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Shephard A, Kolaczkowski L, Barker N, Nahal D, Oreja-Guevara C, Reyes S, Gray H, Salloukh H, Giovannoni G. Making Information About Cladribine Tablets Accessible to People with Multiple Sclerosis: A Patient-Survey-Led Narrative Review for Healthcare Professionals. Neurol Ther 2024:10.1007/s40120-024-00608-7. [PMID: 38760637 DOI: 10.1007/s40120-024-00608-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/18/2024] [Indexed: 05/19/2024] Open
Abstract
Cladribine tablets have been granted marketing authorization in Europe and approved by the Food and Drug Administration (FDA) in the USA to treat relapsing forms of multiple sclerosis (MS). However, people with MS (PwMS) may be more familiar, and therefore more confident, with treatments requiring long-term and frequent dosing. Differences in such treatment strategies can lead to questions relating to how short-course non-continuous treatments, such as cladribine tablets, can work and how well they are tolerated. In response to this, we aimed to create an evidence-based report on patient-focused aspects of treatment with cladribine. To inform development, MS experts, including healthcare professionals (HCPs) and PwMS, proposed topics that PwMS and their families and caregivers would most like to discuss with HCPs during consultations to help them better understand cladribine treatment. The statements regarding each topic were then ranked by PwMS and used to inform the topics covered in this report. We explain here the use of cladribine tablets, which includes explanations of how cladribine tablets work, how to take cladribine tablets, and considerations required prior to and while taking cladribine tablets. We also describe how cladribine tablets affect relapse rate and quality of life and detail side effects, when they are likely to happen, and for how long. We also discuss how cladribine tablets affect family planning, fertility, and the use of vaccines. Alongside each section is a brief, plain language description of what is covered and an accompanying visual to aid conversations between HCPs and PwMS. Improved understanding by PwMS of treatments, such as cladribine, can empower them to play a bigger role in shared decision-making regarding their treatment. Additionally, the open dialogue we aim to promote with this type of report could lead to treatment choices being better tailored for individuals with chronic diseases on the basis of personal experiences, preferences, and circumstances.
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Affiliation(s)
- Ardra Shephard
- Patient Author: MS blogger and podcaster [trippingonair.com], patient speaker and advocate, creator, based in Toronto, ON, Canada
| | - Laura Kolaczkowski
- Patient Author: MS blogger [MultipleSclerosis.net], lead patient representative [iConquerMS], patient expert, speaker and advocate, based in Beavercreek, OH, USA
| | - Noreen Barker
- The National Hospital for Neurology and Neurosurgery, London, UK
| | - Donna Nahal
- Patient Author: MS patient advocate and speaker, based in Birmingham, UK
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Saúl Reyes
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Fundación Santa Fe de Bogotá, Bogotá, Colombia
- School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Helen Gray
- Merck Healthcare KGaA, Darmstadt, Germany
| | | | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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Filippi M, Ferrè L, Zanetta C, Rizzi C, Pessina G, Assogna F, Rocca MA. Prospective observational study to evaluate treatment satisfaction and effectiveness in patients with relapsing multiple sclerosis starting cladribine tablets (CLADREAL) in Italy. Front Neurol 2024; 15:1379712. [PMID: 38638312 PMCID: PMC11024245 DOI: 10.3389/fneur.2024.1379712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/14/2024] [Indexed: 04/20/2024] Open
Abstract
Disease-modifying therapies (DMTs) for multiple sclerosis (MS) reduce relapse frequency, magnetic resonance imaging (MRI) activity, and slow disability progression. Numerous DMTs are approved for relapsing forms of MS although real-world data on patient-reported outcomes (PROs) and quality of life (QoL) are needed to inform treatment choice. Immune reconstitution therapy with cladribine tablets is a highly effective treatment for relapsing MS (RMS). We present the protocol for an observational study to prospectively assess the effectiveness of cladribine tablets on clinical and MRI parameters as well as on PROs, including treatment satisfaction, QoL, sleep quality, self-perceived health, fatigue, and physical function. Enrolled patients at study sites in Italy will be adults with RMS (including relapsing-remitting and active secondary progressive MS) who are either treatment naïve or have received at least one first-line disease modifying DMT or no more than one second-line DMT. The primary objective will be change in global treatment satisfaction measured with the Treatment Satisfaction Questionnaire for Medication Version 1.4 approximately 24 months after initiating cladribine tablets in patients switching from previous DMTs. Secondary objectives will include global treatment satisfaction at earlier timepoints, will comprise treatment naïve patients, and will quantify treatment effectiveness and tolerability. We will also assess relapses, disability progression, MRI activity, and other PROs at approximately 12 and 24 months. The findings will provide insight from daily clinical practice into the patient's experience to complement data from controlled trials and inform treatment choice. EU PAS Registration Number EUPAS49334 filed 17/10/2022.
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Affiliation(s)
- Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Laura Ferrè
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Zanetta
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Caterina Rizzi
- Merck Serono S.p.A., An Affiliate of Merck KGaA, Rome, Italy
| | | | | | - Maria A. Rocca
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Liu Z, Fan T, Mo X, Kan J, Zhang B. Association between multiple sclerosis and cancer risk: A two-sample Mendelian randomization study. PLoS One 2024; 19:e0298271. [PMID: 38502664 PMCID: PMC10950213 DOI: 10.1371/journal.pone.0298271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/22/2024] [Indexed: 03/21/2024] Open
Abstract
Multiple Sclerosis (MS) is an immune-related disease and the relationship between MS and cancer has raised attention. Previous studies of the relationship between MS and cancer have reached conflicting conclusions. In this study, the two-sample MR method is used to investigate whether MS has a causal correlation with cancers and offer scientific evidence for cancer prevention. Single nucleotide polymorphisms (SNPs) related to MS were obtained from the genome-wide association study (GWAS) based on International Multiple Sclerosis Genetics Consortium (IMSGC) and SNPs related to 15 types of cancers were obtained from the GWASs based on UK Biobank. Inverse variance weighted (IVW) method was mainly used to assess causal effects. Sensitivity analyses were conducted with Cochran's Q-test, MR Egger intercept, leave-one-out test, and MR Steiger method. IVW analysis showed that MS was only associated with a marginal increased risk of cervical cancer (OR 1.0004, 95% CI 1.0002-1.0007, p = 0.0003). Sensitivity analyses showed that the results of MR analysis were robust and found no heterogeneity, no pleiotropy, and no reverse causation. In conclusion, this study finds no causal relationship between MS and 15 types of cancers except cervical cancer.
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Affiliation(s)
- Zeyu Liu
- VIP Inpatient Department, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Teng Fan
- VIP Inpatient Department, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Xiaoyan Mo
- VIP Inpatient Department, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Jun Kan
- VIP Inpatient Department, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Bei Zhang
- VIP Inpatient Department, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
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Tramacere I, Virgili G, Perduca V, Lucenteforte E, Benedetti MD, Capobussi M, Castellini G, Frau S, Gonzalez-Lorenzo M, Featherstone R, Filippini G. Adverse effects of immunotherapies for multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2023; 11:CD012186. [PMID: 38032059 PMCID: PMC10687854 DOI: 10.1002/14651858.cd012186.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic disease of the central nervous system that affects mainly young adults (two to three times more frequently in women than in men) and causes significant disability after onset. Although it is accepted that immunotherapies for people with MS decrease disease activity, uncertainty regarding their relative safety remains. OBJECTIVES To compare adverse effects of immunotherapies for people with MS or clinically isolated syndrome (CIS), and to rank these treatments according to their relative risks of adverse effects through network meta-analyses (NMAs). SEARCH METHODS We searched CENTRAL, PubMed, Embase, two other databases and trials registers up to March 2022, together with reference checking and citation searching to identify additional studies. SELECTION CRITERIA We included participants 18 years of age or older with a diagnosis of MS or CIS, according to any accepted diagnostic criteria, who were included in randomized controlled trials (RCTs) that examined one or more of the agents used in MS or CIS, and compared them versus placebo or another active agent. We excluded RCTs in which a drug regimen was compared with a different regimen of the same drug without another active agent or placebo as a control arm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for data extraction and pairwise meta-analyses. For NMAs, we used the netmeta suite of commands in R to fit random-effects NMAs assuming a common between-study variance. We used the CINeMA platform to GRADE the certainty of the body of evidence in NMAs. We considered a relative risk (RR) of 1.5 as a non-inferiority safety threshold compared to placebo. We assessed the certainty of evidence for primary outcomes within the NMA according to GRADE, as very low, low, moderate or high. MAIN RESULTS This NMA included 123 trials with 57,682 participants. Serious adverse events (SAEs) Reporting of SAEs was available from 84 studies including 5696 (11%) events in 51,833 (89.9%) participants out of 57,682 participants in all studies. Based on the absolute frequency of SAEs, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 18 additional people would have a SAE compared to placebo. Low-certainty evidence suggested that three drugs may decrease SAEs compared to placebo (relative risk [RR], 95% confidence interval [CI]): interferon beta-1a (Avonex) (0.78, 0.66 to 0.94); dimethyl fumarate (0.79, 0.67 to 0.93), and glatiramer acetate (0.84, 0.72 to 0.98). Several drugs met our non-inferiority criterion versus placebo: moderate-certainty evidence for teriflunomide (1.08, 0.88 to 1.31); low-certainty evidence for ocrelizumab (0.85, 0.67 to 1.07), ozanimod (0.88, 0.59 to 1.33), interferon beta-1b (0.94, 0.78 to 1.12), interferon beta-1a (Rebif) (0.96, 0.80 to 1.15), natalizumab (0.97, 0.79 to 1.19), fingolimod (1.05, 0.92 to 1.20) and laquinimod (1.06, 0.83 to 1.34); very low-certainty evidence for daclizumab (0.83, 0.68 to 1.02). Non-inferiority with placebo was not met due to imprecision for the other drugs: low-certainty evidence for cladribine (1.10, 0.79 to 1.52), siponimod (1.20, 0.95 to 1.51), ofatumumab (1.26, 0.88 to 1.79) and rituximab (1.01, 0.67 to 1.52); very low-certainty evidence for immunoglobulins (1.05, 0.33 to 3.32), diroximel fumarate (1.05, 0.23 to 4.69), peg-interferon beta-1a (1.07, 0.66 to 1.74), alemtuzumab (1.16, 0.85 to 1.60), interferons (1.62, 0.21 to 12.72) and azathioprine (3.62, 0.76 to 17.19). Withdrawals due to adverse events Reporting of withdrawals due to AEs was available from 105 studies (85.4%) including 3537 (6.39%) events in 55,320 (95.9%) patients out of 57,682 patients in all studies. Based on the absolute frequency of withdrawals, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 31 additional people would withdraw compared to placebo. No drug reduced withdrawals due to adverse events when compared with placebo. There was very low-certainty evidence (meaning that estimates are not reliable) that two drugs met our non-inferiority criterion versus placebo, assuming an upper 95% CI RR limit of 1.5: diroximel fumarate (0.38, 0.11 to 1.27) and alemtuzumab (0.63, 0.33 to 1.19). Non-inferiority with placebo was not met due to imprecision for the following drugs: low-certainty evidence for ofatumumab (1.50, 0.87 to 2.59); very low-certainty evidence for methotrexate (0.94, 0.02 to 46.70), corticosteroids (1.05, 0.16 to 7.14), ozanimod (1.06, 0.58 to 1.93), natalizumab (1.20, 0.77 to 1.85), ocrelizumab (1.32, 0.81 to 2.14), dimethyl fumarate (1.34, 0.96 to 1.86), siponimod (1.63, 0.96 to 2.79), rituximab (1.63, 0.53 to 5.00), cladribine (1.80, 0.89 to 3.62), mitoxantrone (2.11, 0.50 to 8.87), interferons (3.47, 0.95 to 12.72), and cyclophosphamide (3.86, 0.45 to 33.50). Eleven drugs may have increased withdrawals due to adverse events compared with placebo: low-certainty evidence for teriflunomide (1.37, 1.01 to 1.85), glatiramer acetate (1.76, 1.36 to 2.26), fingolimod (1.79, 1.40 to 2.28), interferon beta-1a (Rebif) (2.15, 1.58 to 2.93), daclizumab (2.19, 1.31 to 3.65) and interferon beta-1b (2.59, 1.87 to 3.77); very low-certainty evidence for laquinimod (1.42, 1.01 to 2.00), interferon beta-1a (Avonex) (1.54, 1.13 to 2.10), immunoglobulins (1.87, 1.01 to 3.45), peg-interferon beta-1a (3.46, 1.44 to 8.33) and azathioprine (6.95, 2.57 to 18.78); however, very low-certainty evidence is unreliable. Sensitivity analyses including only studies with low attrition bias, drug dose above the group median, or only patients with relapsing remitting MS or CIS, and subgroup analyses by prior disease-modifying treatments did not change these figures. Rankings No drug yielded consistent P scores in the upper quartile of the probability of being better than others for primary and secondary outcomes. AUTHORS' CONCLUSIONS We found mostly low and very low-certainty evidence that drugs used to treat MS may not increase SAEs, but may increase withdrawals compared with placebo. The results suggest that there is no important difference in the occurrence of SAEs between first- and second-line drugs and between oral, injectable, or infused drugs, compared with placebo. Our review, along with other work in the literature, confirms poor-quality reporting of adverse events from RCTs of interventions. At the least, future studies should follow the CONSORT recommendations about reporting harm-related issues. To address adverse effects, future systematic reviews should also include non-randomized studies.
