immunotherapy of multiple sclerosis
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REVIEW ARTICLE
Immunotherapy of Multiple Sclerosis
The State of the Art
Dimitrios Karussis
� Springer International Publishing Switzerland 2013
Abstract It is widely accepted that the main common
pathogenetic pathway in multiple sclerosis (MS) involves
an immune-mediated cascade initiated in the peripheral
immune system and targeting CNS myelin. Logically,
therefore, the therapeutic approaches to the disease include
modalities aiming at downregulation of the various
immune elements that are involved in this immunologic
cascade. Since the introduction of interferons in 1993,
which were the first registered treatments for MS, huge
steps have been made in the field of MS immunotherapy.
More efficious and specific immunoactive drugs have been
introduced and it appears that the increased specificity for
MS of these new treatments is paralleled by greater effi-
cacy. Unfortunately, this seemingly increased efficacy has
been accompanied by more safety issues. The immuno-
therapeutic modalities can be divided into two main
groups: those affecting the acute stages (relapses) of the
disease and the long-term treatments that are aimed at
preventing the appearance of relapses and the progression
in disability. Immunomodulating treatments may also be
classified according to the level of the ‘immune axis’ where
they exert their main effect. Since, in MS, a neurodegen-
erative process runs in parallel and as a consequence of
inflammation, early immune intervention is warranted to
prevent progression of relapses of MS and the accumula-
tion of disability. The use of neuroimaging (MRI) tech-
niques that allow the detection of silent inflammatory
activity of MS and neurodegeneration has provided an
important tool for the substantiation of the clinical efficacy
of treatments and the early diagnosis of MS. This review
summarizes in detail the existing information on all the
available immunotherapies for MS, old and new, classifies
them according to their immunologic mechanisms of action
and proposes a structured algorithm/therapeutic scheme for
the management of the disease.
1 Introduction
Multiple sclerosis (MS) is a chronic disease of the central
nervous system (CNS) that is characterized by loss of motor
and sensory function, caused by immune-mediated inflam-
mation, demyelination, and subsequent neuronal/axonal dam-
age [1–3]. Clinically, most MS patients experience recurrent
episodes (relapses) of neurological impairment (relapsing-
remitting MS: RRMS). Early neurological dysfunction may
resolve spontaneously, partially or completely, but usually the
course of the disease becomes chronic and progressive (pri-
mary or secondary progressive MS: PPMS, SPMS), leading to
accumulating motor disability and cognitive deficits.
Histologically, perivenular inflammatory lesions involving
infiltrating mononuclear cells are evident in the earlier phases
of the disease, resulting in demyelinating plaques which are
the hallmark pathological feature of MS [2]. Inflammation
leads to damage or loss of oligodendrocytes and demyelina-
tion leads to disruption of the conduction of neuronal signals
in the affected regions. In the initial stages of MS, compen-
satory pathways (such as the upregulation of ion-channels in
the affected areas) may partially restore conduction and
reverse the neurological dysfunction. As the disease pro-
gresses, significant axonal loss and eventually neuronal
damage occurs [4] and the lost function becomes permanent
and non-reversible.
D. Karussis (&)
Department of Neurology, MS Center and the Agnes-Ginges
Center for Neurogenetics, Hadassah-Hebrew University
Hospital, Laboratory of Neuroimmunology, Hadassah,
Ein-Kerem, Jerusalem, IL 91120, Israel
e-mail: karus@cc.huji.ac.il
BioDrugs
DOI 10.1007/s40259-013-0011-z
It is widely accepted that the inflammatory process in
MS is caused or propagated by an autoimmune cascade,
involving mainly T cells that target myelin self-antigens [5,
6], possibly through mechanisms known as molecular
mimicry (cross-reactive antigens expressed by viruses or
other microorganisms and myelin components) [7]. An
alternative hypothesis is that myelin-specific T cells that
are present ‘naturally’ may expand to critical pathogenic
quantities [8] due to malfunctioning immunoregulatory
mechanisms (such as those involving the Th2, Th3 and
CD8? T cells and the regulatory T cells: Tr1 and Treg).
Although the autoimmune hypothesis is attractive and
supported by concrete data (including the efficacy of
immunomodulatory treatments in MS), the initial insult
which initiates the whole immune-mediated cascade is still
obscure. Environmental, genetic and infectious factors
seem to play an important role in MS pathogenesis, but it
seems that the role of any putative infectious agent is to
trigger/drive the autoimmune process [8], rather than to
serve as the primary target of infiltrating cells. In any case,
T cells of the Th1 and Th17 phenotype specific for myelin
antigenic epitopes seem to represent the common final
pathogenetic effector pathway, regardless of the initial
insult of the disease [9–11]. However, MS is not a
homogenous disease and it is now increasingly recognized
that it has several distinct immunopathological profiles,
including prominent humoral immune mechanisms in some
MS patients [12].
The initial stages of the autoimmune cascade in MS are
probably initiated in the peripheral immune system. Fol-
lowing activation by the macrophages and dendritic cells
(antigen-presenting cells: APC), Th1 and Th17 lympho-
cytes, which express the antigens specific for myelin,
T-cell receptors (TCR), proliferate and begin to express on
their membranes, adhesion molecules, and chemokine
receptors that enhance their ability to extravasate to the site
of inflammation in the CNS [13–18] (and to produce
interleukin [IL]-2, IL-17, tumor necrosis factor-alpha
[TNFa] and interferon-gamma [IFNc] [pro-inflammatory
cytokines]). This migration possibly follows ‘damage sig-
nals’ from the CNS tissue or is due to an opening/
destruction of the blood-brain barrier. Adhesion molecules
such as VLA4 are crucially important for this process and
their blockage may prevent the extravasation of the lym-
phocytes through the blood vessels’ endothelium [19, 20].
Interestingly, the best existing evidence that MS is indeed
an autoimmune disease and that the whole process is ini-
tiated in the periphery comes form the reported evidence of
high efficacy in MS (and the ‘rebound’ of MS activity
following their discontinuation) of medications that spe-
cifically block the migration of the lymphocytes into the
CNS (such as natalizumab which targets the CD40L mol-
ecule) [20].
B cells have traditionally been considered to play a
secondary T-cell-dependent role, producing antibodies that
may promote tissue destruction by recruiting macrophages
and through activation of the complement pathway [21].
Additionally, activated B cells can act as antigen-specific
APCs for T cells and produce costimulatory molecules that
influence the differentiation of T cells into Th1 or Th2 cells
[22]. Patients with MS have increased B-cell numbers in
the CNS, mainly memory cells and short-lived plasma-
blasts [23]. Plasmablasts persist in the cerebrospinal fluid
(CSF) throughout the course of MS, and the numbers of
these cells correlate with intrathecal immunoglobulin G
(IgG) synthesis (oligoclonal antibodies, one of the hall-
marks of MS diagnosis) and with active inflammatory
disease [23, 24]. Moreover, B cells, plasma cells, autoan-
tibodies, and complement have been detected in MS lesions
[25, 26], indicating their implication in demyelination.
Additional indications for antibody-mediated mechanisms
in MS come from the presence of ectopic lymphoid folli-
cles in the CNS of patients with MS [23, 27–29], especially
those with progressive disease. It appears, therefore, that as
the disease evolves into the progressive stage, the inflam-
mation becomes compartmentalized and predominantly
mediated by B cells. Further evidence for the role of B cells
in the immunopathology of MS is the efficacy of B-cell-
and antibody-directed therapies, such as plasmapheresis
and rituximab, in treating selected subgroups of MS
patients [30, 31]. The involvement of antibody-mediated
pathogenetic mechanisms is particularly pronounced in
variants of CNS demyelinating disease, such as neur-
omyelitic types of MS (neuromyelitis optica [NMO]-
spectrum of disorders) associated with anti-aquaporin
antibodies and long magnetic resonance imaging (MRI)
lesions in the cervical spine.
2 Multiple Sclerosis (MS) Immunotherapy
Logically, based on this widely accepted model for MS
immunopathogenesis described in Sect. 1 (Fig. 1), the
therapeutic approaches to the disease include modalities
aimed at downregulating the various immune elements that
are involved in the immunological cascade. Since the
introduction of interferons in 1993, which were the first
registered immunotherapies for MS, huge steps have been
made in the field of MS immunotherapy. The novel, at that
time, concept of ‘immunomodulation’ (referring to a spe-
cific dowregulation of the pathogenic immune cells
through induction of a shift of the immune response or
enhancement of the intrinsic regulatory immune networks),
as opposed to the generalized immunosuppression
approach, was initially introduced from the studies with
interferons and linomide, in the early 1990s [32–34].
D. Karussis
During the last two decades, since the advent of IFN, more
target-focused immunoactive drugs have been introduced
and it appears that these new treatments are more efficious
(Fig. 2). However, this seemingly increased efficacy of the
new immunomodulatory drugs has to be carefully inter-
preted as the clinical trials during the last decade included
MS patients with a lower relapse rate, and this fact com-
plicates the comparisons between old and new generation
drugs. In addition, more safety issues have arisen with
these new immunomodulators (Fig. 2).
Since, as mentioned in Sect. 1, a neurodegenerative
process runs in parallel and as a consequence of inflam-
mation, early immune intervention is warranted to prevent
the relapses of MS and the accumulation of disability. The
Th1
CD4+ CD25+ FOXP3
ThCD4
CD8B
cells
Th17
Th17
Th1B cells
CD8
IL4IL5IL10IL13
BAFFIL4, IL10
VCAMICAM
MMPs
IFNγTNFa
VLA4
LFA1
B7
CD40L
MHC+Myelin ags
CD40
CD80
TCR
IL23
IL6TGFB
(-)
IL17
BBB
NOTNFa
NOTNFa
Myelin damageMyelin
damage
Myelin damage
IL10
CD8 Cytotoxicity
HMyelin
Antibodiescomplement
Tregs
F
APC
Th2/Th3
VCAMICAMVCAMICAMVCAMICAMVCAMICAMVCAMICAMVCAMICAM
Microglial cells
Secondary activation
G
F
CB
DE
A
(-)
CN
SP
IS
Fig. 1 A model of multiple sclerosis (MS) immunopathogenesis; target
sites for immunotherapy. Levels of the immunopathogenetic mecha-
nisms of MS, which may represent targets for immune intervention:
Level A antigen presentation to lymphocytes and early lymphocyte
activation; Level B activation and proliferation/expansion of the
autoimmune, myelin reactive Th1 and Th17 lymphocytes; Level Cimmune regulation by regulatory cells (Tregs) or immunological (Th1 to
Th2) shift; Level D expansion of B cells and anti-myelin antibodies
production (humoral immunity); Level G production of proinflammatory
cytokines and mediators of tissue damage (such as TNFs and NO); LevelF migration or homing of the lymphocytes and entrance through the
BBB; Level H oligodendrocyte damage. APC antigen presenting cell,
BAFF B-cell activating factor, BBB blood brain barrier, CNS central
nervous system, FOXP3 forkhead box P3, ICAM intercellular adhesion
molecule, MMPs metaloproteinases, NO nitric oxide, Oligo oligoden-
drocytes, PIS peripheral immune system, TCR T-cell receptor, TNFatumor necrosis factor alpha, VLA4 very late antigen-4 (adhesion
molecule), VCAM vascular cell adhesion protein
β
Increasing intensity and target focusing
Eff
icac
y Safety
Fig. 2 Increasing intensity and target-focusing of new immunotherapies
is associated with more efficacy but also with more safety issues. GAglatiramer acetate, IFNb interferon beta, mAbs monoclonal antibodies
Immunotherapy of MS
use of neuroimaging (MRI) techniques that allow the
detection of silent inflammatory activity of MS and neu-
rodegeneration has provided an important tool for the
substantiation of the clinical efficacy of treatments and the
early diagnosis of MS. The introduction of new diagnostic
criteria [35] for clinically definite MS (CDMS) does not
necessitate—as in the past years—the occurrence of a
second clinical relapse, but only the dissemination in time
and space, reflected by MRI dynamic changes. This has
paved the path to the concept of early immunotherapy in
selected patients experiencing the first demyelinating epi-
sode, which is defined as clinically isolated syndrome
(CIS), or even (theoretically) in individuals with a sole
neuroradiological evidence of demyelination (radiologi-
cally isolated syndrome: RIS). However, the prognosis of
MS is highly variable and therefore additional clinical,
radiological and immunological surrogate biomarkers
should be used to define those cases with a bad prognosis in
which early immunotherapy at the stage of CIS or RIS may
be justified.
The immunotherapeutic modalities can be divided into
two main groups: those affecting the acute stages (relapses)
of the disease and the long-term treatments that aim at
preventing the appearance of relapses and the progression
in disability. Immunomodulating treatments may also be
classified according to the level of the ‘immune axis’ where
they exert their main effect (Fig. 1; Tables 1, 2).
