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Khan AA, Gutlapalli SD, Sohail M, Patel P, Midha S, Shukla S, Dhamija D, Bello AO, Elshaikh AO. Fingolimod-Associated Macular Edema in the Treatment of Multiple Sclerosis. Cureus 2023; 15:e41520. [PMID: 37551255 PMCID: PMC10404465 DOI: 10.7759/cureus.41520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 07/07/2023] [Indexed: 08/09/2023] Open
Abstract
Multiple sclerosis is a neurological disorder categorized by inflammatory processes with a high prevalence worldwide. It affects both motor and sensory pathways and is also associated with the visual pathway. Fingolimod is a commonly used drug for relapsing-remitting multiple sclerosis. It is a sphingosine 1-phosphate modulator acting on its receptors for immune cell accumulation, neuronal function, embryological development, vascular permeability, smooth muscle cell function, and endothelial barrier maintenance. This review aims to understand the processes, mechanisms, risks, and management of fingolimod-associated macular edema. Due to the anti-inflammatory properties of fingolimod, it decreases various cytokines, including interleukin (IL)-1B and IL-6, spike wave, and spike amplitude, in electrophysiological activities and decreases insoluble receptors for advanced glycation end product ligand. A daily dosage of 0.5 mg of fingolimod has an increased association with macular edema. The serious adverse events of fingolimod are lymphopenia, cardiovascular events, ocular events, and carcinoma. Fingolimod decreases brain volume and increases vascular permeability, resulting in increased macular volume and damage to the blood-retinal barrier, which causes an increased risk for macular edema. Cystoid macular edema is more common in older individuals suffering from comorbidities affecting the retina, such as diabetes, or those undergoing ophthalmological surgeries. This review also highlights the importance of regular ophthalmology examinations on patients consuming fingolimod both in the initial stages and chronic use. The treatment options for macular edema include nonsteroidal anti-inflammatory drugs, acetazolamide, triamcinolone, ketorolac, corticosteroids, and intravitreal procedures.
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Affiliation(s)
- Asma A Khan
- Medical School, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sai Dheeraj Gutlapalli
- Internal Medicine, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine, New York, USA
- Internal Medicine Clinical Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mehvish Sohail
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Priyansh Patel
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Baroda Medical College, Vadodara, IND
| | - Sidharth Midha
- Radiology, Bharati Vidyapeeth University, Pune, IND
- Radiology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Surmai Shukla
- Medicine and Surgery, Qingdao University College of Medical Science, Qingdao, CHN
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Divyanshu Dhamija
- Internal Medicine, Government Medical College Amritsar, Amritsar, IND
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Adedamola O Bello
- Psychiatry, St. Martinus University Faculty of Medicine, Willemstad, USA
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Abeer O Elshaikh
- Internal Medicine/Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Constantinescu V, Haase R, Akgün K, Ziemssen T. S1P receptor modulators and the cardiovascular autonomic nervous system in multiple sclerosis: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221133163. [PMID: 36437849 PMCID: PMC9685213 DOI: 10.1177/17562864221133163] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 09/29/2022] [Indexed: 01/21/2024] Open
Abstract
UNLABELLED Sphingosine 1-phosphate (S1P) receptor (S1PR) modulators have a complex mechanism of action, which are among the most efficient therapeutic options in multiple sclerosis (MS) and represent a promising approach for other immune-mediated diseases. The S1P signaling pathway involves the activation of five extracellular S1PR subtypes (S1PR1-S1PR5) that are ubiquitous and have a wide range of effects. Besides the immunomodulatory beneficial outcome in MS, S1P signaling regulates the cardiovascular function via S1PR1-S1PR3 subtypes, which reside on cardiac myocytes, endothelial, and vascular smooth muscle cells. In our review, we describe the mechanisms and clinical effects of S1PR modulators on the cardiovascular system. In the past, mostly short-term effects of S1PR modulators on the cardiovascular system have been studied, while data on long-term effects still need to be investigated. Immediate effects detected after treatment initiation are due to parasympathetic overactivation. In