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Yoshii F, Moriya Y, Ohnuki T, Ryo M, Takahashi W. Neurological safety of fingolimod: An updated review. ACTA ACUST UNITED AC 2017; 8:233-243. [PMID: 28932291 PMCID: PMC5575715 DOI: 10.1111/cen3.12397] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/23/2017] [Accepted: 05/08/2017] [Indexed: 12/16/2022]
Abstract
Fingolimod (FTY) is the first oral medication approved for treatment of relapsing–remitting multiple sclerosis (RRMS). Its effectiveness and safety were confirmed in several phase III clinical trials, but proper evaluation of safety in the real patient population requires long‐term post‐marketing monitoring. Since the approval of FTY for RRMS in Japan in 2011, it has been administered to approximately 5000 MS patients, and there have been side‐effect reports from 1750 patients. Major events included infectious diseases, hepatobiliary disorders, nervous system disorders and cardiac disorders. In the present review, we focus especially on central nervous system adverse events. The topics covered are: (i) clinical utility of FTY; (ii) safety profile; (iii) post‐marketing adverse events in Japan; (iv) white matter (tumefactive) lesions; (v) rebound after FTY withdrawal; (vi) relationship between FTY and progressive multifocal leukoencephalopathy; (vii) FTY and progressive multifocal leukoencephalopathy‐related immune reconstitution inflammatory syndrome; and (viii) neuromyelitis optica and leukoencephalopathy.
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Affiliation(s)
- Fumihito Yoshii
- Department of Neurology Saiseikai Hiratsuka Hospital Hiratsuka Japan.,Department of Neurology Tokai University Oiso Hospital Oiso Japan
| | - Yusuke Moriya
- Department of Neurology Tokai University Oiso Hospital Oiso Japan
| | - Tomohide Ohnuki
- Department of Neurology Tokai University Oiso Hospital Oiso Japan
| | - Masafuchi Ryo
- Department of Neurology Tokai University Oiso Hospital Oiso Japan
| | - Wakoh Takahashi
- Department of Neurology Tokai University Oiso Hospital Oiso Japan
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Abstract
Multiple sclerosis (MS) is the most common disabling neurologic disease of young adults. There are now 16 US Food and Drug Administration (FDA)-approved disease-modifying therapies for MS as well as a cohort of other agents commonly used in practice when conventional therapies prove inadequate. This article discusses approved FDA therapies as well as commonly used practice-based therapies for MS, as well as those therapies that can be used in patients attempting to become pregnant, or in patients with an established pregnancy, who require concomitant treatment secondary to recalcitrant disease activity.
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González-Suarez I, Rodríguez de Antonio L, Orviz A, Moreno-García S, Valle-Arcos MD, Matias-Guiu JA, Valencia C, Jorquera Moya M, Oreja-Guevara C. Catastrophic outcome of patients with a rebound after Natalizumab treatment discontinuation. Brain Behav 2017; 7:e00671. [PMID: 28413713 PMCID: PMC5390845 DOI: 10.1002/brb3.671] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/30/2017] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Natalizumab (NTZ) is an effective drug for the treatment of relapsing-remitting multiple sclerosis. In some patients discontinuation is mandatory due to the risk of progressive multifocal leukoencephalopathy. However, severe clinical and radiological worsening has been described after drug cessation. Our aim was to describe the clinical and radiological features of the rebound phenomenon. MATERIAL AND METHODS Patients switched from NTZ to Fingolimod (FTY) who had presented a rebound after discontinuation were selected. Clinical and magnetic resonance imaging (MRI) data were collected. RESULTS Four JC virus positive patients were included. The mean disease duration was 9.5 years (SD: 4.12) with a mean time of 3.1 years on NTZ. All patients started FTY within 3-4 months. Neurological deterioration started in a mean time of 3.5 months (SD: 2.08) with multifocal involvement: 75% motor disturbances, 50% cognitive impairment, 25% seizures. The average worsening in Expanded Disability Status Scale [EDSS] was of 3.25 points (SD: 2.33). The MRI showed a very large increase in T2 and gadolinium-enhanced lesions (mean: 23.67, SD: 18.58). All patients received 5 days of IV methylprednisolone, one patient required plasma exchange. All the patients presented neurological deterioration with an EDSS worsening of 1.13 points (SD: 0.48). After the rebound three patients continued treatment with FTY, only one patient restarted NTZ. CONCLUSION Discontinuation of NTZ treatment may trigger a severe rebound with marked clinical and radiological worsening. A very careful evaluation of benefit-risk should be considered before NTZ withdrawal, and a close monitoring and a short washout period is recommended after drug withdrawal.
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Affiliation(s)
- Inés González-Suarez
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | | | - Aida Orviz
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | - Sara Moreno-García
- Demyelinating Disease Unit Neurology Department Hospital Universitario 12 de Octubre Madrid Spain
| | - María D Valle-Arcos
- Demyelinating Disease Unit Neurology Department Hospital Universitario 12 de Octubre Madrid Spain
| | - Jordi A Matias-Guiu
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | - Cristina Valencia
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | | | - Celia Oreja-Guevara
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
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Fagius J, Feresiadou A, Larsson EM, Burman J. Discontinuation of disease modifying treatments in middle aged multiple sclerosis patients. First line drugs vs natalizumab. Mult Scler Relat Disord 2017; 12:82-87. [PMID: 28283113 DOI: 10.1016/j.msard.2017.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/29/2016] [Accepted: 01/13/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Several disease-modifying drugs (DMD) are available for the treatment of MS, and most patients with relapsing-remitting disease are currently treated. Data on when and how DMD treatment can be safely discontinued are scarce. METHODS Fifteen MS patients, treated with natalizumab for >5 years without clinical and radiological signs of inflammatory disease activity, suspended treatment and were monitored with MRI examinations and clinical follow-up to determine recurrence of disease activity. This group was compared with a retrospectively analysed cohort comprising 55 MS patients treated with first-line DMDs discontinuing therapy in the time period of 1998-2015 after an analogous stable course. RESULTS Natalizumab discontinuers were followed for on average 19 months, and follow-up data for 56 months were available for first-line DMD quitters. Two-thirds of natalizumab treated patients experienced recurrent inflammatory disease activity, and one third had recurrence of rebound character. In contrast, 35% of first-line DMD quitters had mild recurrent disease activity, and no one exhibited rebound. CONCLUSIONS Withdrawal of a first-line DMD after prolonged treatment in middle-aged MS patients with stable disease appears to be relatively safe, while natalizumab withdrawal in a similar group of patients cannot be safely done without starting alternative therapy.
