Friday, 31 July 2015

ClinicSpeak: derisking natalizumab

De-risking natalizumab has not proved as simple as I had expected. #ClinicSpeak #MSBlog #MSResearch

How do you switch from natalizumab to alemtuzumab? #ClinicSpeak #MSBlog #MSResearch


"At Barts-MS we are trying to de-risk natalizumab-treated MSers as much as possible. Now that we have other options for MSers why would anyone want to stay on natalizumab who is JCV seropositive? In addition, there are more treatments coming, for example, ocrelizumab and daclizumab. In Sweden the drug of choice is rituximab that is being used off-label."


"I am reposting on this as one of my patients has now finished 12 months of bridging with fingolimod (option 3 below) and has decided that as she is doing so well on fingolimod she doesn't want alemtuzumab; c'est la vie!"

"The switch is relatively straight forward if you are JC virus seronegative and are switching because of lack of  efficacy, or for a life-style choice, for example if you are tired of monthly infusions, or you want to an induction therapy that offers you the freedom to fall pregnant without worrying about rebound activity, or you simply prefer the long-term potential that an induction therapy offers. In this situation switching without a wash-out period to prevent rebound makes sense and should be relatively safe (option 1 below)."


"The situation if you are JC virus seropositive is much more problematic because of the risk of carry-over PML. With a maintenance agent such as fingolimod we simply exclude asymptomatic PML by doing a lumbar puncture to look for JCV DNA in the spinal fluid and an MRI; if these tests are clear we start fingolimod as soon as possible after the last natalizumab infusion with the knowledge that if PML should develop we can always stop fingolimod and it will be cleared from the body within in 6-8 weeks. This early switching strategy also prevents rebound activity when natalizumab wears after approximately 3-4 months." 

"With an induction agent, such as alemtuzumab, things are more complicated because we can't reverse its action hence we have to be confident that there is no carry-over PML. Why am I so concerned? Simple, if you develop carry-over PML post-alemtuzumab before reconstitution of your immune system your are likely to succumb to the PML. I am aware of one person already who has died under these circumstances. The reason for this is that we have to rely on a functioning immune system to clear the virus, in particular a population of cells called CD8+ cytotoxic T-lymphocytes (CTLs). As you can see from the graph below CD8+ lymphocytes take many months to reconstitute and even at 12 months, the time you would be due your second course of alemtuzumab, they are not back to normal."



From Coles et al. Multiple Sclerosis 1998; 4:232-238.

"The pivotal questions are: (1) how long is the period of asymptomatic PML and (2) can we be confident in excluding asymptomatic PML by simply doing a lumbar puncture for spinal fluid JCV DNA detection and an MRI for suspicious lesions? I suspect not. The process that underlies the development of PML is long and complicated. The JC virus has to acquire several mutations to be able to cause PML; acquiring mutations takes time typically more than 12-24 months. Once the virus has acquired the mutations it must then infect the glial cells within the brain and start dividing and spreading. This initial infection must start microscopically below the threshold of detection by MRI and spinal fluid analysis. So simply switching to alemtuzumab without a break from natalizumab is risky; how risky is difficult to say at present."


"I envisage 3 scenarios: 


(1) The most risky one is the immediate switch from natalizumab to alemtuzumab without a wash-out; the risk being a small chance of carrying over asymptomatic PML.


(2) A switch after a 3-6 month wash-out of natalizumab; this will allow time for asymptomatic PML to declare itself and it will also allow immune surveillance to of the nervous system to find any mutant JC virus. This strategy was initially proposed with fingolimod and had to be stopped because of the risk of rebound MS activity. Because of rebound, I don't think this is a strategy that most MSers will be prepared to take. 