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Affiliation(s)
- Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Ophthalmology, IRCCS - Fondazione Bietti, Rome, Italy
| | - Vittorio Perduca
- Université Paris Cité, CNRS, MAP5, F-75006 Paris, France
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Ersilia Lucenteforte
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Maria Donata Benedetti
- UOC Neurologia B - Policlinico Borgo Roma, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Capobussi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Greta Castellini
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | | | - Marien Gonzalez-Lorenzo
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Department of Oncology, Laboratory of Clinical Research Methodology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
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Budimkic MS, Ivanovic J, Momcilovic N, Mesaros S, Drulovic J. Eyebrow alopecia associated with cladribine treatment for multiple sclerosis. Neurol Sci 2023; 44:3735-3736. [PMID: 37249666 DOI: 10.1007/s10072-023-06874-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/23/2023] [Indexed: 05/31/2023]
Affiliation(s)
- Maja Stefanovic Budimkic
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jovana Ivanovic
- Neurology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nikola Momcilovic
- Neurology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Sarlota Mesaros
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelena Drulovic
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
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Velișcu EM, Liguori V, Anatriello A, Maniscalco GT, Cantone A, Di Costanzo L, Stefanelli P, Scavone C, Capuano A. Hepatobiliary Adverse Reactions during Treatment with Cladribine: Analysis of Data from the European Spontaneous Reporting System. Pharmaceuticals (Basel) 2023; 16:1071. [PMID: 37630986 PMCID: PMC10459297 DOI: 10.3390/ph16081071] [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: 07/04/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Cladribine belongs to the group of disease-modifying therapies (DMTs) used to treat multiple sclerosis (MS). According to the highlights of a meeting held by the Pharmacovigilance Risk Assessment Committee (PRAC) on 14 January 2022, cladribine may be associated with the occurrence of liver injury, and thus liver function monitoring is recommended. OBJECTIVES AND METHODS Using data from the European spontaneous reporting database (EudraVigilance-EV), we aimed to describe the main characteristics of Individual Case Safety Reports (ICSRs) reporting cases of hepatobiliary disorders related to cladribine. The reporting odds ratio (ROR) was calculated to provide the probability of reporting hepatobiliary ICSRs among DMTs used to treat MS. RESULTS Overall, 118 ICSRs described the occurrence of cladribine-induced hepatobiliary ADRs. The majority of the ICSRs reported ADRs that were classified as serious (93%), and the outcome was mostly reported as "unknown" (50.8%). The most reported hepatobiliary disorders were drug-induced liver injury, abnormal hepatic function, ALT increases, liver disorders, hepatic failure, jaundice, lymphocyte count decreases, hepatotoxicity and hypertransaminasemia. The majority of cladribine-induced hepatic ADRs occurred in female patients belonging to the age group of 18-65 years. CONCLUSION Considering the seriousness of cladribine-induced hepatic ADRs, a close monitoring of patients receiving this drug is highly recommended. In this context, further pharmacovigilance studies evaluating the hepatic safety profile of cladribine are strongly needed.
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Affiliation(s)
| | - Valerio Liguori
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.L.); (A.C.); (L.D.C.); (A.C.)
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, 80138 Naples, Italy
| | - Antonietta Anatriello
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.L.); (A.C.); (L.D.C.); (A.C.)
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, 80138 Naples, Italy
| | - Giorgia Teresa Maniscalco
- Multiple Sclerosis Regional Center, “A. Cardarelli” Hospital, 80131 Naples, Italy
- Neurological Clinic and Stroke Unit, “A. Cardarelli” Hospital, 80131 Naples, Italy
| | - Andrea Cantone
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.L.); (A.C.); (L.D.C.); (A.C.)
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, 80138 Naples, Italy
| | - Luigi Di Costanzo
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.L.); (A.C.); (L.D.C.); (A.C.)
| | - Pasquale Stefanelli
- Dipartimento Farmaceutico, UOC Farmaceutica Convenzionata e Territoriale, ASL Napoli 1 Centro, 80131 Naples, Italy;
| | - Cristina Scavone
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.L.); (A.C.); (L.D.C.); (A.C.)
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, 80138 Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.L.); (A.C.); (L.D.C.); (A.C.)
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, 80138 Naples, Italy
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Rolfes L, Pfeuffer S, Skuljec J, He X, Su C, Oezalp SH, Pawlitzki M, Ruck T, Korsen M, Kleinschnitz K, Aslan D, Hagenacker T, Kleinschnitz C, Meuth SG, Pul R. Immune Response to Seasonal Influenza Vaccination in Multiple Sclerosis Patients Receiving Cladribine. Cells 2023; 12:cells12091243. [PMID: 37174643 PMCID: PMC10177067 DOI: 10.3390/cells12091243] [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: 03/06/2023] [Revised: 04/17/2023] [Accepted: 04/22/2023] [Indexed: 05/15/2023] Open
Abstract
Cladribine has been approved for the treatment of multiple sclerosis (MS) and its administration results in a long-lasting depletion of lymphocytes. As lymphopenia is known to hamper immune responses to vaccination, we evaluated the immunogenicity of the influenza vaccine in patients undergoing cladribine treatment at different stages vs. controls. The antibody response in 90 cladribine-treated MS patients was prospectively compared with 10 control subjects receiving platform immunotherapy (NCT05019248). Serum samples were collected before and six months after vaccination. Response to vaccination was determined by the hemagglutination-inhibition test. Postvaccination seroprotection rates against influenza A were comparable in cladribine-treated patients and controls (H1N1: 94.4% vs. 100%; H3N2: 92.2% vs. 90.0%). Influenza B response was lower in the cladribine cohort (61.1% vs. 80%). The increase in geometric mean titers was lower in the cladribine group vs. controls (H1N1: +98.5 vs. +188.1; H3N2: +225.3 vs. +300.0; influenza B: +40.0 vs. +78.4); however, titers increased in both groups for all strains. Seroprotection was achieved irrespective of vaccination timing and lymphocyte subset counts at the time of vaccination in the cladribine cohort. To conclude, cladribine-treated MS patients can mount an adequate immune response to influenza independently of treatment duration and time interval to the last cladribine administration.
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Affiliation(s)
- Leoni Rolfes
- Department of Neurology, HeinrichHeine University Düsseldorf, 40225 Duesseldorf, Germany
| | - Steffen Pfeuffer
- Department of Neurology, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, 35392 Giessen, Germany
| | - Jelena Skuljec
- Department of Neurology and Center for Translational Neuro and Behavioral Science, University Medicine Essen, 45127 Essen, Germany
- Center for Translational Neuro and Behavioral Sciences (C-TNBS), University Medicine Essen, 45127 Essen, Germany
| | - Xia He
- Department of Neurology and Center for Translational Neuro and Behavioral Science, University Medicine Essen, 45127 Essen, Germany
- Center for Translational Neuro and Behavioral Sciences (C-TNBS), University Medicine Essen, 45127 Essen, Germany
| | - Chuanxin Su
- Department of Neurology and Center for Translational Neuro and Behavioral Science, University Medicine Essen, 45127 Essen, Germany
- Center for Translational Neuro and Behavioral Sciences (C-TNBS), University Medicine Essen, 45127 Essen, Germany
| | - Sinem-Hilal Oezalp
- Department of Neurology and Center for Translational Neuro and Behavioral Science, University Medicine Essen, 45127 Essen, Germany
- Center for Translational Neuro and Behavioral Sciences (C-TNBS), University Medicine Essen, 45127 Essen, Germany
| | - Marc Pawlitzki
- Department of Neurology, HeinrichHeine University Düsseldorf, 40225 Duesseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, HeinrichHeine University Düsseldorf, 40225 Duesseldorf, Germany
| | - Melanie Korsen
- Department of Neurology, HeinrichHeine University Düsseldorf, 40225 Duesseldorf, Germany
| | - Konstanze Kleinschnitz
- Department of Neurology and Center for Translational Neuro and Behavioral Science, University Medicine Essen, 45127 Essen, Germany
- Center for Translational Neuro and Behavioral Sciences (C-TNBS), University Medicine Essen, 45127 Essen, Germany
| | - Derya Aslan
- Department of Neurology and Center for Translational Neuro and Behavioral Science, University Medicine Essen, 45127 Essen, Germany
- Center for Translational Neuro and Behavioral Sciences (C-TNBS), University Medicine Essen, 45127 Essen, Germany
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro and Behavioral Science, University Medicine Essen, 45127 Essen, Germany
- Center for Translational Neuro and Behavioral Sciences (C-TNBS), University Medicine Essen, 45127 Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro and Behavioral Science, University Medicine Essen, 45127 Essen, Germany
- Center for Translational Neuro and Behavioral Sciences (C-TNBS), University Medicine Essen, 45127 Essen, Germany
| | - Sven G Meuth
- Department of Neurology, HeinrichHeine University Düsseldorf, 40225 Duesseldorf, Germany
| | - Refik Pul
- Department of Neurology and Center for Translational Neuro and Behavioral Science, University Medicine Essen, 45127 Essen, Germany
- Center for Translational Neuro and Behavioral Sciences (C-TNBS), University Medicine Essen, 45127 Essen, Germany
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Sorensen PS, Pontieri L, Joensen H, Heick A, Rasmussen PV, Schäfer J, Ratzer R, Pihl CE, Sellebjerg F, Magyari M. Real-world experience of cladribine treatment in relapsing-remitting multiple sclerosis: A Danish nationwide study. Mult Scler Relat Disord 2023; 70:104491. [PMID: 36623393 DOI: 10.1016/j.msard.2022.104491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cladribine is a nucleoside analogue interfering with synthesis and repair of DNA. Treatment with cladribine leads to a preferential reduction in lymphocytes, resulting in profound depletion of B-cells with a rapid recovery of naïve B-cells, while T-cell show a lesser but long-lasting depletion It is approved for treatment of relapsing multiple sclerosis (MS). Cladribine tablets 3.5 mg/kg bodyweight are administered in two yearly treatment courses, each including two treatment series lasting 4 or 5 days, one at the start of the first month and the other at the start of the second month. OBJECTIVE To describe treatment patterns of cladribine in a real-world setting. METHODS Registry based observational cohort study with prospectively enrolled cases from December 2017 through June 2021. The data source is The Danish Multiple Sclerosis Registry, which is a near complete nationwide population-based registry. Outcomes were length of the treatment, preceding and following treatments, treatment response, and safety data. RESULTS In total 268 patients had started therapy with cladribine tablets, 89 men and 179 women, with a median age of 40 years (interquartile range (IQR) 32-48. The disease course was relapsing-remitting MS in 97.8% of the patients, and at treatment start the median time from disease onset was 8.1 years (IQR 4.2-14.5) and EDSS 2.5 (IQR 1.5-3.5). Thirty-four patients (12.7%) were treatment naïve while 56 (20.9%) had received one previous disease-modifying therapy (DMT), 67 (25.0%) two, and 111 (41.4%) three or more previous DMTs. In total, 214 (80.0%) patients had completed the full treatment of two courses of cladribine, while 54 (20.0%) had received only one course of cladribine tablets. The median follow-up time after cladribine initiation was 34.7 months (IQR 23.3-43.7). Compared with an annualized relapse rate (ARR) of 0.67 (95% CI [0.56, 0.79]) in the year prior to start of cladribine, ARR was reduced to 0.11 (95% CI [0.08, 0.15]) in year 0-2 after 3-month re-baseline with cladribine (84.8% reduction). Adverse events, reported in 44 (16.4%) of the patients, were mild or moderate, and herpes zoster was only reported in 2 patients. In total, 30 (11.2%) patients discontinued cladribine treatment, of whom 7 (2.6%) discontinued because of adverse effects and 12 (4.5%) discontinued because of disease activity. CONCLUSION In this nationwide review of all Danish patients starting therapy with cladribine tablets in a real-world setting, cladribine treatment was safe, and the therapeutic response was as expected from previous clinical trials. A prolonged observation period is necessary to assess the long-term benefit and risk of cladribine.
