Safety of Alemtuzumab and Autologous Hematopoietic Stem Cell Transplantation Compared to Noninduction Therapies for Multiple Sclerosis
Peter Alping, Joachim Burman, Jan Lycke, Thomas Frisell, Fredrik Piehl, Peter Alping, Joachim Burman, Jan Lycke, Thomas Frisell, Fredrik Piehl
Abstract
Objective: To assess safety outcomes for the induction therapies alemtuzumab and autologous hematopoietic stem cell transplantation (AHSCT) compared to noninduction disease-modifying therapies.
Methods: We performed a population-based cohort study linking the Swedish Multiple Sclerosis Register to national health care registers. Alemtuzumab, AHSCT, and a matched reference group of noninduction therapies (natalizumab, dimethyl fumarate, rituximab, fingolimod) were included if started between 2008 and 2017. Main outcomes were death, thyroid disease, nonthyroid autoimmune disease, and infection.
Results: We identified 132 alemtuzumab-treated and 139 AHSCT-treated (68% high-dose cyclophosphamide and anti-thymocyte globulin [ATG], 32% BCNU, etoposide, cytosine-arabinoside, and melphalan/ATG) patients, together with 2,486 matched patients treated with noninduction therapies. Four patients in the alemtuzumab group died (incidence rate [IR] per 1,000 person-years 8.6, 95% confidence interval [CI] 2.3-22.0) compared to 1 patient in the AHSCT group (IR 1.7, 95% CI 0.0-9.6), and the mortality rate in the reference group was 0.7 (95% CI 0.3-1.3). Thyroid disease was most frequent in the alemtuzumab group (IR 109, 95% CI 75-154) but also occurred more often for AHSCT (IR 34, 95% CI 18-56) compared to the reference (IR 5.3 95% CI 3.9-7.1). The incidence of nonthyroid autoimmune disease was similar in all groups. IR for infection diagnosed ≥6 months from therapy initiation was 53 (95% CI 30-87) for alemtuzumab, 108 (95% CI 75-150) for AHSCT, and 51 (95% CI 46-57) for the reference.
Conclusion: We confirmed a high incidence of thyroid disease in alemtuzumab- and, to a smaller extent, AHSCT-treated patients and found a higher incidence of infection for AHSCT compared to both alemtuzumab and noninduction therapies. The incidence of nonthyroid autoimmune disease was low for both therapies.
Classification of evidence: This study provides Class III evidence of an increased risk of thyroid disease with alemtuzumab and an increased risk of infection with AHSCT treatment.
Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
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References
- Fassas A, Anagnostopoulos A, Kazis A, et al. . Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transpl 1997;20:631–638.
- Coles AJ, Twyman CL, Arnold DL, et al. . Alemtuzumab for patients with relapsing multiple sclerosis after disease-modifying therapy: a randomised controlled phase 3 trial. Lancet 2012;380:1829–1839.
- Muraro PA, Martin R, Mancardi GL, Nicholas R, Sormani MP, Saccardi R. Autologous haematopoietic stem cell transplantation for treatment of multiple sclerosis. Nat Rev Neurol 2017;13:391–405.
- Hillert J. : Swedish Multiple Sclerosis Register. Available at: . Accessed July 1, 2020.
- Alping P, Piehl F, Langer-Gould A, Frisell T; COMBAT-MS Study Group. Validation of the Swedish Multiple Sclerosis Register: further improving a resource for pharmacoepidemiologic evaluations. Epidemiology 2019;30:230–233.
- Hillert J, Stawiarz L. The Swedish MS Registry clinical support tool and scientific resource. Acta Neurol Scand 2015;132:11–19.
- Ludvigsson JF, Andersson E, Ekbom A, et al. . External review and validation of the Swedish National Inpatient Register. BMC Public Health 2011;11:450.
- Wettermark B, Hammar N, Fored CM, et al. . The new Swedish Prescribed Drug Register: opportunities for pharmacoepidemiological research and experience from the first six months. Pharmacoepidemiol Drug Saf 2007;16:726–735.
- Socialstyrelsen. Swedish Cancer Registry. Accessed July 1, 2020.
- Python. A Language and Environment for Statistical Computing. Delaware: Python Software Foundation; 2018.
- Cohen JA, Coles AJ, Arnold DL, et al. . Alemtuzumab versus interferon beta 1a as first-line treatment for patients with relapsing-remitting multiple sclerosis: a randomised controlled phase 3 trial. Lancet 2012;380:1819–1828.
- CAMMS223 Trial Investigators, Coles AJ, Compston DAS, et al. . Alemtuzumab vs. interferon beta-1a in early multiple sclerosis. N Engl J Med 2008;359:1786–1801.
- Scappaticcio L, Castellana M, Virili C, et al. . Alemtuzumab-induced thyroid events in multiple sclerosis: a systematic review and meta-analysis. J Endocrinol Invest 2020;43:219–229.
- Luna G, Alping P, Burman J, et al. . Infection risks among patients with multiple sclerosis treated with fingolimod, natalizumab, rituximab, and injectable therapies. JAMA Neurol 2020;77:184–191.
Source: PubMed