contrast, long-term effects may arise from a shift of the autonomic regulation toward sympathetic predominance along with S1PR1 downregulation. A mild increase in blood pressure has been reported in long-term studies, as well as decreased baroreflex sensitivity. In most studies, sustained hypertension was found to represent a significant adverse event related to treatment. The shift in the autonomic control and blood pressure values could not be just a consequence of disease progression but also related to S1PR modulation. Reduced cardiac autonomic activation and decreased heart rate variability during the long-term treatment with S1PR modulators may increase the risk for subsequent cardiac events. For second-generation S1PR modulators, this observation has to be confirmed in further studies with longer follow-ups. The periodic surveillance of cardiovascular function and detection of any cardiac autonomic dysfunction can help predict cardiac outcomes not only after the first dose but also throughout treatment. PLAIN LANGUAGE SUMMARY What is the cardiovascular effect of S1P receptor modulator therapy in multiple sclerosis? Sphingosine 1-phosphate (S1P) receptor (S1PR) modulators are among the most efficient therapies for multiple sclerosis. As small molecules, they are not only acting on the immune but on cardiovascular and nervous systems as well. Short-term effects of S1PR modulators on the cardiovascular system have already been extensively described, while long-term effects are less known. Our review describes the mechanisms of action and the short- and long-term effects of these therapeutic agents on the cardiovascular system in different clinical trials. We systematically reviewed the literature that had been published by January 2022. One hundred seven articles were initially identified by title and abstract using targeted keywords, and thirty-nine articles with relevance to cardiovascular effects of S1PR therapy in multiple sclerosis patients were thereafter considered, including their references for further accurate clarification. Studies on fingolimod, the first S1PR modulator approved for treating multiple sclerosis, primarily support the safety profile of this therapeutic class. The second-generation therapeutic agents along with a different treatment initiation approach helped mitigate several of the cardiovascular adverse effects that had previously been observed at the start of treatment. The heart rate may decrease when initiating S1PR modulators and, less commonly, the atrioventricular conduction may be prolonged, requiring cardiac monitoring for the first 6 h of medication. Continuous therapy with S1PR modulators can increase blood pressure values; therefore, the presence of arterial hypertension should be checked during long-term treatment. Periodic surveillance of the cardiovascular and autonomic functions can help predict cardiac outcomes and prevent possible adverse events in S1PR modulators treatment. Further studies with longer follow-ups are needed, especially for the second-generation of S1PR modulators, to confirm the safety profile of this therapeutic class.
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Affiliation(s)
- Victor Constantinescu
- Department of Neurology, Center of Clinical
Neuroscience, University Hospital Carl Gustav Carus, Dresden University of
Technology, Dresden, Germany
| | - Rocco Haase
- Department of Neurology, Center of Clinical
Neuroscience, University Hospital Carl Gustav Carus, Dresden University of
Technology, Dresden, Germany
| | - Katja Akgün
- Department of Neurology, Center of Clinical
Neuroscience, University Hospital Carl Gustav Carus, Dresden University of
Technology, Dresden, Germany
| | - Tjalf Ziemssen
- Department of Neurology, Center of Clinical
Neuroscience, University Hospital Carl Gustav Carus, Dresden University of
Technology, Fetscherstrasse 74, D-01307 Dresden, Germany
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Zhao Z, Lv Y, Gu ZC, Ma CL, Zhong MK. Risk for Cardiovascular Adverse Events Associated With Sphingosine-1-Phosphate Receptor Modulators in Patients With Multiple Sclerosis: Insights From a Pooled Analysis of 15 Randomised Controlled Trials. Front Immunol 2021; 12:795574. [PMID: 34950154 PMCID: PMC8688957 DOI: 10.3389/fimmu.2021.795574] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/18/2021] [Indexed: 12/18/2022] Open
Abstract