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Affiliation(s)
- Per Soelberg Sorensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Luigi Pontieri
- The Danish Multiple Sclerosis Registry, Department of Neurology, Rigshospitalet, Glostrup, Denmark
| | - Hanna Joensen
- The Danish Multiple Sclerosis Registry, Department of Neurology, Rigshospitalet, Glostrup, Denmark
| | - Alex Heick
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | | | - Jakob Schäfer
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Rikke Ratzer
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Caroline Ellinore Pihl
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; The Danish Multiple Sclerosis Registry, Department of Neurology, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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9
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Lycett MJ, Lea RA, Maltby VE, Min M, Lechner-Scott J. The effect of cladribine on immunoglobulin levels compared to B cell targeting therapies in multiple sclerosis. Mult Scler J Exp Transl Clin 2023; 9:20552173221149688. [PMID: 36636583 PMCID: PMC9830094 DOI: 10.1177/20552173221149688] [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: 06/24/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
Background Cladribine is a useful therapeutic option in RRMS with moderate to high disease activity. Its oral formulation and tolerability make it a useful alternative to infusion therapies. Cladribine is known to deplete CD19+ B lymphocytes, but its effect on immunoglobulin subsets is unclear. Objective To identify whether cladribine therapy in pwMS reduces immunoglobulin subset levels as a surrogate marker of infection risk. Methods A 'real-world' retrospective analysis of 341 pwMS presenting to a single tertiary centre between March 2017 and July 2021. Differences in immunoglobulin levels between cladribine, other disease-modifying therapies and no active treatment were assessed using a univariate ANOVA. Results Three hundred and forty-one patients had immunoglobulin levels assessed, with 29 patients treated with cladribine. The mean IgG, IgM and IgA levels on cladribine therapy were 10.44 ± 0.40, 0.99 ± 0.09 and 2.04 ± 0.18 g/L respectively. These were not significantly different from patients not on active treatment. There was a statistically significant reduction in IgG and IgM levels for patients treated with ocrelizumab (9.37 ± 0.19 and 0.68 ± 0.04 g/L) and natalizumab (8.72 ± 0.53 and 0.69 ± 0.12 g/L) compared to patients not on treatment. Conclusion Cladribine therapy for RRMS was not associated with immunoglobulin subset deficiencies. This is contrasted to ocrelizumab and natalizumab which demonstrate significant reductions in both IgG and IgM levels.
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Affiliation(s)
- Mitchell J Lycett
- Mitchell J Lycett, Department of Neurology,
John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia.
| | - Rodney A Lea
- Hunter Medical Research
Institute, New Lambton Heights,
NSW, Australia,Centre for Genomics and Personalised Health,
School of Biomedical Science, Queensland University of Technology, Kelvin
Grove, QLD, Australia
| | - Vicki E Maltby
- Department of
Neurology,
John
Hunter Hospital, New Lambton
Heights, NSW, Australia,Hunter Medical Research
Institute, New Lambton Heights,
NSW, Australia
| | - Myintzu Min
- Department of
Neurology,
John
Hunter Hospital, New Lambton
Heights, NSW, Australia
| | - Jeannette Lechner-Scott
- Department of
Neurology,
John
Hunter Hospital, New Lambton
Heights, NSW, Australia,Hunter Medical Research
Institute, New Lambton Heights,
NSW, Australia
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10
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Hepatotoxicity of Drugs Used in Multiple Sclerosis, Diagnostic Challenge, and the Role of HLA Genotype Susceptibility. Int J Mol Sci 2023; 24:ijms24010852. [PMID: 36614299 PMCID: PMC9821303 DOI: 10.3390/ijms24010852] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system and the association with other autoimmune diseases is well-documented. There are many therapeutic options for the treatment of MS. Most of the available drugs cause drug-induced liver injury (DILI) to variable extents with heterogeneous clinical and biological manifestations, including liver injury with or without signs of hypersensitivity and autoimmunity. The diagnosis of DILI may be particularly difficult because MS is frequently associated with idiopathic autoimmune hepatitis. Recent advances suggest that MS and immune-mediated DILI could be promoted by genetic factors, including HLA genotype. In addition, some of these drugs may promote hepatitis B virus reactivation. This review explores the potential hepatotoxicity of drugs used to treat MS and the criteria to distinguish DILI from idiopathic autoimmune hepatitis associated with MS. The role of susceptible genes both promoting MS and causing the hepatotoxicity of the drug used for MS treatment is also discussed.
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11
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Muacevic A, Adler JR, Albeladi F, Tahiri AA, Kinani EM, Almohsen RA, Alamoudi NH, Alanazi AA, Alkhamshi SJ, Althomali NA, Alrubaiei SN, Altowairqi FK. An Overview of the History, Pathophysiology, and Pharmacological Interventions of Multiple Sclerosis. Cureus 2023; 15:e33242. [PMID: 36733554 PMCID: PMC9888604 DOI: 10.7759/cureus.33242] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/03/2023] Open
Abstract
Multiple sclerosis (MS) is an immune-inflammatory disease that attacks and damages myelinated axons in the central nervous system (CNS) and causes nontraumatic neurological impairment in young people. Historically, Lidwina of Schiedam documented the first MS case. After that, Augustus d'Este wrote for years about how his MS symptoms worsened. Age, sex, genetics, environment, smoking, injuries, and infections, including herpes simplex and rabies, are risk factors for MS. According to epidemiology, the average age of onset is between 20 and 40 years. MS is more prevalent in women and is common in Europe and America. As diagnostic methods and criteria change, people with MS may be discovered at earlier and earlier stages of the disease. MS therapy has advanced dramatically due to breakthroughs in our knowledge of the disease's etiology and progression. Therefore, the efficacy and risk of treatment medications increased exponentially. Management goals include reducing lesion activity and avoiding secondary progression. Current treatment approaches focus on managing acute episodes, relieving symptoms, and reducing biological activity. Disease-modifying drugs such as fingolimod, interferon-beta, natalizumab, and dimethyl fumarate are the most widely used treatments for MS. For proof of the efficacy and safety of these medications, investigations in the real world are necessary.
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12
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Specific Aspects of Immunotherapy for Multiple Sclerosis in Switzerland—A Structured Commentary, Update 2022. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2022. [DOI: 10.3390/ctn7010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Multiple sclerosis (MS), particularly relapsing MS (RMS), has become a treatable disease in recent decades, and immunotherapies are now able to influence long-term disease course. A wide range of disease-modifying drugs are available, which makes the choice of therapy in individual cases considerably more complex. Due to specific regulatory aspects (partly diverging approvals by Swissmedic compared to the European Medicines Agency (EMA), and an independent evaluation process for the Federal Office of Public Health (FOPH) specialities list (SL)), we issued a consensus recommendation regarding specific aspects of immunotherapy for MS in Switzerland in 2019. Here, we present revised recommendations with an update on newly approved drugs and new safety aspects, also in reference to the risk of COVID-19 infection and vaccination.
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13
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Saraceno L, Pirro F, Stigliano R, Agostoni EC, Protti A. Acute idiosyncratic liver injury after Cladribine treatment for multiple sclerosis: first case report and review on associated hepatic disorders. Mult Scler 2022; 28:2142-2145. [PMID: 36169305 DOI: 10.1177/13524585221125360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In recent years, several disease-modifying therapies have been developed for the treatment of multiple sclerosis (MS). Cladribine transiently depletes B and T lymphocytes, with subsequent gradual cell recovery. No cases are reported in literature describing Cladribine drug-induced liver injury (DILI). We describe the case of a 19-year-old woman who developed acute idiosyncratic liver injury 12 days after treatment with Cladribine. Post-marketing adverse event reporting is of paramount importance to allow an early recognition and treatment. Moreover, evaluation of the physiopathological mechanism underlying drug-induced hepatic toxicity can provide clinicians with valuable instruments for prevention and treatment.
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Affiliation(s)
- Lorenzo Saraceno
- Department of Neurosciences, Multiple Sclerosis Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy/Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fiammetta Pirro
- Department of Neurosciences, Multiple Sclerosis Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy/Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Rosa Stigliano
- Gastroenterology Department, Hepatitis Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elio Clemente Agostoni
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandra Protti
- Department of Neurosciences, Multiple Sclerosis Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy/Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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14
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Śladowska K, Kawalec P, Holko P, Osiecka O. Comparative safety of high-efficacy disease-modifying therapies in relapsing–remitting multiple sclerosis: a systematic review and network meta-analysis. Neurol Sci 2022; 43:5479-5500. [DOI: 10.1007/s10072-022-06197-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/04/2022] [Indexed: 10/18/2022]
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15
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Meuth SG, Bayas A, Kallmann B, Linker R, Rieckmann P, Wattjes MP, Mäurer M, Kleinschnitz C. Long-term management of multiple sclerosis patients treated with cladribine tablets beyond year 4. Expert Opin Pharmacother 2022; 23:1503-1510. [PMID: 35930260 DOI: 10.1080/14656566.2022.2106783] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Oral cladribine is a highly effective pulsed selective immune reconstitution therapy licensed for relapsing multiple sclerosis (RMS) since 2017. A full treatment course comprises two treatment cycles given 1 year apart, followed by two treatment-free years. The management of cladribine-treated patients beyond year 4 needs to be addressed as patients have now passed the initial 4 years since European Medical Agency approval. AREAS COVERED A panel of neurologists and a neuroradiologist experienced in MS treatment/monitoring evaluated clinical trial data and real-world evidence and proposed recommendations for the management of cladribine-treated patients beyond year 4. EXPERT OPINION Continuous monitoring of disease activity during the treatment-free period is important. Subsequent management depends on the presence or absence of inflammatory disease activity, determined in the absence of consistent guidelines via practice-driven neurological decision criteria. Persisting or newly occurring inflammatory disease activity is an indication for further treatment, i.e. either re-initiation of cladribine or switching to another highly effective disease-modifying therapy. The decision to retreat or switch should be based on clinical and radiological evaluation considering disease course, treatment history, and safety aspects. In the absence of disease activity, either retreatment can be offered, or the treatment-free period can be extended under structured monitoring.
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Affiliation(s)
- Sven G Meuth
- Klinik für Neurologie des Universitätsklinikums Düsseldorf, Düsseldorf, Germany
| | - Antonios Bayas
- Klinik für Neurologie und Klinische Neurophysiologie, Medizinische Fakultät, Universität Augsburg, Augsburg, Germany
| | | | - Ralf Linker
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Peter Rieckmann
- Abteilung für Neurologie, Medical Park Loipl, Regensburg, Germany
| | - Mike P Wattjes
- Department of diagnostic and interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Mathias Mäurer
- Klinik für Neurologie, Juliusspital Würzburg Klinikum Würzburg Mitte gGmbH, Würzburg, Germany
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16
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Porwal MH, Salter A, Patel D, Obeidat AZ. Alopecia in Multiple Sclerosis Patients Treated with Disease Modifying Therapies. J Cent Nerv Syst Dis 2022; 14:11795735221109674. [PMID: 35769950 PMCID: PMC9234852 DOI: 10.1177/11795735221109674] [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: 01/23/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There is currently limited literature addressing the reporting of alopecia in
multiple sclerosis (MS) patients treated with disease-modifying therapies
(DMTs). Anecdotal reports of hair thinning from patients on various DMTs
prompted further investigation of a large database. OBJECTIVE To analyze total reports, source of reporting, age distribution, and sex
distribution of alopecia associated with DMTs. METHODS FDA Adverse Event Reporting System (FAERS) public dashboard and OpenFDA
database were analyzed for alopecia reports between January 1, 2009, and
June 30, 2020, attributed to usage in MS of FDA approved DMTs. The main
outcomes included total reports for each drug, age, sex distribution, and
reporting source. OpenFDA data was used for statistical analyses including
reporting odds ratios (ROR) and information components. RESULTS 8759 alopecia reports were identified among 44 114 adverse events in skin and
subcutaneous tissue disorders (19.9%). 3701 (42.3%) with teriflunomide, 1675
(19.1%) with dimethyl fumarate, 985 (11.2%) with natalizumab, 926 (10.6%)
with fingolimod, 659 (7.5%) with interferon beta-1a, 257 (2.9%) with
glatiramer acetate, 243 (2.8%) with ocrelizumab, 124 (1.4%) with interferon
beta-1b, 117 (1.3%) with alemtuzumab, 36 (.4%) with siponimod, 24 (.3%) with
cladribine, and 12 (.1%) with rituximab. Reports were mostly made by
patients (78.3%) and highest in fifth and sixth decades of life. OpenFDA
analyses showed increased ROR (ROR 95% confidence interval) of alopecia in
females with teriflunomide (18.00, 17.12-18.93), alemtuzumab (1.43,
1.16-1.76), dimethyl fumarate (1.26, 1.18-1.34), and ocrelizumab (1.28,
1.11-1.49). Increased ROR in males was associated with teriflunomide (24.65,
20.72-29.31). CONCLUSION We identified many reports of alopecia for DMTs in addition to teriflunomide.