Based on their molecular construction and their basic
mechanism of action, immunotherapeutic agents may be
also classified as: (i) cytotoxic drugs; (ii) synthetic
Table 1 Description of the mechanisms of action of immunotherapeutic agents in MS and their class evidence of efficacy
Immuno-
therapeutic agents
Basic mechanism of action Class evidence of
efficacy in MS
Corticosteroids • Induction of lipocortin-1 (annexin-1) synthesis, with resulting diminished eicosanoid
production
Class I–II (in attacks
of MS)
• Suppression of cyclooxygenase (COX-1 and COX-2) expression
• Inhibition of genes affecting production of cytokines IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-8,
IFNc, TNFa, resulting in T-cell inhibition
Class II–III (as long-
term treatment)
• Downregulation of antibody production
• Downregulation of adhesion molecules expression
• Reduction of BBB permeability
IFNb • Reduction of T-cell activation and proliferation Class I in RRMS
• Downregulation of antigen presentation (reduction of MHC/HLA expression and blocking of
co-stimulatory signals from APCs
• Upregulation of CCR7, TGFb and IL-10 and enhancement of regulatory cell function Class I–II in SPMS with
relapses
• Induction of cytokine shift in favor of anti-inflammatory profile (Th1 to Th2 shift) Class II–III in other
SPMS
• Prevention of T-cell adhesion and extravasation across BBB (increased sVCAM and reduced
metalloproteinase-MMP9 production)
• Induction of Tregs None in PPMS
• Activation of B cells
• Neuroprotection
GA • Blockage of lymphocyte sensitization to MBP Class I in RRMS
• Downregulation of antigen presentation (competitive inhibition for binding with MHC/HLA)
• Induction of a Th2 shift None in SPMS or PPMS
• Induction of bystander suppression
• Induction of regulatory and CD8 suppressor GA-reactive cells
• Induction of a shift towards an M2 type of APCs
• Neuroprotective effects
Fingolimod • Action as a super agonist of the S1P1 receptor on lymphocytes, inducing its uncoupling/
internalization and intracellular lysosomal degradation, depriving CD4? and CD8? positive T
cells and B cells of the obligatory signal to egress from lymphoid organs and recirculate to
peripheral inflammatory tissues
Class I in RRMS
PLEX • Mechanical clearance of circulating antibodies Class II-III in relapses of
MS and NMO
D. Karussis
Table 1 continued
Immuno-
therapeutic agents
Basic mechanism of action Class evidence of
efficacy in MS
IVIG • Formation of immune complexes and blockage of circulating antibodies Class I in RRMS
• Interaction with Fc receptors on dendritic cells, which then mediate anti-inflammatory effects
• Activation of complement No evidence in
progressive MS
• Blockage of macrophages
• Direct suppression of T and B cells
Natalizumab • A humanized monoclonal antibody against cellular adhesion molecule a4-integrin, which is
crucial for lymphocyte migration to target organs
Class I in RRMS
• Prevents all activated lymphocytes from entering CNS through the BBB
Rituximab • Genetically engineered chimeric murine/human IgG1 monoclonal antibody that targets the
CD20 antigen, expressed only on pre-B and mature B cells
Class II in RRMS
• Rituximab lyses B cells via complement and antibody-dependent cellular cytotoxicity
Alemtuzumab • A recombinant humanized monoclonal antibody directed against cell surface glycoprotein
CD52
Class I in RRMS
• Depletion (antibody-dependent lysis) of all B and T cells
• Reduction of the number of monocytes, macrophages, NK cells, and part of granulocytes
Daclizumab • A humanized mAb that blocks IL-2 receptor alpha subunit (CD25) expressed on activated T
cells
Class II in RRMS
• Inhibition of T-cell expansion
• Expansion of CD56 NK cells which, in turn, inhibit T-cell survival
Cyclo-
phosphamide
• A nitrogen mustard alkylating agent from the oxazophorine group with broad cytotoxic and
immunosuppressive effects; its main metabolite phosphoramide mustard is only formed in
cells with low ALDH levels
Class II–III in
progressive cases
• Formation of DNA crosslinks at guanine positions, leading to cell death
• Suppression mostly of B cells
• Suppression of T cells and IFNc and IL-12 cytokine production
• Increase in IL-4 and IL-10 production and induction of a Th2 shift
Azathioprine • Inhibition of the first step in de novo purine biosynthesis, with resulting prevention of mitosis
and proliferation of fast dividing cells (especially lymphocytes), leading to decreased T-cell
number and reduced antibody synthesis
Class II in RRMS and
SPMS
Mitoxanthrone • A cytotoxic agent from the anthracenedione family; acts by intercalating with DNA and
inhibiting topoisomerase II
Class I in RRMS
• Reduction of the number of B cells
• Inhibition of the T helper cells and the Th1-related cytokine production
• Augmentation of T-cell suppressor activity
Methotrexate • A folate antagonist; diminishes proliferation of immune cells by inhibiting de novo purine and
pyrimidine synthesis
Class II–III in RRMS
• Decrease of neutrophil leukotriene synthesis the adenosine-mediated inflammation
• Inhibits AICAR transformylase, resulting in intracellular accumulation of AICAR, which
promotes release of the anti-inflammatory autocoid adenosine
• Suppression of antigen-dependent T-cell proliferation
Mycophenolate • Inhibition of purine synthesis and non-competitive inhibition of type II isomer of inosine
monophosphate dehydrogenase
Class III
• Depletion of guanosine and deoxyguanosine nucleotides in T and B lymphocytes, therefore
inhibiting their proliferation and immunoglobin production
• Suppression of dendritic cells maturation decreasing their capacity of antigen presentation to T
lymphocytes
Cyclosporine A • A calcineurin inhibitor that acts on IL-2 by inhibiting its production, leading to decreased
T-lymphocyte proliferation
Class III
Immunotherapy of MS
immunomodulators; (iii) monoclonal antibodies; (iv)
vaccines (T-cell vaccines, antigen vaccines); (v) oral tolerizing
agents; (vi) modalities that act as indirect immunosuppressants
(plasmapheresis, intravenous immunoglobulins: IVIG); and
(vii) cellular therapies (stem cells, progenitors).
2.1 Treatment of Acute Deterioration/Relapses of MS
2.1.1 Corticosteroids
The most widely used treatment, especially during an acute
MS relapse, is methylprednisolone or other corticosteroid
preparations.
In high, supraphysiologic doses, glucocorticoids
strongly downregulate inflammation. They suppress cellu-
lar immunity by inhibiting genes that affect the production
of the cytokines IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-8,
and TNFc and by reducing the proliferative ability of T
cells [36–40]. Glucocorticoids also suppress humoral
immunity, causing B cells to express smaller amounts of
IL-2 and IL-2 receptors, thus diminishing their expansion
and antibody production.
Glucocorticoids downregulate all types of inflammatory
events by inducing the synthesis of lipocortin-1 (annexin-
1), which then binds to cell membranes preventing the
phospholipase A2 from coming into contact with its sub-
strate, arachidonic acid. This leads to diminished eicosa-
noid production. Cyclooxygenase (both COX-1 and COX-
2) expression is also suppressed, potentiating the effect.
Steroids reduce the permeability of the blood-brain barrier
[38, 41, 42] as reflected by the reduction in gadolinium
diethylenetriaminepentaacetic acid (Gd-DTPA) enhance-
ment in the MRI.
Results from the National Cooperative ACTH study
revealed that corticotropin (ACTH) may hasten recovery at
1 month after treatment [36]. Other studies have shown
comparable or superior results with methylprednisolone
[37, 43, 44]. Data from the Optic Neuritis Treatment Trial
showed that intravenous methylprednisolone is superior to
oral prednisone for the treatment of acute optic neuritis [39,
45]. However, the long term effect of both treatment reg-
imens on the visual acuity was marginal and there was no
significant ‘protection’ against later development of defi-
nite MS [39, 45]. A review of the trials with either intra-
venous methylprednisolone or ACTH showed the clear
benefit of steroids in MS exacerbations [46].
In patients with chronic progressive MS, repeated
intravenous infusions of methylprednisolone showed a
milder effect and failed to inhibit disease progression [47].
However, two more recent studies have shown a short-term
Table 1 continued
Immuno-
therapeutic agents
Basic mechanism of action Class evidence of
efficacy in MS
Cladribine • A synthetic purine nucleoside that acts as anti-metabolite, interfering with DNA synthesis and
repair and with immunosuppressive effects (mainly causing lymphocyte depletion)
Class I in RRMS
• Suppression mainly of the CD4? and CD8? T cells and B cells Class II in SPMS
• Prevention of lymphocyte migration through BBB
Dimethyl
fumarate
(BG12)
• Induction of anti-inflammatory effects Class I in RRMS
• Suppression of macrophages
• Activation of nuclear factor erythroid 2-related factor 2 (Nrf2) pathway, the innate cellular
phase 2 detoxifying pathway-anti oxidant
• Th1 to Th2 shift
• Neuroprotection
Laquinimod • A synthetic immunomodulator Class I–II in RRMS
• Downregulation of antigen presentation
• Induction of a shift towards Th2
• Neuroprotective effects
Teriflunomide • An active metabolite of leflunomide Class I in RRMS
• Inhibition of dihydroorotate dehydrogenase, a key mitochondrial enzyme involved in new
pyrimidine synthesis for DNA replication
• Reduction of T- and B-cell activation and proliferation
AICAR 5-Aminoimidazole-4-carboxamide 1-b-D-ribofuranoside, ALDH aldehyde dehydrogenase, APCs antigen presenting cells, BBB blood–
brain barrier, GA glatiramer acetate, IFN interferon, IgG immunoglobulin gamma, IL interleukin, mAb monoclonal antibody, IVIG intravenous
immunoglobulins, MBP myelin basic protein, MMP matrix metalloproteinase, MS multiple sclerosis, NK natural killer, NMO neuromyelitis
optica, PLEX plasmapheresis, PPMS primary progressive MS, RRMS relapsing-remitting MS, SPMS secondary progressive MS, sVCAMvascular cell adhesion molecule, TGFb transforming growth factor beta, TNFa tumor necrosis factor alpha, Tregs regulatory T cells
D. Karussis
improvement following high dose intravenous methylpred-
nisolone [48] or a long-term beneficial effect by 4-monthly
intravenous methylprednisolone boosts which slowed the
development of T1 black holes and delayed whole-brain
atrophy and disability progression [49].
Despite these data and the documented transient beneficial
effect during the acute MS relapse, steroids do not seem to
significantly alter the natural course of the disease. Therefore,
their chronic use does not seem justified. In addition, chronic
steroid administration is associated with several adverse
effects, including osteoporosis, aseptic bone necrosis, hyper-
tension, hyperglycemia, cataracts, and psychotic events.
Despite wide agreement on the efficacy of steroidal
treatment in MS relapses, the optimal protocol for
Table 2 Mechanisms of action of immunotherapeutic agents in multiple sclerosis (MS)
Suppression of T
lymphocytes
Suppression
of antigen
presentation
Suppression of
B lymphocytes
and humoral
immunity
Suppression or
shift of
cytokines and
chemokines
Inhibition of
lymphocyte migration/
blockage of blood
brain barrier (BBB)
Induction
of immune
shift (Th1
to Th2)
Enhancement
of regulatory
cells
Levels of action
on the immune
cascade described
in Fig. 1
Corticosteroids ?? ?? ??? ?? ?? ? ? A, B, E, F, G
Interferon b (IFNb) ??? ?? - (probable
enhancement)
?? ? ??? ?? A, B, C, F, G
Glatiramer acetate
(GA)
?? ??? ?/- ? - ??? ? A, C, D, G
Fingolimod ??? (blockage
of their
eggerssion from
the lymph
nodes )
- ?? unknown ??? ? unknown B, D, E
Plasmapheresis - - ??? ?? - - - E
Intravenous
immunoglobulins
(IVIG)
? ? ??? ? - ? ?/- A, E
Natalizumab ?? (blockage of
their homing to
target organs)
- ?? (blockage
of their
homing to
target organs)
- ??? - - D, E, F
Rituximab - - ??? ? ? - - A, E
Alemtuzumab ??? - - ? ? ?/- - B, C, D, E, G
Daclizumab ??? - - ?? ? ? (from T
cells to
NK)
?? B, C, D
Cyclophosphamide ?? ? ??? ??? ? ?? ?? A, B, C, D, E
Azathioprine ?? ? ??? ?? ? ? ? A, B, C, D, E
Mitoxanthrone ??? ? ??? ?? - ? ?/- B, C, D, E
Methotrexate ?? ? ?? ? - - unknown A, B, C, D, E
Mycophenolate
(MMF)
??? ?? ??? ?/- - ?/- - B, C, D, E
Cyclosporine A
(CsA)
??? - ? ??? - - - (possible
suppression)
B, C, G
Cladribine ??? - ?? ? ?? - - B, C, D, E
Dimethyl fumarate
(BG12)
?? ?? ? ?? unknown ?? unknown A, B, G
Laquinimod ?? ??? ? (modulation) ?? ?? ?? ?? A, B, C, D, E
Teriflunomide ??? ??? ?? ?? unknown ?? ? B, C, D, E
Tarcolimus/
Sirolimus
??? - ? ??? ?/- unknown - B, D, E, G
?, mild effect; ??,moderate effect; ???, strong effect; ?/-, questionable effect
Level A Antigen presentation to lymphocytes and early lymphocyte activation: glatiramer acetate (GA), interferon b (IFNb), vaccines, laquinimod, steroids, rituximab. Levels Band D Activation and proliferation/expansion of the autoimmune, myelin reactive lymphocytes: chemotherapeutic/cytotoxic agents (azathiorpine, cyclophosphamide, meth-
otrexate, cyclosporine, mycophenolate, cladribine, mitoxanthrone, tarcolimus, teriflunomide); immunoablation and reseting of the immune system by hematopoietic stem cell
transplantation; lymphocyte depletion with monoclonal antibodies (alemtuzumab, rituximab, daclizumab); specific reduction of autoimmune myelin-responsive lymphocytes
with vaccination techniques (i.e., T-cell vaccination, myelin peptides vaccination). Levels C and D Regulatory cells or immunological shift: IFNb, GA, laquinimod, fingolimod,
alemtuzumab, teriflunomide, cyclophosphamide. Level E B cells and antibodies/humoral immunity: plasmapheresis, IVIG, anti-CD20 monoclonal antibodies, steroids,
cytotoxic drugs (azathiorpine, mycophenolate, cyclopshosphamide), alemtuzumab. Levels B and G Cytokine production: various immunosuppressants, corticosteroids, IFNb,
GA, fingolimod, teriflunomide, cyclosporine-A, laquinimod, cyclophosphamide, azathioprine, alemtuzumab. Level F Migration or homing of the lymphocytes and entrance
through the blood brain barrier: fingolimod, natalizumab, corticosteroids. Level H Oligodendrocyte damage and axonal/neuronal loss: neuroprotective modalities, stem cells,
dimethyl fumarate (BG12) and possibly (but largely unknown) many immunomodulating drugs (such as interferons, GA, laquinimod, fingolimod, natalizumab)
Immunotherapy of MS
administration of the drug is still not settled. Current pro-
tocols (mostly empirical) include 3, 5, or even 10 days of
1–2 g intravenous methylprednisolone with or without oral
tapering with prednisone. Oral administration of high dose
methylprednisolone appears to be equally efficient to
intravenous administration [50–52]. There are indications,
not based on published studies in MS but on experience in
other autoimmune diseases (such as systemic lupus ery-
thematosus: SLE), that abrupt discontinuation of intrave-
nous steroidal treatment in MS relapses may increase the
risk of a recurrence of the symptoms. Therefore, a tapering-
off protocol following high-dose intravenous methylpred-
nisolone appears preferable.
