How Do We Manage And Treat A Patient With Multiple Sclerosis At Risk Of Tuberculosis?

Tuberculosis continues to be a serious health problem worldwide. The disease continues to be underdiagnosed and not properly treated. In conditions that affect the immune system, such as multiple sclerosis (MS), latent tuberculosis may thrive and reactivate during the use of immunomodulatory and immunosuppressive drugs. Among the best treatment options for patients with latent or active tuberculosis who have MS are IFN-β, glatiramer acetate and mitoxantrone. Drugs leading to a reduced number and/or function of lymphocytes should be avoided or used with caution. Tuberculosis must always be investigated in patients with MS and treated with rigor.141112511260Noseworthy, J.H., Lucchinetti, C., Rodriguez, M., Weinshenker, B.G., Multiple sclerosis (2000) N Engl J Med, 343 (13), pp. 938-952Wingerchuk, D.M., Carter, J.L., Multiple sclerosis: Current and emerging disease-modifying therapies and treatment strategies (2014) Mayo Clin Proc, 89 (2), pp. 225-240Happe, L.E., Choosing the best treatment for multiple sclerosis: Comparative effectiveness, safety, and other factors involved in disease-modifying therapy choice (2013) Am J Manag Care, 19 (17), pp. s332-s342Freedman, M.S., Selchen, D., Arnold, D.L., Treatment optimization in MS: Canadian MS Working Group updated recommendations (2013) Can J Neurol Sci, 40 (3), pp. 307-323Norbis, L., Miotto, P., Alagna, R., Cirillo, D.M., Tuberculosis: Lights and shadows in the current diagnostic landscape (2013) New Microbiol, 36 (2), pp. 111-120Fritsche, A., Engel, R., Buhl, D., Zellweger, J.P., Mycobacterium bovis tuberculosis: From animal to man and back (2004) Int J Tuberc Lung Dis, 8 (7), pp. 903-904De Jong, B.C., Antonio, M., Gagneux, S., Mycobacterium africanum-review of an important cause of human tuberculosis in West Africa (2010) PLoS Negl Trop Dis, 4, p. e744Panteix, G., Gutierrez, M.C., Boschiroli, M.L., Pulmonary tuberculosis due to Mycobacterium microti: A study of six recent cases in France (2010) J Med Microbiol, 59, pp. 984-989Buonora, N., Chiavarini, M., Salmasi, L., Impact of immigration on burden of tuberculosis in Umbria: A low-incidence Italian region with high immigrants rates (2013) J Prev Med Hyg, 54 (1), pp. 29-34Lawn, S.D., Zumla, A.I., Tuberculosis (2011) Lancet, 378 (9785), pp. 57-72Corbett, E.L., Watt, C.J., Walker, N., The growing burden of tuberculosis: Global trends and interactions with the HIV epidemic (2003) Arch Intern Med, 163 (9), pp. 1009-1021Frieden, T.R., Six components necessary for effective public health program implementation (2014) Am J Public Health, 104 (1), pp. 17-22Frieden, T.R., Sterling, T.R., Munsiff, S.S., Tuberculosis (2003) Lancet, 362 (9387), pp. 887-889Dye, C., Making wider use of the world's most widely used vaccine: Bacille Calmette-Guerin revaccination reconsidered (2013) J R Soc Interface, 10 (87), p. 20130365Barreto, M.L., Cunha, S.S., Pereira, S.M., Neonatal BCG protection against tuberculosis lasts for 20 years in Brazil (2005) Int J Tuberc Lung Dis, 9 (10), pp. 1171-1173Chiang, C.Y., Riley, L.W., Exougenous reinfection in tuberculosis (2005) Lancet Infect Dis, 5 (10), pp. 629-636Ramakrishnan, L., Revisiting the role of the granuloma in tuberculosis (2012) Nat Rev Immunol, 12 (5), pp. 352-366Schwander, S., Dheda, K., Human lung immunity against Mycobacterium tuberculosis: Insights into pathogenesis and protection (2011) Am J Respir Crit Care Med, 183 (6), pp. 696-707Rajni Rao, N., Meena, L.S., Biosynthesis and virulent behavior of lipids produced by Mycobacterium tuberculosis: LAM and