Within the limitations of the database, increased RORs of alopecia were
observed for females treated with alemtuzumab, dimethyl fumarate, and
ocrelizumab. The source of reporting was largely driven by female patients.
Possible alopecia, even if transient, should be considered during patient
education when starting DMTs.
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Affiliation(s)
- Mokshal H Porwal
- Department of neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amber Salter
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dhruvkumar Patel
- Midwestern University Arizona College of Osteopathic Medicine, Glendale, AZ, USA
| | - Ahmed Z Obeidat
- Department of neurology, Medical College of Wisconsin, Milwaukee, WI, USA
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17
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Basu S, Munafo A, Ben‐Amor A, Roy S, Girard P, Terranova N. Predicting disease activity in patients with multiple sclerosis: An explainable machine‐learning approach in the Mavenclad trials. CPT Pharmacometrics Syst Pharmacol 2022; 11:843-853. [PMID: 35521742 PMCID: PMC9286719 DOI: 10.1002/psp4.12796] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 02/04/2022] [Accepted: 03/09/2022] [Indexed: 11/09/2022] Open
Abstract
Multiple sclerosis (MS) is among the most common autoimmune disabling neurological conditions of young adults and affects more than 2.3 million people worldwide. Predicting future disease activity in patients with MS based on their pathophysiology and current treatment is pivotal to orientate future treatment. In this respect, we used machine learning to predict disease activity status in patients with MS and identify the most predictive covariates of this activity. The analysis is conducted on a pooled population of 1935 patients enrolled in three cladribine tablets clinical trials with different outcomes: relapsing–remitting MS (from CLARITY and CLARITY‐Extension trials) and patients experiencing a first demyelinating event (from the ORACLE‐MS trial). We applied gradient‐boosting (from XgBoost library) and Shapley Additive Explanations (SHAP) methods to identify patients' covariates that predict disease activity 3 and 6 months before their clinical observation, including patient baseline characteristics, longitudinal magnetic resonance imaging readouts, and neurological and laboratory measures. The most predictive covariates for early identification of disease activity in patients were found to be treatment duration, higher number of new combined unique active lesion count, higher number of new T1 hypointense black holes, and higher age‐related MS severity score. The outcome of this analysis improves our understanding of the mechanism of onset of disease activity in patients with MS by allowing their early identification in clinical settings and prompting preventive measures, therapeutic interventions, or more frequent patient monitoring.
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Affiliation(s)
- Sreetama Basu
- Merck Institute for Pharmacometrics, Merck Serono S.A. (an affiliate of Merck KGaA, Darmstadt, Germany) Lausanne Switzerland
| | - Alain Munafo
- Merck Institute for Pharmacometrics, Merck Serono S.A. (an affiliate of Merck KGaA, Darmstadt, Germany) Lausanne Switzerland
| | | | - Sanjeev Roy
- Ares Trading SA (an affiliate of Merck KGaA, Darmstadt, Germany) Eysins Switzerland
| | - Pascal Girard
- Merck Institute for Pharmacometrics, Merck Serono S.A. (an affiliate of Merck KGaA, Darmstadt, Germany) Lausanne Switzerland
| | - Nadia Terranova
- Merck Institute for Pharmacometrics, Merck Serono S.A. (an affiliate of Merck KGaA, Darmstadt, Germany) Lausanne Switzerland
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18
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Rolfes L, Pfeuffer S, Huntemann N, Schmidt M, Su C, Skuljec J, Aslan D, Hackert J, Kleinschnitz K, Hagenacker T, Pawlitzki M, Ruck T, Kleinschnitz C, Meuth SG, Pul R. Immunological consequences of cladribine treatment in multiple sclerosis: A real-world study. Mult Scler Relat Disord 2022; 64:103931. [DOI: 10.1016/j.msard.2022.103931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
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19
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Potential therapeutic strategies in chronic inflammatory demyelinating polyradiculoneuropathy. Clin Exp Rheumatol 2022; 21:103032. [PMID: 34999243 DOI: 10.1016/j.autrev.2022.103032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/01/2022] [Indexed: 11/23/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune neuropathy involving peripheral nerve and nerve roots. The pathological hallmark of CIDP is macrophage-induced demyelination. Antibodies against nerve fibers, complement decomposition, abnormalities in plasma and cerebrospinal fluid cytokine profile, and changes of peripheral blood cell proportion were also reported in CIDP patients. These findings in immunopathology provide support for the introduction of potential therapeutic options for the treatment of CIDP. In this review, we systematically listed the potential therapeutic strategies targeting different components of the immune system by comparing the treatment of other autoimmune inflammatory diseases of the nervous system. Several ongoing clinical trials will assess the efficacy and safety of potential CIDP treatments.
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20
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Brochet B, Hupperts R, Langdon D, Solari A, Piehl F, Lechner-Scott J, Montalban X, Selmaj K, Valis M, Rejdak K, Havrdova EK, Patti F, Alexandri N, Nolting A, Keller B. Treatment satisfaction, safety, and tolerability of cladribine tablets in patients with highly active relapsing multiple sclerosis: CLARIFY-MS study 6-month interim analysis. Mult Scler Relat Disord 2022; 57:103385. [PMID: 35158476 DOI: 10.1016/j.msard.2021.103385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/24/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
Abstract
Background Multiple sclerosis (MS) is a chronic disabling disease that is associated with negative effects on health-related quality of life (HRQoL) due to reduced physical and psychosocial functioning. Cladribine tablets 10 mg (3.5 mg/kg cumulative dose over 2 years) have been approved for the treatment of adult patients with highly active relapsing multiple sclerosis (RMS). The ongoing CLARIFY-MS study (NCT03369665; EudraCT number: 2017-002632-17) aims to assess the effect of cladribine tablets 3.5 mg/kg on HRQoL of patients with highly active RMS. Objective To report on the design of the CLARIFY-MS study, baseline patient characteristics, and results of a pre-planned interim analysis focusing on treatment satisfaction, safety, and tolerability that includes all data reported till 6 months after start of treatment. Methods The CLARIFY-MS study is a 2-year, open-label, single-arm, prospective, multicenter, phase IV study. Eligible patients with highly active RMS were assigned to receive cladribine tablets 3.5 mg/kg over 2 years. Treatment satisfaction was assessed using the Treatment Satisfaction Questionnaire for Medication (TSQM, v1.4; scale range from 0 to 100, higher values indicating higher satisfaction). Safety assessments, including occurrence of treatment-emergent adverse events (TEAEs; any adverse event reported after drug administration), serious adverse events (SAEs), and lymphocyte counts, were summarized descriptively. Results A total of 482 patients from 85 sites in Europe were treated with cladribine tablets. Mean patient age was 37.4 years, 338 (70.1%) were women, median EDSS was 2.5, and 345 (71.6%) were prior users of disease-modifying therapy (DMT). During the first 6 months after the start of treatment, and before reaching the full dose of cladribine tablets, mean TSQM global satisfaction score for the overall population was 70.4 (standard deviation, ± 18.48). The side effects score was 91.9 (± 17.68), convenience scored 86.6 (± 13.57), and effectiveness was 65.8 (± 21.14). A total of 275 patients (57.1%) reported at least one TEAE and 9 patients (1.9%) had a SAE. The majority of observed lymphopenia cases were of grade 1 or 2; 33 (6.8%) of the total study cohort had grade 3 lymphopenia, and no grade 4 lymphopenia was reported. Conclusion Patients reported high treatment satisfaction (TSQM) with cladribine tablets in this pre-planned interim analysis at 6 months. Few serious, and no unexpected, adverse events were reported, and there were no instances of grade 4 lymphopenia over the first 6 months. These preliminary data indicate good tolerability and convenience of administration of cladribine tablets in patients with highly active RMS.
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Affiliation(s)
- Bruno Brochet
- INSERM U 1215, University of Bordeaux, Bordeaux, France.
| | - Raymond Hupperts
- Zuyderland Medisch Centrum Sittard, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Dawn Langdon
- Department of Psychology, Royal Holloway, University of London, Egham, United Kingdom
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jeannette Lechner-Scott
- University of Newcastle, Newcastle, NSW, Australia; Division of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Xavier Montalban
- Department of Neurology-Neuroimmunology Centre of Multiple Sclerosis of Catalonia (Cemcat), University Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Martin Valis
- Charles University and University Hospital, Hradec Králové, Czech Republic
| | | | - Eva K Havrdova
- Charles University, First Medical Faculty, Prague, Czech Republic
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, University of Catania, and Azienda Ospedaliero Universitaria Policlinico "G Rodolico"- San Marco, University of Catania, Catania, Italy
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Abrantes FF, Moraes MPMD, Albuquerque Filho JMVD, Alencar JMD, Lopes AB, Pinto WBVDR, Souza PVSD, Oliveira EMLD, Oliveira ADSBD, Pedroso JL, Barsottini OGP. Immunosuppressors and immunomodulators in Neurology - Part I: a guide for management of patients underimmunotherapy. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:1012-1025. [PMID: 34816994 DOI: 10.1590/0004-282x-anp-2020-0593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/12/2021] [Indexed: 11/22/2022]
Abstract
For patients with autoimmune diseases, the risks and benefits of immunosuppressive or immunomodulatory treatment are a matter of continual concern. Knowledge of the follow-up routine for each drug is crucial, in order to attain better outcomes and avoid new disease activity or occurrence of adverse effects. To achieve control of autoimmune diseases, immunosuppressive and immunomodulatory drugs act on different pathways of the immune response. Knowledge of the mechanisms of action of these drugs and their recommended doses, adverse reactions and risks of infection and malignancy is essential for safe treatment. Each drug has a specific safety profile, and management should be adapted for different circumstances during the treatment. Primary prophylaxis for opportunistic infections and vaccination are indispensable steps during the treatment plan, given that these prevent potential severe infectious complications. General neurologists frequently prescribe immunosuppressive and immunomodulatory drugs, and awareness of the characteristics of each drug is crucial for treatment success. Implementation of a routine before, during and after use of these drugs avoids treatment-related complications and enables superior disease control.
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Affiliation(s)
- Fabiano Ferreira Abrantes
- Universidade Federal de São Paulo, Departamento de Neurologia, Divisão de Neurologia Geral, São Paulo SP, Brazil
| | | | | | - Jéssica Monique Dias Alencar
- Universidade Federal de São Paulo, Departamento de Neurologia, Divisão de Neurologia Geral, São Paulo SP, Brazil
| | - Alexandre Bussinger Lopes
- Universidade Federal de São Paulo, Departamento de Neurologia, Divisão de Neurologia Geral, São Paulo SP, Brazil
| | | | - Paulo Victor Sgobbi de Souza
- Universidade Federal de São Paulo, Departamento de Neurologia, Divisão de Neurologia Geral, São Paulo SP, Brazil
| | | | | | - José Luiz Pedroso
- Universidade Federal de São Paulo, Departamento de Neurologia, Divisão de Neurologia Geral, São Paulo SP, Brazil
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22
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Moser T, O’Sullivan C, Puttinger C, Feige J, Pilz G, Haschke-Becher E, Cadamuro J, Oberkofler H, Hitzl W, Harrer A, Kraus J, Trinka E, Wipfler P. Pre-Existing Humoral Immunological Memory Is Retained in Patients with Multiple Sclerosis Receiving Cladribine Therapy. Biomedicines 2021; 9:biomedicines9111584. [PMID: 34829815 PMCID: PMC8615381 DOI: 10.3390/biomedicines9111584] [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: 10/05/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 12/23/2022] Open
Abstract
Cladribine (CLAD) is a lymphodepleting agent approved for active relapsing multiple sclerosis (MS). The impact of CLAD on the adaptive humoral immune system has not sufficiently been studied. This study aimed to assess the influence of CLAD treatment on specific antibody titers to common pathogens. We included 18 MS patients treated with CLAD. Serum IgG antibody levels to measles, mumps, rubella, hepatitis B and varicella zoster virus (VZV), as well as diphtheria and tetanus toxins, were measured prior to the initiation of treatment and at 12 and 24 months after first CLAD administration. Moreover, specimens were longitudinally analyzed regarding absolute blood concentrations of IgG and main lymphocyte subsets. No reduction in antibody levels against measles, mumps, rubella, VZV, hepatitis B, diphtheria toxin and tetanus toxin associated with CLAD treatment was observed. Loss of seroprotection occurred in <1%. We found no significant impact of CLAD on absolute serum IgG levels. Absolute lymphocyte counts were significantly reduced at the end of each treatment year (p < 0.00001 and p < 0.000001). This study suggests that CLAD does not interfere with the pre-existing humoral immunologic memory in terms of pathogen-specific antibody titers.