2.1.2 Plasmapheresis
Plasmapheresis, also known as therapeutic plasma
exchange (PLEX), is a procedure that separates the blood
components, exchanging the plasma (typically with donor
plasma or albumin), and returning the other components,
primarily red blood cells, to the patient. PLEX has been
proven to be effective in various autoimmune diseases,
including neurological ones, such as Gulliain–Barre syn-
drome, idiopathic thrombocytopenic purpura and myas-
thenia gravis [53–55].
Since the late 1980s, PLEX has been tried in several
studies on MS patients, but with inconsistent effects. This
may be related to (a) the small size of the studies, (b) the
lack of homogeneity in the treatment porotocols, (c) the use
of PLEX as an adjuvant therapy to other immunomodula-
tory modalities, and (d) the patient populations and type/
course of MS, which greatly varied among these studies
[56–59].
In a more recent and randomized trial, which repre-
sented the revival of PLEX as a treatment modality for MS,
PLEX (7 courses within 14 days) was for the first time
checked as a single modality in patients with various types
of acute CNS demyelinating diseases (including acute
disseminated encephalomyelitis and neuromyelitic types of
MS [NMO spectrum of disorders], either chronic or
relapsing) [31]. Clinical improvement was noted in 8 of the
19 (42.1 %) PLEX-treated patients compared with 1 of 17
(5.9 %) in the sham group. When the patients were swit-
ched from PLEX to sham and from sham to PLEX, the
clinical beneficial effects of PLEX noted in the first part of
the trial were strengthened in favor of PLEX.
A follow-up study by Keegan et al. [60] suggested that
patients with myelitis and Pattern II immunopathogenesis
(according to Lucchinetti et al. [12], a predominantly
antibody-mediated disease) had the best response to PLEX.
A recent retrospective analysis of 153 patients treated with
PLEX for a steroid-refractory CNS demyelinating episode,
showed that 59 % exhibited moderate to marked functional
neurological improvement within 6 months following
treatment. Plasma exchange was less effective for patients
with MS who subsequently developed a progressive dis-
ease course. Radiographic features associated with a ben-
eficial PLEX response were the presence of ring-enhancing
lesions and/or mass effect [61].
Logically, since NMO corresponds to the type II histo-
pathological phenotype of MS lesions, NMO patients are
expected to have an optimal response to PLEX. Indeed two
small open studies and a restrospective one in NMO
patients during an acute attack of the disease showed an
early and significant improvement following PLEX in most
of the treated patients [62–64].
In purely progressive MS, a study of combination
treatment with azathioprine and PLEX in eight patients
with SPMS led to the conclusion that PLEX did not
improve clinical outcomes [65], nor was there any signif-
icant difference in the number of MRI-enhancing lesions.
However, the total MS lesion load in MRI was significantly
lower and central motor conduction times decreased sig-
nificantly during PLEX treatment.
Recently, an American Academy of Neurology task
committee, upon evaluating the neurological indications of
PLEX, gave a level B recommendation for its use as sec-
ond-line treatment of steroid-resistant exacerbations in
relapsing forms of MS and of NMO [66].
2.2 Preventive Long-Term Immunotherapy of MS
2.2.1 The First Generation: The ‘Old Players’
2.2.1.1 Corticosteroids and Plasmapheresis Corticoste-
roids and PLEX are usually applied for the management of
acute exacerbations or deterioration phases of MS. How-
ever, as described above, these modalities may also be used
as chronic treatments in selected cases, usually in combi-
nation with other immunotherapeutic drugs.
2.2.1.2 Interferon Beta (IFN-b)
2.2.1.2.1 IFN-b in Relapsing MS. The type-I interferons
(IFNa and IFNb) were first used in the 1970s on the
grounds of their antiviral activity, which could possibly
help in the elimination of the putative viral agents involved
in MS pathogenesis. However, an initial trial with IFNc(type II) showed that the treatment actually promoted
relapses of MS [67]. IFNb, on the other hand, (initially
administered intrathecally) induced beneficial effects in
patients with MS [68]. Then IFNa was given subcutane-
ously in 12 MS patients and induced some positive clinical
effects [69].
In parallel, IFNb was shown to suppress experimental
autoimmune encephalomyelitis (EAE), the animal model
D. Karussis
of MS [70, 71], to inhibit T-cell activation [72], enhance
suppressor cell activity [73], reduce IFNc production and
MHC-II expression [74], increase IL-10 production [75],
downregulate antigen presentation, induce a Th1 to Th2 shift,
and reduce the permeability of the blood-brain barrier [76].
In the two large, pivotal, double-blind studies performed
in the US (which paved the way to a new era in MS
management and introduced a new generation of immu-
nomodulatory medications for MS) in patients with RRMS,
IFNb was found to significantly inhibit the activity of the
disease.
In the first trial, recombinant IFNb-1b (Betaferon�,
Schering/Bayer), given subcutaneously every other day,
was reported to reduce the relapse rate by 31 % (0.84/year
in the treated group vs 1.27/year in the placebo group),
especially at the high dose of 8 million IU, but without
significantly affecting the disability status [77]. IFNb-
treated patients had a significantly lower MRI T2 burden of
disease and a 75–80 % reduction in active scans [78]. This
effect was long-lasting even after 3–5 years of treatment
[79]. The treatment was generally well tolerated with the
exception of ‘flu-like’ symptoms (fever, chills, myalgias,
and fatigue) that occurred in the majority (76 %) of
patients, but tended to decrease after the first months of
treatment. Injection-site irritation was also very common.
About a third of the patients developed neutralizing anti-
bodies against IFNb, and this may be a limiting factor in
long-term treatment.
In a second study, recombinant glycosylated IFNb-1a
(Avonex�, Biogen), at a dose of 6 MIU intramuscularly
once per week, induced a reduction in relapse rate from
0.90/year (placebo) to 0.61/year. The treatment also
resulted in a decrease in the number and volume of Gd-
DTPA-enhancing lesions in the MRI and, most impor-
tantly, delayed the sustained progression of disability and
reduced the 1- and 2-year progression rates by about 40 %
[80].
A third type of recombinant IFNb (Rebif�, Merk-Ser-
ono) almost identical to Avonex�, was introduced later.
The first study with IFNb-1a given once weekly [81] pro-
vided evidence of IFNb-1a dose response in relapsing-
remitting MS, as reflected by the MRI outcomes. The
subsequent phase III trial, PRISMS [see Table 3 for full
trial names], with two doses of Rebif� (6 or 12 million IU
subcutaneously every other day), showed significant ben-
eficial effects in all the clinical and MRI parameters tested
in relapsing-remitting MS patients [82]. Clinical data on
533 patients revealed a significantly lower relapse rate in
the Rebif�-treated patients (risk reduction 27–33 % for
Rebif� 22 lg and 44 lg three times a week, respectively),
accompanied by a delay in the progression of disability.
The MRI analysis of the PRISMS study showed robust
effects in all MRI parameters [83]. Over the 2 years, the
placebo group had a median increase in disease burden of
10.9 %, whereas the 22 lg group and 44 lg group showed
median decreases of 1.2 % and 3.8 %, respectively. In the
subgroup undergoing initial monthly scanning, this reduc-
tion in activity became statistically significant 2 months
after the onset of treatment.
The original studies with IFNb were of 2 years duration.
The long-term effects of IFNb were evaluated in follow-up
open studies arising from the original pivotal ones. The
long-term data, although biased due to the fact that patients
continuing treatment and followed up are those who
responded to the treatment, show that in a great proportion,
the beneficial clinical effects were sustained for several
years [84]. In the PRISMS follow-up trial, patients origi-
nally assigned to Rebif� 44 lg subcutaneously three times
weekly showed lower Kurtzke Expanded Disability Status
Scale (EDSS) progression, relapse rate and T2 burden of
disease for up to 8 years compared with those in the late
treatment group [85]. In the longest follow-up study with
IFNb, early treatment with IFNb-1b (Betaferon�) proved,
in addition to the sustained clinical effect, to significantly
reduce the MS-related mortality rate [86].
2.2.1.2.2 Early Treatment with IFN-b in Clinically Iso-
lated Syndrome (CIS). It is only logical to assume that
IFNb may also delay the conversion to multiple sclerosis—
defined either by a second clinical episode or the accu-
mulation of new MRI lesions—in patients with CIS.
Clinical trials (CHAMPS, ETOMS, and BENEFIT) with
IFNb performed in such patients showed a reduction in the
conversion rate to CDMS over 2–3 years, from 45–50 % in
the placebo group to 28–35 % in the IFNb-treated patients
[87–89].
In an extension of the CHAMPS study, no gain in terms
of disability with Avonex� treatment could be detected at
5 years. However, this 5-year follow up showed that
patients who were assigned to the immediate/early IFN1a
treatment group had a significantly reduced risk of devel-
oping CDMS, that is, of developing a second demyelinat-
ing episode [90].
Similarly, the BENEFIT trial, the largest and perhaps
the best of the three IFN studies [89], showed a moderate
but significant effect of IFN on the accumulation of dis-
ability over 3 years favoring early initiation of treatment
[91].
The 5-year follow up of the same (BENEFIT) trial
showed a robust long-standing effect on the prevention of
CDMS. Early treatment with Betaferon� reduced the risk
of CDMS by 37 % compared with delayed treatment [92].
In a more recent study (REFLEX) [93], 517 patients
with CIS were randomly assigned to either subcutaneous
IFNb-1a (Rebif�) three times weekly, to subcutaneous
IFNb-1a (Rebif�) once weekly, or to placebo). The 2-year
Immunotherapy of MS
cumulative probability of McDonald MS was significantly
lower in both groups of patients treated with subcutaneous
IFNb-1a, with a clearly stronger beneficial effect of the
higher frequency regimen (62.5 %, vs 75.5 % and vs
85.8 %). 2-year rates of conversion to CDMS were lower
and similar for both IFNb-1a dosing regimens.
In all the previously mentioned trials, the most signifi-
cant effects of IFN were on the relapse rate (an approxi-
mately 30 % reduction) and on the MRI activity. The
effects on disability were less pronounced. Moreover, these
pivotal studies were fairly small (involving only a few
hundred patients) and of short duration (2–3 years). A
systematic review of the efficacy of IFNs in MS concluded
that there is evidence only for RRMS and this mainly in
terms of a reduction in relapse frequency during the first
(and less in the second) year of treatment, with no con-
vincing efficacy thereafter and no effect on the accumu-
lation of disability [94]. This surprising conclusion may be
related to the variability in the efficacy among the IFN-
treated patients, possibly caused by the pathological het-
erogeneity of MS (at least four distinct types have been
recognized) [12] and to the high numbers of drop-outs.
2.2.1.2.3 IFNb in Progressive MS. The European Study
Group showed that Betaferon� significantly increased (by
9–12 months) the time to confirmed disease progression
and to becoming wheelchair-bound compared with placebo
in patients with SPMS. Relapse rate and severity were also
lower in the Betaferon� group. This beneficial effect was
seen in patients with superimposed relapses and in patients
who had only progressive deterioration without relapses
[95].
As for MRI activity, the difference in total lesion vol-
ume between treatment groups was highly significant in
both trials. In the placebo group, there was an increase of
15 % from baseline to last scan, whereas in the IFN group,
Table 3 Trial names and acronyms
Acronym Trial name
ALLEGRO Safety and Efficacy of Orally Administered Laquinimod Versus Placebo for Treatment of Relapsing Remitting Multiple
Sclerosis (RRMS)
BECOME Betaseron vs Copaxone in MS with Triple-Dose Gadolinium and 3-T MRI Endpoints
BENEFIT Betaferon� in Newly Emerging Multiple Sclerosis for Initial Treatment
BEYOND Betaferon/Betaseron Efficacy Yielding Outcomes of a New Dose in Multiple Sclerosis
BRAVO Laquinimod Double-Blind Placebo-Controlled Study in RRMS Patients with a Rater Blinded Reference Arm of Interferon b-
1a (Avonex�)
CARE-MS Comparison of Alemtuzumab and Rebif� Efficacy in Multiple Sclerosis
CHAMPS Controlled High Risk Avonex� Multiple Sclerosis
CLARITY Cladribine Tablets Treating MS Orally
DEFINE Determination of the Efficacy and Safety of Oral Fumarate in Relapsing-Remitting MS
ETOMS Early Treatment of Multiple Sclerosis
EVIDENCE Evidence of Interferon Dose–Response-European North American Comparative Efficacy
FREEDOMS Efficacy and Safety of Fingolimod in Patients with Relapsing-Remitting Multiple Sclerosis
GLANCE Glatiramer Acetate and Natalizumab Combination Evaluation
HERMES Helping to Evaluate Rituxan in Relapsing–Remitting Multiple Sclerosis
IMPACT International Multiple Sclerosis Secondary Progressive Avonex� Clinical Trial
INCOMIN Independent Comparison of Interferon
MECOMBIN Methylprednisolone in Combination with Interferon beta-1a for Relapsing–Remitting Multiple Sclerosis
NORMIMS Nordic Trial of Oral Methylprednisolone as Add-On Therapy to Interferon beta-1a for Treatment of Relapsing–Remitting
Multiple Sclerosis
PRISMS Prevention of Relapses and Disability by Interferon beta-1a Subcutaneously in Multiple Sclerosis
REFLEX Rebif� Flexible Dosing in Early MS
REGARD Rebif� vs Glatiramer Acetate in Relapsing MS Disease
SENTINEL Safety and Efficacy of Natalizumab in Combination with Interferon beta-1a
SPECTRIMS Secondary Progressive Efficacy Clinical Trial of Recombinant Interferon-Beta-1a in MS
TEMSO Teriflunomide Multiple Sclerosis Oral
TENERE A Study Comparing the Effectiveness and Safety of Teriflunomide and Interferon Beta-1a in Patients With Relapsing Multiple
Sclerosis
TRANSFORMS Efficacy and Safety of Fingolimod in Patients With Relapsing-Remitting Multiple Sclerosis With Optional Extension Phase
D. Karussis
a reduction of 2 % was seen. In the frequent MRI sub-
group, treatment was associated with a significant 65 %
reduction in new lesion activity between months 1 and 6,
and a 78 % reduction from months 19 to 24 [96].