Background All agents engaging sphongosine-1-phospate receptors (S1PRs) will have some cardiovascular effect. This study aimed to elucidate the risk of cardiovascular adverse events (AEs) in patients with multiple sclerosis (MS) treated with S1PR modulators (S1PRMs). Methods We systematically searched the PubMed, EMBASE, and Cochrane Library databases for randomised controlled trials (RCTs) published through January 5, 2021. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated using the random-effects model. Sensitivity analyses and meta-regression were performed. Results Seventeen RCTs (12 for fingolimod; 3 for ozanimod; 2 for siponimod) involving 13,295 patients were included. Compared with the control treatment, S1PRMs significantly increased the risk of cardiovascular AEs (RR, 2.21; 95% CI, 1.58–3.10; I2, 75.6%). Notably, the high-risk cardiovascular AEs associated with S1PRMs were primarily bradyarrhythmia (RR, 2.92; 95% CI, 1.91–4.46; I2, 30.8%) and hypertension (RR, 2.00; 95% CI, 1.49–2.67; I2, 56.5%). Subgroup analysis results were consistent with the primary outcomes except that ozanimod was associated with a higher risk of hypertension only (RR, 1.76; 95% CI, 1.10–2.82; I2, 0.0%), while siponimod was associated with a higher risk of bradyarrhythmia only (RR, 2.75; 95% CI, 1.75–4.31; I2, 0.0%). No significant inter-subgroup differences were observed (Pinteraction > 0.05). Conclusions S1PRM use increased the risk of cardiovascular AEs by 1.21 times in patients with MS, and increased risks for bradyarrhythmia and hypertension were at 2.92- and 2.00-fold, respectively. These findings can help clinicians assess the risk of cardiovascular AEs in patients treated with S1PRMs. Systematic Review Registration The PROSPERO ID is CRD42020183215.
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Affiliation(s)
- Zhao Zhao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Yang Lv
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China.,The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chun-Lai Ma
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Ming-Kang Zhong
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
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Limmroth V, Ziemssen T, Kleiter I, Wagner B, Schmidt S, Lassek C, Baier-Ebert M, Wendt G, Dechend R, Haverkamp W. A Comprehensive Monitoring Study on Electrocardiographic Assessments and Cardiac Events After Fingolimod First Dose-Possible Predictors of Cardiac Outcomes. Front Neurol 2020; 11:818. [PMID: 32903376 PMCID: PMC7434833 DOI: 10.3389/fneur.2020.00818] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/30/2020] [Indexed: 12/28/2022] Open
Abstract
Background: First dose observation for cardiac effects is required for fingolimod. Previous results in patients with relapsing remitting multiple sclerosis (RRMS) suggest that transient bradycardia and conduction abnormalities during the observation phase are rare, benign and reversible. Prior analyses corroborate these findings. The present large scale dataset allows subgroup analyses for differences in the incidence of cardiac findings depending on patient characteristics. Methods: START was an open-label, multi-center study that enrolled 6,998 RRMS patients. Primary endpoints were incidence of bradycardia (heart rate < 45 bpm) and second-/third-degree atrioventricular (AV) block during treatment initiation. Subgroup analyses were performed according to age, gender, body mass index (BMI), baseline expanded disability status scale (EDSS), and concomitant medication to determine the impact of these variables on cardiac outcomes parameters. Results: 63 patients (0.9%) developed bradycardia (<45 bpm), 120 patients (1.7%) had a second-degree Mobitz I (Wenkebach) block and/or 2:1 AV block. One case of an asymptomatic third-degree AV block occurred. No Mobitz II AV block was observed. After 1 week, no second-/third-degree AV block was observed. The incidence of second- or third-degree AV blocks was significantly higher in older patients (≥50 years; p = 0.014 vs. patients 35–49 years). Second- or third-degree AV blocks were more frequent in females (87.5% of all patients with a second- or third-degree AV block; p < 0.001), while bradycardia occurred more often in males (58.7% of all bradycardia events; p < 0.001). Furthermore, patients with a BMI below 25 had a higher incidence of second- or third-degree AV block. Conclusions: In summary, transient bradycardia and AV conduction abnormalities after the first dose of fingolimod were rare and asymptomatic. When compared to females, male patients might have a higher risk for bradycardia during treatment initiation, presumably due to a lower resting heart rate. Furthermore, a low heart rate before treatment initiation, low body weight, or low BMI possibly increases the risk for bradycardia. Second- or third-degree AV blocks were more frequent in females, older patients and patients with a low BMI. Nevertheless, these cardiac events remained rare and benign, confirming the favorable cardiac safety profile of fingolimod upon treatment initiation in MS patients without cardiovascular comorbidities.