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Affiliation(s)
- Tobias Moser
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, 5020 Salzburg, Austria (C.P.); (J.F.); (G.P.); (A.H.); (E.T.); (P.W.)
- Correspondence: ; Tel.: +43-57255-30300
| | - Ciara O’Sullivan
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, 5020 Salzburg, Austria (C.P.); (J.F.); (G.P.); (A.H.); (E.T.); (P.W.)
| | - Christian Puttinger
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, 5020 Salzburg, Austria (C.P.); (J.F.); (G.P.); (A.H.); (E.T.); (P.W.)
| | - Julia Feige
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, 5020 Salzburg, Austria (C.P.); (J.F.); (G.P.); (A.H.); (E.T.); (P.W.)
| | - Georg Pilz
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, 5020 Salzburg, Austria (C.P.); (J.F.); (G.P.); (A.H.); (E.T.); (P.W.)
| | - Elisabeth Haschke-Becher
- Department of Laboratory Medicine, Paracelsus Medical University, 5020 Salzburg, Austria; (E.H.-B.); (J.C.); (H.O.); (J.K.)
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, 5020 Salzburg, Austria; (E.H.-B.); (J.C.); (H.O.); (J.K.)
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University, 5020 Salzburg, Austria; (E.H.-B.); (J.C.); (H.O.); (J.K.)
| | - Wolfgang Hitzl
- Research Management (RM): Team Biostatistics and Publikation of Clincial Studies, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria;
- Department of Ophthalmology and Optometry Salzburg, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Andrea Harrer
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, 5020 Salzburg, Austria (C.P.); (J.F.); (G.P.); (A.H.); (E.T.); (P.W.)
- Department of Dermatology and Allergology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Jörg Kraus
- Department of Laboratory Medicine, Paracelsus Medical University, 5020 Salzburg, Austria; (E.H.-B.); (J.C.); (H.O.); (J.K.)
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, 40225 Düsseldorf, Germany
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, 5020 Salzburg, Austria (C.P.); (J.F.); (G.P.); (A.H.); (E.T.); (P.W.)
- Neuroscience Institute, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, 5020 Salzburg, Austria
| | - Peter Wipfler
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, 5020 Salzburg, Austria (C.P.); (J.F.); (G.P.); (A.H.); (E.T.); (P.W.)
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Hammond D, Montalban-Bravo G. Management and Outcomes of Blast Transformed Chronic Myelomonocytic Leukemia. Curr Hematol Malig Rep 2021; 16:405-417. [PMID: 34499330 DOI: 10.1007/s11899-021-00643-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Despite recent advances in the treatment of de novo acute myeloid leukemia (AML), AML arising from antecedent chronic myelomonocytic leukemia (CMML) continues to have dismal outcomes. While the unique biological drivers of CMML and subsequent leukemic transformation (LT) have been revealed with advances in molecular characterization, this has not yet translated to the bedside. Here, we review these biologic drivers, outcomes with current therapies, and rationale avenues of future investigation specifically in blast phase CMML (CMML-BP). RECENT FINDINGS CMML-BP outcomes are studied as an aggregate with more common categories of AML with myelodysplasia-related changes (AML-MRCs) or the even broader category of secondary AML (sAML), which illustrates the crux of the problem. While a modest survival advantage with allogeneic hematopoietic stem cell transplant exists, the difficulty is bridging patients to transplant and managing patients that require an allograft-sparing approach. Limited data suggest that short-lived remissions can be obtained employing CPX-351 or venetoclax-based lower intensity combination therapy. Promising future strategies include repurposing cladribine, exploiting the supportive role of dendritic cell subsets with anti-CD123 therapies, MCL-1 inhibition, dual MEK/PLK1 inhibition, FLT3 inhibition in RAS-mutated and CBL-mutated subsets, and immune therapies targeting novel immune checkpoint molecules such as the leukocyte immunoglobulin-like receptor B4 (LILRB4), an immune-modulatory transmembrane protein restrictively expressed on monocytic cells. The successful management of an entity as unique as CMML-BP will require a cooperative, concerted effort to design and conduct clinical trials dedicated to this rare form of sAML.
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Affiliation(s)
- Danielle Hammond
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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24
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Multiple Sclerosis, Disease-Modifying Therapies and COVID-19: A Systematic Review on Immune Response and Vaccination Recommendations. Vaccines (Basel) 2021; 9:vaccines9070773. [PMID: 34358189 PMCID: PMC8310076 DOI: 10.3390/vaccines9070773] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022] Open
Abstract
Understanding the risks of COVID-19 in patients with Multiple Sclerosis (MS) receiving disease-modifying therapies (DMTs) and their immune reactions is vital to analyze vaccine response dynamics. A systematic review on COVID-19 course and outcomes in patients receiving different DMTs was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Emerging data on SARS-CoV-2 vaccines was used to elaborate recommendations. Data from 4417 patients suggest that MS per se do not portend a higher risk of severe COVID-19. As for the general population, advanced age, comorbidities, and higher disability significantly impact COVID-19 outcomes. Most DMTs have a negligible influence on COVID-19 incidence and outcome, while for those causing severe lymphopenia and hypogammaglobulinemia, such as anti-CD20 therapies, there might be a tendency of increased hospitalization, worse outcomes and a higher risk of re-infection. Blunted immune responses have been reported for many DMTs, with vaccination implications. Clinical evidence does not support an increased risk of MS relapse or vaccination failure, but vaccination timing needs to be individually tailored. For cladribine and alemtuzumab, it is recommended to wait 3-6 months after the last cycle until vaccination. For the general anti-CD20 therapies, vaccination must be deferred toward the end of the cycle and the next dose administered at least 4-6 weeks after completing vaccination. Serological status after vaccination is highly encouraged. Growing clinical evidence and continuous surveillance are extremely important to continue guiding future treatment strategies and vaccination protocols.
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25
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Schönfelder K, Schuh H, Pfister F, Krämer J, Eisenberger U, Skuljec J, Hackert J, Ruck T, Pfeuffer S, Fleischer M, Gäckler A, Hagenacker T, Kribben A, Meuth SG, Kleinschnitz C, Pul R. Autoimmune glomerulonephritis in a multiple sclerosis patient after cladribine treatment. Mult Scler 2021; 27:1960-1964. [PMID: 34165361 PMCID: PMC8521349 DOI: 10.1177/13524585211022719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Oral cladribine is an approved disease-modifying drug for the treatment of relapsing multiple sclerosis. In controlled clinical trials as well as in post marketing safety assessments, autoimmune conditions have not yet been reported as a specific side effect of cladribine. OBJECTIVE AND RESULTS Here, we report a case of anti-glomerular basement membrane antibody-mediated glomerulonephritis that occurred shortly after the fourth cladribine treatment cycle. CONCLUSION Neurologists should be attentive to the development of secondary autoimmunity in cladribine-treated patients.
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Affiliation(s)
- Kristina Schönfelder
- Department of Nephrology, University Medicine Essen, Essen, Germany Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Helene Schuh
- Department of Neurology, University Medicine Essen, Essen, Germany/Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Frederick Pfister
- Department of Nephropathology, University Medicine Erlangen, Erlangen, Germany
| | - Julia Krämer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Ute Eisenberger
- Department of Nephrology, University Medicine Essen, Essen, Germany Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Jelena Skuljec
- Department of Neurology, University Medicine Essen, Essen, Germany/Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Jana Hackert
- Department of Neurology, University Medicine Essen, Essen, Germany/Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Michael Fleischer
- Department of Neurology, University Medicine Essen, Essen, Germany/Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Anja Gäckler
- Department of Nephrology, University Medicine Essen, Essen, Germany Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, University Medicine Essen, Essen, Germany/Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Medicine Essen, Essen, Germany Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, University Medicine Essen, Essen, Germany/Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Refik Pul
- Department of Neurology, University Medicine Essen, Essen, Germany/Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
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26
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Piehl F. Current and emerging disease-modulatory therapies and treatment targets for multiple sclerosis. J Intern Med 2021; 289:771-791. [PMID: 33258193 PMCID: PMC8246813 DOI: 10.1111/joim.13215] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/08/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
The treatment of multiple sclerosis (MS), the most common chronic inflammatory, demyelinating and neurodegenerative disease of the central nervous system (CNS), continues to transform. In recent years, a number of novel and increasingly effective disease-modulatory therapies (DMTs) have been approved, including oral fumarates and selective sphingosine 1-phosphate modulators, as well as cell-depleting therapies such as cladribine, anti-CD20 and anti-CD52 monoclonals. Amongst DMTs in clinical development, inhibitors of Bruton's tyrosine kinase represent an entirely new emerging drug class in MS, with three different drugs entering phase III trials. However, important remaining fields of improvement comprise tracking of long-term benefit-risk with existing DMTs and exploration of novel treatment targets relating to brain inherent disease processes underlying the progressive neurodegenerative aspect of MS, which accumulating evidence suggests start already early in the disease process. The aim here is to review current therapeutic options in relation to an improved understanding of the immunopathogenesis of MS, also highlighting examples where controlled trials have not generated the desired results. An additional aim is to review emerging therapies undergoing clinical development, including agents that interfere with disease processes believed to be important for neurodegeneration or aiming to enhance reparative responses. Notably, early trials now have shown initial evidence of enhanced remyelination both with small molecule compounds and biologicals. Finally, accumulating evidence from clinical trials and post-marketing real-world patient populations, which underscore the importance of early high effective therapy whilst maintaining acceptable tolerability, is discussed.
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Affiliation(s)
- F. Piehl
- From theDepartment of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- The Karolinska University Hospital and Academic Specialist CentreStockholm Health ServicesStockholmSweden
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27
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De Stefano N, Sormani MP, Giovannoni G, Rammohan K, Leist T, Coyle PK, Dangond F, Keller B, Alexandri N, Galazka A. Analysis of frequency and severity of relapses in multiple sclerosis patients treated with cladribine tablets or placebo: The CLARITY and CLARITY Extension studies. Mult Scler 2021; 28:111-120. [PMID: 33969750 PMCID: PMC8688984 DOI: 10.1177/13524585211010294] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background: In the CLARITY (CLAdRIbine Tablets treating multiple sclerosis orallY) study of patients with relapsing-remitting multiple sclerosis, treatment with cladribine tablets 3.5 mg/kg (CladT) significantly reduced the annualised relapse rate (ARR) versus placebo; this effect was sustained in CLARITY Extension, without further treatment. Objective: To assess the frequency and severity of relapses in patients treated with CladT versus placebo in CLARITY over 2 years and evaluate the durability of effect in patients who received no further treatment for 2 years in CLARITY Extension. Methods: In this post hoc analysis, ARRs were calculated for qualifying and all relapses, and qualifying and all severe relapses (i.e. requiring steroid treatment or leading to hospitalisation) in patients treated with CladT (n = 433) and placebo (n = 437) in CLARITY, and those from the CladT group who received placebo in CLARITY Extension (n = 98). Results: At Month 6, Year 1 and Year 2, patients receiving CladT had a significantly lower risk of qualifying or all relapses (all p < 0.0001), and qualifying or all severe relapses (all p < 0.005), compared with placebo. This effect was sustained in CLARITY Extension without further treatment. Conclusion: The results show durable efficacy of cladribine tablets 3.5 mg/kg for reducing frequency and severity of relapses in patients with relapsing-remitting multiple sclerosis. CLARITY: NCT00213135; CLARITY Extension: NCT00641537
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Affiliation(s)
- Nicola De Stefano
- Department of Neurological and Behavioural Sciences, University of Siena, Siena, Italy/Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Kottil Rammohan
- Department of Neurology, University of Miami School of Medicine, MS Research Center, Miami, FL, USA
| | - Thomas Leist
- Division of Clinical Neuroimmunology, Jefferson University, Comprehensive MS Center, Philadelphia, PA, USA
| | - Patricia K Coyle
- Department of Neurology, Stony Brook University, Stony Brook, NY, USA
| | - Fernando Dangond
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA
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Scotto R, Reia A, Buonomo AR, Moccia M, Viceconte G, Pisano E, Zappulo E, Brescia Morra V, Gentile I. Risk of invasive fungal infections among patients treated with disease modifying treatments for multiple sclerosis: a comprehensive review. Expert Opin Drug Saf 2021; 20:925-936. [PMID: 33880975 DOI: 10.1080/14740338.2021.1918673] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Disease modifying treatments are commonly used in the treatment of multiple sclerosis. As different opportunistic infections have been reported, concerns are also raised regarding the risk of invasive fungal infections.Areas covered: Both clinical trials and observational studies on safety and efficacy of diseases modifying treatment for multiple sclerosis were reviewed and data regarding the occurrence of invasive fungal infections were reported. Papers evaluating the following drugs were reviewed: rituximab, ocrelizumab, alemtuzumab, fingolimod, natalizumab, dimethyl fumarate, interferon, glatiramer acetate, cladribine, teriflunomide.Expert opinion: Overall, the occurrence of invasive fungal infections was low, with most infective events reported among patients treated with monoclonal antibodies and fingolimod. Aspergillosis and cryptococcal meningitidis were the most representative fungal infections. Although not common, these infections may be difficult to diagnose and their fatality rate is often high. For this reason, screening protocols for fungal infections must be implemented in the clinical practice when managing patients with MS.