On the other hand, the North American trial on SPMS
failed to show any beneficial effect of Betaferon� on dis-
ease activity [97]. Although there was no significant dif-
ference in time to confirmed progression in EDSS compared
with the placebo group, there was improvement in sec-
ondary outcome measures including the number of super-
imposed clinical relapses and various MRI-activity criteria.
The differences found between the outcomes of these
two studies remain puzzling [98]. They might be related to
the different populations of MS patients included in these
two trials; the positive European study including more
patients with superimposed relapses than the American
trial, possibly indicating that IFNb is mainly effective in
the inflammatory active patients. This possibility is further
strengthened by the positive MRI results in both studies,
indicating that IFNb has an important beneficial impact
mainly on the inflammatory process in MS.
In another trial (SPECTRIMS) testing IFNb-1a in
SPMS, a total of 618 patients received subcutaneous Re-
bif�, 22 or 44 lg or placebo, three times weekly for
3 years. Treatment with IFNb-1a did not significantly
affect disability progression in this cohort, although sig-
nificant treatment benefit was observed on exacerbation-
related outcomes [99] and MRI activity [99]. The effect on
MRI parameters was more prominent in patients who had
at least one relapse in the 2 years prior to inclusion, again
indicating that the effects of IFN are mainly exerted on the
inflammatory components of the disease.
Finally, in a study with the third type of commercial
interferon (IMPACT) in 436 patients with SPMS [100],
although no differences in EDSS were detected, there were
significant beneficial effects on the Multiple Sclerosis
Functional Composite (MSFC) scale and on the relapse-
related parameters.
In PPMS there are only two randomized control trials
involving a total of 123 patients. IFNb treatment compared
with placebo did not show differences regarding the pro-
portion of patients with disease progression. However, the
total tested population was too small to allow definitive
conclusions to be drawn on the efficacy of the treatment in
PPMS patients [101].
In the first trial, 50 subjects with PPMS were random-
ized to weekly treatment with intramuscular Avonex� at
30 lg, 60 lg, or placebo for 2 years [102]. No effect was
seen on the primary endpoint (time to sustained progres-
sion in disability). Subjects on 30 lg Avonex� had a lower
rate of accumulation of T2 lesion load than the controls;
patients on 60 lg had a greater rate of ventricular
enlargement than the controls.
In the second double-blind study, involving IFNb-1b
(Betaferon�), 73 patients with primary progressive or
transitional MS were included [103]. Statistically signifi-
cant differences favoring treatment were observed for the
Multiple Sclerosis Functional Composite score and for
several secondary MRI parameters. Modest but beneficial
effects of IFNb-1b on clinical variables and brain atrophy
were observed 5 years after termination of this trial [104].
2.2.1.2.4 Comparative Efficacy of IFNs (Different Doses
of IFNb). Few studies have compared the efficacy of the
registered IFNs and investigated the optimal dosing of IFN.
The EVIDENCE trial [110], reported greater efficacy with
high-dose subcutaneous Rebif� (IFNb-1a) administration
three times weekly than with low-dose Avonex� (IFNb-1a)
once weekly, but the trial lasted only 24 weeks. 74.9 % of
patients receiving the high dose IFNb remained relapse
free compared with 63.3 % of those given the lower dose.
In addition, patients receiving Rebif� 44 lg three times
weekly had fewer active MRI lesions compared with those
receiving Avonex� once weekly. Injection-site reactions
were more frequent with Rebif� 44 lg three times weekly
(83 % vs 28 %), as were asymptomatic abnormalities of
liver enzymes. NAbs developed in 25 % of the Rebif�
44 lg three times weekly treated patients and in 2 % of
patients receiving Avonex� [110]. During the crossover
phase of the trial [111], a 50 % reduction in mean relapse
rates was observed in patients who switched from low-dose
once weekly IFNa to high-dose treatment, with significant
concomitant reductions in MRI activity.
Similarly, the 2-year INCOMIN trial [112] showed
greater efficacy with Betaferon� (IFNb-1b) given on
alternate days than with Avonex� given once weekly, in
terms of the percentage of relapse-free and progression-
free patients and the proportion of patients without new
MRI-documented lesions. The superiority of higher dose/
frequency of IFNb-1a (Rebif�) was also evidenced in the
REFLEX study [93], in patients with CIS.
On the other hand, the BECOME trial [113], showed no
significant differences between Betaferon� and subcuta-
neous Avonex� once weekly (Danish MS Group trial), in
all of the outcomes [114]. The practical relevance of these
findings is questionable, as there is no commercially
available IFN type given once a week subcutaneously.
[115, 116]
2.2.1.3 Glatiramer Acetate (GA)/Copaxone
2.2.1.3.1 GA in Relapsing-Remitting MS. GA (COP-1,
Copaxone�, Teva, Israel) is a synthetic co-polymer, com-
posed of alanine, glutamine, lysine and tyrosine, with some
immunologic similarities to the myelin basic protein
(MBP) molecule (as well as to other myelin antigens),
Immunotherapy of MS
without itself being encephalitogenic. COP-1 inhibited
EAE [117] and is presumed to block the MHC/TCR
complex and to downregulate the presentation of antigens
such as MBP, proteolipid protein (PLP) and myelin/oli-
godendrocyte glycoprotein (MOG), to T cells (competitive
inhibition) and/or induce regulatory cells. In a pilot con-
trolled study [118] in 50 patients with RRMS an impressive
reduction in the number of relapses in the GA-treated
group (annual relapse rate [ARR] 0.3 in the COP-1 group
vs 1.35 in the placebo group) was observed. A later and
larger pivotal, double-blind, 2-year trial involving 251
patients [119] showed that daily treatment with subcuta-
neous injections of GA induced a 29 % reduction in relapse
rate. The proportion of patients free of relapse or pro-
gression of disability at 2 years was no different between
the two groups, nor was the time to first relapse. MRI
monitoring was performed in one of the centers and
showed only marginal (and not statistically significant)
inhibition of the ‘MRI activity’ in the GA- treated patients.
Adverse effects were usually mild, including mainly
localized, injection-site reactions (at least once in 90 % of
the patients) and a systemic reaction occurring within
moments of GA administration (associated with chest pain,
palpitations or dyspnea lasting up to 30 min) in 15 % of the
patients.
The effect of GA on disease activity monitored with
MRI was evaluated in a separate randomized study that
included 239 patients. Treatment with GA led to a signif-
icant reduction in the total number of enhancing lesions
compared with placebo (-10.8 %) [120].
The efficacy of an oral preparation of GA (two doses)
was evaluated in a large trial including 1,651 RRMS
patients. The cumulative number of confirmed relapses did
not differ between the two active treatment groups and the
placebo group. No drug effect was detected for any of the
secondary and tertiary endpoints [121].
In a recent study [122], two doses of subcutaneously
administered GA (the regular dose of 20 mg and a higher
one of 40 mg per day) were compared in 569 patients. No
significant differences were observed in any of the clinical,
MRI, and safety parameters.
In long-term follow-up studies, in patients with RRMS
treated for up to 22 years with GA, 57 % maintained
improved or unchanged EDSS scores and the annualized
relapse rates remained low, indicating a long-term efficacy
of GA [123]. In the long-term treated patients, the long-
standing efficacy of GA was associated with an immuno-
logic shift which mainly included an anti-GA antibody
shift (decrease in IgG2 subtype) [124].
2.2.1.3.2 Neutralizing Antibodies Against Interferon. About
5–30 % of treated patients develop persistent neutralizing
antibodies, usually in the first year of treatment and more
commonly in those receiving IFNb-1b. Their presence is
associated with a reduction in treatment effect on relapse
activity.
An open-label study involving 78 patients with MS
treated with IFN [105] analyzed the impact of neutralizing
antibodies (NAbs) on the clinical efficacy of IFNb. The
incidence of persistent NAb? patients was 35 % for
Betaferon�, 20 % for Rebif�, and 3 % for Avonex�.
During IFNb treatment, both NAb? and NAb- patients
showed a reduction in relapse rate; the reduction (25 %)
was not significant in NAb ? patients but was significant
(67 %) in NAb- patients. This indicated a compromise in
IFN efficacy in those NAb? patients.
Data from the PRISMS study showed that persistent
NAbs, above 20 NU/mL, were present in 14 % of the
44 lg and 24 % of the 22 lg three-times-weekly group
over 4 years. Over the entire period of study, relapse and
disability measures were similar between the NAb? and
the NAb- patients. However, once NAbs developed, sig-
nificant differences were noted between the NAb? and
NAb- groups, particularly on MRI and relapse measures
[106].
In another study, NAbs were measured in 277 of 292
early-treated patients and detected at least once in 31.8 %
of the patients, with 60.2 % of them reverting to NAb
negativity by year 5. Time to CDMS, time to confirmed
disability progression, and annualized relapse rate did not
differ between NAb? and NAb- patients, but an increase
in newly active lesion number and T2 lesion volume and
conversion to McDonald MS were associated with NAb
positivity, which was more pronounced with higher titers
[107].
In a recent study, the frequency and impact of neutral-
izing antibodies (NAbs) to IFNb-1b (Betaferon�) on clin-
ical and radiographic outcomes was evaluated in the
patients from the BEYOND study. NAb ? titers were
detected in 37.0–40.7 % of the Betaferon�-treated patients.
Of these, 35 % reverted later to a NAb-seronegative.
NAb? status was not associated with a convincing impact
on any clinical outcome measure. By contrast, NAbs were
associated with a very consistent deleterious impact on
most MRI outcomes [108]. In the BECOME trial, a small,
but more sophisticated study, high levels of anti-IFNbantibodies, which resulted in diminished bioactivity (evi-
denced by the effect on gene expression), were correlated
with reduced therapeutic efficacy of IFNb, as reflected by
the MRI activity [109].
2.2.1.3.3 Early Treatment with GA (CIS). In a random-
ized, double-blind trial, 481 patients presenting with CIS,
and two or more T2-weighted brain lesions in the MRI,
were randomly assigned to treatment with subcutaneous
20 mg per day GA or placebo for up to 36 months, unless
D. Karussis
they converted to CDMS. GA reduced the risk of devel-
oping clinically definite MS by 45 % compared with pla-
cebo [125].
2.2.1.3.4 GA in Progressive MS. A double-blind, pla-
cebo-controlled, 3-year study involving 943 patients with
primary progressive MS tested the efficacy of GA in pro-
gressive disease. The trial was terminated after an interim
analysis by an independent data safety monitoring board
indicated no discernible treatment effect on primary out-
come. Intention-to-treat analyses of disability and MRI end
points showed a nonsignificant delay in time to sustained
accumulated disability in GA-treated patients, with sig-
nificant decreases in enhancing lesions in the first year. The
slow rate of disease activity in the control group may be
one of the explanations for these negative results [126,
127].
2.2.1.3.5 Comparative Efficacy of IFN vs GA. In a large
prospective randomized comparative study (BEYOND),
2,244 patients were enrolled. Patients were randomly
assigned 2:2:1 to receive one of two doses of Betaferon�
(250 lg or 500 lg) subcutaneously every other day or
20 mg GA subcutaneously every day. No differences in
relapse risk, EDSS progression, T1-hypointense lesion
volume, or normalized brain volume was observed between
the treatment groups. A 500 lg dose of IFNb-1b was not
more effective than the standard 250 lg dose, and both
doses had clinical effects similar to those of GA. The
overall tolerability to both drugs was similar [113, 115].
Similar results (no difference in efficacy between IFN and
GA) were obtained from the REGARD study in which
Rebif�, 44 lg three times weekly was used in the com-
parator group. In this study, the primary outcome was MRI
activity using a more sensitive way to detect active lesions
by triple dose gadolinium administration [116].
2.2.1.4 Intravenous Immunoglobulins (IVIG) Data from
an open pilot controlled study indicated that IVIG had
some efficacy in reducing the number of relapses in RRMS
[128]. However, two other trials failed to show any efficacy
of this treatment in patients with RRMS or progressive MS
[129, 130]. MRI monitoring in the latter trial did not reveal
any effect of IVIG treatment in preventing the appearance
of new lesions in the brain [131]. A pilot study examining
the issue of recovery of apparently fixed, irreversible
neurological deficits, by IVIG treatment, showed that this
treatment may enhance recovery in optic neuritis patients,
raising the possibility of remyelination induction [132]. A
later controlled study with monthly IVIG injections showed
a reduction of 59 % in the relapse rate in patients with
RRMS [133, 134]. There was also a statistically significant
difference between the placebo- and IVIG-treated groups
in the progression of disability (changes in EDSS score),
but the effects on MRI activity were not evaluated. In
general, there is some evidence pointing to a reduction in
relapse rate (weighted mean difference [WMD] -0.73) and
longer relapse-free periods during IVIG treatment.
In SPMS, two studies [135, 136] failed to show any
difference between the IVIG-treatment and the placebo
groups in terms of time to sustained disease progression. In
PPMS, a single study reported significantly fewer partici-
pants with EDSS progression in the IVIG-treated group
than in the placebo group, with a non-significant trend to a
delay in time to disease progression [136].