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Affiliation(s)
- Jan Fagius
- Department of Neuroscience, Uppsala University, Uppsala, Sweden.
| | | | - Elna-Marie Larsson
- Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
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Villaverde-González R, Gracia Gil J, Pérez Sempere A, Millán Pascual J, Marín Marín J, Carcelén Gadea M, Gabaldón Torres L, Moreno Escribano A, Candeliere Merlicco A. Observational Study of Switching from Natalizumab to Immunomodulatory Drugs. Eur Neurol 2017; 77:130-136. [PMID: 28052269 DOI: 10.1159/000453333] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 11/07/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine the effect of disease-modifying drugs (DMDs) on disease activity rebound in patients discontinuing natalizumab (NTZ). METHODS Twenty-one patients with relapsing-remitting multiple sclerosis (RRMS) treated with NTZ for ≥1 year and who switched to DMDs (glatiramer acetate [GA] or interferon) were followed up for 12 months in clinical practice. Clinical outcomes after NTZ cessation were assessed every 3 months for 1 year and MRI was performed at 12 months. RESULTS Twelve months after switching from NTZ to DMDs, there were no significant differences in the annualized relapse rate (ARR) compared to the days that NTZ was used (0.3 vs. 0.1; p = 0.083); and the ARR never reached similar values to those prior to NTZ use (1.61; p < 0.001). The percentage of relapse-free patients after switching from NTZ was 71.4%. These patients did not have lower disease activity before NTZ compared with those with clinical relapses (1.3 vs. 1.7; p = 0.302), but they had lower Expanded Disability Status Scale scores (3.4 vs. 5.7; p = 0.001). DMDs had beneficial effects on MRI parameters, as 10 of 16 patients (62.5%) presented no evidence of radiological activity 12 months after NTZ discontinuation. CONCLUSIONS Patients with RRMS and moderate disability who discontinued NTZ for safety reasons may benefit from the DMDs GA and interferon with no known risk for progressive multifocal leukoencephalopathy.
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Abstract
Natalizumab is a monoclonal antibody that acts as an α4 integrin antagonist to prevent leukocyte trafficking into the central nervous system. It is US Food and Drug Administration (FDA) approved for the treatment of relapsing-remitting multiple sclerosis (RRMS). Natalizumab demonstrated high efficacy in Phase III trials by reducing the annualized relapse rate, preventing multiple sclerosis (MS) lesion accumulation on magnetic resonance imaging, and decreasing the probability of sustained progression of disability. The leading safety concern with natalizumab is its association with progressive multifocal leukoencephalopathy (PML), a rare brain infection typically seen only in severely immunocompromised patients caused by reactivation of the John Cunningham virus (JCV). Careful analysis of risk factors for PML in natalizumab-treated MS patients, specifi-cally the presence of anti-JCV antibodies, has led to risk mitigation strategies to improve safety. Additional biomarkers are under investigation to further aid risk stratification. Natalizumab's high efficacy and favorable tolerability profile have led to a broad use by MS physicians, as both first-and second-line treatments. This review discusses the natalizumab efficacy, safety, and tolerability and finishes with pragmatic considerations regarding its use in clinical practice.
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Affiliation(s)
- Rachel Brandstadter
- Department of Neurology, Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilana Katz Sand
- Department of Neurology, Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Boudot de la Motte M, Louapre C, Bertrand A, Reach P, Lubetzki C, Papeix C, Maillart E. Extensive white matter lesions after 2 years of fingolimod: Progressive multifocal leukoencephalopathy or MS relapse? Mult Scler 2016; 23:614-616. [PMID: 28273764 DOI: 10.1177/1352458516682858] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Fingolimod is a widely used treatment for highly active relapsing-remitting multiple sclerosis. OBJECTIVES To describe the case of a 27-year-old patient treated for more than 2 years by Fingolimod, who presented hemiplegia and speech disturbances associated with extensive white matter lesions on brain magnetic resonance imaging (MRI). METHODS Case study. RESULTS Although initial presentation questioned the possibility of progressive multifocal leukoencephalopathy, final diagnosis was multiple sclerosis (MS) relapse. Appropriate treatment resulted in clinical and radiological improvement. CONCLUSION Severe MS relapses under Fingolimod have been reported, but late onset after treatment initiation and extensive subcortical topography is unusual and represents a diagnostic challenge.
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Affiliation(s)
| | - Céline Louapre
- Neurology Department, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Anne Bertrand
- Diagnostic and Functional Neuroradiology Department, Pitié-Salpêtrière Hospital, APHP, Paris, France/Inserm U1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Inria Paris-Rocquencourt, Paris, France
| | - Pauline Reach
- Neurology Department, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | | | - Caroline Papeix
- Neurology Department, Pitié-Salpêtrière Hospital, APHP, Paris, France
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Papeix C, Vukusic S, Casey R, Debard N, Stankoff B, Mrejen S, Uhry Z, Van Ganse E, Castot A, Clanet M, Lubetzki C, Confavreux C. Risk of relapse after natalizumab withdrawal: Results from the French TYSEDMUS cohort. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e297. [PMID: 27844037 PMCID: PMC5087255 DOI: 10.1212/nxi.0000000000000297] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/23/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess disease activity within 12 months after natalizumab (NZ) discontinuation in a large French postmarketing cohort. METHODS In France, patients exposed at least once to NZ were included in the TYSEDMUS observational and multicenter cohort, part of the French NZ Risk Management Plan. Clinical disease activity during the year following NZ discontinuation was assessed in this cohort. Time to first relapse after NZ stop was analyzed using Kaplan-Meier method and potentially associated factors were studied using a multivariate Cox model. RESULTS Out of the 4,055 patients with multiple sclerosis (MS) included in TYSEDMUS, 1,253 discontinued NZ and 715 of them had relevant data for our study. The probability of relapse within the year after NZ stop was estimated at 45% (95% confidence interval 0.41-0.49). CONCLUSIONS This large and systematic survey of patients with MS after NZ withdrawal allows quantifying the risk of increased disease activity following treatment discontinuation. This study provides large-scale, multicenter, systematic data after NZ cessation in real-life settings.
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Affiliation(s)
- Caroline Papeix
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Sandra Vukusic
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Romain Casey
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Nadine Debard
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Bruno Stankoff
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Serge Mrejen
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Zoe Uhry
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Eric Van Ganse
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Anne Castot
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Michel Clanet
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Catherine Lubetzki
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
| | - Christian Confavreux
- Neurology Department (C.P., S.M., C.L.), Pitié-Salpêtrière Hospital, Paris; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer (S.V., C.C.), and Neuro-epidemiology and Pharmaco-epidemiology (E.V.G.), Hospices Civils de Lyon, Lyon/Bron; Centre des Neurosciences de Lyon (S.V., C.C.), INSERM 1028 et CNRS UMR5292, Equipe Neuro-oncologie et Neuro-inflammation; Université de Lyon (S.V., C.C.); Observatoire Français de la Sclérose en Plaques (R.C., N.D., Z.U.), Bron; Neurology Department (B.S.), Saint Antoine Hospital, Paris; Agence Nationale de Sécurité des Médicaments (ANSM, formerly Agence Française de Sécurité Sanitaire des Produits de Santé-AFSSAPS) (A.C.), Saint-Denis; and Neurology Department (M.C.), Purpan Hospital, Toulouse, France
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Endo H, Chihara N, Sekiguchi M D K, Kowa H, Kanda F, Toda T. [A case of multiple sclerosis who relapsed early after fingolimod therapy introduced]. Rinsho Shinkeigaku 2016; 55:417-20. [PMID: 26103815 DOI: 10.5692/clinicalneurol.cn-000515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The patient was a 46-year-old woman having a history of multiple sclerosis (MS) for 14 years. She had been treated with interferon β-1b since 2001, but discontinued because of psychiatric problems in 2006. Thereafter relapses were observed 1-2 times a year, and EDSS became 2.5 to 6.5. In April 2012, relapse of MS was noticed and the patient received introduction of fingolimod (FTY) after methylprednisolone (mPSL) pulse therapy. Twenty days later, dysarthria and lower limb weakness were appeared. Brain MRI showed more than 20 several millimeter Gd enhanced lesions in periventricular white matter, juxta-cortical white matter, and cerebellum. Careful determination and observation are required upon the FTY administration into the MS with high frequency of relapse.