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Affiliation(s)
- R Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - A Reia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - A R Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - M Moccia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - G Viceconte
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - E Pisano
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - E Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - V Brescia Morra
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - I Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
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Bose G, Rush C, Atkins HL, Freedman MS. A real-world single-centre analysis of alemtuzumab and cladribine for multiple sclerosis. Mult Scler Relat Disord 2021; 52:102945. [PMID: 33901969 DOI: 10.1016/j.msard.2021.102945] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/24/2021] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Highly active MS may warrant higher efficacy treatments for disease control. However, these often confer more risk and have not been compared in head-to-head clinical trials, making relative efficacy and safety difficult to interpret. Alemtuzumab and cladribine are two high-efficacy treatments given as discrete courses separated by one year, followed by a durable response that potentially does not require ongoing treatment. Before the approval of oral cladribine, our centre had been treating patients with a bioequivalent intravenous (IV) regimen since 2010. The objective of this study is to report the safety and efficacy data of alemtuzumab and cladribine in a real-world, single centre setting. METHODS We retrospectively reviewed all patients treated with alemtuzumab or cladribine at the Ottawa Hospital MS Clinic with 2 or more years of follow-up. Information on baseline demographic variables, previous treatment, and prior disease activity was collected. Outcomes investigated were "no evidence of disease activity" (NEDA) and its constituents: new clinical relapse, new MRI activity, and Expanded Disability Status Scale (EDSS) progression; as well as any adverse events or treatment discontinuation. We performed univariate and multiple logistic regression to determine differences in 2-year NEDA and time-to-event analyses with Cox regression models to determine factors associated with each outcome through the study period. RESULTS Forty-six patients were treated with alemtuzumab and 65 with cladribine of whom 51 (78%) received the intravenous regimen, followed for a total of 420.1 person-years. The cladribine group was older (p=.0002), with higher baseline EDSS (p=.0015), and more likely secondary progressive (p<.0001). Alemtuzumab had a higher rate of 2-year NEDA than cladribine (OR 4.78, 95%CI: 1.57-14.50, p=.006), but beyond 2 years the difference was not statistically significant (HR 0.50, 95%CI: 0.25-1. 30, p=.061). More prior treatments were associated with lower likelihood of retaining NEDA (HR 1.26, 95%CI: 1.03-1.54, p=.027). Alemtuzumab had more infusion reactions (80% vs. 17%, p<.0001), shingles (22% vs. 2%, p=.005), and secondary autoimmunity (52% vs. 3%, p<.0001) than cladribine, but there was no difference in grade 3 or higher adverse events (21.7% vs. 18.5%, p=1.0). CONCLUSION In our cohort alemtuzumab and cladribine achieved similar rates of NEDA in long-term follow-up, with overall less adverse events with cladribine. Patient registries would allow more robust comparisons, detection of adverse events, and assessment of a durable response.
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Affiliation(s)
- Gauruv Bose
- University of Ottawa and The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa ON K1Y 4E9, Canada.
| | - Carolina Rush
- University of Ottawa and The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital General Campus, Multiple Sclerosis Clinic, 501 Smyth Road, Box 601, Ottawa ON K1H 8L6, Canada.
| | - Harold L Atkins
- University of Ottawa and The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital General Campus, Blood and Marrow Transplant Program, 501 Smyth Road, Box 926, Ottawa, ON K1H 8L6, Canada.
| | - Mark S Freedman
- University of Ottawa and The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital General Campus, Multiple Sclerosis Clinic, 501 Smyth Road, Box 601, Ottawa ON K1H 8L6, Canada.
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30
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Rolfes L, Pfeuffer S, Hackert J, Pawlitzki M, Ruck T, Sondermann W, Korsen M, Wiendl H, Meuth SG, Kleinschnitz C, Pul R. Skin Reactions in Patients With Multiple Sclerosis Receiving Cladribine Treatment. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/3/e990. [PMID: 33837059 PMCID: PMC8042777 DOI: 10.1212/nxi.0000000000000990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/16/2021] [Indexed: 11/15/2022]
Abstract
Objective To report 77 patients with multiple sclerosis (MS) who developed skin-related adverse events (AEs) following treatment with cladribine. Methods We evaluated our prospective bicentric cladribine cohort. Cladribine-treated patients with a skin AE were identified. Results Two hundred thirty-nine cladribine-treated patients with MS were evaluated. Seventy-seven patients (32%) showed at least 1 skin AE at median 1 month after cladribine initiation (range: 1–12). Within first 3 months following last cladribine exposition, hair thinning (n = 28, 12%), skin rash (n = 20; 8%), mucositis (n = 13, 5%), and pruritus (n = 6, 3%) were observed. Furthermore, 35 patients (15%) developed herpes virus infections (time since last cladribine exposition: median 83 [range: 10–305]). In 15 patients, herpes zoster infection was severe (CTCAE grade ≥ 3) and required hospitalization. Delayed skin AEs (≥3 months after a cladribine treatment cycle) involved 1 case of leukocytoclastic vasculitis and 2 cases of alopecia areata. Finally, 2 patients presented with in total 3 isolated precancerous lesions (1 leukoplakia simplex and 2 actinic keratosis) and 1 patient developed a squamous cell carcinoma. Conclusion Skin AEs are common in patients with MS treated with cladribine. Until risk management plans have been adjusted to include these phenomena, clinicians should perform a thorough clinical follow-up and in suspicious cases seek early interdisciplinary support. In light of the observed delayed skin reactions, we further emphasize the necessity of careful clinical surveillance of cladribine-treated patients for yet undescribed secondary autoimmune events. Classification of Evidence This study provides Class IV evidence that skin-related AEs are frequent in patients with MS following cladribine in a real-world setting.
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Affiliation(s)
- Leoni Rolfes
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany.
| | - Steffen Pfeuffer
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Jana Hackert
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Marc Pawlitzki
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Tobias Ruck
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Wiebke Sondermann
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Melanie Korsen
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Heinz Wiendl
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Sven G Meuth
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Christoph Kleinschnitz
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Refik Pul
- From the Department of Neurology (L.R., S.P., M.P., T.R., H.W.), Institute of Translational Neurology, University Hospital of Münster, Germany; Department of Neurology (J.H., C.K., R.P.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Dermatology (W.S.), University Hospital Essen, University Duisburg-Essen, Essen, Germany; and Department of Neurology (M.K., S.G.M.), University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
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Wijburg MT, Warnke C, McGuigan C, Koralnik IJ, Barkhof F, Killestein J, Wattjes MP. Pharmacovigilance during treatment of multiple sclerosis: early recognition of CNS complications. J Neurol Neurosurg Psychiatry 2021; 92:177-188. [PMID: 33229453 DOI: 10.1136/jnnp-2020-324534] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/27/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022]
Abstract
An increasing number of highly effective disease-modifying therapies for people with multiple sclerosis (MS) have recently gained marketing approval. While the beneficial effects of these drugs in terms of clinical and imaging outcome measures is welcomed, these therapeutics are associated with substance-specific or group-specific adverse events that include severe and fatal complications. These adverse events comprise both infectious and non-infectious complications that can occur within, or outside of the central nervous system (CNS). Awareness and risk assessment strategies thus require interdisciplinary management, and robust clinical and paraclinical surveillance strategies. In this review, we discuss the current role of MRI in safety monitoring during pharmacovigilance of patients treated with (selective) immune suppressive therapies for MS. MRI, particularly brain MRI, has a pivotal role in the early diagnosis of CNS complications that potentially are severely debilitating and may even be lethal. Early recognition of such CNS complications may improve functional outcome and survival, and thus knowledge on MRI features of treatment-associated complications is of paramount importance to MS clinicians, but also of relevance to general neurologists and radiologists.
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Affiliation(s)
- Martijn T Wijburg
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands .,Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Clemens Warnke
- Department of Neurology, University Hospital Köln, University of Cologne, Köln, Germany.,Department of Neurology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Christopher McGuigan
- Department of Neurology, St Vincent's University Hospital & University College Dublin, Dublin, Ireland
| | - Igor J Koralnik
- Department of Neurological Sciences, Division of Neuroinfectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Institutes of Neurology and Healthcare Engineering, UCL, London, UK
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mike P Wattjes
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
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Sempere AP, Berenguer-Ruiz L, Borrego-Soriano I, Burgos-San Jose A, Concepcion-Aramendia L, Volar L, Aragones M, Palazón-Bru A. Ocrelizumab in Multiple Sclerosis: A Real-World Study From Spain. Front Neurol 2021; 11:592304. [PMID: 33519676 PMCID: PMC7844090 DOI: 10.3389/fneur.2020.592304] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022] Open
Abstract
Objectives: The aim of this study was to describe the tolerability, safety, and effectiveness of ocrelizumab for primary progressive multiple sclerosis (PPMS) and relapsing multiple sclerosis (RMS) in a clinical practice setting. Methods: In this retrospective observational study, we analyzed clinical and MRI data in all patients with PPMS and RMS who had received at least one infusion of ocrelizumab in two health areas in south-eastern Spain. Patients involved in any ocrelizumab trial and those patients with a follow-up shorter than 6 months were excluded. Results: The cohort included 70 patients (42 women) who had received ocrelizumab; 30% had PPMS and 70%, RMS. At baseline, patients' mean age was 47.1 years in the PPMS group and 39.2 years in the RMS group, while the median EDSS was 3.0 and 2.5, respectively. Median follow-up was 13.6 months. The median number of treatment cycles was three. Most patients remained free from clinical and MRI activity after ocrelizumab initiation. Baseline MRI showed T1 Gd-enhancing lesions in 57% of the patients; by the first MRI control at 4–6 months, all patients except one were free of T1 Gd-enhancing lesions (69/70, 98.6% P < 0.001). The proportion of patients with NEDA was 94% in the group of RMS patients who were followed for at least 1 year. Ocrelizumab was generally well-tolerated; the most common adverse events were infusion-related reactions and infections, none of which were serious. Conclusions: Our real-world study supports the tolerability, safety, and effectiveness of ocrelizumab in clinical practice.
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Affiliation(s)
- Angel P Sempere
- Neurology Service, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.,Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
| | | | - Ines Borrego-Soriano
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
| | - Amparo Burgos-San Jose
- Pharmacy Department, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | | | - Lucian Volar
- Department of Radiology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Miguel Aragones
- Neurology Service, Hospital Marina Baixa, Villajoyosa, Spain
| | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
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The Disease-Modifying Therapies of Relapsing-Remitting Multiple Sclerosis and Liver Injury: A Narrative Review. CNS Drugs 2021; 35:861-880. [PMID: 34319570 PMCID: PMC8354931 DOI: 10.1007/s40263-021-00842-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 02/08/2023]
Abstract
In this narrative review, we analyze pre-registration and post-marketing data concerning hepatotoxicity of all disease-modifying therapies (DMTs) available for the treatment of relapsing-remitting multiple sclerosis, including beta interferon, glatiramer acetate, fingolimod, teriflunomide, dimethyl fumarate, cladribine, natalizumab, alemtuzumab, and ocrelizumab. We review the proposed causal mechanisms described in the literature and we also address issues like use of DMTs in patients with viral hepatitis or liver cirrhosis. Most data emerged in the post-marketing phase by reports to national pharmacovigilance agencies and published case reports or case series. Serious liver adverse events are rare, but exact incidence is largely unknown, as are predictive factors. Unfortunately, none of the DMTs currently available for the treatment of multiple sclerosis is free of potential hepatic toxic effects. Cases of acute liver failure have been reported for beta-interferon, fingolimod, natalizumab, alemtuzumab, and ocrelizumab by different mechanisms (idiosyncratic reaction, autoimmune hepatitis, or viral reactivation). Patients with multiple sclerosis should be informed about possible hepatic side effects of their treatment. Most cases of liver injury are idiosyncratic and unpredictable. The specific monitoring schedule for each DMT has been reviewed and the clinician should be ready to recognize clinical symptoms suggestive for liver injury. Not all DMTs are indicated in cirrhotic patients. For some DMTs, screening for hepatitis B virus and hepatitis C virus is required before starting treatment and a monitoring or antiviral prophylaxis schedule has been established. Beta interferon, glatiramer acetate, natalizumab, and alemtuzumab are relatively contraindicated in autoimmune hepatitis due to the risk of disease exacerbation.
