IMPIEGO DI G-CSF DOPO MITOXANTRONE NELLA SCLEROSI MULTIPLA SECONDARIA PROGRESSIVA

La sclerosi multipla (SM) è una malattia infiammatoria autoimmune del sistema nervoso centrale, caratterizzata da un processo demielinizzante che comporta anche degenerazione assonale e gliosi. La SM viene classificata in recidivante-remittente (circa 85% dei casi), primariamente progressiva (15% dei casi), secondariamente progressiva e secondariamente progressiva con ricadute. La forma secondariamente progressiva si sviluppa nella metà dei soggetti con SM recidivante-remittente dopo circa dieci anni dall’esordio. Le forme progressive si accompagnano ad un crescente accumulo di disabilità, che tende a divenire irreversibile. Ad oggi il trattamento della SM secondariamente progressiva è rappresentato da farmaci immunosoppressori, quali il mitoxantrone. Anche se il mitoxantrone è uno dei farmaci più efficaci nel trattamento della SM e determina un rallentamento della progressione di malattia nei pazienti non rispondenti alle terapie immunomodulanti, molti pazienti con SM particolarmente aggressiva non traggono benefici dal trattamento. In tali circostanze sono necessari ulteriori e più incisivi interventi terapeutici, che possano potenziare l’effetto del mitoxantrone. Il “granulocyte colony stimulating factor” (GCS-F) è un fattore di crescita che determina la mobilizzazione dal midollo osseo di cellule staminali ematopoietiche. Per tale motivo è stato utilizzato nella procedura di mobilizzazione precedente il trapianto autologo di cellule staminali ematopoietiche in pazienti affetti da malattie autoimmuni, tra cui la SM. Il trapianto in pazienti con SM è tuttavia una terapia ad alto rischio di morbilità e di mortalità, per cui tale trattamento è al momento utilizzato in maniera limitata. Il G-CSF determina inoltre la mobilizzazione dal midollo osseo di cellule mesenchimali staminali, che hanno un effetto immunosoppressivo e presenta inoltre proprietà immunoregolatrici, che si esplicano attraverso la modulazione delle citochine e dell’attività dei linfociti T. Il G-CSF, potrebbe quindi essere utilizzato in associazione al mitoxantrone ed agire in sinergia con quest’ultimo nella regolazione del sistema immunitario nei pazienti affetti da SM. Lo scopo del presente studio è stato quindi quello di valutare l’effetto terapeutico del G-CSF in aggiunta al mitoxantrone, in pazienti affetti da sclerosi multipla refrattaria al trattamento convenzionale rispetto a pazienti trattati con il solo mitoxantrone. Sono state valutate la risposta clinica (EDSS, Ambulation Index, SNRS), la risonanza magnetica encefalica ed il profilo citochinico, in due gruppi di pazienti con SM secondaria progressiva comparabili per età (t-test, p=0.29) e sesso: quello in trattamento con solo mitoxantrone (6 M/1 F; età: 42,1 ± 10,5) e quello in trattamento con mitoxantrone e G-CSF (5 M/2 F; età: 45,3 ± 8,6). L’analisi statistica dei dati clinici non ha mostrato differenze significative tra i due gruppi, indicando tuttavia una tendenza alla stabilizzazione del decorso della malattia dopo G-CSF. I pazienti che hanno assunto il G-CSF hanno presentato una stabilizzazione del quadro di risonanza magnetica per i parametri valutati (carico lesionale e numero di lesioni attive). Un paziente ha inoltre presentato una diminuzione del carico lesionale durante la terapia con G-CSF che si è mantenuta nei follow-up successivi. Nel gruppo trattato con solo mitoxantrone invece un paziente ha presentato un incremento del carico lesionale, mentre negli altri è stata riscontrata una stabilizzazione delle lesioni. Per quanto riguarda i valori delle citochine, l’analisi statistica con ANOVA per misure ripetute ha evidenziato una tendenza alla significatività per il fattore di crescita tumorale beta 1. Il test di Wilcoxon ha rivelato una significatività (P<0.062) per la interleuchina 12. Il dosaggio citofluorimetrico delle cellule CD34+ nei giorni successivi alla somministrazione del G-CSF ha mostrato che i pazienti non hanno raggiunto valori tali da indicare un’avvenuta mobilizzazione. Il trattamento sequenziale con G-CSF dopo mitoxantrone è stato ben tollerato in tutti i pazienti, con l’assenza pressoché completa di manifestazioni avverse. In conclusione i dati analizzati non hanno rilevato variazioni statisticamente significative degli indicatori clinici di malattia dopo trattamento con il G-CSF, anche per osservazioni cliniche con follow-up prolungato. La relativa modesta dimensione del campione esaminato può essere un fattore responsabile della mancata osservazione di significatività statistica. L’analisi di gruppi più numerosi di pazienti potrebbe in futuro dare maggiori indicazioni sul piano della riposta clinica al trattamento. Riguardo al trattamento con G-CSF, la bassa percentuale di linfociti T CD34+, rilevata dopo la somministrazione del farmaco, dimostra la mancata efficacia della procedura di mobilizzazione delle cellule staminali ematopoietiche. Ciò può essere dovuto al fatto che il mitoxantrone non presenta buone proprietà come mobilizzatore di cellule staminali in associazione al G-CSF. Sulla base delle indicazioni rilevate dall’analisi delle citochine, si può inoltre ipotizzare che per una risposta clinica significativa sarebbe stato utile arruolare i pazienti in una diversa fase della malattia, quando cioè l’attività infiammatoria è ancora preponderante. Ciò consentirebbe al G-CSF di esplicare a pieno la sua attività immunomodulante. I pazienti inclusi nello studio erano invece consistentemente in una fase di progressione di malattia, in assenza di attività infiammatoria, caratteristica irrinunciabile per il rispetto della eticità per un trattamento sperimentale