MRI data were reported in two RRMS studies [137, 138]
and in one on SPMS [135]. The RRMS results are con-
flicting. Lewanska et al. [137] reported a significant
reduction in both new lesions on T2 and in the number of
gadolinium-enhancing lesions on T1 in both IVIG-treat-
ment groups compared with placebo, accompanied by a
non-significant trend to reduced T2 lesion burden. In the
second study, no difference could be detected in any of the
MRI variables [138]. In SPMS, there was no evidence of
any beneficial effect of IVIG on the MRI parameters.
In an additional trial with clinical and MRI end-points,
significant differences were reported between the placebo
and the IVIG-treatment groups [139]. However, this study
suffers from considerable methodological difficulties, par-
ticularly with respect to blinding and allocation concealment.
Two additional trials [140, 141], of a rigorous method-
ological quality, were entirely negative across a wide range
of clinical and paraclinical outcome measures, including a
subset of participants undergoing serial MRI examinations.
The two trials included 122 participants with RRMS or
SPMS. Essentially, these trials tested without success the
hypothesis that IVIG would reverse established neurologic
impairments in MS.
Infusion-related side effects were reported in 4 % of the
participants [133, 135] and in 3.8 % (3.0 %) of the infu-
sions [142]. One study reported six participants with deep
venous thrombosis, four of whom also developed pul-
monary embolism in the treatment group. However, two of
these had a known coagulation defect. IVIG was extremely
poorly tolerated in one trial [138], with 11/21 (52 %)
experiencing severe cutaneous reactions. In the same study,
there was one case with hepatitis C viral infection and one
mortality from a pulmonary embolus [134–136, 142].
2.2.1.5 Immunosuppressants Several immunosuppres-
sive treatments have been tried in MS in the past decades,
with variable efficacy.
2.2.1.5.1 Azathioprine. Azathioprine, an antimetabolite
with broad spectrum immunosuppressive effects and one of
the main immunosuppressive cytotoxic substances
Immunotherapy of MS
available, is used extensively to control transplant rejec-
tion reactions. It is nonenzymatically cleaved to mercap-
topurine, which acts as a purine analog and an inhibitor of
DNA synthesis. By preventing the clonal expansion of
lymphocytes in the induction phase of the immune
response, it affects both cellular and humoral immunity
and is therefore efficient in the treatment of autoimmune
diseases. Azathioprine was initially tested in some pilot
clinical trials [142–144]. In the British and Dutch Multi-
ple Sclerosis Trial [143] it was shown to reduce the rate
of progression at 3 years. Worsening of the EDSS scale
was 0.62 in the azathioprine group and 0.80 in the pla-
cebo-treated patients.
In total, azathioprine was tested in five controlled trials
[143–146]. Both relapsing and remitting MS patients and
patients with progressive disease were included in these
five trials (RRMS = 388; SPMS = 188; PPMS = 62;
other progressive MS = 65). Almost half of the included
patients suffered from progressive disease and this is
unique in trials with such immunomodulating drugs (most
of which showed efficacy only in RRMS). In one of the
trials, only patients with progressive types of MS were
included [146]. In general, there were clear beneficial
effects of azathioprine treatment in the whole group
(including the progressive cases).
With regard to its efficacy on relapses, analysis of the
cumulative data from 698 patients (from these five trials)
showed that treatment with azathioprine was associated
with a significant reduction in the number of patients who
had relapses during the first year compared with placebo
(relative risk reduction [RRR] = 20 %), at 2 years
(RRR = 23 %) and at 3 years (RRR = 18 %) [147].
Cumulative data on disability progression rates, avail-
able from three trials [144, 146] involving 87 patients;
showed that the proportion of patients who progressed
during 2–3 years of treatment was 61 % (range of
46–83 %) in the placebo group and 34 % (range 30–43 %)
in the azathioprine group (a statistically significant RRR of
42 %).
Effects on MRI: In the only existing small study that
evaluated the effect of azathioprine on the MRI parameters
of MS [148], the MRI scans of 14 patients were followed
monthly for 6 months before and following the initiation of
azathioprine treatment. A reduction of more than 50 % in
both the gadolinium-enhancing lesions and the T2 lesions
was observed in almost all of the patients.
The azathioprine dose in the reported trials varied from
2 mg/kg to more than 4.4 mg/kg. The recommended dose
should be that which leads to a target white blood cell
count of 3,000–4,000 and an absolute lymphocyte count of
800–1,000. Mean cell volume, which should increase to
values of around 100, is also a reliable marker for drug
efficacy.
The side effects included gastrointestinal discomfort or
pain and a cutaneous rash (5 % for each) and a 9 % inci-
dence of liver enzyme elevation. Macrocytic anemia
occurred in 3 % of the azathioprine-treated patients. There
was a small but not significant absolute increase of 3.4 %
in the risk for malignancies from a 3-year course of aza-
thioprine and a slightly increased mortality rate in the
azathioprine groups [149]. In general, it is recommended
that the total cumulative dose of azathioprine should not
exceed 600 g per patient.
Azathioprine was also tested in a combination regimen.
In an open study, azathioprine given as an add-on treatment
(either with or without steroids) did not offer a significant
additional benefit to that of interferon treatment [150].
2.2.1.5.2 Cyclophosphamide. Cyclophosphamide is an
alkylating drug (a member of the nitrogen mustards), that
binds to DNA and interferes with mitosis and cell repli-
cation. Its immunologic actions include (i) suppression of
both cellular and humoral immunity through its effects on
B and T cells, with a somehow greater suppressive effect
on B cells; (ii) decreased secretion of IFNc and IL-12 by
monocytes [151, 152]; (iii) increased secretion of IL-4 and
IL-10; (iv) a shift from a Th1-type to a Th2-type cytokine
profile. Cyclophosphamide is commonly used as an anti-
neoplastic drug and for the treatment of severe systemic
autoimmune disorders, such as SLE [153, 154].
Initial pilot open studies back in the early 1970s, and later,
showed positive indications of the efficacy of cyclophos-
phamide in MS. In an uncontrolled, open-label trial, stabil-
ization of the disease for up to 5 years was observed in 69 %
of the 86 progressive MS patients treated with a short course
of cyclophosphamide (400 mg) and 1 g prednisone [155]. In
another open-label, prospective, randomized trial in 58
progressive MS patients, treatment with a short course of
high-dose intravenous cyclophosphamide and ACTH was
compared with ACTH alone and with low-dose cyclophos-
phamide plus ACTH and PLEX: 80 % of the patients in the
high-dose cyclophosphamide group stabilized or improved,
compared with 20–50 % in the two other groups.
Later, two large trials reported conflicting results. The
Northeast Cooperative Multiple Sclerosis Treatment
Group, randomizing a four-arm trial in 256 patients with
progressive MS [156], included two induction regimens of
intravenous cyclophosphamide and ACTH, with or without
subsequent intravenous boosters of cyclophosphamide
every other month. Although there were no differences in
disease stabilization between the two induction regimens,
the patients who received maintenance boosters of cyclo-
phosphamide had a significant delay in EDSS progression
compared with the patients who did not receive boosters.
The beneficial effect was more pronounced in patients of a
younger age. However the difference in stabilization rates
D. Karussis
(38 vs 24 % in 24 months) was small and disappeared by
36 months.
The Canadian Cooperative Multiple Sclerosis Group
[59] performed a single-blinded, placebo-controlled, mul-
ticenter trial including 168 patients with progressive MS
who received intravenous cyclophosphamide and oral
prednisone, or oral cyclophosphamide and oral prednisone
on alternate days, combined with weekly PLEX. The
control group received oral placebo and sham plasma
exchange. There was no significant difference in the time
to worsening of one or more points in the EDSS.
Since the early 1990s there have been several trials and
case reports with cyclophosphamide in patients with rapidly
worsening or treatment-refractory MS. An open-label
observational study in 95 patients with progressive MS
showed that 80 % of patients with SPMS who were treated
with monthly cyclophosphamide and intravenous pulses of
methylprednisolone had stable or improved EDSS scores at
12 months [157].
Gobbini et al. [303] reported a rapid reduction in gad-
olinium-enhancing lesions, in monthly brain MRI scans,
and clinical stability in five patients with rapidly deterio-
rating RRMS who were treated with monthly cyclophos-
phamide for 6 months followed by cyclophosphamide on
alternate months. In another open-label study of intrave-
nous cyclophosphamide given monthly to 14 patients with
RRMS who were rapidly deteriorating [158], the mean
EDSS scores were significantly lower than baseline at
follow-up (up to 18 months) and no relapses were reported.
In an open-label study of 24 patients with clinically active
and treatment-refractory MS, significant improvement in
EDSS scores, relapse rate, and MRI measures were docu-
mented in the patients treated with intravenous cyclo-
phosphamide plus intravenous methylprednisolone
(monthly in the first year and bimonthly in the second)
[159]. A retrospective, open-label review of 362 patients
with SPMS and 128 patients with PPMS who were given
12-monthly pulses of intravenous cyclophosphamide [160]
showed that compared with baseline, the EDSS score sta-
bilized or improved at month 12 in 78.6 % of the patients
with SPMS and in 73.5 % of the patients with PPMS. A
report of a single patient with RRMS who accidentally
received a dose of cyclophosphamide 3,800 mg (3.8 times
the normal dose) showed no evidence of clinical or MRI
disease activity for the next 7 years [161]. This observation
advocates the concept of autologous bone marrow trans-
plantation in MS. Finally, an open-label study in which 15
treatment-refractory MS patients were treated with cyclo-
phosphamide 200 mg/kg over 4 days showed a significant
stability in disease and improvement in quality of life after
15 months [162].
Several combination studies have been performed to test
the efficacy of cyclophosphamide combined with other
immunomodulators. In a randomized, multi-center trial of
59 patients with RRMS who did not respond to IFNb, the
combination of cyclophosphamide and IFNb-1a reduced
clinical disease activity and gadolinium-enhancing MRI
lesions in the brain [163]. In a smaller study, in ten patients
who had frequent and severe attacks despite IFNb therapy,
the addition of monthly intravenous cyclophosphamide led
to a significant reduction in the number of relapses, EDSS
score, and number of T2-weighted lesions. These benefits
were maintained for 36 months after cyclophosphamide
was discontinued [164].
Cyclophosphamide can cause several side effects,
including alopecia, nausea, vomiting, hemorrhagic cystitis,
leukopenia, myocarditis, infertility, and pulmonary inter-
stitial fibrosis.
2.2.1.5.3 Mitoxanthrone. Mitoxanthrone is an anthra-
cenedione antineoplastic drug that intercalates with DNA
and inhibits both DNA and RNA synthesis that was
developed in the 1970s. Mitoxanthrone inhibits B-cell
function, including antibody secretion, abates helper and
cytotoxic T-cell activity, and decreases the secretion of Th1
cytokines such as IFNc, TNFa, and IL-2 [165].
The first placebo-controlled trial of mitoxanthrone,
which was performed in 51 patients with RRMS randomly
assigned to monthly infusions of mitoxanthrone (8 mg/m2)
or saline for 1 year, showed a significant reduction in the
annual relapse rate and an increase in the proportion of
patients who were relapse-free at the end of 1 and 2 years,
but no differences in EDSS scores [166]. There was also a
trend to a reduction in the number of new brain MRI T2
lesions. In an unblinded, multi-center trial in 42 patients
with worsening RRMS and SPMS, Edan and co-workers
found that monthly infusion of intravenous mitoxanthrone
20 mg and intravenous methylprednisolone 1 g improved
the clinical and MRI parameters of MS activity over
6 months, as compared with those of the group on intra-
venous steroids alone [167]. In a double-blind trial of 49
patients with SPMS with superimposed relapses, who were
randomly assigned to receive 13 infusions of mitoxan-
throne 12 mg/m2) or intravenous methylprednisolone 1 g
over 32 months, neurological disability, relapse rate, and
the number of gadolinium-enhancing lesions in MRI were
significantly reduced in the mitoxanthrone group [168].
In a phase III trial, 194 patients with worsening RRMS
or SPMS were randomly assigned to receive either placebo
or intravenous mitoxanthrone 12 mg/m2 or 5 mg/m2 every
3 months for 2 years [169]. The higher dose of mitoxan-
throne was significantly more effective in the combined
clinical outcome measurement, consisting of five clinical
parameters (change in EDSS, change in ambulation index,
number of treated relapses, time to first treated relapse, and
change in neurological status). The results of this trial led
Immunotherapy of MS
to the regulatory approval of mitoxantrone as the first
immunosuppressive chemotherapeutic drug for patients
with MS.
Le Page and co-workers reported an observational study
on 100 patients with aggressive RRMS who were induced
with intravenous mitoxanthrone 20 mg and intravenous
prednisolone 1 g every month for 6 months [170]. This
was followed by mitoxanthrone maintenance therapy every
3 months, IFNb, GA, azathioprine, or methotrexate in 57
patients, with a mean follow-up of 3.8 years. In the year
after induction, the relapse rate, EDSS score, and MRI
activity were significantly decreased, the decrease sus-
tained for up to 5 years.
2.2.1.5.3.1 Combination Studies. Jeffery and co-workers
conducted an open-label, add-on, pilot study on ten active
disease MS patients despite at least 6 months of IFNbtreatment [171]. With the addition of mitoxanthrone
(12 mg/m2 for the first month, then 5 mg/m2 every month
for 2 months, and then 5 mg/m2 every third month), the
mean frequency and volume of gadolimium-enhancing
lesions decreased by 90 % and 96 %, respectively, after
7 months, and the relapse rate was reduced by 64 %. In
another open-label study, 27 consecutive patients with
clinically-active RRMS were treated with monthly infu-
sions of mitoxanthrone for 3–6 months followed by boosts
every 3 months, in combination with GA [172]. At a mean
follow-up of 36 months, EDSS scores and relapse rates
were significantly reduced compared with baseline.