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Affiliation(s)
- Hironobu Endo
- Division of Neurology, Kobe University Graduate School of Medicine
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Fragoso YD, Adoni T, Alves-Leon SV, Apostolos-Pereira SL, Araujo YRD, Becker J, Brooks JBB, Correa EC, Damasceno A, Damasceno CADA, Ferreira MLB, Gama PDD, Gama RADD, Gomes S, Goncalves MVM, Grzesiuk AK, Machado SCN, Matta APDC, Mendes MF, Ribeiro TAGJ, Rocha CFD, Ruocco HH, Sato H, Simm RF, Tauil CB, Vasconcelos CCF, Vieira VLF. Alternatives for reducing relapse rate when switching from natalizumab to fingolimod in multiple sclerosis. Expert Rev Clin Pharmacol 2016; 9:541-546. [DOI: 10.1586/17512433.2016.1145053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Gajofatto A, Turatti M, Monaco S, Benedetti MD. Clinical efficacy, safety, and tolerability of fingolimod for the treatment of relapsing-remitting multiple sclerosis. DRUG HEALTHCARE AND PATIENT SAFETY 2015; 7:157-67. [PMID: 26715860 PMCID: PMC4686225 DOI: 10.2147/dhps.s69640] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Fingolimod is a selective immunosuppressive agent approved worldwide for the treatment of relapsing-remitting multiple sclerosis (MS), a chronic and potentially disabling neurological condition. Randomized double-blind clinical trials have shown that fingolimod significantly reduces relapse rate and ameliorates a number of brain MRI measures, including cerebral atrophy, compared to both placebo and intramuscular interferon-β1a. The effect on disability progression remains controversial, since one Phase III trial showed a significant benefit of treatment while two others did not. Although fingolimod has a very convenient daily oral dosing, the possibility of serious cardiac, ocular, infectious, and other rare adverse events justified the decision of the European Medicines Agency to approve the drug as a second-line treatment for MS patients not responsive to first-line therapy, or those with rapidly evolving course. In the United States, fingolimod is instead authorized as a first-line treatment. The aim of this review is to describe and discuss the characteristics of fingolimod concerning its efficacy, safety, and tolerability in the clinical context of multiple sclerosis management.
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Affiliation(s)
- Alberto Gajofatto
- Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy ; Division of Neurology B, Verona University Hospital, Verona, Italy
| | - Marco Turatti
- Division of Neurology B, Verona University Hospital, Verona, Italy
| | - Salvatore Monaco
- Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy ; Division of Neurology B, Verona University Hospital, Verona, Italy
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Lo Re M, Capobianco M, Ragonese P, Realmuto S, Malucchi S, Berchialla P, Salemi G, Bertolotto A. Natalizumab Discontinuation and Treatment Strategies in Patients with Multiple Sclerosis (MS): A Retrospective Study from Two Italian MS Centers. Neurol Ther 2015; 4:147-57. [PMID: 26647006 PMCID: PMC4685862 DOI: 10.1007/s40120-015-0038-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Indexed: 11/12/2022] Open
Abstract
Introduction Natalizumab (NTZ) discontinuation can be followed by multiple sclerosis (MS) disease reactivation. Currently no disease-modifying drug (DMD) has been shown to be able to abolish disease reactivation. The aims of the current study were: (1) to determine the frequency of MS reactivation after NTZ discontinuation; (2) to evaluate predictors of reactivation risk, and (3) to compare the effect of different treatments in reducing this risk. Methods Data from 132 patients with MS followed-up for 2 years before NTZ treatment and 1 year after interruption were collected from two Italian MS centers and retrospectively evaluated. Results Overall, 72 of 132 patients (54.5%) had relapses after NTZ discontinuation and 60 of 125 patients (48%), who had magnetic resonance imaging, had radiological reactivation. Rebound was observed in 28 of 132 patients (21.2%). A higher number of relapses in the 2 years before NTZ treatment, a longer washout period, and a lower number NTZ infusions correlated with reactivation and rebound. Untreated patients (n = 37) had higher clinical and radiological activity and rebound in comparison to patients receiving DMDs. Moreover, a lower risk of relapses was found in patients treated with second-line therapies (NTZ and fingolimod) than in those treated with first-line therapies (interferon beta, glatiramer acetate, teriflunomide, azathioprine). Interestingly, no disease reactivation in off-label treatment (rituximab, autologous hematopoietic stem cell transplantation) was observed. Conclusion NTZ discontinuation is a risk for MS reactivation and rebound. An alternative treatment should be promptly resumed mainly in patients with a previous very active disease course and with a shorter NTZ therapy. Second-line therapies demonstrate superiority in preventing relapses after NTZ discontinuation. Electronic supplementary material The online version of this article (doi:10.1007/s40120-015-0038-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marianna Lo Re
- Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy.
| | - Marco Capobianco
- Regional Multiple Sclerosis Centre, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Paolo Ragonese
- Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy
| | - Sabrina Realmuto
- Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy
| | - Simona Malucchi
- Regional Multiple Sclerosis Centre, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Turin, Torino, Italy
| | - Giuseppe Salemi
- Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy
| | - Antonio Bertolotto
- Regional Multiple Sclerosis Centre, San Luigi Gonzaga Hospital, Orbassano, Italy
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Abdoli M, Freedman MS. Neuro-oncology dilemma: Tumour or tumefactive demyelinating lesion. Mult Scler Relat Disord 2015; 4:555-66. [PMID: 26590662 DOI: 10.1016/j.msard.2015.07.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/15/2015] [Accepted: 07/27/2015] [Indexed: 12/29/2022]
Abstract
Tumefactive demyelinating lesions (TDLs) are not an uncommon manifestation of demyelinating disease but can pose diagnostic challenges in patients without a pre-existing diagnosis of multiple sclerosis (MS) as well as in known MS patients. Brain tumours can also arise in MS patients and can be seen in chronic MS patients as co-morbidities. Delayed diagnosis or unnecessary intervention or treatment will affect the ultimate prognosis of these patients. In this article, we will review some typical cases illustrating the dilemma and review the information that helps to differentiate the two conditions. The intention is not to present an extensive differential diagnosis of both entities, but to examine some typical examples when the decision arises to decide between the two. We take a somewhat different approach, by presenting the cases in "real time", allowing the readers to consider in their own minds which diagnosis they favour, discussing in detail some of the pertinent literature, then revealing later the actual diagnosis. We would urge readers to consider re-visiting their first thoughts about each case after reading the discussion, before reading the follow-up of each case. The overall objective is to highlight the real possibility of being forced to decide between these two entities in clinical practise, present a reasonable approach to help differentiate them and especially to focus on the possibility of TDLs in order to avoid unnecessary biopsy.
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Affiliation(s)
- Mohammad Abdoli
- University of Ottawa, Canada; The Ottawa Hospital Research Institute, Canada.
| | - Mark S Freedman
- University of Ottawa, Canada; The Ottawa Hospital Research Institute, Canada.