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Jalkh G, Abi Nahed R, Macaron G, Rensel M. Safety of Newer Disease Modifying Therapies in Multiple Sclerosis. Vaccines (Basel) 2020; 9:12. [PMID: 33375365 PMCID: PMC7823546 DOI: 10.3390/vaccines9010012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022] Open
Abstract
In the past decade, the therapeutic arsenal for multiple sclerosis has expanded greatly. Newer more potent disease modifying therapies (DMTs) with varying mechanisms of actions are increasingly used early in the disease course. These newer DMTs include oral therapies (teriflunomide, dimethyl fumarate, fingolimod, siponimod, ozanimod, and cladribine) and infusion therapies (natalizumab, alemtuzumab, and ocrelizumab), and are associated with better control of disease activity and long-term outcomes in patients with MS compared to older injectable therapies (interferon beta and glatiramer acetate). However, they are associated with safety concerns and subsequent monitoring requirements. Adverse events are initially observed in phase 2 and 3 clinical trials, and further long-term data are collected in phase 3 extension studies, case series, and post-marketing reports, which highlight the need to periodically re-evaluate and adjust monitoring strategies to optimize treatment safety in an individualized approach.
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Affiliation(s)
- Georges Jalkh
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Rachelle Abi Nahed
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Dong H, Shen Y, Shen Y, Wu D. Severe Systemic Rash in the Treatment of Hairy Cell Leukemia with Cladribine: Case Report and Literature Review. Int J Gen Med 2020; 13:1187-1192. [PMID: 33239902 PMCID: PMC7682778 DOI: 10.2147/ijgm.s281476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/04/2020] [Indexed: 12/16/2022] Open
Abstract
A 49-year-old male patient who had been diagnosed with variable hairy cell leukemia (HCL-V) was treated with interferon for half a year but exert no obvious effect. After two courses of chemotherapy with cladribine, he achieved remission, and splenomegaly significantly improved (the length in craniocaudal dimension decreased from 15.8cm to 11.8cm). Four years later, the patient got disease relapse and was recommended for another cycle of cladribine (6mg for 7 days). On the last day of cladribine, the patient developed fever with needle-like red rashes on the face, limbs, and trunk. At the very beginning, the rash was lighter in color, sparsely distributed, and without obvious itching. Three days later, the rash gradually darkened, expanded and merged, with itching. With the application of high dose gamma globulin and corticosteroids (prednisolone combined with dexamethasone), the rash finally faded, and the patient was discharged. Rash caused by cladribine is not uncommon, such serious and widespread drug-induced rash is rare, and there are few reports. This article reviewed relevant studies and treatments.
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Affiliation(s)
- Huijie Dong
- First Clinical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, People's Republic of China
| | - Yingying Shen
- First Clinical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, People's Republic of China.,Department of Hematology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310006, People's Republic of China
| | - Yiping Shen
- First Clinical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, People's Republic of China.,Department of Hematology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310006, People's Republic of China
| | - Dijiong Wu
- First Clinical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, People's Republic of China.,Department of Hematology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310006, People's Republic of China
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Biernacki T, Sandi D, Bencsik K, Vécsei L. Medicinal Chemistry of Multiple Sclerosis: Focus on Cladribine. Mini Rev Med Chem 2020; 20:269-285. [PMID: 31644403 DOI: 10.2174/1389557519666191015201755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 04/28/2019] [Accepted: 05/19/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the recent years, many novel Disease-Modifying Drugs (DMD) have been introduced to the market in the treatment of multiple sclerosis. OBJECTIVES To provide the reader with an up to date, compact review on the pharmacokinetic properties, mechanism of action, and clinical attributes of one of the most recently approved drugs in the therapy of multiple sclerosis, cladribine. CONCLUSION Cladribine tablets proved to be a highly efficient treatment choice for Relapsing- Remitting Multiple Sclerosis (RRMS), especially for patients with high disease activity. It is the first DMD for MS with a complex mechanism of action, by inhibiting the adenosine-deaminase enzyme it increases the intracellular levels of deoxyadenosine triphosphate, which with relative selectivity depletes both T- and B-cells lines simultaneously. However long term follow-up safety and effectiveness data are still missing, and clear treatment protocols are lacking beyond the first two treatment years cladribine should prove to be a valuable addition to the therapeutic palette of RRMS, and potentially for Clinically Isolated Syndrome (CIS) as well.
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Affiliation(s)
- Tamás Biernacki
- Department of Neurology, Szent-Gyorgyi Albert Clinical Center, University of Szeged, Szeged, Hungary
| | - Dániel Sandi
- Department of Neurology, Szent-Gyorgyi Albert Clinical Center, University of Szeged, Szeged, Hungary
| | - Krisztina Bencsik
- Department of Neurology, Szent-Gyorgyi Albert Clinical Center, University of Szeged, Szeged, Hungary
| | - László Vécsei
- Department of Neurology, Szent-Gyorgyi Albert Clinical Center, University of Szeged, Szeged, Hungary.,MTA-SZTE Neuroscience Research Group, Szeged, Hungary
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Findling O, Sellner J. Second-generation immunotherapeutics in multiple sclerosis: can we discard their precursors? Drug Discov Today 2020; 26:416-428. [PMID: 33248250 DOI: 10.1016/j.drudis.2020.11.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/18/2020] [Accepted: 11/17/2020] [Indexed: 12/27/2022]
Abstract
Options for disease-modifying therapies in multiple sclerosis have increased over the past two decades. Among these innovations are interferon-β, glatiramer acetate, fumaric acid and dihydroorotate dehydrogenase inhibitors, an antibody targeting the migration of immune cells, a compound that traps immune cells in lymphoid organs by sphingosine 1-phosphate receptor (S1PR) modulation and immune-reconstitution therapies. Second-generation drugs such as pegylated interferon-β, advanced CD20 depleting antibodies, more-specific S1PR modulators and new formulations have been developed to achieve higher efficacy while exhibiting fewer side effects. In this review, we address the shortcomings of the parent drugs, present the pros and cons of the second-generation therapies and summarize upcoming developments in the field of immunotherapy for multiple sclerosis.
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Affiliation(s)
- Oliver Findling
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland; Department of Neurology, University Hospital Tulln, Karl-Landsteiner-University, Tulln, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria; Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany.
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Severe lymphopenia after subcutaneous cladribine in a patient with multiple sclerosis: To vaccinate or not? eNeurologicalSci 2020; 21:100279. [PMID: 33163633 PMCID: PMC7599429 DOI: 10.1016/j.ensci.2020.100279] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/07/2020] [Accepted: 09/30/2020] [Indexed: 12/25/2022] Open
Abstract
Objective To describe a fatal case of influenza A pneumonia in a patient with severe lymphopenia after receiving subcutaneous cladribine to treat her multiple sclerosis (MS). Methods Case report. Results A 53-year-old woman developed fatal influenza pneumonia associated with grade 4 lymphopenia two months after receiving a total dose of 60mg subcutaneous cladribine. Despite treatment with oseltamivir, her condition deteriorated and the patient passed away after developing respiratory failure. Conclusion Cladribine-related lymphopenia is usually mild to moderate, however severe lymphopenia may occur. People with MS, especially those who are immunosuppressed, should be offered the inactivated influenza vaccine annually. We report a case of lethal influenza A infection with severe lymphopenia in an MS patient receiving s.c. cladribine. Cladribine-related lymphopenia is usually mild to moderate, however severe lymphopenia may occur. Annual influenza immunisation should be recommended for people with MS, especially those who are immunosuppressed.
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Zrzavy T, Wimmer I, Rommer PS, Berger T. Immunology of COVID-19 and disease-modifying therapies: The good, the bad and the unknown. Eur J Neurol 2020; 28:3503-3516. [PMID: 33090599 PMCID: PMC7675490 DOI: 10.1111/ene.14578] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/04/2020] [Indexed: 01/08/2023]
Abstract
Objective The outbreak of the SARS‐CoV‐2 pandemic, caused by a previously unknown infectious agent, posed unprecedented challenges to healthcare systems and unmasked their vulnerability and limitations worldwide. Patients with long‐term immunomodulatory/suppressive therapies, as well as their physicians, were and are concerned about balancing the risk of infection and effects of disease‐modifying therapy. Over the last few months, knowledge regarding SARS‐CoV‐2 has been growing tremendously, and the first experiences of infections in patients with multiple sclerosis (MS) have been reported. Methods This review summarizes the currently still limited knowledge about SARS‐CoV‐2 immunology and the commonly agreed modes of action of approved drugs in immune‐mediated diseases of the central nervous system (MS and neuromyelitis optica spectrum disorder). Specifically, we discuss whether immunosuppressive/immunomodulatory drugs may increase the risk of SARS‐CoV‐2 infection and, conversely, may decrease the severity of a COVID‐19 disease course. Results At present, it can be recommended in general that none of those therapies with a definite indication needs to be stopped per se. A possibly increased risk of infection for most medications is accompanied by the possibility to reduce the severity of COVID‐19. Conclusions Despite the knowledge gain over the last few months, current evidence remains limited, and, thus, further clinical vigilance and systematic documentation is essential.
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Affiliation(s)
- Tobias Zrzavy
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Isabella Wimmer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Kleiter I, Ayzenberg I, Havla J, Lukas C, Penner IK, Stadelmann C, Linker RA. The transitional phase of multiple sclerosis: Characterization and conceptual framework. Mult Scler Relat Disord 2020; 44:102242. [DOI: 10.1016/j.msard.2020.102242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/17/2020] [Accepted: 05/24/2020] [Indexed: 10/24/2022]
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Advani D, Gupta R, Tripathi R, Sharma S, Ambasta RK, Kumar P. Protective role of anticancer drugs in neurodegenerative disorders: A drug repurposing approach. Neurochem Int 2020; 140:104841. [PMID: 32853752 DOI: 10.1016/j.neuint.2020.104841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/24/2020] [Accepted: 08/18/2020] [Indexed: 12/13/2022]
Abstract
The disease heterogeneity and little therapeutic progress in neurodegenerative diseases justify the need for novel and effective drug discovery approaches. Drug repurposing is an emerging approach that reinvigorates the classical drug discovery method by divulging new therapeutic uses of existing drugs. The common biological background and inverse tuning between cancer and neurodegeneration give weight to the conceptualization of repurposing of anticancer drugs as novel therapeutics. Many studies are available in the literature, which highlights the success story of anticancer drugs as repurposed therapeutics. Among them, kinase inhibitors, developed for various oncology indications evinced notable neuroprotective effects in neurodegenerative diseases. In this review, we shed light on the salient role of multiple protein kinases in neurodegenerative disorders. We also proposed a feasible explanation of the action of kinase inhibitors in neurodegenerative disorders with more attention towards neurodegenerative disorders. The problem of neurotoxicity associated with some anticancer drugs is also highlighted. Our review encourages further research to better encode the hidden potential of anticancer drugs with the aim of developing prospective repurposed drugs with no toxicity for neurodegenerative disorders.
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Affiliation(s)
- Dia Advani
- Department of Biotechnology, Molecular Neuroscience and Functional Genomics Laboratory, Room# FW4TF3, Mechanical Engineering Building, Shahbad Daulatpur, Bawana Road, Delhi, 110042, India
| | - Rohan Gupta
- Department of Biotechnology, Molecular Neuroscience and Functional Genomics Laboratory, Room# FW4TF3, Mechanical Engineering Building, Shahbad Daulatpur, Bawana Road, Delhi, 110042, India
| | - Rahul Tripathi
- Department of Biotechnology, Molecular Neuroscience and Functional Genomics Laboratory, Room# FW4TF3, Mechanical Engineering Building, Shahbad Daulatpur, Bawana Road, Delhi, 110042, India
| | - Sudhanshu Sharma
- Department of Biotechnology, Molecular Neuroscience and Functional Genomics Laboratory, Room# FW4TF3, Mechanical Engineering Building, Shahbad Daulatpur, Bawana Road, Delhi, 110042, India
| | - Rashmi K Ambasta
- Department of Biotechnology, Molecular Neuroscience and Functional Genomics Laboratory, Room# FW4TF3, Mechanical Engineering Building, Shahbad Daulatpur, Bawana Road, Delhi, 110042, India
| | - Pravir Kumar
- Department of Biotechnology, Molecular Neuroscience and Functional Genomics Laboratory, Room# FW4TF3, Mechanical Engineering Building, Shahbad Daulatpur, Bawana Road, Delhi, 110042, India.