As mentioned, mitoxanthrone is the only licensed
cytotoxic medication for MS (for patients with SPMS,
progressive relapsing or worsening RRMS but not for those
with PPMS) and is probably equally or more efficacious
than IFNs and GA, but its use is confined to cases with
sufficiently aggressive MS to justify its toxic effects. Mi-
toxanthrone causes cardiotoxicity (the cumulative allowed
dose should not exceed 120 mg/m2) and acute leukemia
(AML); the cumulative risk for both these adverse effects
is 0.2 %.
2.2.1.5.4 Methotrexate. Methotrexate, a folic acid ana-
log, is a potent immunosuppressant, whose mode of action
is predominantly through inhibition of dihydrofolate
reductase and thus thymidine biosynthesis, although there
are other anti-inflammatory effects which do not rely upon
this specific mechanism [173]. By inhibiting purine and
pyrimidine synthesis, methotrexate suppresses antigen-
dependent T-cell proliferation and promotion of adenosine-
mediated inflammation. It is used in the treatment of
autoimmune diseases (for example, rheumatoid arthritis or
Behcet’s disease) and in transplantations.
In a placebo-controlled study, methotrexate, at a low
dose, was reported to have a mild beneficial effect in
progressive MS [174, 175]. In that study, 60 patients were
treated with methotrexate (7.5 mg weekly) or with a pla-
cebo for 2 years. Methotrexate significantly reduced sus-
tained worsening, as assessed by a composite measure of
disability using the EDSS, the ambulation index, and two
arm function tests. However, the effect of this treatment
was less pronounced when changes in the ‘traditional’
measures, such as the EDSS score and the Ambulation
Index, were used as outcomes. The effect of methotrexate
on MRI activity was also marginal. Another trial with
methotrexate [176], included 44 participants, of whom 20
had RRMS and 24 suffered from progressive forms of MS.
The authors reported a trend to fewer relapses in the RRMS
group, but no difference in EDSS progression in the pro-
gressive group.
A recent study [177] evaluated the feasibility of intra-
thecal administration (up to eight treatments) of metho-
trexate in 121 progressive MS patients. No serious adverse
effects were noted during the study period. In 89 % of the
87 SPMS patients, EDSS scores were stable or improved. In
82 % of the four PPMS patients, EDSS scores were stable.
In general, methotrexate toxicity is usually low if
treatment is paralleled by folate substitution. However,
long-term methotrexate administration is associated with
serious side effects, including hepatic fibrosis.
2.2.1.5.5 Cyclosporin-A. Cyclosporin A, a cyclic fungal
peptide composed of 11 amino acids, is a calcineurin
inhibitor, similar in this aspect to tacrolimus. It has been in
use since 1983 and is one of the most widely administered
immunosuppressive drugs. It binds to the cytosolic protein
cyclophilin (an immunophilin) of immunocompetent lym-
phocytes, especially T-lymphocytes. This complex of
cyclosporin and cyclophilin inhibits calcineurin which,
under normal circumstances, induces the transcription of
IL-2, leading to the reduced function of effector T cells,
including a reduction in the frequency of regulatory T cells.
Cyclosporin A is used in the treatment of acute rejection
reactions, but has been increasingly substituted by newer
and less nephrotoxic immunosuppressants.
Cyclosporin A was studied in a 2-year, multicenter,
double-blind, clinical trial involving 547 progressive MS
patients [178] with an increase in EDSS of 1–3 grades in
the year prior to entry. Cyclosporine was given to 273
patients, placebo to 274. The mean increase in EDSS was
0.39 ± 1.07 for the cyclosporine-treated patients and
0.65 ± 1.08 in the placebo group. Cyclosporin A delayed
the time to becoming wheelchair-bound (relative risk:
0.765), but statistically significant effects were not
observed for ‘time to sustained progression’ or on a com-
posite score of ‘activities of daily living’.
The high rate of hypertension and nephrotoxicity
induced by this treatment limit its use. Calcineurin
D. Karussis
inhibitors and azathioprine have been linked also with post-
transplant malignancies and skin cancers.
2.2.1.5.6 Cladribine. The synthetic purine nucleoside
analog cladribine (2-chloro-20-deoxyadenosine) enters the
cell through purine nucleoside transporters and is phos-
phorylated by deoxycytidine kinase. Lymphocytes have
fairly high concentrations of this enzyme and low levels of
50 nucleotidase, leading to the preferential accumulation of
cladribine in lymphocytes [179]. Cladribine nucleotide
accumulation disturbs DNA synthesis and repair mecha-
nisms, resulting in lymphocyte depletion and long-lasting
lymphopenia. The drug targets mainly CD4? T cells,
CD8? T cells, and B cells [179]. Because cladribine can
penetrate the CNS, it interacts with cells in both the
peripheral circulation and in the CNS. The therapeutic
efficacy and safety of cladribine have been assessed in
several autoimmune disorders and the parenteral formula-
tion of cladribine is used as first-line treatment for hairy
cell leukemia.
Older studies in a total of 262 patients have shown the
efficacy of parenteral cladribine in RRMS and progressive
MS, both in clinical and MRI parameters [180–182]. In the
large and recent CLARITY trial, a placebo-controlled,
double-blind trial, a new preparation of oral cladribine (in
two doses) and a new treatment scheme, were tested in 1,326
patients with RRMS [183]. There was a significantly lower
annualized relapse rate in both cladribine groups compared
with the placebo group (0.14–0.15, vs 0.33), a higher relapse-
free rate (79.7–78.9 % vs 60.9 %), a lower risk of 3-month
sustained progression of disability, and significant reduc-
tions in brain lesion count upon MRI. Adverse events that
were more frequent in the cladribine groups included lym-
phocytopenia (21.6 % in the 3.5 mg group and 31.5 % in the
5.25 mg group) and herpes zoster infections. Neoplasms
arose in 6 (1.4 %) patients in the 3.5 mg/kg cladribine group
and 4 (\1 %) in the 5.25 mg/kg group, but in none of the
patients in the placebo group. Neoplasms included leio-
myomata (n = 5), cervical carcinoma in situ (n = 1), mel-
anoma (n = 1), ovarian carcinoma (n = 1), pancreatic
cancer (n = 1), and myelodysplasia (n = 1). These risks for
adverse events have probably been the main reason for
rejection of the drug as a registered treatment for MS by the
European and American authorities. A recently published
follow-up of the CALRITY study in 1,192 patients evaluated
the parameter of freedom from disease activity (no relapses,
no EDSS progression, no active or new lesions in the MRI) at
96 weeks. Of the patients in the two doses of cladribine
groups, 67–70 % were free of disease activity, versus 39 %
in the placebo group [184].
2.2.1.5.7 Mycophenolate Mofetil. Mycophenolate mofe-
til (MMF) belongs to the antimetabolite drug class and is a
pro-drug of its active metabolite, mycophenolic acid. By
depleting guanosine and deoxyguanosine nucleotides in T
and B lymphocytes, it inhibits their proliferation and,
hence, immunoglobin (Ig) production. MMF also sup-
presses dendritic cell maturation, decreasing its capacity of
antigen presentation to T lymphocytes. Small trials in
progressive MS suggest some efficacy, and its adminis-
tration appeared well tolerated [185, 186]. Interestingly, in
an open-label trial, the combination of MMF with IFNb-1a
exhibited superior efficacy, compared with IFNb-1a alone
[187]. In this study, 30 RRMS patients already treated with
IFNb-1a were given MMF at a progressive dose of 2 g per
day orally for 6 months. The annualized relapse rate was
0.57 ± 0.3 at the end of the study, as compared with
2.0 ± 0.7 at enrollment. No gadolinium-enhancing lesions
were detected upon MRI at the end of the study, as com-
pared with 11 active patients at baseline (a total of 35
lesions).
In a retrospective trial, MMF was shown to prevent
relapses in 24 NMO patients [188]. Adverse events inclu-
ded benign infectious diseases, insomnia and dizziness,
nausea and abdominal pains. Controlled and larger studies
are warranted.
2.2.1.5.8 Tacrolimus. Tacrolimus/FK506 (Prograf�, As-
tellas, US) is a product of the bacterium Streptomyces
tsukubaensis. It binds to the immunophilin FKBP1A, fol-
lowed by binding of the complex to calcineurin and the
inhibition of its phosphatase activity. In this way, it pre-
vents the cells from transitioning from the G0 to the G1
phase of the cell cycle. The drug, which is more potent than
cyclosporin and has less pronounced side effects, is used
primarily in transplantations.
A pilot clinical trial [189] with tacrolimus in chronic
progressive MS did not detect any significant change in the
proportion of circulating CD25?CD4? or CD45R?CD4?
cells over the study period. The side effects of tacrolimus
were mild and the overall degree of disability did not
deteriorate significantly in the 19 patients studied over the
12 months of tacrolimus administration.
2.2.1.6 Combination Immunotherapy The rationale for
combination immunotherapy (reviewed in [190]), comes
from the reported synergistic effects and increased efficacy
of such combinations of immunomodulatory agents in
other autoimmune diseases [191]. It is also justified by the
acknowledged complexity of MS immunopathogenesis,
which may necessitate the use of more than one drug to
interfere with the various distinct immune elements
involved at multiple levels of the immune axis, in order to
maximize treatment efficacy. However, owing to the
complex interactions and the delicate balance between the
various immune cells and cytokine/chemokine networks,
Immunotherapy of MS
unexpected or paradoxical effects may occur when differ-
ent drugs affecting the immune system are combined. Such
combinations must, therefore, be tested in clinical trials.
Small-size pilot studies have provided some positive
indications supporting the principle of combination treat-
ments. In one of them, Calabresi and colleagues [192]
added methotrexate 20 mg weekly to the existing therapy
with IFNb in 15 MS patients and reported a 40 % reduction
in gadolinium-enhancing lesion number (p = 0.02) after 4,
5, and 6 months, and a reduction in relapse rate from 0.73
to 0.27. A similar open-label trial of 12 participants com-
bined azathioprine 3 mg/kg with subcutaneous IFNb-1b
[193]. After the addition of azathioprine, there was a 65 %
reduction in gadolinium-enhancing MRI lesions after
6 months, compared with the baseline.
However, the results of the subsequently performed
larger controlled studies using IFN as basic therapy and
methotrexate, steroids, or azathioprine as add-ons, were
negative with the exception of the NORMIMS.
Specifically, in a 2-year study in which azathioprine or
azathioprine plus low dose oral prednisone were added to
IFNb, although a beneficial trend could be detected
favoring the triple therapy, these differences were not of
statistical significance [150].
In another trial involving 313 MS patients, methotrexate
20 mg weekly or methotrexate plus bi-monthly, 3-day,
intravenous, high-dose methylprednisolone were added to
weekly IFNb-1a. The combinations were generally safe and
well tolerated. Although the trends suggesting a modest
benefit were seen for some intravenous methylprednisolone
outcomes, the overall results did not point to a significant
benefit [194].
The MECOMBIN double-blind trial examined whether
the addition of methylprednisolone 500 mg/day orally for 3
consecutive days per month for 3–4 years to IFNb-1a could
provide any additional benefit in RRMS patients, in terms of
disability progression. A total of 341 patients were included
in this trial. Monthly pulses of methylprednisolone were not
shown to affect disability progression any more than IFNb-
1a treatment alone. Some positive effects, but only in sec-
ondary measurements, were detected [195]. In the NORM-
IMS (the only positive trial), a higher dose of IFNb-1a (44 lg
three times a week) was combined with 5-day monthly pulses
of oral methylprednisolone (200 mg each day). The combi-
nation led to a significant reduction in relapse rate [196].
Additional immunotherapeutic schemes tested included
combinations with natalizumab. In the SENTINEL trial,
natalizumab was added to weekly intramuscular IFNb. The
1-year annualized relapse rate was 0.82 in the monotherapy
group and 0.38 in the combination group, a 54 % reduction,
p \ 0.001). This effect persisted at 2 years. Additionally, the
two-year sustained disability was 29 % in the monotherapy
group and 23 % among participants who received
combination therapy, this representing a 24 % decrease
(p = 0.02). At 2 years, the percentage of relapse-free par-
ticipants was 32 % in the monotherapy group and 54 % in
the combination group (p \ 0.001).
The trial was terminated 1 month early because of two
cases of progressive multifocal leukoencephalopathy (PML)
in the natalizumab-Avonex� combination group [197].
GLANCE was a smaller study (n = 110) in which na-
talizumab was added to glatiramer acetate for 6 months.
For the imaging endpoints in this trial, there was a better
outcome in the combination group. In terms of relapses and
EDSS changes, the two groups did not differ significantly
(but, as mentioned above, this was a short study and its
primary outcome was MRI parameters). In both the above
trials, there was no natalizumab-alone group, which makes
it more difficult to draw definite conclusions on the com-
bination effect. These trials did not reveal any increased
danger for adverse events, and the two initially reported
cases of PML in SENTINEL seem to be related to natal-
izumab and not necessarily to the combination, since all the
(more than 200) later PML cases were in patients treated
with natalizumab alone. However, an increased risk for
PML from the combination treatment can not be ruled out.
Pilot studies combining cyclophosphamide with IFNbhave yielded encouraging results [164, 198, 199].
A randomized, double-blind, placebo-controlled trial of
cyclophosphamide as an add-on therapy to IFNb is in pro-
gress [164]. Treatment strategies entailing a rescue thera-
peutic scheme (see treatment algorithm) of strong
immunosuppression followed by maintenance treatment with
first-line immunomodulators have been suggested and vali-
dated. In one such approach, a short course of mitoxantrone
was used to induce immunosuppression, followed by
immunomodulation with IFNb or glatiramer acetate. Pilot
studies showed promising results with both combinations
[171, 172].
In the larger of the pilot open studies, 100 consecutive
patients with aggressive RRMS received mitoxanthrone
20 mg monthly combined with methylprednisolone 1 g for
6 months. During the 12 months following initiation of
mitoxantrone treatment, the annual relapse rate was
reduced by 91 % (with 78 % of the patients remaining
relapse-free), MRI activity was reduced by 89 %, the mean
EDSS decreased by 1.2 points and 64 % of the patients
improved by 1 point or more in the EDSS. In the longer
term, the ARR reduction was sustained and disability
remained improved after 5 years [200].