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15
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Ward MD, Jones DE, Goldman MD. Overview and safety of fingolimod hydrochloride use in patients with multiple sclerosis. Expert Opin Drug Saf 2015; 13:989-98. [PMID: 24935480 DOI: 10.1517/14740338.2014.920820] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Fingolimod (Gilenya®, FTY720) is an oral sphingosine-1-phosphate analogue that was approved by the FDA in 2010 for the treatment of relapsing forms of multiple sclerosis (MS). Fingolimod's mechanism of action is primarily related to lymphocyte sequestration in primary and secondary lymphoid tissues. Phase III trials demonstrated a reduction in annualized relapse rate and MRI progression in fingolimod-treated subjects compared with both placebo and IFN-β-treated subjects. Frequent adverse effects include fatigue, gastrointestinal disturbance, headache and upper respiratory tract infection. More serious, but rare, adverse events associated with fingolimod include atrioventricular block, symptomatic bradycardia, herpetic viral infections and macular edema. AREAS COVERED We discuss the mechanism of action, pharmacokinetics, clinical efficacy and safety profile of fingolimod in patients with relapsing MS. EXPERT OPINION Fingolimod is an effective treatment for relapsing MS and its oral route of administration may be preferred by some. Fingolimod is generally well tolerated but requires diligence in patient selection and monitoring. Additional information is needed regarding risk of infection, malignancy and rebound disease with long-term use of fingolimod.
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Affiliation(s)
- Melanie D Ward
- University of Virginia, Department of Neurology , PO Box 800394, Charlottesville, VA 22908 , USA
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Lee JM, Han MH. Patient experience and practice trends in multiple sclerosis - clinical utility of fingolimod. Patient Prefer Adherence 2015; 9:685-93. [PMID: 26056436 PMCID: PMC4446999 DOI: 10.2147/ppa.s57354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Targeting sphingosine-1-phosphate pathway with orally available immune-modulatory fingolimod (Gilenya™) therapy ameliorates relapsing-remitting multiple sclerosis (RRMS) by decreasing relapse rate as shown in FREEDOMS and TRANSFORMS. Fingolimod has also been shown to be superior to interferon-beta therapy as evidenced by TRANSFORMS. Albeit multiple benefits in treatment of multiple sclerosis including high efficacy and ease of administration, potential untoward effects such as cardiotoxicity, risk of infection, and cancer exist, thus mandating careful screening and frequent monitoring of patients undergoing treatment with fingolimod. This review outlines mechanism of action, observations, side effects, and practice guidelines on use of fingolimod in treatment of RRMS.
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Affiliation(s)
- Jong-Mi Lee
- Stanford Healthcare, Multiple Sclerosis Center, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - May H Han
- Stanford Healthcare, Multiple Sclerosis Center, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
- Correspondence: May H Han, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, 1201 Welch Road, Stanford, CA 94305, USA, Email
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Dubey D, Kieseier BC, Hartung HP, Hemmer B, Miller-Little WA, Stuve O. Clinical management of multiple sclerosis and neuromyelitis optica with therapeutic monoclonal antibodies: approved therapies and emerging candidates. Expert Rev Clin Immunol 2014; 11:93-108. [PMID: 25495182 DOI: 10.1586/1744666x.2015.992881] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Therapeutic monoclonal antibodies (mAbs) are a relatively novel class of drugs that has substantially advanced immunotherapy for patients with multiple sclerosis. The advantage of these agents is that they bind specifically and exclusively to predetermined proteins or cells. Natalizumab was the first mAb in neurology to obtain approval. It is also considered one of the most potent options for annualized relapse rate reduction among available therapeutic options. Alemtuzumab is currently also approved in several countries. Several mAbs have been tested in clinical studies in multiple sclerosis. Here, we review the history of drug development of therapeutic mAbs and their classification. Furthermore, we outline the putative mechanisms of action, clinical evidence and safety of approved mAbs and those in different stages of clinical development in multiple sclerosis and neuromyelitis optica.
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Intense immunosuppression for the treatment of an immune reconstitution inflammatory syndrome-like exacerbation after natalizumab withdrawal: a case report. J Neurol 2014; 262:219-21. [DOI: 10.1007/s00415-014-7574-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/03/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
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Bianco A, Patanella AK, Nociti V, Marti A, Frisullo G, Plantone D, De Fino C, Fetta A, Batocchi AP, Rossini PM, Mirabella M. Second-line therapy with fingolimod for relapsing-remitting multiple sclerosis in clinical practice: the effect of previous exposure to natalizumab. Eur Neurol 2014; 73:57-65. [PMID: 25402749 DOI: 10.1159/000365968] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 07/13/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND To evaluate efficacy and safety of fingolimod for relapsing-remitting multiple sclerosis, particularly in patients previously exposed to natalizumab. METHOD Prospective observational single-centre second-line cohort study. RESULTS Among 71 patients treated with fingolimod 0.5 mg/day for a mean duration of 21.75 ± 12.60 months, the annualized relapse rate was 0.66 (C.I. 95% 0.27-1.05) with a significant difference between 26 patients with prior natalizumab exposure (1.15; C.I. 95% 0.12-2.17) and 45 not exposed (0.38; C.I. 95% 0.18-0.57; p = 0.002). In a multivariate negative regression model, only previous exposure to natalizumab (p = 0.049) and duration of fingolimod treatment (p < 0.001) significantly correlated with the annualized relapse rate. Previous exposure to natalizumab (p = 0.028) and duration of treatment with fingolimod (p < 0.001) were confirmed by restricting the analysis to the first 12 months of treatment with fingolimod, but were no longer statistically significant by analysing only patients (n = 51) with at least 12 months of treatment with fingolimod (0.32; C.I. 95% 0.08-0.55 vs. 0.22; C.I. 95% 0.11-0.32; p = NS). No differences were observed in neuroradiological outcomes and disability progression in patients exposed to natalizumab and not exposed. The rate of discontinuation due to adverse events was 11.3%, with no differences between the two groups. CONCLUSIONS Our study confirms efficacy and side effects of fingolimod in a second-line clinical practice cohort. Prior natalizumab exposure and duration of treatment with fingolimod are independent predictors of annualized relapse rate during the first 12 months of treatment with fingolimod, but not in the long-term, and may be influenced by the 3 months washout period between the two drugs.
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Affiliation(s)
- Assunta Bianco
- Institute of Neurology, Catholic University, Rome, Italy
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Gajofatto A, Bianchi MR, Deotto L, Benedetti MD. Are natalizumab and fingolimod analogous second-line options for the treatment of relapsing-remitting multiple sclerosis? A clinical practice observational study. Eur Neurol 2014; 72:173-80. [PMID: 25226868 DOI: 10.1159/000361044] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 02/26/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is unclear whether natalizumab and fingolimod have analogous efficacy for relapsing-remitting multiple sclerosis (RRMS). OBJECTIVE To compare the outcome of RRMS patients treated with either therapy. METHODS RRMS patients treated with natalizumab or fingolimod at Verona Hospital, Italy, were included. The study design was retrospective, based on prospectively collected clinical and MRI data. As efficacy outcomes, time to relapse, relapse rate, expanded disability status scale (EDSS) score change, and new T2/gadolinium-enhancing lesions on brain MRI were compared over treatment period between the two groups. Multivariate Cox and logistic regression models were used to control for potential confounders. RESULTS Fifty-seven subjects receiving natalizumab and 30 receiving fingolimod for a median duration of 23 (1-63) and 22 (2-35) months, respectively (p = 0.22) were included. Patients treated with natalizumab had a more active pre-treatment disease course compared to those treated with fingolimod. In multivariate analysis, the relapse risk was reduced in patients on natalizumab (Hazard Ratio = 0.33; 95% CI = 0.11-1.03; p = 0.056) compared to those on fingolimod. There was no significant difference in EDSS and MRI outcomes. No relevant unexpected adverse events occurred. One patient discontinued natalizumab for progressive multifocal leukoencephalopathy. CONCLUSIONS RRMS patients receiving natalizumab had higher baseline disease activity and lower relapse risk over 20 months of treatment compared to those receiving fingolimod. Head-to-head randomized clinical trials are needed.