cord factor: An overview (2011) Biotechnol Res Int, 2011, p. 274693Walzl, G., Ronacher, K., Hanekom, W., Immunological biomarkers of tuberculosis (2011) Nat Rev Immunol, 11 (5), pp. 343-354Bozzano, F., Marras, F., De Maria, A., Immunology of tuberculosis (2014) Mediterr J Hematol Infect Dis, 6 (1), p. e2014027Coelho Filho, J.C., Takenami, I., Arruda, S., Revisiting the Rich's formula: An update about granulomas in human tuberculosis (2013) Braz J Infect Dis, 17 (2), pp. 234-238Prezzemolo, T., Giggino, G., La Manna, M.P., Functional signatures of human CD4 and CD8 T cell responses to Mycobacterium tuberculosis (2014) Front Immunol, 5, p. 180Brighenti, S., Andersson, J., Local immune responses in human tuberculosis: Learning from the site of infection (2012) J Infect Dis, 205, pp. S316-S324Feng, C.G., Kaviratne, M., Rothfuchs, A.G., NK cell-derived IFN-gamma differentially regulates innate resistance and neutrophil response in T cell-deficient hosts infected with Mycobacterium tuberculosis (2006) J Immunol, 177 (10), pp. 7086-7093Cole, S.T., Brosch, R., Parkhill, J., Deciphering the biology of Mycobacterium tuberculosis from the complete genome sequence (1988) Nature, 393 (6685), pp. 537-544Hoffmann, C., Leis, A., Niederweis, M., Disclosure of the mycobacterial outer membrane: Cryo-electron tomography and vitreous sections reveal the lipid bilayer structure (2008) Proc Natl Acad Sci USA, 105 (10), pp. 3963-3967Delogu, G., Sali, M., Fadda, G., The biology of mycobacterium tuberculosis infection (2013) Mediterr J Hematol Infect Dis, 5, p. e2013070Boshoff, H.I., Lun, D.S., Systems biology approaches to understanding mycobacterial survival mechanisms (2010) Drug Discov Today Dis Mech, 7 (1), pp. e75-82Abdallah, A.M., Gey Van Pittius, N.C., Champion, P.A., Type VII secretion-mycobacteria show the way (2007) Nat Rev Microbiol, 5 (11), pp. 883-891Houben, E.N., Bestebroer, J., Ummels, R., Composition of the type VII secretion system membrane complex (2012) Mol Microbiol, 86 (2), pp. 472-484Volkman, H.E., Pozos, T.C., Zheng, J., Tuberculous granuloma induction via interaction of a bacterial secreted protein with host epithelium (2010) Science, 327 (5964), pp. 466-469Korch, S.B., Contreras, H., Clark-Curtiss, J.E., Three Mycobacterium tuberculosis Rel toxin-antitoxin modules inhibit mycobacterial growth and are expressed in infected human macrophages (2009) J Bacteriol, 191 (5), pp. 1618-1630Fox, W., Ellard, G.A., Mitchison, D.A., Studies on the treatment of tuberculosis undertaken by the British Medical Research Council tuberculosis units 1946-1986, with relevant subsequent publications (1999) Int J Tuberc Lung Dis, 3, pp. S231-S279Hernandez, C., Cetner, A.S., Jordan, J.E., Tuberculosis in the age of biologic therapy (2008) J Am Acad Dermatol, 59 (3), pp. 363-380Esmail, H., Barry, C.E., III, Young, D.B., Wilkinson, R.J., The ongoing challenge of latent tuberculosis (2014) Philos Trans R Soc Lond B Biol Sci, 369 (1645), p. 20130437Rich, A.R., (1951) The Pathogenesis of Tuberculosis. 2 Edition, , Charles ThomasIL USA:Hosoglu, S., Ayaz, C., Et Al. G.Mf, Tuberculous meningitis in adults: An eleven-year review (1998) Int J Tuberc Lung Dis, 2 (7), pp. 553-557Be, N.A., Kim, K.S., Bishai, W.R., Jain, S.K., Pathogenesis of central nervous system tuberculosis (2009) Curr Mol Med, 9 (2), pp. 94-99Ghosh, K., Patwardhan, M., Pradhan, V., Mycobacterium tuberculosis infection precipitates SLE in patients from endemic areas (2009) Rheumatol Int, 29 (9), pp. 1047-1050Pradhan, V., Patwardhan, M., Athavale, A., Mycobacterium tuberculosis triggers autoimmunity (2012) Indian J Tuberc, 59 (1), pp. 