In a recent 3-year, randomized, controlled, clinical and
MRI study, 109 patients with aggressive MS (two or more
relapses in the previous 12 months and one or more gad-
olinium-enhancing MRI lesions) were randomized and
received mitoxanthrone monthly (12 mg/m2) combined
with methylprednisolone 1 g for 6 months followed by
D. Karussis
IFNb for the last 27 months, or IFNb for 3 years combined
with methylprednisolone 1 g monthly for the first
6 months. The time to worsening by at least one EDSS
point was delayed by 18 months in this group versus the
IFNb group (p \ 0.012). The 3-year risk of worsening
disability was reduced by 65 % in the mitoxanthrone res-
cue group compared with the IFN group. Mitoxanthrone-
treated patients had a reduced number of Gd-enhancing
lesions at month 9 and a slower accumulation of new T2
lesions at each time point [201].
Two small pilot studies did not detect any significant
beneficial effect of the addition of mycophenolate to IFNb-
1a treatment [202, 203]. In the second study, the MMF
group showed a trend to a lower accumulation of combined
active lesions in MRI.
Additional combination studies (examining the possibility
of enhancing the effect of GA or IFN by neuroprotective
agents) were also performed or are under way. A combination
of simvastatin, a cholesterol-lowering agent with putative
immunomodulatory and neuroprotective properties, with
IFNb-1a, did not offer any additional beneficial effect [204].
2.2.2 The New Generation of Immunotherapies
2.2.2.1 Antibodies Synthetically produced antibodies may
serve as a quick and potent immunosuppressive therapy.
2.2.2.1.1 Polyclonal Antibodies. Animal-derived poly-
clonal antibodies, such as antilymphocyte and antithymocyte
antigens, have been successfully used as adjuvant treatment
(to immunosuppressants in order to reduce their dose and
toxicity) for steroid-resistant acute rejection reaction and
aplastic anemia. Polyclonal antibodies inhibit T lympho-
cytes and cause their lysis (complement-mediated or cell-
mediated opsonization). In this way, polyclonal antibodies
inhibit cell-mediated immune reactions, including graft
rejection, delayed hypersensitivity, and graft-versus-host
disease.
Polyclonal antibodies affect all lymphocytes and cause
general immunosuppression, possibly leading to post-
transplant lymphoproliferative disorders or serious infec-
tions, especially by cytomegalovirus. Because of their high
immunogenicity, almost all patients have an acute reaction,
characterized by fever, rigor, and even anaphylaxis.
A small pilot study with antilymphocyte antigens in 12
MS patients showed some efficacy in progressive disease
[205], but in general the use of polyclonal antibodies is not
justified for MS due to the high toxicity, except in the
frame of autologous hematopoietic transplantation.
2.2.2.1.2 Monoclonal Antibodies. Monoclonal antibod-
ies are directed towards precisely-defined antigens.
Therefore, they cause fewer side effects.
2.2.2.1.2.1 Natalizumab. Pioneer animal studies in EAE
back in the early 1990s [19], demonstrated that an antibody
against the a4b1 integrin, a surface molecule of lympho-
cytes, could reduce lymphocytic infiltration and clinical
disease severity. These data led to clinical trials of a
humanized anti-a4 integrin antibody, natalizumab (Tysa-
bri, Biogen, US). Monthly infusions of this antibody
showed strong efficacy against placebo, reducing the
relapse rate at 1 year by 68 % and the chance of acquiring
fixed disability over 2 years by 42 % [20]. Moreover, na-
talizumab-treated patients were free of any disease activity
(relapses, progression of disability and new MRI activity)
by around 30 %. Although this efficacy appears higher than
that observed in the interferon and glatiramer acetate piv-
otal studies, such cross comparison between different
studies (of different design and MS patients populations) is
not scientifically sound. Only direct head-to-head pro-
spective trials (which do not exist at the present) can pro-
vide definite information on the relative efficacy of the
drugs. US and European authorities licensed natalizumab
for relapsing multiple sclerosis, but the drug was later
withdrawn from the market months when two cases of
PML were identified in a trial combining Avonex� (IFNb-
1a) with natalizumab [206]. As a result, natalizumab is now
licensed as monotherapy only for severe RRMS, or as
second-line immunotherapy for MS. Since licensing, many
(more than 200) additional cases of PML have been iden-
tified, almost exclusively among the patients treated for
more than 2 years with natalizumab. Three parameters
have been identified as being related to an increased risk of
PML: (i) duration of treatment for [2 years; (ii) previous
exposure to cytotoxic medications; and (iii) the presence of
anti-JC (John Cunningham) virus antibodies (which are
found in half of the MS and general population and indicate
previous exposure to the virus) [207]. All reported cases of
PML following natalizumab treatment were positive for the
JC virus antibodies. Introduction of the test for these
antibodies has helped in the selection of patients to be
treated with natalizumab and those in whom the treatment
should be discontinued due to a high risk of PML.
2.2.2.1.2.2 Alemtuzumab. Alemtuzumab is a humanized
monoclonal antibody against the CD52 antigen on T and B
lymphocytes [208] that produces rapid and sustained
lymphocyte depletion and is an approved therapy for B-cell
chronic lymphocytic leukemia.
The first trial of alemtuzumab in MS was performed by
Coles and co-workers, and was a rater-blinded, phase II
trial comparing two doses of the drug given once a year
with IFNb-1a (44 lg subcutaneously, three times a week)
in treatment-naive patients with RRMS [209]. The study
was suspended after immune thrombocytopenic purpura
developed in three patients, one of whom died.
Immunotherapy of MS
Alemtuzumab treatment reduced the relapse rate compared
with IFNb-1a by up to 74 %, and the chance of accumu-
lating disability by up to 71 %, over 3 years. MRI out-
comes were also significant, favoring alemtuzumab.
Adverse events in the alemtuzumab group included auto-
immunity (thyroid disorders and immune thrombocytope-
nic purpura [3 %]) and infections.
Two large phase III trials (CARE-MS I and II) have
been concluded and their preliminary results presented in
scientific meetings. CARE-MS I, a phase III trial in
patients with RRMS, showed a 55 % reduction in relapse
rate in the group treated with two annual cycles of ale-
mtuzumab as compared with Rebif over 2 years. Eight
percent of alemtuzumab-treated patients had a sustained
increase in their EDSS score (or worsening) compared with
11 % of those who received Rebif�. In CARE II, the
second randomized, phase III clinical trial, alemtuzumab
was compared with Rebif� in patients with RRMS who had
relapsed while on prior therapy. There was a 42 % reduc-
tion in the risk of sustained accumulation of disability in
patients treated with alemtuzumab, accompanied by a
49 % reduction in relapse rate, compared with Rebif� over
2 years.
In a recent open trial, alemtuzumab showed similarly
positive effects in 45 highly active RRMS patients who
experienced two or more relapses during 2 years prior to
admission to the study while receiving IFNb therapy. The
annualized relapse rate was reduced by 94 %, compared
with pre-treatment levels and 86 % of the patients showed
stable or improved scores on the EDSS [210]. The side
effects of alemtuzumab include a high incidence of auto-
immune diseases (22 %), especially autoimmune throm-
bocytopenia and thyroiditis (up to 33 %) [211].
2.2.2.1.2.3 Rituximab/Ocrelizumab. The accumulating
evidence on the involvement of B lymphocytes in the
pathophysiology of MS paved the way for B-cell-directed
therapies [212]. B-cell depletion affects antibody produc-
tion, cytokine networks, and B-cell-mediated antigen pre-
sentation and activation of T cells and macrophages [213].
Rituximab is a genetically engineered, chimeric murine/
human IgG1 monoclonal antibody that targets the CD20
antigen, a transmembrane phosphoprotein expressed only
by pre-B and mature B cells [214]. Rituximab lyses B cells
via complement and antibody-dependent cellular cytotox-
icity [214]. In MS patients, treatment with rituximab
resulted in depletion of CSF B cells after 24 weeks, asso-
ciated also with a reduction in CSF T cells [215].
Rituximab has shown significant efficacy in the sup-
pression of several autoimmune disorders such as SLE and
rheumatoid arthritis.
In a pilot open study, 26 MS patients received two
courses of rituximab 6 months apart, and were followed for
a total 72 weeks. No serious adverse events were noted, the
events limited to mild-to-moderate infusion-associated
reactions. Fewer new gadolinium-enhancing or T2 lesions
were seen starting from week 4 and through week 72.
Although this was not a trial designed to detect clinical
efficacy, there was an apparent reduction in relapses (which
was also observed over the 72 weeks compared with the
year before therapy (0.23 vs 1.27) [216]. An additional trial
included 30 MS patients with a relapse within the past
18 months, despite the use of an injectable disease-modi-
fying agent, and with at least one gadolinium-enhancing
lesion in any of three pretreatment MRIs. The patients were
treated with rituximab 375 mg/m2 weekly for four weeks.
A total 74 % of the post-treatment MRI scans were free of
gadolinium-enhancing lesions compared with 26 % at
baseline. The median number of gadolinium-enhancing
lesions was reduced from 1.0 to 0 and the mean number
from 2.81 per month to 0.33 after treatment (88 % reduc-
tion). The MSFC disability scores improved and the EDSS
remained stable [217].
A total of 104 patients with RRMS were included in the
only randomized, phase II, double-blind, placebo-con-
trolled trial (HERMES). Treatment with rituximab
1,000 mg, given once every 6 months, led to a significant
reduction of 91 % in gadolinium-enhancing lesions seen on
MRI, and in T2-weighted lesion volume, compared with
placebo. Patients in the rituximab group had a lower
annualized rate of relapses, which was significant at
24 weeks (0.37 vs 0.84) but not at 48 weeks (0.37 vs 0.72)
[218]. More patients in the rituximab group than in the
placebo group had adverse events within 24 h after the first
infusion, most of which were mild-to-moderate. After the
second infusion, the number of events was similar in the
two groups.
Rituximab treatment was also evaluated in 439 patients
with PPMS in a 96–122-week trial [219]. The patients
received two 1,000 mg intravenous rituximab or placebo
infusions every 24 weeks, through 96 weeks (4 courses).
The differences between the two groups in terms of time to
confirmed disease progression were not significant;
96-week rates: 38.5 %, placebo; 30.2 %, rituximab). From
baseline to week 96, rituximab patients had a significantly
lower increase in T2 lesion volume, although the brain
volume change was similar to that of the placebo group.
Subgroup analysis showed significant differences in time to
confirmed disease progression in patients aged \51 years
and those with gadolinium-enhancing lesions, compared
with placebo. Adverse events were comparable between
groups. However, serious infections occurred in 4.5 % of
the rituximab and\1.0 % of the placebo patients. Infusion-
related events, predominantly mild-to-moderate, were
more common with rituximab during the first course, and
decreased to rates comparable to placebo on successive
D. Karussis
courses. Additional phase III trials of rituximab are under
way.
Another, totally humanized, anti-CD20 monoclonal
antibody, ocrelizumab (at 2 doses) was also tested recently
[220] in 220 patients with RRMS in a multicenter, ran-
domized, double-blind, placebo-controlled study involving
79 centers in 20 countries. At week 24, the number of
gadolinium-enhancing lesions was 89 % lower in the
600 mg ocrelizumab group than in the placebo group, and
96 % lower in the 2,000 mg group, with similarly pro-
nounced effects in secondary relapse-related outcomes.
2.2.2.1.2.4 Daclizumab and Interleukin-2 Receptor-
Directed Antibodies. IL-2 is an important immune sys-
tem regulator necessary for clone expansion and survival of
activated T-lymphocytes. Its effects are mediated by the
trimer cell surface receptor IL-2a, consisting of the a, b,
and c chains. IL-2a (CD25) is expressed only by the
already-activated T-lymphocytes. Therefore, it is of special
significance for selective immunosuppressive treatment.
Two chimeric mouse/human anti-CD25 antibodies were
produced: basiliximab (Simulect�) and daclizumab (Zen-
apax�). These drugs act by binding the IL-2a receptor’s achain, preventing the IL-2-induced clonal expansion of
activated lymphocytes and shortening their survival. They
are used in the prophylaxis of acute organ rejection after
bilateral kidney transplantation, both being similarly
effective and with only a few side effects.
A pilot study with daclizumab provided some initial
indications of efficacy in reducing gadolinium-enhancing
lesions in nine MS patients [228]. In a randomized, double-
blind, placebo-controlled, phase II trial, subcutaneous
daclizumab was administered weekly or bi-weekly in
addition to IFNb therapy in 230 patients with RRMS. The
combination therapy was associated with a significant
reduction in gadolinium-enhancing lesions [221].
An additional recent study investigated whether dac-
lizumab monotherapy would reduce MRI active lesions in
16 untreated patients with highly active RRMS [222]. A
87.7 % reduction in brain gadolinium-enhancing lesions
and improvements in MSFC were observed in the treated
patients, accompanied by a significant expansion of CD56
(bright) natural killer (NK) cells in the peripheral blood and
CSF, with a resulting decrease in T cells/NK cells and B
cell/NK cell ratios and IL-12p40 in the CSF.
Phase III trials are needed to establish the efficacy and
safety of daclizumab as monotherapy and combination
therapy in patients with MS.
2.2.2.1.2.5 T-cell Receptor Directed Antibodies. Sup-
pression of the pathogenic, myelin-reactive T-lymphocytes
may be achieved by targeting their T-cell receptor mole-
cules. Muromonab-CD3 is a murine anti-CD3 monoclonal
antibody of the IgG2a type that prevents T-cell activation
and proliferation by binding the T-cell receptor complex
present on all differentiated T cells [223, 224]. As such, it
is one of the most potent immunosuppressive drugs and is
administered to control steroid- and/or polyclonal anti-
body-resistant acute organ rejection. As it acts more spe-
cifically than polyclonal antibodies, it is also used
prophylactically in transplantations.
