ T cells as well as CD19+ B cells compared to active patients under DMF treatment. Furthermore, an increased CD4/CD8 ratio ( p < 0.025) in stable patients indicated a disproportionate reduction of CD8+ T cells relative to CD4+ T cells. Reduced lymphocytes, CD8+ T cells, and CD19+ B cells 6 months after DMF start allowed prediction of the treatment response in the first year. CONCLUSION DMF treatment response is reflected by lower circulating lymphocytes and specific lymphocyte subsets. Changes in the cellular immune profiles under DMF treatment are clinically relevant and might serve as a surrogate marker of treatment response.
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Affiliation(s)
- Vinzenz Fleischer
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michaela Friedrich
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ayman Rezk
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Ulrike Bühler
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Esther Witsch
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Timo Uphaus
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sergiu Groppa
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Björn Tackenberg
- Clinical Neuroimmunology Group, Department of Neurology, Philipps University, Marburg, Germany
| | - Amit Bar-Or
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Felix Luessi
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Wu Q, Wang Q, Mao G, Dowling CA, Lundy SK, Mao-Draayer Y. Dimethyl Fumarate Selectively Reduces Memory T Cells and Shifts the Balance between Th1/Th17 and Th2 in Multiple Sclerosis Patients. THE JOURNAL OF IMMUNOLOGY 2017; 198:3069-3080. [PMID: 28258191 DOI: 10.4049/jimmunol.1601532] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 02/08/2017] [Indexed: 01/20/2023]
Abstract
Dimethyl fumarate (DMF; trade name Tecfidera) is an oral formulation of the fumaric acid ester that is Food and Drug Administration approved for treatment of relapsing-remitting multiple sclerosis. To better understand the therapeutic effects of Tecfidera and its rare side effect of progressive multifocal leukoencephalopathy, we conducted cross-sectional and longitudinal studies by immunophenotyping cells from peripheral blood (particularly T lymphocytes) derived from untreated and 4-6 and 18-26 mo Tecfidera-treated stable relapsing-remitting multiple sclerosis patients using multiparametric flow cytometry. The absolute numbers of CD4 and CD8 T cells were significantly decreased and the CD4/CD8 ratio was increased with DMF treatment. The proportions of both effector memory T cells and central memory T cells were reduced, whereas naive T cells increased in treated patients. T cell activation was reduced with DMF treatment, especially among effector memory T cells and effector memory RA T cells. Th subsets Th1 (CXCR3+), Th17 (CCR6+), and particularly those expressing both CXCR3 and CD161 were reduced most significantly, whereas the anti-inflammatory Th2 subset (CCR3+) was increased after DMF treatment. A corresponding increase in IL-4 and decrease in IFN-γ and IL-17-expressing CD4+ T cells were observed in DMF-treated patients. DMF in vitro treatment also led to increased T cell apoptosis and decreased activation, proliferation, reactive oxygen species, and CCR7 expression. Our results suggest that DMF acts on specific memory and effector T cell subsets by limiting their survival, proliferation, activation, and cytokine production. Monitoring these subsets could help to evaluate the efficacy and safety of DMF treatment.
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Affiliation(s)
- Qi Wu
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Qin Wang
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Guangmei Mao
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Catherine A Dowling
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Steven K Lundy
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109; and.,Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109; .,Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI 48109
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44
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Popova EV, Boyko AN, Orlova EV. [Dimethylfumarate in the treatment of relapsing-remitting multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 116:68-72. [PMID: 28139614 DOI: 10.17116/jnevro201611610268-72] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This review includes results of experimental and clinical studies of dimethyl fumarate, a new oral drug for pathogenetic treatment of multiple sclerosis (MS). The mechanism of action, data from clinical trials, including MRI-results related to tolerability and safety of the drug are reviewed. The risk management plan for possible adverse events and a place of dimethyl fumarate in the current pathogenetic treatment of MS are discussed.
