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Aspden JW, Murphy MA, Kashlan RD, Xiong Y, Poznansky MC, Sîrbulescu RF. Intruders or protectors - the multifaceted role of B cells in CNS disorders. Front Cell Neurosci 2024; 17:1329823. [PMID: 38269112 PMCID: PMC10806081 DOI: 10.3389/fncel.2023.1329823] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024] Open
Abstract
B lymphocytes are immune cells studied predominantly in the context of peripheral humoral immune responses against pathogens. Evidence has been accumulating in recent years on the diversity of immunomodulatory functions that B cells undertake, with particular relevance for pathologies of the central nervous system (CNS). This review summarizes current knowledge on B cell populations, localization, infiltration mechanisms, and function in the CNS and associated tissues. Acute and chronic neurodegenerative pathologies are examined in order to explore the complex, and sometimes conflicting, effects that B cells can have in each context, with implications for disease progression and treatment outcomes. Additional factors such as aging modulate the proportions and function of B cell subpopulations over time and are also discussed in the context of neuroinflammatory response and disease susceptibility. A better understanding of the multifactorial role of B cell populations in the CNS may ultimately lead to innovative therapeutic strategies for a variety of neurological conditions.
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Affiliation(s)
- James W. Aspden
- Vaccine and Immunotherapy Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Matthew A. Murphy
- Vaccine and Immunotherapy Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Rommi D. Kashlan
- Vaccine and Immunotherapy Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Yueyue Xiong
- Vaccine and Immunotherapy Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Mark C. Poznansky
- Vaccine and Immunotherapy Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Ruxandra F. Sîrbulescu
- Vaccine and Immunotherapy Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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2
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Kalkowski L, Walczak P, Mycko MP, Malysz-Cymborska I. Reconsidering the route of drug delivery in refractory multiple sclerosis: Toward a more effective drug accumulation in the central nervous system. Med Res Rev 2023; 43:2237-2259. [PMID: 37203228 DOI: 10.1002/med.21973] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 03/08/2023] [Accepted: 04/30/2023] [Indexed: 05/20/2023]
Abstract
Multiple sclerosis is a chronic demyelinating disease with different disease phenotypes. The current FDA-approved disease-modifying therapeutics (DMTs) cannot cure the disease, but only alleviate the disease progression. While the majority of patients respond well to treatment, some of them are suffering from rapid progression. Current drug delivery strategies include the oral, intravenous, subdermal, and intramuscular routes, so these drugs are delivered systemically, which is appropriate when the therapeutic targets are peripheral. However, the potential benefits may be diminished when these targets sequester behind the barriers of the central nervous system. Moreover, systemic drug administration is plagued with adverse effects, sometimes severe. In this context, it is prudent to consider other drug delivery strategies improving their accumulation in the brain, thus providing better prospects for patients with rapidly progressing disease course. These targeted drug delivery strategies may also reduce the severity of systemic adverse effects. Here, we discuss the possibilities and indications for reconsideration of drug delivery routes (especially for those "non-responding" patients) and the search for alternative drug delivery strategies. More targeted drug delivery strategies sometimes require quite invasive procedures, but the potential therapeutic benefits and reduction of adverse effects could outweigh the risks. We characterized the major FDA-approved DMTs focusing on their therapeutic mechanism and the potential benefits of improving the accumulation of these drugs in the brain.
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Affiliation(s)
- Lukasz Kalkowski
- Department of Diagnostic Radiology and Nuclear Medicine, Center for Advanced Imaging Research, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Piotr Walczak
- Department of Diagnostic Radiology and Nuclear Medicine, Center for Advanced Imaging Research, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Marcin P Mycko
- Medical Division, Department of Neurology, Laboratory of Neuroimmunology, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Izabela Malysz-Cymborska
- Department of Neurosurgery, School of Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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3
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Chen BY, Salas JR, Trias AO, Rodriguez AP, Tsang JE, Guemes M, Le TM, Galic Z, Shepard HM, Steinman L, Nathanson DA, Czernin J, Witte ON, Radu CG, Schultz KA, Clark PM. Targeting deoxycytidine kinase improves symptoms in mouse models of multiple sclerosis. Immunology 2023; 168:152-169. [PMID: 35986643 PMCID: PMC9844239 DOI: 10.1111/imm.13569] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/12/2022] [Indexed: 01/19/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease driven by lymphocyte activation against myelin autoantigens in the central nervous system leading to demyelination and neurodegeneration. The deoxyribonucleoside salvage pathway with the rate-limiting enzyme deoxycytidine kinase (dCK) captures extracellular deoxyribonucleosides for use in intracellular deoxyribonucleotide metabolism. Previous studies have shown that deoxyribonucleoside salvage activity is enriched in lymphocytes and required for early lymphocyte development. However, specific roles for the deoxyribonucleoside salvage pathway and dCK in autoimmune diseases such as MS are unknown. Here we demonstrate that dCK activity is necessary for the development of clinical symptoms in the MOG35-55 and MOG1-125 experimental autoimmune encephalomyelitis (EAE) mouse models of MS. During EAE disease, deoxyribonucleoside salvage activity is elevated in the spleen and lymph nodes. Targeting dCK with the small molecule dCK inhibitor TRE-515 limits disease severity when treatments are started at disease induction or when symptoms first appear. EAE mice treated with TRE-515 have significantly fewer infiltrating leukocytes in the spinal cord, and TRE-515 blocks activation-induced B and T cell proliferation and MOG35-55 -specific T cell expansion without affecting innate immune cells or naïve T and B cell populations. Our results demonstrate that targeting dCK limits symptoms in EAE mice and suggest that dCK activity is required for MOG35-55 -specific lymphocyte activation-induced proliferation.
