Sunday, 31 May 2015

ClinicSpeak: Fingolimoders need to be aware of opportunistic infections

If you are on fingolimod please be vigilant about infections, including opportunistic infections. #ClinicSpeak #MSBlog #MSResearch

"In response to an anonymous comment on the Natalizumab retinitis post yesterday. I think it is appropriate to warn all MSers on fingolimod to be vigilant as well about infections and opportunistic infections."

"The two case studies below highlight that opportunistic infections and severe viral infections are an issue on fingolimod. The first case report below is of a near fatal case of herpes simplex virus encephalitis (HSVE). This is not surprising, in fact in the phase 3 TRANSFORMS trial there was a fatality due to HSVE in an MSer on fingolimod, albeit on the higher, 1.25mg, dose."


HSVE
"The second case is of a MSers on fingolimod developing Kaposi's sarcoma, which is due to a specific herpesvirus. Kaposi's sarcoma is classified as an opportunistic infection and is seen most commonly in people with AIDS and in people who have had a transplant and are on immunosuppression. Although this patient had a lymphopenia (<500 lymphocytes per mm3, WHO Grade 3) the counts were never below 200 (WHO Grade 4, a level in Europe at which the EMA guidelines recommend interrupting fingolimod dosing). In relation to lymphocyte counts on fingolimod; there is no correlation between the absolute levels and infectious complications. Therefore it is impossible to predict who will develop infections, including opportunistic infections, based on the lymphocyte count. Therefore the only strategy is clinical vigilance; this means reporting any new skin lesions, or new symptoms, to your neurology team or family doctor. Don't take unnecessary risks; opportunistic infections in immunocompromised patients can be associated with relatively mild and indolent symptoms, at least initially. Based on these and other case reports, e.g. PML, I would predict the occurrence of other opportunistic infections in MSers on fingolimod."

"One infection that can be screened for is HPV, the cause of cervical cancer. If you are a woman on fingolimod please make sure you don't miss your regular cervical, or PAP, smears. If you live in a country in which this is not mandatory please ask your family doctor to arrange for this to happen. As always prevention is better than cure."


Kaposi's sarcoma (source Wikipedia)
Epub: Pfender et al. Reactivation of herpesvirus under fingolimod: A case of severe herpes simplex encephalitis. Neurology. 2015 May 8.

Fingolimod (FTY720 is a sphingosin-1-phosphate (S1P) receptor modulator with immunomodulatory properties that traps naive and central memory T cells in lymph nodes, leading to reduced numbers of peripheral blood lymphocytes, and is the first licensed oral drug for multiple sclerosis (MS). We report a case of a near fatal herpes simplex virus 1 (HSV-1) encephalitis under the licensed dose of fingolimod in a patient with MS.

Epub: Tully et al. Kaposi sarcoma in a patient with relapsing-remitting multiple sclerosis receiving fingolimod. Neurology. 2015 May 12;84(19):1999-2001. 

Kaposi sarcoma (KS) is a tumor derived from capillary endothelial cells associated with serologically identifiable human herpesvirus (KSHV). We report a case of KS in a patient with relapsing-remitting multiple sclerosis (RRMS) who received fingolimod for 19 months. We hypothesize that fingolimod-induced immunosuppression led to the development of KS in this patient.

CoI: multiple

2 comments:

  1. I have mistakenly drank stagnant water (smelly and green) during my last canyon trek in Oman ! , should I be concerned ?, I chose to take a few days of anti-bionics just in case is that wise .. I'm on Fingolomod

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