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Affiliation(s)
- Alberto Gajofatto
- Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
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21
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Tumefactive demyelination and a malignant course in an MS patient during and following fingolimod therapy. J Neurol Sci 2014; 344:193-7. [DOI: 10.1016/j.jns.2014.06.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 05/15/2014] [Accepted: 06/09/2014] [Indexed: 11/19/2022]
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Muris AH, Rolf L, Damoiseaux J, Koeman E, Hupperts R. Fingolimod in active multiple sclerosis: an impressive decrease in Gd-enhancing lesions. BMC Neurol 2014; 14:164. [PMID: 25138918 PMCID: PMC4236684 DOI: 10.1186/s12883-014-0164-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background Fingolimod is a disease modifying therapy (DMT) in highly active relapsing remitting multiple sclerosis (RRMS), as is natalizumab. Fingolimod decreases annual relapse rates and gadolinium enhancing lesions on MRI as compared to either interferon beta (IFNβ) or placebo. The effect of fingolimod on MRI outcomes compared to natalizumab treatment has not been investigated in (head to head) clinical trials. Clinical experience with natalizumab is much more extended and in general practice often preferred. Case presentation This case describes a 31-year old woman with RRMS, who experienced severe side effects on natalizumab. After a voluntary four months treatment free period, a severe relapse appeared which was treated with prednisone and plasmapheresis; thereafter fingolimod was initiated. In the following months MRI signs improved spectacularly. Conclusion This case suggests that fingolimod might be a good alternative for natalizumab, especially for use in RRMS patients, with highly active, advanced disease, when natalizumab treatment is stopped due to side effects or even after a severe relapse.
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Affiliation(s)
- Anne-Hilde Muris
- School for Mental Health and Neuroscience, Maastricht University Medical Center, Universiteitssingel 40, Maastricht, theNetherlands.
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Lovera J, Villemarette-Pittman N. Tumefactive multiple sclerosis and fingolimod. J Neurol Sci 2014; 344:1-2. [PMID: 24993468 DOI: 10.1016/j.jns.2014.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/28/2014] [Accepted: 06/09/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Jesus Lovera
- Department of Neurology, Louisiana State University Health Sciences Center-New Orleans, 1542 Tulane Avenue, Rm 718A, New Orleans, LA 70112, United States.
| | - Nicole Villemarette-Pittman
- Department of Neurology, Louisiana State University Health Sciences Center-New Orleans, 1542 Tulane Avenue, Rm 718A, New Orleans, LA 70112, United States
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Rossi S, Motta C, Studer V, Boffa L, De Chiara V, Castelli M, Barbieri F, Buttari F, Monteleone F, Germani G, Macchiarulo G, Weiss S, Centonze D. Treatment options to reduce disease activity after natalizumab: paradoxical effects of corticosteroids. CNS Neurosci Ther 2014; 20:748-53. [PMID: 24837039 DOI: 10.1111/cns.12282] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/14/2014] [Accepted: 04/15/2014] [Indexed: 11/29/2022] Open
Abstract
AIM Natalizumab (NTZ) discontinuation leads to multiple sclerosis (MS) recurrence, but represents the only known strategy to limit the risk of progressive multifocal leukoencephalopathy (PML) in JCV seropositive patients. Here, we compared the clinical and imaging features of three groups of patients who discontinued NTZ treatment. METHODS We treated 25 patients with subcutaneous INFβ-1b (INF group), 40 patients with glatiramer acetate (GA group), and 40 patients with GA plus pulse steroid (GA+CS group). RESULTS Six of 25 patients (24%) of the INF group were relapse-free 6 months after NTZ suspension. In GA group, a significant higher proportion of patients (26 of 40 patients, 65%) were relapse-free (P<0.05). Far from improving the clinical effects of GA in post-NTZ setting, combination of GA+CS was associated with lower relapse-free rate than GA alone (40% vs. 65%, P=0.04). Also on MRI parameters, combination of GA+CS was associated with worse outcome than GA alone, as 22 of 26 subjects (84.6%) had MRI evidence of disease activity 6 months after NTZ discontinuation. CONCLUSION Corticosteroids should not be used in combination with GA to prevent post-NTZ disease recurrence.
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Affiliation(s)
- Silvia Rossi
- Clinica Neurologica, Dipartimento di Medicina dei Sistemi, Università Tor Vergata, & Centro Europeo per la Ricerca sul Cervello (CERC)/Fondazione Santa Lucia, Rome, Italy
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Hoepner R, Faissner S, Salmen A, Gold R, Chan A. Efficacy and side effects of natalizumab therapy in patients with multiple sclerosis. J Cent Nerv Syst Dis 2014; 6:41-9. [PMID: 24855407 PMCID: PMC4011812 DOI: 10.4137/jcnsd.s14049] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/19/2014] [Accepted: 02/25/2014] [Indexed: 12/24/2022] Open
Abstract
Natalizumab (Nat) is a humanized monoclonal antibody used for the treatment of relapsing multiple sclerosis (MS). Nat inhibits lymphocyte migration via the blood brain barrier (BBB) by blockage of an integrin adhesion molecule, very late antigen 4. During the phase III clinical trials, it was shown that Nat reduces disease activity and prevents disability progression. In addition, several smaller studies indicate a positive influence of Nat on cognition, depression, fatigue, and quality of life (Qol). Therapeutic efficacy has to be weighed against the risk of developing potentially fatal progressive multifocal leukoencephalopathy (PML), an opportunistic infection by JC-virus (JCV) with an incidence of 3.4/1000 (95% CI 3.08–3.74) in Nat treated MS patients. In this review article, we will review data on the presumed mechanism of Nat action, clinical and paraclinical efficacy parameters, and adverse drug reactions with a special focus on PML.
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Affiliation(s)
- Robert Hoepner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Anke Salmen
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Andrew Chan
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
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Rommer PS, Dudesek A, Stüve O, Zettl UK. Monoclonal antibodies in treatment of multiple sclerosis. Clin Exp Immunol 2014; 175:373-84. [PMID: 24001305 DOI: 10.1111/cei.12197] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2013] [Indexed: 01/14/2023] Open
Abstract
Monoclonal antibodies (mAbs) are used as therapeutics in a number of disciplines in medicine, such as oncology, rheumatology, gastroenterology, dermatology and transplant rejection prevention. Since the introduction and reintroduction of the anti-alpha4-integrin mAb natalizumab in 2004 and 2006, mAbs have gained relevance in the treatment of multiple sclerosis (MS). At present, numerous mAbs have been tested in clinical trials in relapsing-remitting MS, and in progressive forms of MS. One of the agents that might soon be approved for very active forms of relapsing-remitting MS is alemtuzumab, a humanized mAb against CD52. This review provides insights into clinical studies with the mAbs natalizumab, alemtuzumab, daclizumab, rituximab, ocrelizumab and ofatumumab.