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Affiliation(s)
- Bao Ying Chen
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Crump Institute for Molecular Imaging, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jessica R. Salas
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Crump Institute for Molecular Imaging, University of California, Los Angeles, Los Angeles, CA, USA
| | - Alyssa O. Trias
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Crump Institute for Molecular Imaging, University of California, Los Angeles, Los Angeles, CA, USA
| | - Arely Perez Rodriguez
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Crump Institute for Molecular Imaging, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jonathan E. Tsang
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Miriam Guemes
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Thuc M. Le
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Ahmanson Translational Imaging Division, University of California, Los Angeles, Los Angeles, CA, USA
| | - Zoran Galic
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Lawrence Steinman
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - David A. Nathanson
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Ahmanson Translational Imaging Division, University of California, Los Angeles, Los Angeles, CA, USA
| | - Johannes Czernin
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Ahmanson Translational Imaging Division, University of California, Los Angeles, Los Angeles, CA, USA
| | - Owen N. Witte
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Caius G. Radu
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Ahmanson Translational Imaging Division, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Peter M. Clark
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Crump Institute for Molecular Imaging, University of California, Los Angeles, Los Angeles, CA, USA
- Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, Los Angeles, CA, USA
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Ortíz GG, Briones-Torres AL, Benitez-King G, González-Ortíz LJ, Palacios-Magaña CV, Pacheco-Moisés FP. Beneficial Effect of Melatonin Alone or in Combination with Glatiramer Acetate and Interferon β-1b on Experimental Autoimmune Encephalomyelitis. Molecules 2022; 27:molecules27134217. [PMID: 35807462 PMCID: PMC9268121 DOI: 10.3390/molecules27134217] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 02/04/2023] Open
Abstract
Experimental autoimmune encephalomyelitis (EAE) is a relevant animal model of multiple sclerosis (MS). Oxidative stress and chronic inflammation play a major role in the pathogenesis of MS and EAE. Melatonin, a neurohormone, has potent anti-inflammatory properties. The aim of our study was to assess the therapeutic properties of melatonin alone or in combination with interferon β-1b (IFNβ-1b) or glatiramer acetate (GA) on EAE. EAE was induced in male Sprague-Dawley rats with an intraperitoneal injection of a homogenate of spinal cord and pig brain. At day 10 post immunization, rats were euthanized, and their brains were immediately excised and processed to measure oxidative stress markers and membrane fluidity. In addition, proinflammatory cytokines were quantified in plasma. Melatonin alone or in combination with GA and IFNβ-1b inhibited the disease process of EAE and the synthesis of proinflammatory cytokines, caused a significant decrement in oxidative stress markers, and preserved the membrane fluidity in the motor cortex, midbrain, and spinal cord. The cumulative index score was significantly reduced in EAE rats treated with melatonin alone or in combination with GA and IFNβ-1b. In conclusion, our findings provide preclinical evidence for the use of melatonin as an adjuvant therapeutic treatment for MS.