49-51Lee, J., Reinke, E.K., Zozulya, A.L., Mycobacterium bovis bacille Calmette-Guérin infection in the CNS suppresses experimental autoimmune encephalomyelitis and Th17 responses in an IFN-gamma-independent manner (2008) J Immunol, 181 (9), pp. 6201-6212Bible, E., Multiple sclerosis: Disease activity is reduced in CIS after BCG vaccination (2014) Nat Rev Neurol, 10 (2), p. 62Wucherpfennig, K.W., Mechanisms for the induction of autoimmunity by infectious agents (2001) J Clin Invest, 108 (8), pp. 1097-1104Chodisetti, S.B., Rai, P.K., Gowthaman, U., Potential T cell epitopes of Mycobacterium tuberculosis that can instigate molecular mimicry against host: Implications in autoimmune pathogenesis (2012) BMC Immunology, 13, p. 13Moseley, P., Stress proteins and the immune response (2000) Immunopharmacology, 48 (3), pp. 299-302Mycko, M.P., Brosnan, C.F., Raine, C.S., Transcriptional profiling of microdissected areas of active multiple sclerosis lesions reveals activation of heat shock protein genes (2012) J Neurosci Res, 90 (10), pp. 1941-1948Wiendl, H., Hohlfeld, R., Therapeutic approaches in multiple sclerosis: Lessons from failed and interrupted treatment trials (2002) BioDrugs, 6, pp. 183-200Shaik, J., Pillay, M., Jeena, P., The role of interferon gamma release assays in the monitoring of response to anti-tuberculosis treatment in children (2013) Paediatr Respir Rev, 13, pp. S1526-0542Beamer, G.L., Cyktor, J., Carruthers, B., Turner, J., H-2 alleles contribute to antigen 85-specific interferon-gamma responses during Mycobacterium tuberculosis infection (2011) Cell Immunol, 271 (1), pp. 53-61Todd, P.A., Goa, K.L., Interferon gamma-1b A review of its pharmacology and therapeutic potential in chronic granulomatous disease (1992) Drugs, 43 (1), pp. 111-122Nikfar, S., Rahimi, R., Abdollahi, M., A meta-analysis of the efficacy and tolerability of interferon-b in multiple sclerosis, overall and by drug and disease type (2010) Clin Ther, 32 (11), pp. 1871-1888Aharoni, R., The mechanism of action of glatiramer acetate in multiple sclerosis and beyond (2013) Autoimmun Rev, 12 (5), pp. 543-553Dheda, K., Schwander, S.K., Zhu, B., The immunology of tuberculosis: From bench to bedside (2010) Respirology, 15 (3), pp. 433-450Musabak, U., Demirkaya, S., Genç, G., Serum adiponectin TNF-A IL-12p70 and IL-13 levels in multiple sclerosis and the effects of different therapy regimens (2011) Neuroimmunomodulation, 18 (1), pp. 57-66Winkelmann, A., Loebermann, M., Reisinger, E.C., Zettl, U.K., Multiple sclerosis treatment and infections issues: Update 2013 (2014) Clin Exp Immunol, 175 (3), pp. 425-438Kappos, L., Radue, E.W., O'Connor, P., A placebo-controlled trial of oral fingolimod in relapsing multiple sclerosis (2010) N Engl J Med, 362 (5), pp. 387-401Connor, L.M., Harvie, M.C., Rich, F.J., A key role for lung-resident memory lymphocytes in protective immune responses after BCG vaccination (2010) Eur J Immunol, 40 (9), pp. 2482-2492Kappos, L., Bates, D., Edan, G., Natalizumab treatment for multiple sclerosis: Updated recommendations for patient selection and monitoring (2011) Lancet Neurol, 10 (8), pp. 745-758Abonia, J.P., Hallgren, J., Jones, T., Alpha-4 integrins and VCAM-1, but not MAdCAM-1, are essential for recruitment of mast cell progenitors to the inflamed lung (2006) Blood, 108 (5), pp. 1588-1594Mulero, P., Caminero, A.B., Neri Crespo, M.J., Latent tuberculosis seems not to reactivate in multiple sclerosis patients on natalizumab (2012) J Neuroimmunol, 243 (1-2), pp. 103-105Dahdaleh, D., Altmann, D.M., Malik, O., Nicholas, R.S., Breathlessness night sweats and weight loss on