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Affiliation(s)
- P S Rommer
- Clinic and Policlinic of Neurology, University of Rostock, Rostock, Germany; Department of Neurology, Medical University of Vienna, Vienna, Austria
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Wipfler P, Harrer A, Pilz G, Oppermann K, Afazel S, Haschke-Becher E, Sellner J, Trinka E, Kraus J. Natalizumab saturation: biomarker for individual treatment holiday after natalizumab withdrawal? Acta Neurol Scand 2014; 129:e12-5. [PMID: 24032536 DOI: 10.1111/ane.12182] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2013] [Indexed: 01/26/2023]
Abstract
BACKGROUND More and more patients with multiple sclerosis (MS) switch from natalizumab to fingolimod because of the risk of progressive multifocal leukoencephalopathy. The duration of the treatment holiday is still under debate referring to a possible recurrence of disease activity. AIM OF THE STUDY The aim of this study was to evaluate the prognostic value of natalizumab saturation on T cells for the recurrence of clinical and radiological disease activity. METHODS Cell surface-bound natalizumab saturation (in%) of CD8+ and CD4+ T cells from five patients with MS was determined before initiation of fingolimod by flow cytometry and related to clinical and MRI outcome during a 6-month follow-up. RESULTS In two patients with either clinical or radiological disease activity, the natalizumab saturation on CD8+ and CD4+ T cells was <30%. In contrast, the remaining three patients with absence of disease activity had a median natalizumab saturation of 70% (range 59-79%) on CD4+ and 66% (range 52-68%) on CD8+ T cells. CONCLUSIONS The data of this pilot study indicate that clinical and radiological disease activity is closely linked to natalizumab saturation at the time point of switch. The determination of natalizumab saturation may be an essential tool to monitor cessation of natalizumab treatment.
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Affiliation(s)
- P. Wipfler
- Department of Neurology; Christian-Doppler-Klinik; Paracelsus Medical University; Salzburg Austria
| | - A. Harrer
- Department of Neurology; Christian-Doppler-Klinik; Paracelsus Medical University; Salzburg Austria
| | - G. Pilz
- Department of Neurology; Christian-Doppler-Klinik; Paracelsus Medical University; Salzburg Austria
| | - K. Oppermann
- Department of Neurology; Christian-Doppler-Klinik; Paracelsus Medical University; Salzburg Austria
| | - S. Afazel
- Central Laboratory; Christian-Doppler-Klinik; Paracelsus Medical University; Salzburg Austria
| | - E. Haschke-Becher
- Central Laboratory; Christian-Doppler-Klinik; Paracelsus Medical University; Salzburg Austria
| | - J. Sellner
- Department of Neurology; Christian-Doppler-Klinik; Paracelsus Medical University; Salzburg Austria
- Department of Neurology; Klinikum rechts der Isar; Technische Universität München; Munich Germany
| | - E. Trinka
- Department of Neurology; Christian-Doppler-Klinik; Paracelsus Medical University; Salzburg Austria
| | - J. Kraus
- Department of Neurology; Christian-Doppler-Klinik; Paracelsus Medical University; Salzburg Austria
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Mohammad MG, Tsai VW, Ruitenberg MJ, Hassanpour M, Li H, Hart PH, Breit SN, Sawchenko PE, Brown DA. Immune cell trafficking from the brain maintains CNS immune tolerance. J Clin Invest 2014; 124:1228-41. [PMID: 24569378 PMCID: PMC3934177 DOI: 10.1172/jci71544] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 11/21/2013] [Indexed: 01/12/2023] Open
Abstract
In the CNS, no pathway dedicated to immune surveillance has been characterized for preventing the anti-CNS immune responses that develop in autoimmune neuroinflammatory disease. Here, we identified a pathway for immune cells to traffic from the brain that is associated with the rostral migratory stream (RMS), which is a forebrain source of newly generated neurons. Evaluation of fluorescently labeled leukocyte migration in mice revealed that DCs travel via the RMS from the CNS to the cervical LNs (CxLNs), where they present antigen to T cells. Pharmacologic interruption of immune cell traffic with the mononuclear cell-sequestering drug fingolimod influenced anti-CNS T cell responses in the CxLNs and modulated experimental autoimmune encephalomyelitis (EAE) severity in a mouse model of multiple sclerosis (MS). Fingolimod treatment also induced EAE in a disease-resistant transgenic mouse strain by altering DC-mediated Treg functions in CxLNs and disrupting CNS immune tolerance. These data describe an immune cell pathway that originates in the CNS and is capable of dampening anti-CNS immune responses in the periphery. Furthermore, these data provide insight into how fingolimod treatment might exacerbate CNS neuroinflammation in some cases and suggest that focal therapeutic interventions, outside the CNS have the potential to selectively modify anti-CNS immunity.
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MESH Headings
- Animals
- CD11 Antigens/metabolism
- Cell Movement
- Cells, Cultured
- Dendritic Cells/physiology
- Encephalomyelitis, Autoimmune, Experimental/chemically induced
- Encephalomyelitis, Autoimmune, Experimental/immunology
- Encephalomyelitis, Autoimmune, Experimental/pathology
- Female
- Fingolimod Hydrochloride
- Immune Tolerance
- Lymph Nodes/immunology
- Lymph Nodes/pathology
- Mice
- Mice, Inbred C57BL
- Mice, Transgenic
- Neck
- Propylene Glycols
- Prosencephalon/immunology
- Prosencephalon/pathology
- Sphingosine/analogs & derivatives
- T-Lymphocytes, Regulatory/immunology
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Affiliation(s)
- Mohammad G. Mohammad
- Laboratory of Neuroinflammation, St. Vincent’s Centre for Applied Medical Research and University of New South Wales, Sydney, New South Wales, Australia.
School of Biomedical Sciences and Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia.
Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia.
Laboratory of Neuronal Structure and Function, Salk Institute for Biological Studies, La Jolla, California, USA
| | - Vicky W.W. Tsai
- Laboratory of Neuroinflammation, St. Vincent’s Centre for Applied Medical Research and University of New South Wales, Sydney, New South Wales, Australia.
School of Biomedical Sciences and Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia.
Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia.
Laboratory of Neuronal Structure and Function, Salk Institute for Biological Studies, La Jolla, California, USA
| | - Marc J. Ruitenberg
- Laboratory of Neuroinflammation, St. Vincent’s Centre for Applied Medical Research and University of New South Wales, Sydney, New South Wales, Australia.
School of Biomedical Sciences and Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia.
Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia.
Laboratory of Neuronal Structure and Function, Salk Institute for Biological Studies, La Jolla, California, USA
| | - Masoud Hassanpour
- Laboratory of Neuroinflammation, St. Vincent’s Centre for Applied Medical Research and University of New South Wales, Sydney, New South Wales, Australia.
School of Biomedical Sciences and Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia.
Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia.
Laboratory of Neuronal Structure and Function, Salk Institute for Biological Studies, La Jolla, California, USA
| | - Hui Li
- Laboratory of Neuroinflammation, St. Vincent’s Centre for Applied Medical Research and University of New South Wales, Sydney, New South Wales, Australia.
School of Biomedical Sciences and Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia.
Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia.