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Affiliation(s)
- Genaro Gabriel Ortíz
- Department of Philosophical and Methodological Disciplines, University Health Sciences Center, University of Guadalajara, Guadalajara 44340, Jalisco, Mexico;
| | - Ana Laura Briones-Torres
- Department of Chemistry, University Center of Exact Sciences and Engineering, University of Guadalajara, Guadalajara 44430, Jalisco, Mexico; (L.J.G.-O.); (C.V.P.-M.)
| | - Gloria Benitez-King
- National Institute of Psychiatry Ramón de la Fuente Muñíz, Mexico City 14370, Mexico;
| | - Luis Javier González-Ortíz
- Department of Chemistry, University Center of Exact Sciences and Engineering, University of Guadalajara, Guadalajara 44430, Jalisco, Mexico; (L.J.G.-O.); (C.V.P.-M.)
| | - Claudia Verónica Palacios-Magaña
- Department of Chemistry, University Center of Exact Sciences and Engineering, University of Guadalajara, Guadalajara 44430, Jalisco, Mexico; (L.J.G.-O.); (C.V.P.-M.)
| | - Fermín Paul Pacheco-Moisés
- Department of Chemistry, University Center of Exact Sciences and Engineering, University of Guadalajara, Guadalajara 44430, Jalisco, Mexico; (L.J.G.-O.); (C.V.P.-M.)
- Correspondence:
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Matsoukas J, Deraos G, Kelaidonis K, Hossain MK, Feehan J, Tzakos AG, Matsoukas E, Topoglidis E, Apostolopoulos V. Myelin Peptide-Mannan Conjugate Multiple Sclerosis Vaccines: Conjugation Efficacy and Stability of Vaccine Ingredient. Vaccines (Basel) 2021; 9:vaccines9121456. [PMID: 34960201 PMCID: PMC8708491 DOI: 10.3390/vaccines9121456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 10/04/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 12/17/2022] Open
Abstract
Myelin peptide–mannan conjugates have been shown to be potential vaccines in the immunotherapy of multiple sclerosis. The conjugates are comprised from the epitope peptide and the polysaccharide mannan which transfers as a carrier the antigenic peptide to dendritic cells that process and present antigenic peptides at their surface in complex with MHC class I or class II resulting in T-cell stimulation. The conjugation of antigenic peptide with mannan occurs through the linker (Lys–Gly)5, which connects the peptide with the oxidized mannose units of mannan. This study describes novel methods for the quantification of the vaccine ingredient peptide within the conjugate, a prerequisite for approval of clinical trials in the pursuit of multiple sclerosis therapeutics. Myelin peptides, such as MOG35–55, MBP83–99, and PLP131–145 in linear or cyclic form, as altered peptide ligands or conjugated to appropriate carriers, possess immunomodulatory properties in experimental models and are potential candidates for clinical trials.
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Affiliation(s)
- John Matsoukas
- Drug Discovery Laboratory, NewfvDrug, P.C., Patras Science Park, 26504 Patras, Greece; (G.D.); (K.K.); (E.M.)
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (M.K.H.); (J.F.)
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Correspondence: (J.M.); (V.A.)
| | - George Deraos
- Drug Discovery Laboratory, NewfvDrug, P.C., Patras Science Park, 26504 Patras, Greece; (G.D.); (K.K.); (E.M.)
| | - Kostas Kelaidonis
- Drug Discovery Laboratory, NewfvDrug, P.C., Patras Science Park, 26504 Patras, Greece; (G.D.); (K.K.); (E.M.)
| | - Md Kamal Hossain
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (M.K.H.); (J.F.)
| | - Jack Feehan
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (M.K.H.); (J.F.)
| | - Andreas G. Tzakos
- Department of Chemistry, University of Ioannina, 45110 Ioannina, Greece;
| | - Elizabeth Matsoukas
- Drug Discovery Laboratory, NewfvDrug, P.C., Patras Science Park, 26504 Patras, Greece; (G.D.); (K.K.); (E.M.)
| | | | - Vasso Apostolopoulos
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (M.K.H.); (J.F.)
- Immunology Program, Australian Institute for Musculoskeletal Science (AIMSS), Melbourne, VIC 3021, Australia
- Correspondence: (J.M.); (V.A.)
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Zarzuelo-Romero MJ, Pérez-Ramírez C, Cura Y, Carrasco-Campos MI, Marangoni-Iglecias LM, Ramírez-Tortosa MC, Jiménez-Morales A. Influence of Genetic Polymorphisms on Clinical Outcomes of Glatiramer Acetate in Multiple Sclerosis Patients. J Pers Med 2021; 11:jpm11101032. [PMID: 34683173 PMCID: PMC8540092 DOI: 10.3390/jpm11101032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 07/05/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 02/07/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory, demyelinating disease of autoimmune origin, in which inflammation and demyelination lead to neurodegeneration and progressive disability. Treatment is aimed at slowing down the course of the disease and mitigating its symptoms. One of the first-line treatments used in patients with MS is glatiramer acetate (GA). However, in clinical practice, a response rate of between 30% and 55% is observed. This variability in the effectiveness of the medication may be influenced by genetic factors such as polymorphisms in the genes involved in the pathogenesis of MS. Therefore, this review assesses the impact of genetic variants on the response to GA therapy in patients diagnosed with MS. The results suggest that a relationship exists between the effectiveness of the treatment with GA and the presence of polymorphisms in the following genes: CD86, CLEC16A, CTSS, EOMES, MBP, FAS, TRBC1, IL1R1, IL12RB2, IL22RA2, PTPRT, PVT1, ALOX5AP, MAGI2, ZAK, RFPL3, UVRAG, SLC1A4, and HLA-DRB1*1501. Consequently, the identification of polymorphisms in these genes can be used in the future as a predictive marker of the response to GA treatment in patients diagnosed with MS. Nevertheless, there is a lack of evidence for this and more validation studies need to be conducted to apply this information to clinical practice.