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Affiliation(s)
- E V Popova
- City Clinical Hospital #24, Moscow, Russia; Pirogov Russian National Resaerch Medical University, Moscow, Russia
| | - A N Boyko
- City Clinical Hospital #24, Moscow, Russia; Pirogov Russian National Resaerch Medical University, Moscow, Russia
| | - E V Orlova
- 'Jonson& ,Jonson Ltd', Moscow, Russia
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Abstract
Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) characterized by loss of motor and sensory function that results from immune-mediated inflammation, demyelination, and subsequent axonal damage. Clinically, most MS patients experience recurrent episodes (relapses) of neurological impairment, but in most cases (60–80%) the course of the disease eventually becomes chronic and progressive, leading to cumulative motor, sensory, and visual disability, and cognitive deficits. The course of the disease is largely unpredictable and its clinical presentation is variable, but its predilection for certain parts of the CNS, which includes the optic nerves, the brain stem, cerebellum, and cervical spinal cord, provides a characteristic constellation of signs and symptoms. Several variants of MS have been nowadays defined with variable immunopathogenesis, course and prognosis. Many new treatments targeting the immune system have shown efficacy in preventing the relapses of MS and have been introduced to its management during the last decade.
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46
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Blewett MM, Xie J, Zaro BW, Backus KM, Altman A, Teijaro JR, Cravatt BF. Chemical proteomic map of dimethyl fumarate-sensitive cysteines in primary human T cells. Sci Signal 2016; 9:rs10. [PMID: 27625306 DOI: 10.1126/scisignal.aaf7694] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Dimethyl fumarate (DMF) is an electrophilic drug that is used to treat autoimmune conditions, including multiple sclerosis and psoriasis. The mechanism of action of DMF is unclear but may involve the covalent modification of proteins or DMF serving as a prodrug that is converted to monomethyl fumarate (MMF). We found that DMF, but not MMF, blocked the activation of primary human and mouse T cells. Using a quantitative, site-specific chemical proteomic platform, we determined the DMF sensitivity of >2400 cysteine residues in human T cells. Cysteines sensitive to DMF, but not MMF, were identified in several proteins with established biochemical or genetic links to T cell function, including protein kinase Cθ (PKCθ). DMF blocked the association of PKCθ with the costimulatory receptor CD28 by perturbing a CXXC motif in the C2 domain of this kinase. Mutation of these DMF-sensitive cysteines also impaired PKCθ-CD28 interactions and T cell activation, designating the C2 domain of PKCθ as a key functional, electrophile-sensing module important for T cell biology.
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Affiliation(s)
- Megan M Blewett
- Department of Chemical Physiology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Jiji Xie
- Division of Cell Biology, La Jolla Institute for Allergy and Immunology, 9420 Athena Circle, La Jolla, CA 92037, USA
| | - Balyn W Zaro
- Department of Chemical Physiology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Keriann M Backus
- Department of Chemical Physiology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Amnon Altman
- Division of Cell Biology, La Jolla Institute for Allergy and Immunology, 9420 Athena Circle, La Jolla, CA 92037, USA
| | - John R Teijaro
- Department of Chemical Physiology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA 92037, USA. Department of Immunology and Microbial Science, The Scripps Research Institute, La Jolla, CA 92037, USA.
| | - Benjamin F Cravatt
- Department of Chemical Physiology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA 92037, USA.
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Al-Jaderi Z, Maghazachi AA. Utilization of Dimethyl Fumarate and Related Molecules for Treatment of Multiple Sclerosis, Cancer, and Other Diseases. Front Immunol 2016; 7:278. [PMID: 27499754 PMCID: PMC4956641 DOI: 10.3389/fimmu.2016.00278] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/06/2016] [Indexed: 11/16/2022] Open
Abstract
Several drugs have been approved for treatment of multiple sclerosis (MS). Dimethyl fumarate (DMF) is utilized as an oral drug to treat this disease and is proven to be potent with less side effects than several other drugs. On the other hand, monomethyl fumarate (MMF), a related compound, has not been examined in greater details although it has the potential as a therapeutic drug for MS and other diseases. The mechanism of action of DMF or MMF is related to their ability to enhance the antioxidant pathways and to inhibit reactive oxygen species. However, other mechanisms have also been described, which include effects on monocytes, dendritic cells, T cells, and natural killer cells. It is also reported that DMF might be useful for treating psoriasis, asthma, aggressive breast cancers, hematopoeitic tumors, inflammatory bowel disease, intracerebral hemorrhage, osteoarthritis, chronic pancreatitis, and retinal ischemia. In this article, we will touch on some of these diseases with an emphasis on the effects of DMF and MMF on various immune cells.