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Affiliation(s)
- Volker Limmroth
- Department of Neurology, Cologne General Hospitals, University of Cologne, Cologne, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Clinic Carl Gustav Carus Dresden, Dresden, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany.,Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | | | - Stephan Schmidt
- Neurologische Gemeinschaftspraxis Schmidt, Neudecker, Viebahn und Kronenberger, Bonn, Germany
| | - Christoph Lassek
- Neurologische Gemeinschaftspraxis Kassel und Vellmar, Kassel, Germany
| | | | | | - Ralf Dechend
- Experimental and Clinical Research Center, Charité-Campus Buch and HELIOS Klinikum, Berlin, Germany
| | - Wilhelm Haverkamp
- Division for Metabolism and Cardiology, Department of Cardiology, Charité Universitaetsmedizin Berlin, Berlin, Germany
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Kremer L, Taleb O, Boehm N, Mensah-Nyagan AG, Trifilieff E, de Seze J, Brun S. FTY720 controls disease severity and attenuates sciatic nerve damage in chronic experimental autoimmune neuritis. J Neuroinflammation 2019; 16:54. [PMID: 30825874 PMCID: PMC6397476 DOI: 10.1186/s12974-019-1441-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 02/22/2019] [Indexed: 12/21/2022] Open
Abstract
Background Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune-mediated inflammatory disease of the peripheral nervous system characterized by a response directed against certain myelin proteins and for which therapies are limited. Previous studies have suggested a beneficial role of FTY720, a sphingosine 1-phosphate (S1P) receptor agonist, known to deplete lymphocytes from the peripheral blood by sequestering them into lymph nodes, in the treatment of experimental autoimmune neuritis (EAN). Therefore, we investigated whether FTY720 is also beneficial in chronic experimental autoimmune neuritis (c-EAN), a recently developed rat model mimicking human CIDP. Methods c-EAN was induced in Lewis rats by immunization with S-palm P0(180–199) peptide. Rats were treated with FTY720 (1 mg/kg) or vehicle intraperitoneally once daily from the onset of clinical signs for 18 days; clinical signs were assessed daily until 60 days post-immunization (dpi). Electrophysiological and histological features were examined at different time points. We also evaluated the serum levels of different pro- and anti-inflammatory cytokines by ELISA or flow cytometry at 18, 40, and 60 dpi. Results Our data demonstrate that FTY720 decreased the severity and abolished the chronicity of the disease in c-EAN rats. Therapeutic FTY720 treatment reversed electrophysiological and histological anomalies, suggesting that myelinated fibers were subsequently preserved, it inhibited macrophage and IL-17+ cell infiltration in PNS, and it significantly reduced circulating pro-inflammatory cytokines. Conclusions FTY720 treatment has beneficial effects on c-EAN, a new animal model mimicking human CIDP. We have shown that FTY720 is an effective immunomodulatory agent, improving the disease course of c-EAN, preserving the myelinated fibers, attenuating the axonal degeneration, and decreasing the number of infiltrated inflammatory cells in peripheral nerves. These data confirm the interest of testing FTY720 or molecules targeting S1P in human peripheral neuropathies. Electronic supplementary material The online version of this article (10.1186/s12974-019-1441-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laurent Kremer
- Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, INSERM U1119/Université de Strasbourg, Faculté de Médecine, 11 rue Humann, 67085, Strasbourg, France.,Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France.,Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Omar Taleb
- Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, INSERM U1119/Université de Strasbourg, Faculté de Médecine, 11 rue Humann, 67085, Strasbourg, France.,Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
| | - Nelly Boehm
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France.,Faculty of Medicine, Institute of Histology, University of Strasbourg, Strasbourg, France
| | - Ayikoe Guy Mensah-Nyagan
- Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, INSERM U1119/Université de Strasbourg, Faculté de Médecine, 11 rue Humann, 67085, Strasbourg, France.,Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
| | - Elisabeth Trifilieff
- Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, INSERM U1119/Université de Strasbourg, Faculté de Médecine, 11 rue Humann, 67085, Strasbourg, France.,Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
| | - Jérôme de Seze
- Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, INSERM U1119/Université de Strasbourg, Faculté de Médecine, 11 rue Humann, 67085, Strasbourg, France.,Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France.,Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Susana Brun
- Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, INSERM U1119/Université de Strasbourg, Faculté de Médecine, 11 rue Humann, 67085, Strasbourg, France. .,Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France.