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Affiliation(s)
- María José Zarzuelo-Romero
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Granada, 18001 Granada, Spain;
| | - Cristina Pérez-Ramírez
- Center of Biomedical Research, Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Technology “José Mataix”, University of Granada, Avda. del Conocimiento s/n., 18016 Armilla, Granada, Spain;
- Pharmacogenetics Unit, Pharmacy Service, Virgen de las Nieves University Hospital, 18012 Granada, Spain; (Y.C.); (M.I.C.-C.); (L.M.M.-I.); (A.J.-M.)
- Correspondence:
| | - Yasmín Cura
- Pharmacogenetics Unit, Pharmacy Service, Virgen de las Nieves University Hospital, 18012 Granada, Spain; (Y.C.); (M.I.C.-C.); (L.M.M.-I.); (A.J.-M.)
| | - María Isabel Carrasco-Campos
- Pharmacogenetics Unit, Pharmacy Service, Virgen de las Nieves University Hospital, 18012 Granada, Spain; (Y.C.); (M.I.C.-C.); (L.M.M.-I.); (A.J.-M.)
| | - Luciana María Marangoni-Iglecias
- Pharmacogenetics Unit, Pharmacy Service, Virgen de las Nieves University Hospital, 18012 Granada, Spain; (Y.C.); (M.I.C.-C.); (L.M.M.-I.); (A.J.-M.)
| | - María Carmen Ramírez-Tortosa
- Center of Biomedical Research, Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Technology “José Mataix”, University of Granada, Avda. del Conocimiento s/n., 18016 Armilla, Granada, Spain;
| | - Alberto Jiménez-Morales
- Pharmacogenetics Unit, Pharmacy Service, Virgen de las Nieves University Hospital, 18012 Granada, Spain; (Y.C.); (M.I.C.-C.); (L.M.M.-I.); (A.J.-M.)
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Abstract
Multiple Sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system. Once thought to be primarily driven by T cells, B cells are emerging as central players in MS immunopathogenesis. Interest in multiple B cell phenotypes in MS expanded following the efficacy of B cell-depleting agents targeting CD20 in relapsing-remitting MS and inflammatory primary progressive MS patients. Interestingly, these therapies primarily target non-antibody secreting cells. Emerging studies seek to explore B cell functions beyond antibody-mediated roles, including cytokine production, antigen presentation, and ectopic follicle-like aggregate formation. Importantly, memory B cells (Bmem) are rising as a key B cell phenotype to investigate in MS due to their antigen-experience, increased lifespan, and rapid response to stimulation. Bmem display diverse effector functions including cytokine production, antigen presentation, and serving as antigen-experienced precursors to antibody-secreting cells. In this review, we explore the cellular and molecular processes involved in Bmem development, Bmem phenotypes, and effector functions. We then examine how these concepts may be applied to the potential role(s) of Bmem in MS pathogenesis. We investigate Bmem both within the periphery and inside the CNS compartment, focusing on Bmem phenotypes and proposed functions in MS and its animal models. Finally, we review how current immunomodulatory therapies, including B cell-directed therapies and other immunomodulatory therapies, modify Bmem and how this knowledge may be harnessed to direct therapeutic strategies in MS.