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Affiliation(s)
- Zaidoon Al-Jaderi
- Department of Clinical Sciences, College of Medicine and Sahrjah Institute for Medical Research, University of Sharjah , Sharjah , United Arab Emirates
| | - Azzam A Maghazachi
- Department of Clinical Sciences, College of Medicine and Sahrjah Institute for Medical Research, University of Sharjah , Sharjah , United Arab Emirates
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48
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Linker RA, Haghikia A. Dimethyl fumarate in multiple sclerosis: latest developments, evidence and place in therapy. Ther Adv Chronic Dis 2016; 7:198-207. [PMID: 27433310 DOI: 10.1177/2040622316653307] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Dimethyl fumarate (DMF) is one of the newer additions to the armamentarium of potent immunomodulators for the treatment of relapsing-remitting multiple sclerosis (RRMS). After more than 2 years of real-world experience and more than 190,000 patients currently treated with DMF worldwide, it is a good timepoint to review the experience gathered so far and to re-evaluate the potential of this first-line oral multiple sclerosis (MS) drug. Post-hoc analyses of clinical and magnetic resonance imaging (MRI) data, some comprising more than 6 years of drug exposure including patients from the clinical trials, and the overall notion in clinical practice widely confirm the good efficacy of DMF in RRMS. Despite an overall good safety profile, it became also clear that the necessary clinical vigilance while using DMF may not be neglected. So far, four reported cases of progressive multifocal leukoencephalopathy (PML), a towering shadow over many MS therapies, warrant proper attention in newly-updated risk management plans. This review recapitulates efficacy and safety aspects of DMF therapy in relation to reported data from the pivotal clinical trials. In addition, we summarize recent insights into DMF mechanisms of action drawn from the field of basic research which may have important implications for clinical practice.
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Affiliation(s)
- Ralf A Linker
- Department of Neurology, Friedrich-Alexander-University Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Aiden Haghikia
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital Bochum, Bochum, Germany
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49
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Lundy SK, Wu Q, Wang Q, Dowling CA, Taitano SH, Mao G, Mao-Draayer Y. Dimethyl fumarate treatment of relapsing-remitting multiple sclerosis influences B-cell subsets. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e211. [PMID: 27006972 PMCID: PMC4784801 DOI: 10.1212/nxi.0000000000000211] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/22/2015] [Indexed: 12/04/2022]
Abstract
Objective: To test the hypothesis that dimethyl fumarate (Tecfidera, BG-12) affects B-cell subsets in patients with relapsing-remitting multiple sclerosis (RRMS). Methods: Peripheral blood B cells were compared for surface marker expression in patients with RRMS prior to initiation of treatment, after 4–6 months, and at more than 1 year of treatment with BG-12. Production of interleukin (IL)–10 by RRMS patient B cells was also analyzed. Results: Total numbers of peripheral blood B lymphocytes declined after 4–6 months of BG-12 treatment, due to losses in both the CD27+ memory B cells and CD27neg B-cell subsets. Some interpatient variability was observed. In contrast, circulating CD24highCD38high (T2-MZP) B cells increased in percentage in the majority of patients with RRMS after 4–6 months and were present in higher numbers in all of the patients after 12 months of treatment. The CD43+CD27+ B-1 B cells also increased at the later time point in most patients but were unchanged at 4–6 months compared to pretreatment levels. Purified B cells from 7 of the 9 patients with RRMS tested after 4–6 months of treatment were able to produce IL-10 following CD40 ligand stimulation, and the amount corresponded with the combined levels of T2-MZP and B-1 B cells in the sample. None of the patients with RRMS in this study have had a relapse while taking BG-12. Conclusions: These data suggest that BG-12 differentially affects B-cell subsets in patients with RRMS, resulting in increased numbers of circulating B lymphocytes with regulatory capacity.