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Li K, Konofalska U, Akgün K, Reimann M, Rüdiger H, Haase R, Ziemssen T. Modulation of Cardiac Autonomic Function by Fingolimod Initiation and Predictors for Fingolimod Induced Bradycardia in Patients with Multiple Sclerosis. Front Neurosci 2017; 11:540. [PMID: 29075174 PMCID: PMC5643482 DOI: 10.3389/fnins.2017.00540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/15/2017] [Indexed: 12/19/2022] Open
Abstract
Objective: It is well-known that initiation of fingolimod induces a transient decrease of heart rate. However, the underlying cardiac autonomic regulation is poorly understood. We aimed to investigate the changes of autonomic activity caused by the first dose of fingolimod using a long-term multiple trigonometric spectral analysis for the first time. In addition, we sought to use the continuous Holter ECG recording to find predictors for fingolimod induced bradycardia. Methods: Seventy-eight patients with relapsing-remitting multiple sclerosis (RRMS) were included. As a part of the START study (NCT01585298), continuous electrocardiogram was recorded before fingolimod initiation, and until no <6 h post medication. Time domain and frequency domain heart rate variability (HRV) parameters were computed hourly to assess cardiac autonomic regulation. A long-term multiple trigonometric regressive spectral (MTRS) analysis was applied on successive 1-h-length electrocardiogram recordings. Decision tree analysis was used to find predictors for bradycardia following fingolimod initiation. Results: Most of the HRV parameters representing parasympathetic activities began to increase since the second hour after fingolimod administration. These changes of autonomic regulations were in accordance with the decline of heart rate. Baseline heart rate was highly correlated with nadir heart rate, and was the only significant predicting factor for fingolimod induced bradycardia among various demographic, clinical and cardiovascular variables in the decision tree analysis. Conclusions: The first dose application of fingolimod enhances the cardiac parasympathetic activity during the first 6 h post medication, which might be the underlying autonomic mechanism of reduced heart rate. Baseline heart rate is a powerful predictor for bradycardia caused by fingolimod.
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Affiliation(s)
- Kai Li
- Autonomic and Neuroendocrinological Lab, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany.,Department of Neurology, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Urszula Konofalska
- MS Center, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Katja Akgün
- MS Center, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Manja Reimann
- Autonomic and Neuroendocrinological Lab, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Heinz Rüdiger
- Autonomic and Neuroendocrinological Lab, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Rocco Haase
- Autonomic and Neuroendocrinological Lab, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Tjalf Ziemssen
- Autonomic and Neuroendocrinological Lab, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany.,MS Center, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
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7
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Pilote S, Simard C, Drolet B. Fingolimod (Gilenya ® ) in multiple sclerosis: bradycardia, atrioventricular blocks, and mild effect on the QTc interval. Something to do with the L-type calcium channel? Fundam Clin Pharmacol 2017; 31:392-402. [PMID: 28299825 DOI: 10.1111/fcp.12284] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/03/2017] [Accepted: 03/13/2017] [Indexed: 11/28/2022]
Abstract
Cardiac arrhythmias and ECG abnormalities including bradycardia, prolongation of the QT interval, and atrioventricular (AV) conduction blocks have been extensively observed with fingolimod, the first marketed oral drug for treating the relapsing-remitting form of multiple sclerosis. This study was aiming to further elucidate the effects of fingolimod on cardiac electrophysiology at three different levels: (i) in vitro, (ii) ex vivo, and (iii) in vivo. (i) Patch-clamp experiments in whole cell configuration were performed on Cav 1.2-transfected tsA201 cells exposed to fingolimod-phosphate 100 or 500 nmol/L (n = 27 cells, total) to measure drug effect on L-type calcium current (ICaL ). (ii) Langendorff perfusion experiments were undertaken on male Hartley guinea-pigs isolated hearts (n = 4) exposed to fingolimod 10 and 100 nmol/L to evaluate drug-induced effects on monophasic action potential duration measured at 90% repolarization (MAPD90 ). (iii) Implanted cardiac telemeters were used to record ECGs in guinea-pigs (n = 7) treated with a single dose of fingolimod 0.0625 mg/kg suspension, administered as an oral gavage. (i) In vitro cellular experiments showed that fingolimod-phosphate causes a concentration-dependent reduction in ICaL . (ii) Ex vivo Langendorff experiments revealed that fingolimod had no significant effect on MAPD90 . (iii) Fingolimod caused significant prolongations of the RR, PR, QT, and QTcF intervals in vivo. Reversible AV blocks were also observed in 7/7 animals. Fingolimod possesses ICaL -blocking properties, further contributing to its AV conduction-slowing effects. These properties are also consistent with its mitigated effect on the QT interval in humans, despite previously shown HERG-blocking effect.