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Affiliation(s)
- Krista D. DiSano
- Department of Neurology, Geisel School of Medicine & Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
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Tacke S, Braune S, Rovituso DM, Ziemssen T, Lehmann PV, Dikow H, Bergmann A, Kuerten S. B-Cell Activity Predicts Response to Glatiramer Acetate and Interferon in Relapsing-Remitting Multiple Sclerosis. Neurol Neuroimmunol Neuroinflamm 2021; 8:8/3/e980. [PMID: 33707177 PMCID: PMC7958588 DOI: 10.1212/nxi.0000000000000980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/12/2021] [Indexed: 11/15/2022]
Abstract
Objective We investigated the predictive value of the enzyme-linked immunospot technique (ELISPOT) in identifying patients with relapsing-remitting multiple sclerosis (RRMS) who will respond to treatment with glatiramer acetate (GA) or interferon-β (IFN-β), based on the brain-reactive B-cell activity of peripheral blood cells. Methods In this retrospective, cross-sectional, real-world multicenter study, we identified patients with RRMS in the NeuroTransData MS registry and stratified them based on their documented treatment response (relapse-free in the first 12 months of treatment) to GA or IFN-β. The GA group comprised 73 patients who responded to GA and 35 nonresponders. The IFN-β group comprised 62 responders to IFN-β and 37 nonresponders. Patients with previous or current therapy affecting B-cell activity were excluded. We polyclonally stimulated mononuclear cells from peripheral blood samples (collected after participant selection) and investigated brain-reactive B-cell activity after incubation on brain tissue lysate-coated ELISPOT plates. Validity metrics of the ELISPOT testing results were calculated (Python 3.6.8) in relation to the clinical responsiveness in the 2 treatment groups. Results The ELISPOT B-cell activity assay showed a sensitivity of 0.74, a specificity of 0.76, a positive predictive value of 0.78, a negative predictive value of 0.28, and a diagnostic OR of 8.99 in predicting clinical response to GA vs IFN-β therapy in patients with RRMS. Conclusion Measurement of brain-reactive B-cell activity by ELISPOT provides clinically meaningful predictive probabilities of individual patients' treatment response to GA or IFN-β. The assay has the potential to improve the selection of optimal first-line treatment for individual patients with RRMS. Classification of Evidence This study provides Class II evidence that in patients with RRMS, the brain reactivity of their peripheral-blood B cells predicts clinical response to GA and IFN-β.
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Affiliation(s)
- Sabine Tacke
- From the Institute of Anatomy and Cell Biology (S.T., D.M.R., S.K.), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; NeuroTransData (S.B., H.D., A.B.), Neuburg an der Donau, Germany; Department of Neurology (T.Z.), Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; and Research and Development Department (P.V.L.), Cellular Technology Limited, Shaker Heights, OH
| | - Stefan Braune
- From the Institute of Anatomy and Cell Biology (S.T., D.M.R., S.K.), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; NeuroTransData (S.B., H.D., A.B.), Neuburg an der Donau, Germany; Department of Neurology (T.Z.), Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; and Research and Development Department (P.V.L.), Cellular Technology Limited, Shaker Heights, OH
| | - Damiano M Rovituso
- From the Institute of Anatomy and Cell Biology (S.T., D.M.R., S.K.), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; NeuroTransData (S.B., H.D., A.B.), Neuburg an der Donau, Germany; Department of Neurology (T.Z.), Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; and Research and Development Department (P.V.L.), Cellular Technology Limited, Shaker Heights, OH
| | - Tjalf Ziemssen
- From the Institute of Anatomy and Cell Biology (S.T., D.M.R., S.K.), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; NeuroTransData (S.B., H.D., A.B.), Neuburg an der Donau, Germany; Department of Neurology (T.Z.), Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; and Research and Development Department (P.V.L.), Cellular Technology Limited, Shaker Heights, OH
| | - Paul V Lehmann
- From the Institute of Anatomy and Cell Biology (S.T., D.M.R., S.K.), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; NeuroTransData (S.B., H.D., A.B.), Neuburg an der Donau, Germany; Department of Neurology (T.Z.), Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; and Research and Development Department (P.V.L.), Cellular Technology Limited, Shaker Heights, OH
| | - Heidi Dikow
- From the Institute of Anatomy and Cell Biology (S.T., D.M.R., S.K.), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; NeuroTransData (S.B., H.D., A.B.), Neuburg an der Donau, Germany; Department of Neurology (T.Z.), Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; and Research and Development Department (P.V.L.), Cellular Technology Limited, Shaker Heights, OH
| | - Arnfin Bergmann
- From the Institute of Anatomy and Cell Biology (S.T., D.M.R., S.K.), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; NeuroTransData (S.B., H.D., A.B.), Neuburg an der Donau, Germany; Department of Neurology (T.Z.), Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; and Research and Development Department (P.V.L.), Cellular Technology Limited, Shaker Heights, OH
| | - Stefanie Kuerten
- From the Institute of Anatomy and Cell Biology (S.T., D.M.R., S.K.), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; NeuroTransData (S.B., H.D., A.B.), Neuburg an der Donau, Germany; Department of Neurology (T.Z.), Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; and Research and Development Department (P.V.L.), Cellular Technology Limited, Shaker Heights, OH.