Very Late Onset Multiple Sclerosis associated with Restless Legs Syndrome. A case report

We report the case of a 83-year-old woman suffering from Restless Legs Syndrome since 2002 and Multiple Sclerosis since 2007. She had been diagnosed as Restless Legs Syndrome five years before multiple sclerosis, with the support of a polysomnographic examination. The clinical diagnosis of multiple sclerosis took place at the age of 75, when she complained of walking difficulties and abnormal sensitivity in lower limbs, especially in the evening. Associated symptoms included dysesthesias on the left leg and arm and left emitrunk, visual acuity reduction, blurred vision and fatigue. The brain magnetic resonance showed multiple lesions in white matter, inconsistent with a vascular disease but suggestive for a demyelinating disease. She was admitted at the hospital, where the spinal fluid examination and a second magnetic resonance confirmed the diagnosis. Since that, the patient regularly performed medical examinations and magnetic resonance controls which didn't show any increase of lesions burden nor pathological enhancement, but a slow worsening of ambulation. Due to the patient's age, a disease modifying therapy for multiple sclerosis was not established, the only drugs being represented by symptomatic agents

Review of the clinical evidence for interferon β 1a (Rebif®) in the treatment of multiple sclerosis

Interferon (INF) β 1a 22 or 44 μg (Rebif®) administered s.c. 3 times a week (t.i.w) is a well established immunomodulating treatment for relapsing remitting multiple sclerosis (RRMS). This review focuses on its mechanisms of action, evidence of efficacy, safety, and tolerability. Several pharmacodynamic properties explain the immunomodulatory actions of INF β 1a 22 or 44 μg s.c. t.i.w. Pivotal trials and post-marketing studies proved that the drug is effective in reducing disease activity and likely in slowing disease progression. Head-to-head comparative studies with other marketed INFs β in RRMS suggested a better therapeutic response associated with higher doses and frequency of administration of Rebif®. Additional evidence indicated a beneficial effect of INF β 1a in patients with clinically isolated syndromes (CIS) suggestive of MS, as treatment reduced time to conversion to clinically definite (CD) disease. Further, although the drug did not prove to slow time to progression there were benefits on relapse- and MRI-related secondary outcome measures in secondary progressive (SP) MS. Pivotal trials, their cross-over extensions, and post-marketing studies consistently showed that INF β 1a 22 or 44 μg s.c. t.i.w. is safe and well tolerated, as adverse drug reactions are usually mild and manageable

Genetic or pharmacological blockade of noradrenaline synthesis enhances the neurochemical, behavioral, and neurotoxic effects of methamphetamine