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Affiliation(s)
- Sylvie Pilote
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (CRIUCPQ), 2725, Chemin Sainte-Foy, Québec, QC, Canada, G1V 4G5
| | - Chantale Simard
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (CRIUCPQ), 2725, Chemin Sainte-Foy, Québec, QC, Canada, G1V 4G5.,Faculté de Pharmacie, Université Laval, 1050 Avenue de la médecine, Québec, QC, Canada, G1V 0A6
| | - Benoit Drolet
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (CRIUCPQ), 2725, Chemin Sainte-Foy, Québec, QC, Canada, G1V 4G5.,Faculté de Pharmacie, Université Laval, 1050 Avenue de la médecine, Québec, QC, Canada, G1V 0A6
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Simula S, Laitinen TP, Laitinen TM, Hartikainen P, Hartikainen JEK. Sequence of cardiovascular autonomic alterations after fingolimod initiation. Ann Noninvasive Electrocardiol 2017; 22. [PMID: 28191684 DOI: 10.1111/anec.12443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 01/02/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Homeostasis between heart rate and blood pressure is based on several interacting regulatory reflexes, which become influenced by fingolimod initiation. The aim of this study was to determine the sequence of changes in cardiovascular autonomic regulation after fingolimod initiation. METHODS Twenty-seven patients with relapsing-remitting multiple sclerosis underwent continuous electrocardiogram recording during the first 6 hr after the first dose of fingolimod. In addition to the time interval between two consecutive R-peaks (RR interval), blood pressure and heart rate variability (HRV) were measured on hourly basis. Cardiac parasympathetic and sympathetic regulation were assessed by the different components of HRV. RESULTS HRV demonstrated an enhancement in cardiac parasympathetic regulation starting 1 hr after the first dose of fingolimod. Blood pressure started to decrease 2 hr and sympathetic cardiac regulation 3 hr after fingolimod initiation. Recovery in RR interval, systolic and diastolic blood pressure, as well as in cardiac autonomic regulation started after 5 hr postdose, whereas pulse pressure (difference between systolic and diastolic blood pressure) continued to increase at the time of hospital discharge. CONCLUSIONS RR interval, blood pressure, as well as the parasympathetic and sympathetic components of cardiac autonomic regulation alter sequentially in different temporal pattern after fingolimod initiation. These findings enhance the understanding of the effects of fingolimod initiation on cardiovascular autonomic regulation in real life.