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9
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Reder AT, Centonze D, Naylor ML, Nagpal A, Rajbhandari R, Altincatal A, Kim M, Berdofe A, Radhakrishnan M, Jung E, Sandrock AW, Smirnakis K, Popescu C, de Moor C. COVID-19 in Patients with Multiple Sclerosis: Associations with Disease-Modifying Therapies. CNS Drugs 2021; 35:317-330. [PMID: 33743151 PMCID: PMC7980129 DOI: 10.1007/s40263-021-00804-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Disease-modifying therapies (DMTs) for multiple sclerosis (MS) target immunity and have the potential to increase the risk of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and alter its clinical course. We assessed these risks in patients with MS (PwMS). OBJECTIVE The objective of this study was to describe the overall risk of coronavirus disease 2019 (COVID-19) infection, severe disease course, and potential population-level predictors of COVID-19 infection in PwMS, and to provide a context using a cohort of patients with systemic lupus erythematosus (SLE). In addition, the association of different MS DMTs with the incidence and clinical course of COVID-19 was evaluated. Safety data from the Biogen Global Safety Database are also presented on reported cases of COVID-19 in patients treated with Biogen MS therapies. METHODS The IBM® Explorys electronic health record database of > 72,000,000 patients from US healthcare networks identified patients with MS or SLE, with and without polymerase chain reaction-confirmed COVID-19. COVID-19 cumulative incidence, hospitalization, and deaths among DMT classes were compared using logistic regression (adjusted for age, sex, body mass index, comorbidities, and race/ethnicity). As a secondary data source to assess safety data, COVID-19 reports for Biogen MS therapies were extracted and described from Biogen's Global Safety Database. RESULTS 30,478 PwMS with an open DMT prescription were identified within Explorys; 344 were COVID-19 positive. The most significant risk factors for acquiring COVID-19 were comorbidity score ≥ 1, body mass index ≥ 30, and Black/African ancestry. Similar risk factors were also identified for patients with SLE. Patients with MS were less likely to develop COVID-19 when treated with interferons (0.61%) and glatiramer acetate (0.51%), vs all other MS DMTs (both p < 0.001); anti-CD20 therapy was associated with the highest risk (3.45%; p < 0.0001). In the Biogen Global Safety Database, we identified 1217 patients who were COVID-19 positive treated with intramuscular interferon beta-1a, peginterferon beta-1a, natalizumab, dimethyl fumarate, diroximel fumarate, or fampridine. CONCLUSIONS Comorbidities, obesity, and Black/African ancestry, but not age, were associated with a higher risk of SARS-CoV-2 infection in PwMS. Interferons and glatiramer acetate were associated with a reduced COVID-19 risk, whereas anti-CD20 therapies were associated with an increased risk, within the treated MS cohort. COVID-19 safety reports for patients receiving Biogen MS therapies were consistent with the Explorys database and MS literature, illustrating the replicability and power of this approach.
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Affiliation(s)
- Anthony T Reder
- Department of Neurology and Brain Research Institute, University of Chicago, Chicago, IL, USA.
| | - Diego Centonze
- Laboratory of Synaptic Immunopathology, Department of Systems Medicine, Tor Vergata University, Rome, Italy
- Unit of Neurology, IRCCS Neuromed, Pozzilli, Italy
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Yordanova IA, Ebner F, Schulz AR, Steinfelder S, Rosche B, Bolze A, Paul F, Mei HE, Hartmann S. The Worm-Specific Immune Response in Multiple Sclerosis Patients Receiving Controlled Trichuris suis Ova Immunotherapy. Life (Basel) 2021; 11:life11020101. [PMID: 33572978 PMCID: PMC7912101 DOI: 10.3390/life11020101] [Citation(s) in RCA: 6] [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: 12/15/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 12/19/2022] Open
Abstract
Considering their potent immunomodulatory properties, therapeutic applications of Trichuris suis ova (TSO) are studied as potential alternative treatment of autoimmune disorders like multiple sclerosis (MS), rheumatoid arthritis (RA), or inflammatory bowel disease (IBD). Clinical phase 1 and 2 studies have demonstrated TSO treatment to be safe and well tolerated in MS patients, however, they reported only modest clinical efficacy. We therefore addressed the cellular and humoral immune responses directed against parasite antigens in individual MS patients receiving controlled TSO treatment (2500 TSO p.o. every 2 weeks for 12 month). Peripheral blood mononuclear cells (PBMC) of MS patients treated with TSO (n = 5) or placebo (n = 6) were analyzed. A continuous increase of serum IgG and IgE antibodies specific for T. suis excretory/secretory antigens was observed up to 12 months post-treatment. This was consistent with mass cytometry analysis identifying an increase of activated HLA-DRhigh plasmablast frequencies in TSO-treated patients. While stable and comparable frequencies of total CD4+ and CD8+ T cells were detected in placebo and TSO-treated patients over time, we observed an increase of activated HLA-DR+CD4+ T cells in TSO-treated patients only. Frequencies of Gata3+ Th2 cells and Th1/Th2 ratios remained stable during TSO treatment, while Foxp3+ Treg frequencies varied greatly between individuals. Using a T. suis antigen-specific T cell expansion assay, we also detected patient-to-patient variation of antigen-specific T cell recall responses and cytokine production. In summary, MS patients receiving TSO treatment established a T. suis-specific T- and B-cell response, however, with varying degrees of T cell responses and cellular functionality across individuals, which might account for the overall miscellaneous clinical efficacy in the studied patients.