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De Angelis M, Petracca M, Lanzillo R, Brescia Morra V, Moccia M. Mild or no COVID-19 symptoms in cladribine-treated multiple sclerosis: Two cases and implications for clinical practice. Mult Scler Relat Disord 2020; 45:102452. [PMID: 32823148 PMCID: PMC7428688 DOI: 10.1016/j.msard.2020.102452] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/15/2020] [Indexed: 01/19/2023]
Abstract
Background The use of disease-modifying therapies (DMTs) in multiple sclerosis (MS) could affect COVID-19 outcomes by modulating the immune response, which, in turn, might favor viral replication and/or confer protection from COVID-19 induced inflammatory response Case report We report on two MS patients treated with cladribine, with heterogeneous demographics and clinical features, who developed mild or no symptoms from COVID-19 and produced anti-SARS-CoV-2 antibodies, notwithstanding low lymphocyte levels. Implications Benign COVID-19 clinical course and anti-SARS-CoV-2 antibody production can occur in MS patients with lymphopenia, suggesting the possibility to respond to COVID-19 vaccination, once available, in this vulnerable population.
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Affiliation(s)
- Marcello De Angelis
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Maria Petracca
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Roberta Lanzillo
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Marcello Moccia
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy.
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Risiken und Chancen von Immuntherapien in Zeiten der Coronavirus-2019-Pandemie. DGNEUROLOGIE 2020. [PMCID: PMC7284681 DOI: 10.1007/s42451-020-00205-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Immuntherapien stellen die essenzielle Grundlage der Behandlung von neuroinflammatorischen Erkrankungen dar. In Zeiten der Coronavirus-2019 (COVID-19)-Pandemie ergibt sich im klinischen Alltag jedoch zunehmend die Frage, ob eine Immuntherapie bei neurologischen Patienten aufgrund des potenziellen Infektionsrisikos eingeleitet, intensiviert, pausiert oder gar beendet werden sollte. Unsicherheit besteht v. a. deshalb, weil verschiedene nationale und internationale Fachgesellschaften diesbezüglich unterschiedliche Empfehlungen veröffentlichten. In diesem Artikel soll ein Überblick über die Wirkmechanismen von Immuntherapien und den daraus abzuleitenden Infektionsrisiken in Bezug auf COVID-19 (durch den Coronavirus verursachte Erkrankung) gegeben werden. Potenzielle Chancen und vorteilhafte Effekte einzelner Substrate in der Akuttherapie von COVID-19 werden diskutiert.
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Moccia M, Lanzillo R, Petruzzo M, Nozzolillo A, De Angelis M, Carotenuto A, Palladino R, Brescia Morra V. Single-Center 8-Years Clinical Follow-Up of Cladribine-Treated Patients From Phase 2 and 3 Trials. Front Neurol 2020; 11:489. [PMID: 32625161 PMCID: PMC7311570 DOI: 10.3389/fneur.2020.00489] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/04/2020] [Indexed: 01/09/2023] Open
Abstract
Background: Cladribine is approved for the treatment of highly-active relapsing multiple sclerosis (MS), where it is also effective on disability progression. In the present single-center study, we aim to report on the 8-years clinical follow-up of 27 patients included in phase 2 and 3 clinical trials for cladribine. Methods: We included patients exposed to cladribine (n = 13) or placebo (n = 14) in ONWARD, CLARITY, and ORACLE-MS trials, and followed-up at the same center after trial termination. Outcomes of long-term disease progression were recorded. Results: During 8-year follow-up, patients treated with cladribine presented with reduced risk of EDSS progression (HR = 0.148; 95%CI = 0.031, 0.709; p = 0.017), of reaching EDSS 6.0 (HR = 0.115; 95%CI = 0.015, 0.872; p = 0.036), and of SP conversion (HR = 0.010; 95%CI = 0.001, 0.329; p = 0.010), when compared with placebo. Conclusions: Our exploratory study provides additional evidence that cladribine may be useful to prevent or, at least, mitigate the risk of disability progression after 8 years.
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Affiliation(s)
- Marcello Moccia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Center, Federico II University, Naples, Italy
| | - Roberta Lanzillo
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Center, Federico II University, Naples, Italy
| | - Martina Petruzzo
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Center, Federico II University, Naples, Italy
| | - Agostino Nozzolillo
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Center, Federico II University, Naples, Italy
| | - Marcello De Angelis
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Center, Federico II University, Naples, Italy
| | - Antonio Carotenuto
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Center, Federico II University, Naples, Italy
| | - Raffaele Palladino
- Department of Primary Care and Public Health, Imperial College, London, United Kingdom.,Department of Public Health, Federico II University, Naples, Italy
| | - Vincenzo Brescia Morra
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Center, Federico II University, Naples, Italy
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Cladribine Treatment Improved Homocysteine Metabolism and Increased Total Serum Antioxidant Activity in Secondary Progressive Multiple Sclerosis Patients. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:1654754. [PMID: 32256946 PMCID: PMC7103043 DOI: 10.1155/2020/1654754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/02/2020] [Accepted: 02/18/2020] [Indexed: 11/17/2022]
Abstract
Hyperhomocysteinemia plays a crucial role in the pathogenesis of many diseases of the central nervous system (CNS). The nervous system is particularly sensitive to high homocysteine (Hcy) level mainly due to its prooxidative and cytotoxic effects. Cladribine, a drug recently registered for the treatment of multiple sclerosis (MS), possesses additionally neuroprotective effects which are independent of its peripheral immunosuppressant action. Accumulating evidence suggests that oxidative stress and homocysteine thiolactone-mediated protein homocysteinylation play a causal role in MS. Both of these processes may be attenuated by paraoxonase 1 (PON1). Therefore, in the present study, we aimed to examine whether the beneficial effects of the drug in MS patients with a secondary progressive (SP) clinical course, treated with cladribine subcutaneously (s.c.), may be related to its ability to modify serum PON1 activity, Hcy concentration, and protein homocysteinylation, as well as to correct total antioxidant status. A total of 118 subjects were enrolled into the study: (1) patients with a SP type of MS, SP-MS (n = 40); (2) patients with a relapsing-remitting (RR) type of MS, RR-MS (n = 30); and (3) healthy people (n = 48). Patients with SP-MS were treated with cladribine. The drug was given in SP-SM patients s.c. six times every 6 weeks up to a total mean cumulative dose of 1.8 mg/kg. PON1 activity was assessed spectrophotometrically. The level of Hcy, homocysteine thiolactone (HTL) attached to plasma proteins (N-Hcy-protein), and antibodies against homocysteinylated proteins was assessed with an enzyme immunoassay. The total antioxidant activity of the serum was assessed with the ferric-reducing activity of plasma (FRAP) method. Basically, there was no difference in PON1 activity between untreated SP-MS, RR-MS, and control subjects. Serum Hcy was significantly higher in RR-MS patients (p < 0.001) and in SP-MS patients (p < 0.01) compared to the control group. The N-Hcy protein level was higher in RR-MS patients (p < 0.05) in comparison to the control group. Moreover, the elevated level of antibodies against homocysteinylated proteins was observed in the serum of patients with SP-MS. The total antioxidant capacity of serum was lower in MS patients vs. the control group (p < 0.001). After cladribine treatment, the activity of PON1 did not change in SP-MS patients, whereas cladribine treatment decreased the level of total Hcy (p < 0.05). Treatment with cladribine increased the total serum antioxidant activity in SP-MS patients (p < 0.01). The Expanded Disability Status Scale (EDSS) score did not change in SP-MS patients. Cladribine treatment in the SP-MS group attenuates hyperhomocysteinemia-induced protein homocysteinylation (n.s.). It also stabilises the neurological condition of SP-MS patients. The stabilisation of a neurological condition observed in SP-MS patients after cladribine treatment may be partially related to its ability to reduce elevated Hcy level and to improve serum antioxidant potential.
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Alshamrani F, Alnajashi H, Almuaigel MF. Efficacy and Safety of Intravenous Cladribine in Patients with Rapidly Evolving or Early Secondary Progressive Multiple Sclerosis. Cureus 2020; 12:e6995. [PMID: 32206459 PMCID: PMC7077152 DOI: 10.7759/cureus.6995] [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] [Indexed: 11/24/2022] Open
Abstract
Background Multiple sclerosis (MS) is an autoimmune and demyelinating inflammatory disease that affects the central nervous system (CNS). The etiology of the disease remains unknown. Multiple theories highlight genetic, environmental, and infectious factors that may a role. MS is considered as the main cause of disability in young people. Cladribine, known chemically as (2-Chloro-2′-deoxyadenosine), is a purine analog chemotherapy used for hairy cell leukemia and other B-cell lymphomas. The goal of this study was to evaluate the safety and efficacy of cladribine in patients with rapidly evolving or early secondary progressive MS. Methods This observational, single-center, retrospective chart review at the MS Clinic in the Ottawa General Hospital, Ottawa, Canada. A total of 24 patients (median Expanded Disability Status Scale (EDSS) of 4.5) received cladribine (0.07 mg/kg/day) for four consecutive days every six months for ≥ 2 cycles with further cycles depending on lymphocyte recovery or disease activity to a maximum of eight cycles from 2005 until 2016 were included. Four patients who were already diagnosed with rapidly evolving or early secondary progressive multiple sclerosis (SPMS) were induced with cladribine. We evaluated relapse, EDSS, and magnetic resonance imaging (MRI) results. Results Out of 24 patients (ages ranging from 30 - 60), 80% were female. Median follow-up time was seven years. The mean relapse rate in the two years before patients were given cladribine was 1.25. Twenty patients had previously received multiple disease-modifying therapies (DMTs) (≥ 2) prior to receiving cladribine. Following cladribine, eight patients suffered 10 relapses (33.3% of the cohort). Annualized relapse rates (ARRs) were reduced from 1.25 to 0.42, which was statistically significant (p-value = 0.002). There was no mean difference in EDSS (p-value = 0.06): 16% deteriorated, 62% did not change, and 12.5% improved. New MRI activity (new T2 or Gad+ lesions) was noted in only seven of 24 patients. Conclusion Parenteral cladribine reduced the relapse rate from 1.25 to 0.42, which was statistically significant (p-value = 0.002). MRI activity in patients with rapidly evolving or early secondary progressive multiple sclerosis had a reasonable safety profile.
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Affiliation(s)
- Foziah Alshamrani
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, SAU
| | - Hind Alnajashi
- Department of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Mohammed F Almuaigel
- Department of Medical Education, College of Medicine, King Faisal University, Al-Ahsa, SAU
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Tintore M, Vidal-Jordana A, Sastre-Garriga J. Treatment of multiple sclerosis - success from bench to bedside. Nat Rev Neurol 2020; 15:53-58. [PMID: 30315270 DOI: 10.1038/s41582-018-0082-z] [Citation(s) in RCA: 182] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The modern era of multiple sclerosis (MS) treatment began 25 years ago, with the approval of IFNβ and glatiramer acetate for the treatment of relapsing-remitting MS. Ten years later, the first monoclonal antibody, natalizumab, was approved, followed by a third important landmark with the introduction of oral medications, initially fingolimod and then teriflunomide, dimethyl fumarate and cladribine. Concomitantly, new monoclonal antibodies (alemtuzumab and ocrelizumab) have been developed and approved. The modern era of MS therapy reached primary progressive MS in 2018, with the approval of ocrelizumab. We have also learned the importance of starting treatment early and the importance of clinical and MRI monitoring to assess treatment response and safety. Treatment decisions should account for disease phenotype, prognostic factors, comorbidities, the desire for pregnancy and the patient's preferences in terms of acceptable risk. The development of treatment for MS during the past 25 years is a fantastic success of translational medicine.
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Affiliation(s)
- Mar Tintore
- Centre d'Esclerosi Múltiple de Catalunya, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Angela Vidal-Jordana
- Centre d'Esclerosi Múltiple de Catalunya, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Centre d'Esclerosi Múltiple de Catalunya, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Bose G, Freedman MS. Precision medicine in the multiple sclerosis clinic: Selecting the right patient for the right treatment. Mult Scler 2020; 26:540-547. [DOI: 10.1177/1352458519887324] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory disease of the central nervous system (CNS), affecting patients of all ages, causing neurologic disability if inadequately treated. Some patients have a relatively benign disease course without significant disability after decades, while a more aggressive course ensues in others and disability progression occurs after only several years. Certain risk factors confer a higher chance of a patient having aggressive MS. Currently over 15 disease-modifying treatments (DMTs) are approved for MS with different efficacy and safety profiles. Deciding which DMT to use in a specific patient requires a careful analysis of a patient’s disease course for high-risk factors for early progression, consideration of the efficacy and safety profile for potential therapy, as well as understanding of a patient’s lifestyle and expectations. The integration of these factors is the art of precision medicine, a necessary practice in the treatment of patients with MS.
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Affiliation(s)
- Gauruv Bose
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada/Division of Neurology, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mark S Freedman
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada/Division of Neurology, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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Cladribine for people with multiple sclerosis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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