Laboratory of Neuronal Structure and Function, Salk Institute for Biological Studies, La Jolla, California, USA
| | - Prue H. Hart
- Laboratory of Neuroinflammation, St. Vincent’s Centre for Applied Medical Research and University of New South Wales, Sydney, New South Wales, Australia.
School of Biomedical Sciences and Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia.
Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia.
Laboratory of Neuronal Structure and Function, Salk Institute for Biological Studies, La Jolla, California, USA
| | - Samuel N. Breit
- Laboratory of Neuroinflammation, St. Vincent’s Centre for Applied Medical Research and University of New South Wales, Sydney, New South Wales, Australia.
School of Biomedical Sciences and Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia.
Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia.
Laboratory of Neuronal Structure and Function, Salk Institute for Biological Studies, La Jolla, California, USA
| | - Paul E. Sawchenko
- Laboratory of Neuroinflammation, St. Vincent’s Centre for Applied Medical Research and University of New South Wales, Sydney, New South Wales, Australia.
School of Biomedical Sciences and Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia.
Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia.
Laboratory of Neuronal Structure and Function, Salk Institute for Biological Studies, La Jolla, California, USA
| | - David A. Brown
- Laboratory of Neuroinflammation, St. Vincent’s Centre for Applied Medical Research and University of New South Wales, Sydney, New South Wales, Australia.
School of Biomedical Sciences and Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia.
Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia.
Laboratory of Neuronal Structure and Function, Salk Institute for Biological Studies, La Jolla, California, USA
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29
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Affiliation(s)
- Giancarlo Comi
- Department of Neurology; University Vita-Salute San Raffaele; San Raffaele Scientific Institute; Milan Italy
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30
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Sato DK, Nakashima I, Bar-Or A, Misu T, Suzuki C, Nishiyama S, Kuroda H, Fujihara K, Aoki M. Changes in Th17 and regulatory T cells after fingolimod initiation to treat multiple sclerosis. J Neuroimmunol 2014; 268:95-8. [PMID: 24507619 DOI: 10.1016/j.jneuroim.2014.01.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 01/13/2014] [Accepted: 01/16/2014] [Indexed: 11/19/2022]
Abstract
Fingolimod has demonstrated efficacy in patients with multiple sclerosis (MS), and patients become gradually lymphopenic after a few days of treatment, with selective reductions in CD4+ subsets. We observed an increase in the frequencies of circulating regulatory T cells after fingolimod administration. However, we also found that half of patients had increased proportion of circulating Th17 cells in CD4+ T cells after treatment (including a patient with MS relapses), whereas the others showed lower frequencies of Th17 cells, indicating some variability among patients. Further studies may confirm if slower reduction of circulating Th17 cells following fingolimod initiation predisposes to relapses.
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Affiliation(s)
| | - Ichiro Nakashima
- Department of Neurology, Tohoku University School of Medicine, Sendai, Japan.
| | - Amit Bar-Or
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Canada
| | - Tatsuro Misu
- Department of Multiple Sclerosis Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Chihiro Suzuki
- Department of Neurology, Tohoku University School of Medicine, Sendai, Japan
| | - Shuhei Nishiyama
- Department of Neurology, Tohoku University School of Medicine, Sendai, Japan
| | - Hiroshi Kuroda
- Department of Neurology, Tohoku University School of Medicine, Sendai, Japan
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masashi Aoki
- Department of Neurology, Tohoku University School of Medicine, Sendai, Japan
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31
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Fragoso YD, Arruda NM, Arruda WO, Brooks JBB, Correa EC, Damasceno A, Damasceno CA, Ferreira MLB, Giacomo MCB, Gomes S, Gonçalves MVM, Grzesiuk AK, Kaimen-Maciel DR, Lopes J, Machado SCN, Oliveira CLS, Stella CRAV. We know how to prescribe natalizumab for multiple sclerosis, but do we know how to withdraw it? Expert Rev Neurother 2014; 14:127-30. [DOI: 10.1586/14737175.2014.874947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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32
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Havla J, Kleiter I, Kümpfel T. Bridging, switching or drug holidays - how to treat a patient who stops natalizumab? Ther Clin Risk Manag 2013; 9:361-9. [PMID: 24124371 PMCID: PMC3794889 DOI: 10.2147/tcrm.s41552] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Natalizumab (NAT) was the first monoclonal antibody to be approved for the treatment of relapsing-remitting multiple sclerosis (RRMS). While pivotal and postmarketing studies have showed considerable and sustained efficacy of NAT in RRMS, the increasing incidence of therapy-associated progressive multifocal leukoencephalopathy (PML), a brain infection caused by the John Cunningham virus (JCV), is a risk associated with long-term therapy. The risk for therapy-associated PML is highest in so-called “triple risk” patients. Therefore, long-term NAT-treated, immunosuppressive-pretreated, and JCV antibody-positive patients often discontinue NAT therapy. However, until now, it is not known which treatment strategy should be followed after NAT cessation. Since disease activity returns to pretreatment levels, or even above, within 4–7 months from the last infusion of NAT, patients who stop NAT are at considerable risk of relapse and worsening of multiple sclerosis (MS)-related disability. Several strategies have been applied to prevent the recurrence of disease activity after discontinuation of NAT. Of these, bridging with intravenous methylprednisolone, and switching to glatiramer acetate or interferon beta (IFN-beta) do not seem to be effective enough. More promising results have been obtained in retrospective studies and case series with fingolimod (FTY), an alternative escalation therapy for RRMS, although some patients have showed a severe disease rebound after starting FTY treatment. The time interval between the discontinuation of NAT and the start of FTY might affect the recurrence of disease activity. Long-term data about the efficacy and safety of FTY treatment after cessation of NAT are urgently needed and should be further investigated. Prospective studies are warranted, to optimize treatment strategies for RRMS patients who discontinue NAT, especially because new therapies will be available in the very near future.
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Affiliation(s)
- Joachim Havla
- Institute of Clinical, Neuroimmunology, Medical Campus, Grosshadern, Ludwig Maximilians, University, Munich, Germany
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33
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Deiß A, Brecht I, Haarmann A, Buttmann M. Treating multiple sclerosis with monoclonal antibodies: a 2013 update. Expert Rev Neurother 2013; 13:313-35. [PMID: 23448220 DOI: 10.1586/ern.13.17] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The third part of this in-depth review series on the treatment of multiple sclerosis (MS) with monoclonal antibodies covers the years 2010-2012. The natalizumab section gives a progressive multifocal leukoencephalopathy update, focusing on clinically relevant aspects. Furthermore, it outlines problems around natalizumab cessation and current evidence on therapeutic strategies thereafter. Finally, it reviews evidence on Janus-faced modes of natalizumab action besides anti-inflammatory effects, including proinflammatory effects. The section on alemtuzumab critically analyzes recent Phase III results and discusses which patients might be best suited for alemtuzumab treatment, and reviews the long-term immunological impact of this anti-CD52 antibody. The daclizumab section critically summarizes results from the Phase IIb SELECT/SELECTION trial and introduces the Phase III program. The section on anti-CD20 antibodies reviews Phase II results on ocrelizumab and ofatumumab, and discusses current perspectives of these antibodies for MS therapy. Promising recent Phase II results on the anti-IL-17A antibody secukinumab (AIN457) are outlined and a short update on tabalumab (LY2127399) is given. Other highlighted antibodies currently being tested in MS patients include GNbAC1, BIIB033, MOR103 and MEDI-551. Finally, the authors give an update on the role monoclonal antibodies could play in the therapeutic armamentarium for MS in the medium term.