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Affiliation(s)
- Ivet A. Yordanova
- Institute of Immunology, Center for Infection Medicine, Freie Universität Berlin, D-14163 Berlin, Germany; (I.A.Y.); (F.E.)
| | - Friederike Ebner
- Institute of Immunology, Center for Infection Medicine, Freie Universität Berlin, D-14163 Berlin, Germany; (I.A.Y.); (F.E.)
| | - Axel Ronald Schulz
- German Rheumatism Research Center Berlin (DRFZ), a Leibniz Institute, D-10117 Berlin, Germany; (A.R.S.); (H.E.M.)
| | | | - Berit Rosche
- Department of Neurology and Experimental Neurology, Charité—Universitätsmedizin Berlin, D-10117 Berlin, Germany;
- Clinical and Experimental Multiple Sclerosis Research Center, Charité—Universitätsmedizin Berlin, D-10117 Berlin, Germany;
| | - Anna Bolze
- NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, D-10117 Berlin, Germany;
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine, Charité—Universitätsmedizin Berlin, D-10117 Berlin, Germany
| | - Friedemann Paul
- Clinical and Experimental Multiple Sclerosis Research Center, Charité—Universitätsmedizin Berlin, D-10117 Berlin, Germany;
- NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, D-10117 Berlin, Germany;
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine, Charité—Universitätsmedizin Berlin, D-10117 Berlin, Germany
| | - Henrik E. Mei
- German Rheumatism Research Center Berlin (DRFZ), a Leibniz Institute, D-10117 Berlin, Germany; (A.R.S.); (H.E.M.)
| | - Susanne Hartmann
- Institute of Immunology, Center for Infection Medicine, Freie Universität Berlin, D-14163 Berlin, Germany; (I.A.Y.); (F.E.)
- Correspondence:
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Guerrera G, Ruggieri S, Picozza M, Piras E, Gargano F, Placido R, Gasperini C, Salvetti M, Buscarinu MC, Battistini L, Borsellino G, Angelini DF. EBV-specific CD8 T lymphocytes and B cells during glatiramer acetate therapy in patients with MS. Neurol Neuroimmunol Neuroinflamm 2020; 7:7/6/e876. [PMID: 32817203 PMCID: PMC7455312 DOI: 10.1212/nxi.0000000000000876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/08/2020] [Indexed: 12/31/2022]
Abstract
Objective Infection with Epstein-Barr virus (EBV) has been associated with clinical activity and risk of developing MS. The purpose of this study is to investigate the impact of glatiramer acetate (GA) therapy on EBV-specific immune responses and disease course. Methods We characterized EBV-specific CD8 T lymphocytes and B cells during disease-modifying treatments in 2 groups of patients with MS. We designed a 2-pronged approach consisting of a cross-sectional study (39 untreated patients, 38 patients who had undergone 12 months of GA treatment, and 48 healthy donors compatible for age and sex with the patients with MS) and a 12-month longitudinal study (35 patients treated with GA). CD8 EBV-specific T cells and B lymphocytes were studied using pentamers and multiparametric flow cytometry. Results We find that treatment with GA enhances viral recognition by inducing an increased number of circulating virus-specific CD8 T cells (p = 0.0043) and by relieving their features of exhaustion (p = 0.0053) and senescence (p < 0.0001, p = 0.0001). B cells, phenotypically and numerically tracked along the 1-year follow-up study, show a steady decrease in memory B-cell frequencies (p = 0.025), paralleled by an increase of the naive B subset. Conclusion GA therapy acts as a disease-modifying therapy restoring homeostasis in the immune system, including anti-EBV responses.