(3) A bridging strategy in which you switch to a maintenance oral agent, such as teriflunomide, dimethyl fumarate or fingolimod. The bridging agent will hopefully prevent rebound MS activity and give you a sufficient period of time to observe for the development of PML. I suggest this period of observation would need to be for a 6-12 months. Once this period of observation is over and PML has not emerged you could probably transition to alemtuzumab without too many concerns. The one proviso is we don't have data in using alemtuzumab after these new oral agents and hence can't be confident that the kinetics of immune system reconstitution will be the same as when using alemtuzumab as a 1st-line therapy or following interferon-beta or glatiramer acetate. Please note that at present only fingolimod has robust enough data to be confident that it prevents rebound. There have been several poster presentations at meetings showing that DMF is not up to the task. I also have personal experience with one of my patients who transferred to me from the USA that had a devastating spinal cord relapse 4 months after stopping natalizumab despite being started on DMF without a washout."



Click on picture to see large image.

"Please note that this advice is not evidence-based and is my opinion backed-up by clinical experience and a theoretical knowledge. Hopefully, Genzyme will do a formal clinical study to test these different options. I think it is very important to know what happens when using alemtuzumab after the oral bridging agents; in particular we need data on safety. Another factor that I have not discussed is availability and local guidelines; firstly you may not have access to the agents outlined above and you may be restricted by local guidelines on how you to use these agents. Finally, a lot of you may disagree with the above proposal; If you are considering switching from natalizumab to alemtuzumab I suggest you have a discussion about these issues with your neurologist. At present I favour option 3; but as with all treatment decisions in MS this should be personalised to the individual concerned and hopefully it will become evidence-based in the future."


CoI: multiple

10 comments:

  1. Ugh, what a choice. I'm having a hard time on Ty (infusion reaction and symptoms return in week4) and I can't take fingolomid. I have the option of switching around the end of the year to Lemtrada. I'm JC positive (very low titre) so understand I will need an LP. Given I will have only been on Ty for less than a year in December and my titre is quite low (0.246), I'm minded to go with option 1,

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    1. If you have infusion reactions and the drug is not working for long enough it may be that you have started to make neutralising antibodies. This will mop up the drug to stop it working and can give infusion reactions and be warned anaphylaxis could be a possibility.

      I would suggest having this checked and also perhaps have your white cells checked at 3 weeks post infusion to see if the tysabri is still coating the white blood cells, it may be that it is being neutralised so it stops working properly, suggesting you need more frequent infusions or that you need to change to something else.

      P.S. I am not a Doctor so talk to your neurologist.

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  2. Will Plasma Exchange not help de-risking PML? Offer Plasma Exchange for patients who are coming off the drug to limit the carry over risk? Once Plas,a Exchange is completed the patient shou;d be able to start the next treatment a lot quicker than waiting for a wash out period?

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  3. I think it would make no difference as plasma exchange removes stuff in the fluid but virus is a parasite that lives in cells and uses them to replicate so you wouldnt remove the virus. You would however remove any free antibody and so the risk of disease rebound would increase. However the worry is virus i. the brain at the time of the switch.

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  4. DEAR ANON 1111

    Neuros are away on hols but have not posted because there is too much info on yourself.

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    1. P.S. There are lots of posts on blog about switching.

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  5. It's interesting that they are now finding PML cases on Fingolimod too... I wonder if it's an issue with that drug or if they are being who have been previously exposed to Tysabri?

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    1. There are cases of people who have never been on tysabri, getting PML. This risk is part of the immunosuppressive risk although the risk of PML on gilenya is much lower than with natalizumab.

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    2. "risk of PML on gilenya is much lower than with natalizumab". Do we know this to be true? There were a lot of immunosuppressants given before natalizumab which would have colored the PML presentations in natalizumab, I think we're a lot more cautious than before, lowering its incidence as a whole.

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    3. From my uniformed perspective, I agree with you. I have more reservations about Fingolomid than Tysabri (I'm on this and jc positive). Mind you, I'm just as concerned about Tecfidera (aka furniture polish). Mainly because on Tysabri there is much more monitoring than with the other two.

      Delete

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