natalizumab (2012) Lancet, 380 (9843), pp. 726-727Anderson, C., Hopkins, S., Adeboyeku, D., Maguire, H., Tuberculosis in London: Not unexpected (2013) Lancet, 381 (9862), p. 201Boumpas, D.T., Paliogianni, F., Anastassiou, E.D., Balow, J.E., Glucocorticosteroid action on the immune system: Molecular and cellular aspects (1991) Clin Exp Rheumatol, 9 (4), pp. 413-423Gold, R., Buttgereit, F., Toyka, K.V., Mechanism of action of glucocorticosteroid hormones: Possible implications for therapy of neuroimmunological disorders (2001) J Neuroimmunol, 117 (1-2), pp. 1-8Critchley, J.A., Young, F., Orton, L., Garner, P., Corticosteroids for prevention of mortality in people with tuberculosis: A systematic review and meta-analysis (2013) Lancet Infect Dis, 13 (3), pp. 223-237Segal, B.H., Sneller, M.C., Infectious complications of immunosuppressive therapy in patients with rheumatic diseases (1997) Rheum Dis Clin North Am, 23 (2), pp. 219-237Jick, S.S., Lieberman, E.S., Rahman, M.U., Choi, H.K., Glucocorticoid use, other associated factors, and the risk of tuberculosis (2006) Arthritis Rheum, 55, pp. 19-26Cline, J.C., Davis, S.M., Risks of infection or reactivation of tuberculosis associated with chronic corticosteroid therapy (1997) Ann Pharmacother, 31 (6), pp. 775-776Tam, L.S., Li, E.K., Wong, S.M., Szeto, C.C., Risk factors and clinical features for tuberculosis among patients with systemic lupus erythematosus in Hong Kong (2002) Scand J Rheumatol, 31 (5), pp. 296-300Hirata, N., Koerner, M.M., Tenderich, G., Influence of cytoimmunological state on the development of tuberculosis in heart transplant recipients (2001) Surg Today, 31 (6), pp. 482-486Tiede, I., Fritz, G., Strand, S., CD28-dependent Rac1 activation is the molecular target of azathioprine in primary human CD4+ T lymphocytes (2003) J Clin Invest, 111 (8), pp. 1133-1145Casetta, I., Iuliano, G., Filippini, G., Azathioprine for multiple sclerosis (2009) J Neurol Neurosurg Psychiatry, 80 (2), pp. 131-132Casetta, I., Iuliano, G., Filippini, G., Azathioprine for multiple sclerosis (2007) Cochrane Database Syst Rev, 4, p. CD003982Ludeman, S.M., The chemistry of the metabolites of cyclophosphamide (1999) Curr Pharm des, 5 (8), pp. 627-643Agency, B.C., (2013) Cancer Drug Manual: Cyclophosphamide, pp. 1-12Binymin, K., Cooper, R.G., Late reactivation of spinal tuberculosis by low-dose methotrexate therapy in a patient with rheumatoid arthritis (2001) Rheumatology (Oxford), 40 (3), pp. 341-342Zorlu, M., Kiskac, M., Karatoprak, C., Pott's disease and hypercalcemia in a patient with rheumatoid arthritis receiving methotrexate monotherapy (2013) Indian J Pharmacol, 45 (6), pp. 631-633Mor, A., Bingham, C.O., III, Kishimoto, M., Methotrexate combined with isoniazid treatment for latent tuberculosis is well tolerated in patients with rheumatoid arthritis: Experience from an urban arthritis clinic (2008) Ann Rheumatol Dis, 67 (4), pp. 462-465Wehenkel, A., Fernandez, P., Bellinzoni, M., The structure of PknB in complex with mitoxantrone, an ATP-competitive inhibitor, suggests a mode of protein kinase regulation in mycobacteria (2006) FEBS Lett, 580 (13), pp. 3018-3022Martinelli Boneschi, F., Vacchi, L., Rovaris, M., Mitoxantrone for multiple sclerosis (2013) Cochrane Database Syst Rev, 5, p. CD002127Darlington, P.J., Boivin, M.N., Bar-Or, A., Harnessing the therapeutic potential of mesenchymal stem cells in multiple sclerosis (2011) Expert Rev Neurother, 11 (9), pp. 1295-1303Russo, R.L., Dulley, F.L., Suganuma, L., Tuberculosis in hematopoietic stem cell transplant patients: Case report and review of the literature (2010) Int J Infect