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Affiliation(s)
- Steven K Lundy
- Department of Internal Medicine, Division of Rheumatology (S.K.L.), Graduate Program in Immunology, Program in Biomedical Sciences (S.K.L., S.H.T., Y.M.-D.), and Department of Neurology (Q. Wu, Q. Wang, C.A.D., G.M., Y.M.-D.), University of Michigan Medical School, Ann Arbor
| | - Qi Wu
- Department of Internal Medicine, Division of Rheumatology (S.K.L.), Graduate Program in Immunology, Program in Biomedical Sciences (S.K.L., S.H.T., Y.M.-D.), and Department of Neurology (Q. Wu, Q. Wang, C.A.D., G.M., Y.M.-D.), University of Michigan Medical School, Ann Arbor
| | - Qin Wang
- Department of Internal Medicine, Division of Rheumatology (S.K.L.), Graduate Program in Immunology, Program in Biomedical Sciences (S.K.L., S.H.T., Y.M.-D.), and Department of Neurology (Q. Wu, Q. Wang, C.A.D., G.M., Y.M.-D.), University of Michigan Medical School, Ann Arbor
| | - Catherine A Dowling
- Department of Internal Medicine, Division of Rheumatology (S.K.L.), Graduate Program in Immunology, Program in Biomedical Sciences (S.K.L., S.H.T., Y.M.-D.), and Department of Neurology (Q. Wu, Q. Wang, C.A.D., G.M., Y.M.-D.), University of Michigan Medical School, Ann Arbor
| | - Sophina H Taitano
- Department of Internal Medicine, Division of Rheumatology (S.K.L.), Graduate Program in Immunology, Program in Biomedical Sciences (S.K.L., S.H.T., Y.M.-D.), and Department of Neurology (Q. Wu, Q. Wang, C.A.D., G.M., Y.M.-D.), University of Michigan Medical School, Ann Arbor
| | - Guangmei Mao
- Department of Internal Medicine, Division of Rheumatology (S.K.L.), Graduate Program in Immunology, Program in Biomedical Sciences (S.K.L., S.H.T., Y.M.-D.), and Department of Neurology (Q. Wu, Q. Wang, C.A.D., G.M., Y.M.-D.), University of Michigan Medical School, Ann Arbor
| | - Yang Mao-Draayer
- Department of Internal Medicine, Division of Rheumatology (S.K.L.), Graduate Program in Immunology, Program in Biomedical Sciences (S.K.L., S.H.T., Y.M.-D.), and Department of Neurology (Q. Wu, Q. Wang, C.A.D., G.M., Y.M.-D.), University of Michigan Medical School, Ann Arbor
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50
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Prosperini L, Pontecorvo S. Dimethyl fumarate in the management of multiple sclerosis: appropriate patient selection and special considerations. Ther Clin Risk Manag 2016; 12:339-50. [PMID: 27042079 PMCID: PMC4780395 DOI: 10.2147/tcrm.s85099] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Delayed-release dimethyl fumarate (DMF), also known as gastroresistant DMF, is the most recently approved oral disease-modifying treatment (DMT) for relapsing multiple sclerosis. Two randomized clinical trials (Determination of the Efficacy and Safety of Oral Fumarate in Relapsing-Remitting MS [DEFINE] and Comparator and an Oral Fumarate in Relapsing-Remitting Multiple Sclerosis [CONFIRM]) demonstrated significant efficacy in reducing relapse rate and radiological signs of disease activity, as seen on magnetic resonance imaging. The DEFINE study also indicated a significant effect of DMF on disability worsening, while the low incidence of confirmed disability worsening in the CONFIRM trial rendered an insignificant reduction among the DMF-treated groups when compared to placebo. DMF also demonstrated a good safety profile and acceptable tolerability, since the most common side effects (gastrointestinal events and flushing reactions) are usually transient and mild to moderate in severity. Here, we discuss the place in therapy of DMF for individuals with relapsing multiple sclerosis, providing a tentative therapeutic algorithm to manage newly diagnosed patients and those who do not adequately respond to self-injectable DMTs. Literature data supporting the potential role of DMF as a first-line therapy are presented. The possibility of using DMF as switching treatment or even as an add-on strategy in patients with breakthrough disease despite self-injectable DMTs will also be discussed. Lastly, we argue about the role of DMF as an exit strategy from natalizumab-treated patients who are considered at risk for developing multifocal progressive leukoencephalopathy.
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Affiliation(s)
- Luca Prosperini
- Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Simona Pontecorvo
- Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
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