N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine (DSP-4) lesions of the locus coeruleus, the major brain noradrenergic nucleus, exacerbate the damage to nigrostriatal dopamine (DA) terminals caused by the psychostimulant methamphetamine (METH). However, because noradrenergic terminals contain other neuromodulators and the noradrenaline (NA) transporter, which may act as a neuroprotective buffer, it was unclear whether this enhancement of METH neurotoxicity was caused by the loss of noradrenergic innervation or the loss of NA itself. We addressed the specific role of NA by comparing the effects of METH in mice with noradrenergic lesions (DSP-4) and those with intact noradrenergic terminals but specifically lacking NA (genetic or acute pharmacological blockade of the NA biosynthetic enzyme dopamine beta-hydroxylase; DBH). We found that genetic deletion of DBH (DBH-/- mice) and acute treatment of wild-type mice with a DBH inhibitor (fusaric acid) recapitulated the effects of DSP-4 lesions on METH responses. All three methods of NA depletion enhanced striatal DA release, extracellular oxidative stress (as measured by in vivo microdialysis of DA and 2,3-dihydroxybenzoic acid), and behavioral stereotypies following repeated METH administration. These effects accompanied a worsening of the striatal DA neuron terminal damage and ultrastructural changes to medium spiny neurons. We conclude that NA itself is neuroprotective and plays a fundamental role in the sensitivity of striatal DA terminals to the neurochemical, behavioral, and neurotoxic effects of METH

Gly482Ser PGC-1α gene polymorphism and exercise-related oxidative stress in amyotrophic lateral sclerosis patients

The role of exercise in Amyotrophic lateral sclerosis (ALS) pathogenesis is controversial and unclear. Exercise induces a pleiotropic adaptive response in skeletal muscle, largely through the peroxisome proliferator-activated receptor γ coactivator 1α (PGC-1α), a transcriptional coactivator that regulates mitochondrial biogenesis and antioxidant defense mechanisms. It has been suggested that a Gly482Ser substitution in PGC-1α has functional relevance in human disorders and in athletic performance. To test this hypothesis, we examined the genotype distribution of PGC-1α Gly482Ser (1444 G > A) in ALS patients to evaluate whether or not the minor serine-encoding allele 482Ser is involved in oxidative stress responses during physical exercise. We genotyped 197 sporadic ALS patients and 197 healthy controls in order to detect differences in allelic frequencies and genotype distribution between the two groups. A total of 74 ALS patients and 65 controls were then comparatively assessed for plasmatic levels of the oxidative stress biomarkers, advanced oxidation protein products, ferric reducing ability and thiol groups. In addition a subgroup of 35 ALS patients were also assessed for total SOD and catalase plasmatic activity. Finally in 28 ALS patients we evaluated the plasmatic curve of the oxidative stress biomarkers and lactate during an incremental exercise test. No significant differences were observed in the genotype distribution and allelic frequency in ALS patients compared to the controls. We found significant increased advanced oxidation protein products (p A SNP, ALS patients with Gly482Ser allelic variant show increased exercise-related oxidative stress. This thus highlights the possible role of this antioxidant defense transcriptional coactivator in ALS

Antibody response elicited by the SARS-CoV-2 vaccine booster in patients with multiple sclerosis: Who gains from it?

Background and purpose: Although two doses of COVID-19 vaccine elicited a protective humoral response in most persons with multiple sclerosis (pwMS), a significant group of them treated with immunosuppressive disease-modifying therapies (DMTs) showed less efficient responses.Methods: This prospective multicenter observational study evaluates differences in immune response after a third vaccine dose in pwMS.Results: Four hundred seventy-three pwMS were analyzed. Compared to untreated patients, there was a 50-fold decrease (95% confidence interval [CI]=14.3-100.0, p &lt; 0.001) in serum SARS-CoV-2 antibody levels in those on rituximab, a 20-fold decrease (95% CI=8.3-50.0, p &lt; 0.001) in those on ocrelizumab, and a 2.3-fold decrease (95% CI = 1.2-4.6, p = 0.015) in those on fingolimod. As compared to the antibody levels after the second vaccine dose, patients on the anti-CD20 drugs rituximab and ocrelizumab showed a 2.3-fold lower gain (95% CI = 1.4-3.8, p=0.001), whereas those on fingolimod showed a 1.7-fold higher gain (95% CI = 1.1-2.7, p = 0.012), compared to patients treated with other DMTs.Conclusions: All pwMS increased their serum SARS-CoV-2 antibody levels after the third vaccine dose. The mean antibody values of patients treated with ocrelizumab/rituximab remained well below the empirical "protective threshold" for risk of infection identified in the CovaXiMS study (&gt;659 binding antibody units/mL), whereas for patients treated with fingolimod this value was significantly closer to the cutoff