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Affiliation(s)
- Gisella Guerrera
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Serena Ruggieri
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Mario Picozza
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Eleonora Piras
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Francesca Gargano
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Roberta Placido
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Claudio Gasperini
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Marco Salvetti
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Maria Chiara Buscarinu
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Luca Battistini
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Giovanna Borsellino
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy
| | - Daniela F Angelini
- From the Neuroimmunology Unit (G.G., S.R., M.P., E.P., F.G., R.P., B.L., G.B., D.F.A.), IRCSS Fondazione Santa Lucia, Rome; Department of Neurosciences (C.G.), San Camillo-Forlanini Hospital, Rome; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS) (M.S., M.C.B.), Center for Experimental Neurological Therapies, S. Andrea Hospital-site, "Sapienza" University of Rome; and Neurological Institute (M.S.), NEUROMED, Molise, Italy.
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Traub J, Häusser-Kinzel S, Weber MS. Differential Effects of MS Therapeutics on B Cells-Implications for Their Use and Failure in AQP4-Positive NMOSD Patients. Int J Mol Sci 2020; 21:E5021. [PMID: 32708663 DOI: 10.3390/ijms21145021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 12/25/2022] Open
Abstract
B cells are considered major contributors to multiple sclerosis (MS) pathophysiology. While lately approved disease-modifying drugs like ocrelizumab deplete B cells directly, most MS medications were not primarily designed to target B cells. Here, we review the current understanding how approved MS medications affect peripheral B lymphocytes in humans. These highly contrasting effects are of substantial importance when considering these drugs as therapy for neuromyelitis optica spectrum disorders (NMOSD), a frequent differential diagnosis to MS, which is considered being a primarily B cell- and antibody-driven diseases. Data indicates that MS medications, which deplete B cells or induce an anti-inflammatory phenotype of the remaining ones, were effective and safe in aquaporin-4 antibody positive NMOSD. In contrast, drugs such as natalizumab and interferon-β, which lead to activation and accumulation of B cells in the peripheral blood, lack efficacy or even induce catastrophic disease activity in NMOSD. Hence, we conclude that the differential effect of MS drugs on B cells is one potential parameter determining the therapeutic efficacy or failure in antibody-dependent diseases like seropositive NMOSD.
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Korsukewitz C, Reddel SW, Bar-Or A, Wiendl H. Neurological immunotherapy in the era of COVID-19 - looking for consensus in the literature. Nat Rev Neurol 2020; 16:493-505. [PMID: 32641860 DOI: 10.1038/s41582-020-0385-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 01/08/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is concerning for patients with neuroimmunological diseases who are receiving immunotherapy. Uncertainty remains about whether immunotherapies increase the risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or increase the risk of severe disease and death upon infection. National and international societies have developed guidelines and statements, but consensus does not exist in several areas. In this Review, we attempt to clarify where consensus exists and where uncertainty remains to inform management approaches based on the first principles of neuroimmunology. We identified key questions that have been addressed in the literature and collated the recommendations to generate a consensus calculation in a Delphi-like approach to summarize the information. We summarize the international recommendations, discuss them in light of the first available data from patients with COVID-19 receiving immunotherapy and provide an overview of management approaches in the COVID-19 era. We stress the principles of medicine in general and neuroimmunology in particular because, although the risk of viral infection has become more relevant, most of the considerations apply to the general management of neurological immunotherapy. We also give special consideration to immunosuppressive treatment and cell-depleting therapies that might increase susceptibility to SARS-CoV-2 infection but reduce the risk of severe COVID-19. In this Review, the authors synthesize recommendations on the management of neuroimmunological disease in the context of the COVID-19 pandemic. They consider these recommendations alongside the first available data from patients, and provide an overview of management approaches in the COVID-19 era. The risk that the coronavirus disease 2019 (COVID-19) pandemic poses for people who are receiving immunotherapy for neuroimmunological disease remains unclear. Guidelines and statements have been published by societies and individuals, but the level of consensus differs for different aspects; we use a Delphi-like process to clarify where consensus exists. Without evidence, management of neuroimmunological diseases in the context of COVID-19 requires application of the first principles of immunotherapy, taking into account disease-related, patient-related, physician-related, environment-related and COVID-19-related factors. In general, corticosteroids, intravenous immunoglobulin and/or plasma exchange for the treatment of acute neuroimmunological deteriorations can be administered with low risk in the COVID-19 pandemic. In general, ongoing immunotherapy should not be stopped because of the COVID-19 pandemic; treatment initiation and optimization are also recommended. For some aspects of immunotherapy in the context of COVID-19, consensus in the literature is low, and collection of data in patient registries is important for resolving these uncertainties.
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