Dis, 14, pp. e187-e191Akan, H., Arslan, O., Akan, O.A., Tuberculosis in stem cell transplant patients (2006) J Hosp Infect, 62 (4), pp. 421-426De La Câmara, R., Martino, R., Granados, E., Tuberculosis after hematopoietic stem cell transplantation: Incidence, clinical characteristics and outcome (2000) Bone Marrow Transplant, 26 (3), pp. 291-298. , Spanish Group on Infectious Complications in Hematopoietic TransplantationHolloman, J., Ho, C.C., Hukki, A., The development of hematopoietic and mesenchymal stem cell transplantation as an effective treatment for multiple sclerosis (2013) Am J Stem Cell, 2 (2), pp. 95-107Fox, R.J., Kita, M., Cohan, S.L., BG-12 (dimethyl fumarate): A review of mechanism of action efficacy and safety (2014) Curr Med Res Opin, 30 (2), pp. 251-262Gold, R., Kappos, L., Arnold, D.L., Placebo-controlled phase 3 study of oral BG-12 for relapsing multiple sclerosis (2012) N Engl J Med, 367 (12), pp. 1098-1107Phillips, J.T., Fox, R.J., BG-12 in multiple sclerosis (2013) Semin Neurol, 33 (1), pp. 56-65Montoya, M.C., Sancho, D., Bonello, G., Role of ICAM-3 in the initial interaction of T lymphocytes and APCs (2002) Nat Immunol, 3 (2), pp. 159-168Zeyda, M., Poglitsch, M., Geyeregger, R., Disruption of the interaction of T cells with antigen-presenting cells by the active leflunomide metabolite teriflunomide: Involvement of impaired integrin activation and immunologic synapse formation (2005) Arthritis Rheum, 52 (9), pp. 2730-2739Minagar, A., Alexander, J.S., Sahraian, M.A., Zivadinov, R., Alemtuzumab and multiple sclerosis: Therapeutic application (2010) Expert Opin Biol Ther, 10, pp. 421-429Willis, M., Robertson, N.P., Drug safety evaluation of alemtuzumab for multiple sclerosis (2014) Expert Opin Drug Saf, 13 (8), pp. 1115-1124Antohe, I., Dascalescu, A., Burcoveanu, C., Pact with the devil: Alemtuzumab therapy, immune suppression and infectious complications in chronic lymphocytic leukemia (2014) Rev Med Chir Soc Med Nat Iasi, 118, pp. 92-95Abad, S., Gyan, E., Moachon, L., Tuberculosis due to Mycobacterium bovis after alemtuzumab administration (2003) Clin Infect Dis, 37, pp. e27-e28Au, W.Y., Leung, A.Y., Tse, E.W., High incidence of tuberculosis after alemtuzumab treatment in Hong Kong Chinese patients (2008) Leuk Res, 32, pp. 547-551Bosch, W., Poowanawittayakom, N., Chaikriangkrai, K., Tuberculous hepatitis in renal transplant recipients following alemtuzumab induction therapy (2013) Transpl Infect Dis, 15, pp. E33-E39Iannone, F., Cantini, F., Lapadula, G., Diagnosis of latent tuberculosis and prevention of reactivation in rheumatic patients receiving biologic therapy: International recommendations (2014) J Rheumatol Suppl, 91, pp. 41-46Gisondi, P., Pezzolo, E., Lo Cascio, G., Girolomoni, G., Latent tuberculosis infection in patients with chronic plaque psoriasis candidate to biological therapy (2014) Br J Dermatol, , [Epub ahead of print]Kieseier, B.C., The mechanism of action of interferon-b in relapsing multiple sclerosis (2011) CNS Drugs, 25, pp. 491-502Racke, M.K., Lovett-Racke, A.E., Karandikar, N.J., The mecanism of action of glatiramer acetate treatment in multiple sclerosis (2010) Neurology, 74, pp. S25-30Chun, J., Hartung, H.P., Mechanism of action of oral fingolimod (FTY720) in multiple sclerosis (2010) Clin Neuropharmacol, 33, pp. 91-101Engelhardt, B., Kappos, L., Natalizumab: Targeting a4-integrins in multiple sclerosis (2008) Neurodegener Dis, 5, pp. 16-22Schaal, A.D., Alemtuzumab (Campath 1-H) (2005) Clin J Oncol Nurs, 9, pp. 630-63

We Know How To Prescribe Natalizumab For Multiple Sclerosis, But Do We Know How To Withdraw It?