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Affiliation(s)
- Annika Deiß
- Department of Neurology, University of Würzburg, Josef-Schneider-Str 11, Würzburg 97080, Germany
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34
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Lugaresi A, di Ioia M, Travaglini D, Pietrolongo E, Pucci E, Onofrj M. Risk-benefit considerations in the treatment of relapsing-remitting multiple sclerosis. Neuropsychiatr Dis Treat 2013; 9:893-914. [PMID: 23836975 PMCID: PMC3699254 DOI: 10.2147/ndt.s45144] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system and mainly affects young adults. Its natural history has changed in recent years with the advent of disease-modifying drugs, which have been available since the early 1990s. The increasing number of first-line and second-line treatment options, together with the variable course of the disease and patient lifestyles and expectations, makes the therapeutic decision a real challenge. The aim of this review is to give a comprehensive overview of the main present and some future drugs for relapsing-remitting MS, including risk-benefit considerations, to enable readers to draw their own conclusions regarding the risk-benefit assessment of personalized treatment strategies, taking into account not only treatment-related but also disease-related risks. We performed a Medline literature search to identify studies on the treatment of MS with risk stratification and risk-benefit considerations. We focused our attention on studies of disease-modifying, immunomodulating, and immunosuppressive drugs, including monoclonal antibodies. Here we offer personal considerations, stemming from long-term experience in the treatment of MS and thorough discussions with other neurologists closely involved in the care of patients with the disease. MS specialists need to know not only the specific risks and benefits of single drugs, but also about drug interactions, either in simultaneous or serial combination therapy, and patient comorbidities, preferences, and fears. This has to be put into perspective, considering also the risks of untreated disease in patients with different clinical and radiological characteristics. There is no single best treatment strategy, but therapy has to be tailored to the patient. This is a time-consuming task, rich in complexity, and influenced by the attitude towards risk on the parts of both the patient and the clinical team. The broader the MS drug market becomes, the harder it will be for the clinician to help the patient decide which therapeutic strategy to opt for.
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Affiliation(s)
- Alessandra Lugaresi
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Maria di Ioia
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Daniela Travaglini
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Erika Pietrolongo
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
| | - Eugenio Pucci
- Operative Unit Neurologia ASUR Marche Area Vasta 3, Macerata, Italy
| | - Marco Onofrj
- Department of Neuroscience and Imaging, University “G d’Annunzio”, Chieti, Italy
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35
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de Seze J, Ongagna JC, Collongues N, Zaenker C, Courtois S, Fleury M, Benoilid A, Chanson JB, Blanc F. Reduction of the washout time between natalizumab and fingolimod. Mult Scler 2013; 19:1248. [DOI: 10.1177/1352458513490551] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jérôme de Seze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- Clinical Investigation Center, Strasbourg University Hospital, Strasbourg, France
- Department of Neurology, Hôpital E. Muller, Mulhouse, France
| | | | - Nicolas Collongues
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- Clinical Investigation Center, Strasbourg University Hospital, Strasbourg, France
- Department of Neurology, Hôpital E. Muller, Mulhouse, France
| | | | | | - Marie Fleury
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- Department of Neurology, Hôpital E. Muller, Mulhouse, France
| | - Aurélien Benoilid
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- Department of Neurology, Hôpital E. Muller, Mulhouse, France
| | - Jean-Baptiste Chanson
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- Department of Neurology, Hôpital E. Muller, Mulhouse, France
| | - Frédéric Blanc
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- Department of Neurology, Hôpital E. Muller, Mulhouse, France
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36
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Ferraro D, Federzoni L, Vitetta F, Simone AM, Cossarizza A, Nichelli PF, Sola P. Frequent early multiple sclerosis relapses during treatment with fingolimod: a paradoxical effect? Mult Scler 2013; 19:1550. [DOI: 10.1177/1352458513490549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- D Ferraro
- Department of Neurosciences, University of Modena and Reggio Emilia, Italy
| | - L Federzoni
- Department of Neurosciences, University of Modena and Reggio Emilia, Italy
| | - F Vitetta
- Department of Neurosciences, University of Modena and Reggio Emilia, Italy
| | - AM Simone
- Department of Neurosciences, University of Modena and Reggio Emilia, Italy
| | - A Cossarizza
- Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, Italy
| | - PF Nichelli
- Department of Neurosciences, University of Modena and Reggio Emilia, Italy
| | - P Sola
- Department of Neurosciences, University of Modena and Reggio Emilia, Italy
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37
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Abstract
There are currently nine approved disease modifying therapies for relapsing forms of multiple sclerosis, with six distinct mechanisms of action. All have side effects, and none are cures. When a patient cannot tolerate therapy, or there is unacceptable breakthrough disease activity, the most common approach is to change drug. No universal guidelines exist for switching therapy. This overview will propose switch principles and suggestions.
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Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University Medical Center, HSC T12-020, Stony Brook, NY 11794-8121, USA.
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38
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Yokoseki A, Saji E, Arakawa M, Hokari M, Ishiguro T, Yanagimura F, Ishihara T, Okamoto K, Nishizawa M, Kawachi I. Relapse of multiple sclerosis in a patient retaining CCR7-expressing T cells in CSF under fingolimod therapy. Mult Scler 2013; 19:1230-3. [PMID: 23519973 DOI: 10.1177/1352458513481395] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fingolimod acts as a functional antagonist of the sphingosine-1-phosphate receptor, and it traps lymphocytes in secondary lymphoid organs and precludes their migration into the central nervous system. We report the case of a patient who suffered a relatively severe relapse of multiple sclerosis (MS) during the initial 3 months of fingolimod therapy, with retention of CCR7 expression on CD4(+) T cells in the cerebrospinal fluid (CSF) despite decreased numbers of lymphocytes and decreased expression of CCR7 on CD4(+) T cells in the blood. These data suggest that fingolimod may cause differential effects on the CSF and blood lymphocytes of patients with MS during the initial months of therapy.
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Affiliation(s)
- Akiko Yokoseki
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
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39
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Fingolimod reduces recurrence of disease activity after natalizumab withdrawal in multiple sclerosis. J Neurol 2012; 260:1382-7. [DOI: 10.1007/s00415-012-6808-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 12/07/2012] [Accepted: 12/14/2012] [Indexed: 11/26/2022]
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40
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Laroni A, Brogi D, Milesi V, Abate L, Uccelli A, Mancardi GL. Early switch to fingolimod may decrease the risk of disease recurrence after natalizumab interruption. Mult Scler 2012. [DOI: 10.1177/1352458512468498] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Laroni
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health University of Genoa, Italy
| | - D Brogi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health University of Genoa, Italy
| | - V Milesi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health University of Genoa, Italy
| | - L Abate
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health University of Genoa, Italy
| | - A Uccelli
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health University of Genoa, Italy
| | - GL Mancardi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health University of Genoa, Italy
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41
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Stüve O, Hemmer B. Time to talk about timing – when to start, stop and change anti-migratory drugs in MS. Mult Scler 2012; 18:1514-6. [DOI: 10.1177/1352458512464283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Olaf Stüve
- Neurology Section, VA North Texas Health Care System, Medical Service, USA
- Department of Neurology, University of Texas Southwestern Medical Center at Dallas, USA
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Germany
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