Common germline variants within the CDKN2A/2B region affect risk of pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (PNETs) are heterogeneous neoplasms which represent only 2% of all pancreatic neoplasms by incidence, but 10% by prevalence. Genetic risk factors could have an important role in the disease aetiology, however only a small number of case control studies have been performed yet. To further our knowledge, we genotyped 13 SNPs belonging to the pleiotropic CDKN2A/B gene region in 320 PNET cases and 4436 controls, the largest study on the disease so far. We observed a statistically significant association between the homozygotes for the minor allele of the rs2518719 SNP and an increased risk of developing PNET (ORhom = 2.08, 95% CI 1.05-4.11, p = 0.035). This SNP is in linkage disequilibrium with another polymorphic variant associated with increased risk of several cancer types. In silico analysis suggested that the SNP could alter the sequence recognized by the Neuron-Restrictive Silencer Factor (NRSF), whose deregulation has been associated with the development of several tumors. The mechanistic link between the allele and the disease has not been completely clarified yet but the epidemiologic evidences that link the DNA region to increased cancer risk are convincing. In conclusion, our results suggest rs2518719 as a pleiotropic CDKN2A variant associated with the risk of developing PNETs

Common genetic variants associated with pancreatic adenocarcinoma may also modify risk of pancreatic neuroendocrine neoplasms (vol 39, pg 360, 2018)

Pancreatic neuroendocrine neoplasms (pNEN) account for less than 5% of all pancreatic neoplasms and genetic association studies on susceptibility to the disease are limited. We sought to identify possible overlap of genetic susceptibility loci between pancreatic ductal adenocarcinoma (PDAC) and pNEN; therefore, PDAC susceptibility variants (n=23) from Caucasian genome-wide association studies (GWAS) were genotyped in 369 pNEN cases and 3,277 controls from the PANcreatic Disease ReseArch (PANDoRA) consortium to evaluate the odds associated with pNEN risk, disease onset and tumor characteristics. Main effect analyses showed four PDAC susceptibility variants – rs9854771, rs1561927, rs9543325 and rs10919791 to be associated with pNEN risk. Subsequently, only associations with rs9543325, rs10919791 and rs1561927 were noteworthy with false positive report probability (FPRP) tests. Stratified analyses considering age at onset (50 year threshold), showed rs2736098, rs16986825 and rs9854771 to be associated with risk of developing pNEN at a younger age. Stratified analyses also showed some SNPs to be associated with different degrees of tumor grade, metastatic potential and functionality. Our results identify known GWAS PDAC susceptibility loci, which may also be involved in sporadic pNEN etiology and suggest that some genetic mechanisms governing pathogenesis of these two entities may be similar, with few of these loci being more influential in younger cases or tumor subtypes

Disease-Modifying Therapies and Coronavirus Disease 2019 Severity in Multiple Sclerosis

Objective: This study was undertaken to assess the impact of immunosuppressive and immunomodulatory therapies on the severity of coronavirus disease 2019 (COVID-19) in people with multiple sclerosis (PwMS). Methods: We retrospectively collected data of PwMS with suspected or confirmed COVID-19. All the patients had complete follow-up to death or recovery. Severe COVID-19 was defined by a 3-level variable: mild disease not requiring hospitalization versus pneumonia or hospitalization versus intensive care unit (ICU) admission or death. We evaluated baseline characteristics and MS therapies associated with severe COVID-19 by multivariate and propensity score (PS)-weighted ordinal logistic models. Sensitivity analyses were run to confirm the results. Results: Of 844 PwMS with suspected (n = 565) or confirmed (n = 279) COVID-19, 13 (1.54%) died; 11 of them were in a progressive MS phase, and 8 were without any therapy. Thirty-eight (4.5%) were admitted to an ICU; 99 (11.7%) had radiologically documented pneumonia; 96 (11.4%) were hospitalized. After adjusting for region, age, sex, progressive MS course, Expanded Disability Status Scale, disease duration, body mass index, comorbidities, and recent methylprednisolone use, therapy with an anti-CD20 agent (ocrelizumab or rituximab) was significantly associated (odds ratio [OR] = 2.37, 95% confidence interval [CI] = 1.18-4.74, p = 0.015) with increased risk of severe COVID-19. Recent use (&lt;1 month) of methylprednisolone was also associated with a worse outcome (OR = 5.24, 95% CI = 2.20-12.53, p = 0.001). Results were confirmed by the PS-weighted analysis and by all the sensitivity analyses. Interpretation: This study showed an acceptable level of safety of therapies with a broad array of mechanisms of action. However, some specific elements of risk emerged. These will need to be considered while the COVID-19 pandemic persists