Natalizumab is a potent immunosuppressive monoclonal antibody used for the treatment of multiple sclerosis (MS). While definite guidelines for the safety of natalizumab prescriptions are available in all countries, there are no specific recommendations on how to withdraw the drug if the need arises. There are reports describing MS complications after natalizumab infusions were stopped. Most neurologists seem to stop natalizumab treatment according to their idea on how to best carry out the withdrawal. The present study shows the very different manners in which expert neurologists from 14 MS units in Brazil stopped natalizumab in their patients. The authors concluded that pharmacovigilance on natalizumab must persist after the drug is withdrawn in order to have enough data for adequate recommendations. © 2014 Informa UK, Ltd.142127130Nylander, A., Hafler, D.A., Multiple sclerosis (2012) J Clin Invest, 122, pp. 1180-1188McCoyd, M., Update on therapeutic options for multiple sclerosis (2013) Neurol Clin, 31, pp. 827-845McCormack, P.L., Natalizumab: A review of its use in the management of relapsing-remitting multiple sclerosis (2013) Drugs, 73 (13), pp. 1463-1481Fernández, O., Best practice in the use of natalizumab in multiple sclerosis (2013) Ther Adv Neurol Disord, 6, pp. 69-79Sørensen, P.S., Bertolotto, A., Edan, G., Risk stratification for progressive multifocal leukoencephalopathy in patients treated with natalizumab (2012) Mult Scler, 18, pp. 143-152Pucci, E., Giuliani, G., Solari, A., Natalizumab for relapsing remitting multiple sclerosis (2011) Cochrane Database Syst Rev, 10, pp. CD007621Fragoso, Y.D., Alves-Leon, S.V., Arruda, W.O., Natalizumab adverse events are rare in patients with multiple sclerosis (2013) Arq Neuropsiquiatr, 71, pp. 137-141Damasceno, A., Von Glehn, F., Martinez, A.R., Early onset of natalizumab-related progressive multifocal leukoencephalopathy (2011) Mult Scler, 17, pp. 1397-1398Baumgartner, A., Stich, O., Rauer, S., Clinical and radiological disease reactivation after cessation of long-Term therapy with natalizumab (2012) Int J Neurosci, 122, pp. 35-39Rigau, V., Mania, A., Béfort, P., Lethal multiple sclerosis relapse after natalizumab withdrawal (2012) Neurology, 79, pp. 2214-2216Marousi, S., Travasarou, M., Karageorgiou, C.E., Simultaneous PML-IRIS after discontinuation of natalizumab in a patient with MS (2012) Neurology, 79, p. 2160Berger, J.R., Centonze, D., Comi, G., Considerations on discontinuing natalizumab for the treatment of multiple sclerosis (2010) Ann Neurol, 68, pp. 409-411Miravalle, A., Jensen, R., Kinkel, R.P., Immune reconstitution inflammatory syndrome in patients with multiple sclerosis following cessation of natalizumab therapy (2011) Arch Neurol, 68, pp. 186-191Borriello, G., Prosperini, L., Marinelli, F., Observations during an elective interruption of natalizumab treatment: A post-marketing study (2011) Mult Scler, 17, pp. 372-375Papeix, C., Depaz, R., Tourbah, A., Dramatic worsening following plasma exchange in severe post-natalizumab withdrawal multiple sclerosis relapse (2011) Mult Scler, 17, pp. 1520-1522Borriello, G., Prosperini, L., Mancinelli, C., Pulse monthly steroids during an elective interruption of natalizumab: A post-marketing study (2012) Eur J Neurol, 19, pp. 783-787Magraner, M.J., Coret, F., Navarré, A., Pulsed steroids followed by glatiramer acetate to prevent inflammatory activity after cessation of natalizumab therapy: A prospective, 6-month observational study (2011) J Neurol, 258, pp. 1805-1811Rossi, S., Motta, C., Studer, V., Effect of glatiramer acetate on disease reactivation in MS patients discontinuing natalizumab (2013) Eur J Neurol, 20, pp. 87-94Havla, J., Gerdes, L.A., Meinl, I., De-escalation from natalizumab in multiple sclerosis: Recurrence of disease activity despite switching to glatiramer acetate (2011) J Neurol, 258, pp. 1665-1669Gobbi, C., Meier, D.S., Cotton, F., Interferon beta 1b following natalizumab discontinuation: One year, randomized, prospective, pilot trial (2013) BMC Neurol, 13, p. 101Cree, B., De Seze, J., Fox, R., RESTORE Study: Effects of a 24-week natalizumab treatment interruption on immune parameters and multiple sclerosis magnetic resonance imaging disease activity 2012P06.168 (2012) Neurology, (78), pp. 