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Affiliation(s)
- Sakari Simula
- Department of Neurology, Mikkeli Central Hospital, Mikkeli, Finland
| | - Tomi P Laitinen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Tiina M Laitinen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Päivi Hartikainen
- Neuro Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Juha E K Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
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Ritter C, Svačina MKR, Bobylev I, Joshi A, Schneider T, Lehmann HC. Impact of Age and Polytherapy on Fingolimod Induced Bradycardia: a Preclinical Study. J Neuroimmune Pharmacol 2017; 12:204-9. [DOI: 10.1007/s11481-017-9727-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/12/2017] [Indexed: 11/25/2022]
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Meissner A, Limmroth V. Update on the cardiovascular profile of fingolimod in the therapy of relapsing-remitting multiple sclerosis (MS). Mult Scler Relat Disord 2016; 8:19-26. [DOI: 10.1016/j.msard.2016.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 03/05/2016] [Accepted: 04/09/2016] [Indexed: 02/03/2023]
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Sanna MG, Vincent KP, Repetto E, Nguyen N, Brown SJ, Abgaryan L, Riley SW, Leaf NB, Cahalan SM, Kiosses WB, Kohno Y, Brown JH, McCulloch AD, Rosen H, Gonzalez-Cabrera PJ. Bitopic Sphingosine 1-Phosphate Receptor 3 (S1P3) Antagonist Rescue from Complete Heart Block: Pharmacological and Genetic Evidence for Direct S1P3 Regulation of Mouse Cardiac Conduction. Mol Pharmacol 2015; 89:176-86. [PMID: 26494861 DOI: 10.1124/mol.115.100222] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/20/2015] [Indexed: 12/21/2022] Open
Abstract
The molecular pharmacology of the G protein-coupled receptors for sphingosine 1-phosphate (S1P) provides important insight into established and new therapeutic targets. A new, potent bitopic S1P3 antagonist, SPM-354, with in vivo activity, has been used, together with S1P3-knockin and S1P3-knockout mice to define the spatial and functional properties of S1P3 in regulating cardiac conduction. We show that S1P3 is a key direct regulator of cardiac rhythm both in vivo and in isolated perfused hearts. 2-Amino-2-[2-(4-octylphenyl)ethyl]propane-1,3-diol in vivo and S1P in isolated hearts induced a spectrum of cardiac effects, ranging from sinus bradycardia to complete heart block, as measured by a surface electrocardiogram in anesthetized mice and in volume-conducted Langendorff preparations. The agonist effects on complete heart block are absent in S1P3-knockout mice and are reversed in wild-type mice with SPM-354, as characterized and described here. Homologous knockin of S1P3-mCherry is fully functional pharmacologically and is strongly expressed by immunohistochemistry confocal microscopy in Hyperpolarization Activated Cyclic Nucleotide Gated Potassium Channel 4 (HCN4)-positive atrioventricular node and His-Purkinje fibers, with relative less expression in the HCN4-positive sinoatrial node. In Langendorff studies, at constant pressure, SPM-354 restored sinus rhythm in S1P-induced complete heart block and fully reversed S1P-mediated bradycardia. S1P3 distribution and function in the mouse ventricular cardiac conduction system suggest a direct mechanism for heart block risk that should be further studied in humans. A richer understanding of receptor and ligand usage in the pacemaker cells of the cardiac system is likely to be useful in understanding ventricular conduction in health, disease, and pharmacology.
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Affiliation(s)
- M Germana Sanna
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Kevin P Vincent
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Emanuela Repetto
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Nhan Nguyen
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Steven J Brown
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Lusine Abgaryan
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Sean W Riley
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Nora B Leaf
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Stuart M Cahalan
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - William B Kiosses
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Yasushi Kohno
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Joan Heller Brown
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Andrew D McCulloch
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Hugh Rosen
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
| | - Pedro J Gonzalez-Cabrera
- Departments of Chemical Physiology (M.G.S., E.R., N.N., H.R., P.J.G.-C.), Immunology (N.B.L.), and Molecular and Cellular Neuroscience (S.M.C.), Scripps Research Institute Molecular Screening Center (S.J.B., L.A., S.W.R.), Microscopy Core (W.B.K.), Scripps Research Institute, La Jolla, California; Kyorin Pharmaceutical Company, LTD, Tokyo, Japan (Y.K.); and Departments of Bioengineering (A.D.M., K.P.V.) and Pharmacology, University of California, San Diego, California (J.H.B.)
