It’s been a while since i wrote last post, but NeuroImmunology has been busy with several other projects. It’s been a while too since i decided to write a monographic post about the different oral treatments that are already available or are about to arrive but i postponed it until i had enough time to do it carefully. I will try to clarify the different pros and cons of the oral treatments in general and of each one in particular. It’s also an attempt to organize my ideas about the subject. Until very recently the only disease-modifying treatments available for MS were injected therapies (I say disease-modifying because steroids are only used for relapses and do not modify the course of the disease in the long-term). Interferon and glatiramer acetate (subcutaneous or intramuscular), mitoxantrone (intravenous) and, more recently, natalizumab (intravenous) were the only available options for MS. In some countries people used intravenous immunoglobulins (IVIg), azathioprine (oral) and cyclophosphamide (oral or intravenous) but the evidence for their use in MS is very weak and they were not considered standard treatments for MS. Several major claims and complaints of patients with MS related to the treatment route of administration. Needles, need for portable fridges, problems in the airports and customs, an injection every two days, subcutaneous nodules, risk of infections… So, research on oral therapies was one of the main targets of researchers and companies and one of the things patients are more interested and askabout more often. And oral therapies finally arrived. At this moment there is only one treatment fully available in Europe, fingolimod (Gilenya), four more laquinimod, BG-12 (dimethyl fumarate) teriflunomide and cladribine have completed phase III trials and another one, firategrast, is still on phase II trials but shows promising results. The first and most obvious advantage
A few days ago we had access to this alert in Medscape. An MS patient, that had completed the 6-hour vigilance period after the first dose of fingolimod, died unexpectedly the next day. We don’t know much about it and we should wait until this case is resolved and an official report released. We only know that the patient was already taking beta-blockers and calcium channel antagonists, with bradycardia among their side effects. However, it re-inforces my view that Fingolimod safety has to be carefully followed-up. Anyway, one important message is that an oral treatment, a pill, does not necessarily have to be safer than a biological treatment. It may be easier to take for patients but not necessarily innocuous.
Two weeks ago the annual meeting of the ECTRIMS was held in Amsterdam. As usual, several interesting presentations, some of them probably good enough to change the immediate future of MS clinical practice, were presented. Among them, new data regarding the next 3 new oral therapies that probably will be approved when their results are published, laquinimod, teriflunomide and BG-12. These therapies will need a specific review later on. But the focus of this post is on the data of the phase II trial testing Ocrelizumab in MS. Ocrelizumab is a humanized monoclonal antibody targetting the CD20 B-cell marker. It depletes B lymphocytes. It is the molecular and commercial son of Rituximab and the diseases to which is aimed are the same as Rituximab. In fact, what we all expected was that Ocrelizumab improved safety and reduced infussion reactions due to its humanized nature (while Rituximab is chimeric). Rituximab had been tested before in MS with notable success. However, as we explained before, that study did not lead to a phase III trial due to commercial interests. Then its humanized version was tested expecting more safety and tolerability. But it happened that, paradoxically, Ocrelizumab turned out to be less safe. At least, while in Rheumatoid Arthirtis and Lupus Rituximab severe adverse events were very infrequent, their trials with Ocrelizumab were prematurely halted because of several fatal opportunistic infections. In MS the Ocrelizumab phase II trial was continued and, again, a death in the Ocrelizumab arm raised concerns regarding its safety. Now we have additional data regarding both safety and effectiveness. The 96 week results of the phase II trial of Ocrelizumab in MS were presented in ECTRIMS and simultaneously published in Lancet. Effectiveness data are extraordinary. Reduction of 89-96% of the rate of new gadolinium-enhancing lessions and around 80% for
Chronic cerebrospinal venous insufficiency is a novel hypothesis, proposed for the first time by Dr Paolo Zamboni, to try to explain the elusive cause of multiple sclerosis (MS). Briefly, this hypothesis proposes that the autoimmune attack against oligodendrocytes and the demyelination process, hallmarks of MS pathology, are caused by an excessive deposition of iron around small veins in the brain. This hypothesis is proposed after having found that venous blood flow may be altered in MS patients and, attending to Dr Zamboni’s studies, that yugular and azigos veins show an increased frequency of stenosis compared to normal controls. This hypothesis has never been accepted for a number of reasons but what matters most to me are the consequences of the disregard with which the neurological community has received this hypothesis. Nature Journal has recently published a paper about the power of social networks to movilize patients and its potential to divert funding to studies or procedures demanded by patients. The example to illustrate the power of social networks is Zamboni’s CCSVI. In Canada, the attention paid by the mainstream media to this condition and to Dr Zamboni has turned into many patients claiming for the treatment of their vein stenoses, a procedure called, not randomly, “the liberation procedure”. But not always new healers deserve and receive attention by the media. But the context with this story is perfect…for both mainstream media and patients. Dr Zamboni’s wife suffers MS. He is a vascular surgeon, attending to his Pubmed profile, a reputed one in the field of varicose veins surgery, but he has now focused on trying to help his wife (and others) studying MS from his vascular surgeon perspective. That means he is an outsider. Someone not familiar for the “MS stablishment”. He proposes a radically different approach in a pretty
In a previous post we discussed the shameful oblivion in which Rituximab has been left apart because of its patent expiry date. Just this week a new paper on Archives of Neurology deepens our disappointment. Besides the great efficacy of Rituximab, maybe comparable to that of Natalizumab (or even better as seen in their phase II trials), now we know that the most scaring side effect of multiple sclerosis new drugs, the progressive multifocal leukoencephalopathy (PML), occurs much less frequently (in a similar disease, rheumatoid arthritis) than in Natalizumab. Despite this new paper is a case series, with several limitations, i think the neuroimmunological community should think about leaving aside a powerful drug which, moreover, will be soon free of patent. A shameful story, re-visited.
The last issue of the Lancet Neurology journal, has published the extension phase study of the TRANSFORMS trial. Briefly, the TRANSFORMS trial was a randomized controlled trial comparing i.m. interferon beta 1a versus two different doses of fingolimod (0.5mg and 1.25mg). Its results were published on New England Journal of Medicine on February 2010, together with FREEDOMS, a Fingolimod versus placebo trial and CLARITY, a cladribine versus placebo trial. It showed a better perfomance than interferon in annualized relapse rate, with a concerning profile of side effects and some red flags, such as the risk of developing skin neoplasms or herpetic infections. Despite that, the overall performance in that study led to its approval by the FDA and EMEA but, while its being commercialized already in the US, it’s still on its way to the pharmacy in Europe. In the controlled phase of the trial relapse rate with fingolimod was about a 50% lower than with interferon, and 80% o f patients remained free of relapse with fingolimod while only 63% of them were free of relapse with interferon in the first year of the study. Those were quite good results. There were also good results in MRI parameters. However there were no differences in disability outcomes, in one hand probably because the EDSS is not that a precise measure and in the other hand because overall relapse rates were pretty low. Significant side effects were present in the fingolimod arm, mostly on the high those arm, being the most concerning ones two deaths of herpes virus infections (one varicella zoster and one herpes simplex encephalitis). Another intriguing fact was the higher incidence of skin neoplasms (basal cell carcinomas and in-situ melanomas) in the fingolimod arms. Also heart conduction blocks and macular oedema were more frequent on patients taking fingolimod.