106-168. , Meeting Abstracts 1Comi, G., Gold, R., Dahlke, F., Overall safety and relapse outcomes in fingolimod-Treated patients previously treated with natalizumab in the 4-month open-label first study [poster (2013) European Neurology Society (ENS) Meeting Barcelona SpainHavla, J., Tackenberg, B., Hellwig, K., Fingolimod reduces recurrence of disease activity after natalizumab withdrawal in multiple sclerosis (2013) J Neurol, 260, pp. 1382-1387Daelman, L., Maitrot, A., Maarouf, A., Severe multiple sclerosis reactivation under fingolimod 3 months after natalizumab withdrawal (2012) Mult Scler, 11, pp. 1647-1649Sempere, A.P., Martín-Medina, P., Berenguer-Ruiz, L., Switching from natalizumab to fingolimod: An observational study (2013) Acta Neurol Scand, 128, pp. e6-e10Centonze, D., Rossi, S., Rinaldi, F., Gallo, P., Severe relapses under fingolimod treatment prescribed after natalizumab (2012) Neurology, 79, pp. 2004-2005Jander, S., Turowski, B., Kieseier, B.C., Hartung, H.P., Emerging tumefactive multiple sclerosis after switching therapy from natalizumab to fingolimod (2012) Mult Scler, 18, pp. 1650-165

The extrapituitary prolactin promoter polymorphism is associated with rheumatoid arthritis and anti-CCP antibodies in Mexican population

Background and objective: Women with multiple sclerosis (MS) who intend to get pregnant are often advised to discontinue disease modifying therapy (DMT) prior to conception. This recommendation is not based on medical evidence and may interfere with disease control by immunomodulatory drugs. The present study was designed to help discuss the effect of DMT for MS on pregnancy and on disease course. Patients and methods: Retrospective data from 152 pregnancies of 132 women with MS were collected by the physician in charge of the case. All data were entered into a specific file for qualitative and quantitative statistical analysis. Results: From the total group of patients, 89 pregnancies occurred without any exposure to MS drugs, while 61 pregnancies occurred with at least eight weeks of exposure to MS immunomodulatory drugs. The rate of obstetric and neonatal complications was similar in both groups, except for the newborn weight and height which was smaller for mothers receiving medications. Mothers' post-delivery relapse rate and EDSS scores in the follow-up period were significantly higher in the absence of treatment. Conclusion: It is possible that, with further such supportive data, international guidelines on MS treatment in young women who intend to get pregnant may need to be revised. " 2012 Elsevier B.V.",,,,,,"10.1016/j.clineuro.2012.04.024",,,"http://hdl.handle.net/20.500.12104/45105","http://www.scopus.com/inward/record.url?eid=2-s2.0-84872295057&partnerID=40&md5=c20df0b7feedea45f4a1222a90afb6b2",,,,,,"2",,"Clinical Neurology and Neurosurgery",,"15

The effects of long-term exposure to disease-modifying drugs during pregnancy in multiple sclerosis

Background and objective: Women with multiple sclerosis (MS) who intend to get pregnant are often advised to discontinue disease modifying therapy (DMT) prior to conception. This recommendation is not based on medical evidence and may interfere with disease control by immunomodulatory drugs. The present study was designed to help discuss the effect of DMT for MS on pregnancy and on disease course. Patients and methods: Retrospective data from 152 pregnancies of 132 women with MS were collected by the physician in charge of the case. All data were entered into a specific file for qualitative and quantitative statistical analysis. Results: From the total group of patients, 89 pregnancies occurred without any exposure to MS drugs, while 61 pregnancies occurred with at least eight weeks of exposure to MS immunomodulatory drugs. The rate of obstetric and neonatal complications was similar in both groups, except for the newborn weight and height which was smaller for mothers receiving medications. Mothers' post-delivery relapse rate and EDSS scores in the follow-up period were significantly higher in the absence of treatment. Conclusion: It is possible that, with further such supportive data, international guidelines on MS treatment in young women who intend to get pregnant may need to be revised. © 2012 Elsevier B.V