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Fragoso YD, Alves-Leon SV, Barreira AA, Callegaro D, Brito Ferreira ML, Finkelsztejn A, Gomes S, Magno Goncalves MV, Moraes Machado MI, Marques VD, Cunha Matta AP, Papais-Alvarenga RM, Apostolos Pereira SL, Tauil CB. Fingolimod Prescribed for the Treatment of Multiple Sclerosis in Patients Younger Than Age 18 Years. Pediatr Neurol 2015; 53:166-8. [PMID: 26026897 DOI: 10.1016/j.pediatrneurol.2015.03.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 03/27/2015] [Accepted: 03/28/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND There have been no clinical trials for approval of medications for treating multiple sclerosis in patients younger than age 18 years. All treatments are based on personal experience and data from open observational studies. Fingolimod is an oral drug for multiple sclerosis that has been shown to be efficient and safe in adults. The aim of our study is to describe patients with multiple sclerosis who started treatment with fingolimod before the age of 18 years. PARTICIPANTS AND METHODS Seventeen patients treated with fingolimod were identified in the Brazilian database of children and adolescents with multiple sclerosis. The average time of use of the drug was 8.6 months. RESULTS Fingolimod showed a good safety and efficacy profile in these patients, all of whom had very active multiple sclerosis. After starting treatment with fingolimod, only one patient had a relapse and a new lesion on magnetic resonance imaging. The patients' degree of disability did not progress. No major adverse events were reported in relation to the first dose of the drug, nor in the short- and medium-term treatment. No patient has been followed for longer than 18 months, thus limiting long-term conclusions. CONCLUSIONS Off-label use of fingolimod in patients younger than age 18 years may be a good therapeutic option for multiple sclerosis control.
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Affiliation(s)
- Yara Dadalti Fragoso
- Department of Neurology and MS Unit, Universidade Metropolitana de Santos, Santos, SP, Brazil.
| | - Soniza Vieira Alves-Leon
- Department of Neurology and MS Unit, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil; Department of Neurology and MS Unit, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Dagoberto Callegaro
- Department of Neurology and MS Unit, Hospital das Clinicas, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Alessandro Finkelsztejn
- Department of Neurology and MS Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Sidney Gomes
- Department of Neurology and MS Unit, Hospital Beneficencia Portuguesa and Hospital Paulistano, Sao Paulo, SP, Brazil
| | | | | | | | | | | | | | - Carlos Bernardo Tauil
- Department of Neurology and MS Unit, Hospital de Base do Distrito Federal, Brasilia, DF, Brazil
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Correale J, Flores J, Bonitto JG, Rodríguez CC, Oliveira EML. Use of Fingolimod in the Management of Relapsing-Remitting Multiple Sclerosis: Experience from Latin America. Adv Ther 2015; 32:612-25. [PMID: 26170106 PMCID: PMC4522024 DOI: 10.1007/s12325-015-0226-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Indexed: 11/24/2022]
Abstract
UNLABELLED Once-daily fingolimod 0.5 mg (FTY720; Gilenya(®), Novartis Pharma AG, Basel, Switzerland) is a sphingosine 1-phosphate receptor modulator that is approved for the treatment of relapsing multiple sclerosis (MS); currently, this includes approval in 13 Latin American countries. However, despite a well-characterized efficacy and safety profile in a large clinical development program, thus far there has been limited representation of patients from across the Latin American region. Differences in MS disease characteristics have been reported for the Latin American population compared with Caucasians, which may be additional to recent improvements in MS diagnosis. Furthermore, healthcare provision and regional socioeconomic factors exist that are unique to Latin America compared with other regions. Therefore, to optimize MS treatment pathways and improve patient clinical outcomes, it is important to investigate the efficacy and safety profile of fingolimod using ethnically relevant data. Here, we review key data from Hispanic patients enrolled in the fingolimod clinical trial program, summarize recent findings from the FIRST LATAM study, and appraise fingolimod data from real-world patient populations. FUNDING Novartis Pharma AG, Basel, Switzerland.
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Affiliation(s)
- Jorge Correale
- Department of Neurology, Institute for Neurological Research Raúl Carrea, FLENI, Buenos Aires, Argentina,
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