The muromonab mechanism of action is only partially
understood. It is known that the molecule binds the TCR/
CD3 receptor complex. In the first few administrations this
causes a non-specific activation of T cells, leading to a
serious syndrome 30–60 min later. It is characterized by
fever, myalgia, headache, and arthralgia, which may
occasionally develop into a life-threatening reaction of the
cardiovascular system and the CNS. Following this initial
effect, CD3 blocks TCR-antigen binding and causes a
conformational change or the removal of the entire TCR3/
CD3 complex from the T-cell surface. The cross-binding of
CD3 molecules activates an intracellular signal leading to
T-cell anergy or apoptosis, unless the cells receive another
signal through a co-stimulatory molecule. CD3 antibodies
shift the balance from Th1 to Th2 cells [225].
The treated patients may develop neutralizing antibod-
ies, reducing the effectiveness of muromonab-CD3.
Muromonab-CD3 can cause excessive immunosuppres-
sion. Although CD3 antibodies act more specifically than
polyclonal antibodies, they compromise the cell-mediated
immunity significantly, predisposing the patient to oppor-
tunistic infections and malignancies.
An open trial with muromonab-CD3 was conducted in
13 patients with progressive MS and in three with severe
relapse [226]. Side effects were common and severe, and
included hypotension, nausea and vomiting, diarrhea,
fever, and myalgia. No new clinical or MRI activity of MS
was detected during the period of treatment, although many
patients deteriorated transiently in disability scores. At the
conclusion of follow up, only 14 patients had deteriorated
by 1.0 or more points in the EDSS (73 % stabilization
rate). Of those patients who deteriorated, two died of
complications of MS (EDSS 10). Only two patients showed
clinical improvement at the 1-year follow up. The attendant
toxicity of OKT3 makes it unlikely that it will play a major
role in the treatment of MS.
2.2.2.1.2.6 Cytokine-Directed Antibodies. TNFa is a
cytokine with pleiotropic actions, which can appear both as
a transmembrane protein and as a soluble cytokine (sTNF).
Both ligands interact with two different receptors, TNFR1
and TNFR2, which mediate their biological effects. TNFais involved in the pathogenesis of MS [227]. Treatment
with an antibody against TNFa suppresses EAE and was
beneficial in systemic inflammatory diseases in humans.
Immunotherapy of MS
Two rapidly progressive MS patients were treated with
intravenous infusions of a humanized mouse monoclonal
anti-TNFa antibody (cA2) in an open-label phase I safety
trial [228]. The number of gadolinium-enhancing lesions
increased transiently after each treatment in both patients,
and the CSF leukocyte counts and IgG index grew. These
findings suggest that the treatment caused immune activa-
tion and an increase in disease activity, halting the pro-
gramming of further clinical trials in MS.
However, it has been recently recognized that the two
distinct TNFa receptors mediate different effects: TNFR1
causes demyelination and TNFR2 may mediate remyeli-
nation. It may, therefore, be hypothesized that anti-TNFaagents which selectively inhibit sTNF or signals from
TNFR1 could be effective in treating MS [229].
2.2.2.1.2.7 Additional Monoclonal Antibodies. Addi-
tional monoclonal antibodies can be used to block other
specific cell-surface targets or delete particular lymphocyte
groups. Various pilot studies with such novel monoclonal
antibodies are under way.
2.2.2.2 Fingolimod Fingolimod (Gilenya�, Novartis,
Switzerland) modulates sphingosine-1-phosphate (S1P)
receptors and has strong immunoregulatory properties
[230]. In lymphocytes, S1P1 receptor internalization
appears to be a crucial step in their migration process. The
resulting neutralization of the S1P1 pathway does not
reduce lymphocyte activation but inhibits the egress of T
cells and B cells from the lymph nodes. Fingolimod
reduces the number of circulating memory T cells,
including those producing IL-17 cells (Th17 cells) by more
than 90 % [231].
Because fingolimod is lipophilic, it readily enters the
CNS, where it can bind to several S1P receptor subtypes on
different cell types, possibly leading to not well understood
neuroprotective effects. Fingolimod very efficiently sup-
pressed EAE [232]. Pilot clinical trials have indicated that
fingolimod is a highly effective treatment for RRMS. In a
6-month phase II, proof-of-concept randomized trial, 281
patients with active relapsing MS were given a single dose
of placebo or fingolimod 1.25 mg/day or 5.0 mg/day [233].
The numbers of gadolinium-enhancing MRI lesions were
reduced in the fingolimod groups compared with the pla-
cebo group. The relative reduction in ARR was 53 % in the
high-dose fingolimod group and 55 % in the low-dose
group.
The results of two phase III studies in patients with
RRMS (FREEDOMS, a placebo-controlled 24-month trial,
and TRANSFORMS, a 12-month trial with a comparator
IFNb-1a) showed similar to the phase II studies efficacy of
fingolimod over placebo, a clear superiority over IFNb-1a
and an acceptable safety profile. The US Food and Drug
Administration (FDA) approved fingolimod as first-line
treatment for RRMS, whereas the European Medicines
Agency (EMA) restricted its use as a second-line treatment
or a first-line treatment in patients with active disease.
A total of 1,272 patients with relapsing MS participated
in the FREEDOMS study [234] and 1,033 completed the
follow up. Compared with placebo, ARR (the primary
endpoint) was reduced by 60 % in the fingolimod 1.25 mg
group and by 54 % in the 0.5 mg group. Fingolimod also
significantly reduced the cumulative probability of the
3-month confirmed progression, according to the EDSS
(hazard ratio vs placebo 0.68 in the high-dose fingolimod
group and 0.70 in the low-dose fingolimod group). Addi-
tionally, the superiority of both fingolimod doses compared
with placebo was confirmed in all secondary MRI-related
endpoints.
There were no differences in the number of patients with
adverse events in the different study groups. Adverse
events related to fingolimod included bradycardia and
atrioventricular conduction block during the start of fin-
golimod administration, macular edema, elevated liver
enzyme levels, lymphocytopenia, and hypertension.
A total of 1,292 patients with active RRMS were
enrolled in the TRANSFORMS study [235], another phase
III trial. The duration of the core study was 12 months.
Participants were randomly assigned in a double-blind
manner to fingolimod 1.25 mg/day or 0.5 mg/day or to
IFNb-1a once a week. ARR was 0.33 in the IFNb-1a
group, 0.20 in the high-dose fingolimod group, and 0.16 in
the low-dose fingolimod group. Secondary MRI outcome
measures confirmed significant differences in favor of
fingolimod. No differences in the number of adverse events
between study groups were noted. Serious adverse events
and events leading to interruption of treatment, however,
arose most frequently in the high-dose fingolimod group.
Two patients died during treatment with high-dose fingo-
limod—one from a disseminated primary varicella zoster
infection and the other from herpes simplex encephalitis.
The 1-year extension of TRANSFORMS, in 882 par-
ticipants who completed 24 months of follow up, showed
persistent reductions in ARR in patients treated continu-
ously with fingolimod, whereas in those who were initially
given IFNb-1a, the ARR was significantly lower after
switching to fingolimod than in the initial year of the trial
[236].
Fingolimod treatment causes significant lymphopenia
but its effects on circulating lymphocytes are reversible,
with cell counts returning to normal within 4–6 weeks after
cessation of treatment. Safety issues including heart rate
changes, risk of herpes virus dissemination, macular
edema, elevated blood pressure, and the risk of cancer,
should be carefully considered. Long-term safety data are
warranted.
D. Karussis
Further trials, including one in patients with PPMS, are
under way.
2.2.2.3 Teriflunomide Teriflunomide is the active
metabolite of leflunomide [237], which is approved for use
in patients with rheumatoid arthritis. It reduces the activity
of the mitochondrial enzyme dihydroorotate dehydroge-
nase, which is crucial in pyrimidine synthesis. T-lympho-
cyte proliferation largely depends on pyrimidine synthesis.
However, because the drug induces only a small degree of
lymphocytopenia, these processes only partly account for
its effects. The results of a phase II trial of teriflunomide in
patients with relapsing MS showed a reduction in active
lesions on brain MRI scans [238]. The long-term follow-up
of the patients in this phase II study [239] further supported
the beneficial effect of the drug. A total of 147 patients
entered the open-label, 8-year extension phase: 42.2 % of
the patients discontinued the medication (9 % due to
treatment-emergent adverse events [TEAEs]). The most
common TEAEs were mild infections, fatigue, sensory
disturbances, and diarrhea. No serious opportunistic
infections occurred, with no discontinuations due to
infection. The annualized relapse rates remained low and
minimal disability progression was observed, with a dose-
dependent benefit with teriflunomide 14 mg for several
MRI parameters.
In a recent 2-year, randomized, controlled, phase III trial
(TEMSO) in 1,088 patients with active RRMS [240], both
teriflunomide doses (7 mg or 14 mg) significantly lowered
the ARR, with an RRR compared with placebo of 31.2 %
for the lower dose and 31.5 % for the higher dose. At
12 weeks, confirmed EDSS worsening was reduced by
29.8 % with teriflunomide 14 mg. The superiority of the
drug versus placebo was confirmed for a range of MRI
endpoints (39 % reduction in new lesion formation in the
7 mg, and 67 % in the 14 mg group). Both teriflunomide
doses were well tolerated, although diarrhea, nausea, and
liver enzyme elevation were recorded. Teriflunomide has
been suggested to have teratogenic, hepatotoxic, and bone
marrow suppressive effects.
Preliminary results from the TENERE head-to-head trial
revealed no statistical superiority between the Rebif� and
teriflunomide arms (7 mg and 14 mg) on risk of treatment
failure, the primary composite endpoint of the study. The
drug with the trade name Aubagio�, was recently licensed
by the FDA.
2.2.2.4 Laquinimod Laquinimod is a derivative of lino-
mide (Roquinimex�), which effectively suppressed EAE
and had a strong clinical effect in MS [32–34, 241, 242].
However, a phase III trial with linomide had to be termi-
nated because of unforeseen safety concerns [243]. Laqu-
inimod appears to be much better tolerated than linomide.
It seems to mediate its effects through downregulation of
antigen presentation, modulation of the pro-inflammatory
immune responses (induction of a cytokine shift towards
Th2 and Th3 cytokines) and interference with cell traf-
ficking, as well as possibly acting directly in the CNS to
limit demyelination and axonal injury [244]. The results of
two phase II studies showed that laquinimod reduced MRI-
monitored disease activity, based on assessment of the
number of gadolinium-enhancing T1 lesions and new T2
lesions, in patients with RRMS. The results of the first
clinical trial showed a 44 % reduction in the number of
active lesions at weeks 0–24 in patients treated with la-
quinimod 0.3 mg compared with placebo. In the second
study, the 0.6 mg dose resulted in a reduction of 40 % in
the number of gadolinium-enhancing T1 lesions in the last
4-monthly scans compared with placebo, whereas the
0.3 mg dose did not show any evidence of efficacy [245].
A total of 239 (93 %) patients completed an extension of
the phase IIb trial [246]. The number of gadolinium-
enhancing T1 lesions was reduced by 52 % in patients
switching from placebo to either dose of the active drug,
confirming the efficacy results of the core study.
The recently published phase III ALLEGRO study [247]
showed a 23 % reduction in ARR in the laquinimod group.
Additionally, the cumulative probability of 3-month con-
firmed EDSS worsening was reduced by 36 %. Laquini-
mod reduced the mean cumulative number of gadolinium-
enhancing lesions by 37 % and the mean cumulative
number of new T2 lesions by 30 %. Moreover, laquinimod
was associated with a 33 % reduction in the loss of brain
volume over 2 years and proved safe and well tolerated.
The most commonly reported adverse events were gastro-
intestinal side effects and back pain. The incidence of liver
enzyme elevation was higher in laquinimod-treated
patients. However, these elevations were transient,
asymptomatic, and reversible.
In a second phase III study (BRAVO), laquinimod at
0.6 mg was compared with placebo and IFNb-1a in about
1,200 patients with RRMS. The primary endpoint, reduc-
tion in ARR for laquinimod versus placebo, was not sig-
nificant, but secondary endpoints showed indications of
efficacy: a significant reduction in EDSS progression
(33.5 %) and in loss of brain volume (27.5 %).
These studies do support a mild beneficial effect of la-
quinimod in RRMS (probably somehow lower than that
observed with linomide) and may raise the question of
possible increased efficacy with a higher dose of the drug.
2.2.2.5 Dimethyl-fumarate (BG12) BG-12 is an oral
formulation of dimethyl fumarate. Both dimethyl-fumarate
and its primary metabolite, monomethyl-fumarate, induce
activation of the nuclear factor E2-related factor-2 path-
way, which protects against oxidative stress-related
Immunotherapy of MS
neuronal death and damage to myelin in the CNS. Several
neuroprotective and anti-inflammatory mechanisms have
been attributed to the drug, such as the expression of phase
II detoxification enzymes in astroglial and microglial cells
and a drug-induced shift towards a more anti-inflammatory
cytokine profile (induction of Th2-type cytokines and type
II dendritic cells) and adhesion molecule expression [248,
249]. In a pilot study in patients with RRMS, an oral for-
mulation of fumaric acid (Fumaderm�, Biogen Idec),
approved in Germany for the treatment of psoriasis,
reduced the number of gadolinium-enhancing lesions in
brain MRI scans [250].
Subsequently, three doses of BG-12 were tested against
placebo in a phase IIb study in 257 patients with RRMS
[251, 252]. Compared with placebo, BG-12 at 240 mg
three times daily reduced the number of gadolinium-
enhancing, new T2 and T1 lesions from week 12 to 24 by
69 %. A recently concluded phase III trial (DEFINE)
including 1,200 patients showed that BG-12 at 240 mg
twice or three times daily reduced by 49 % the proportion
of patients who relapsed, the ARR by 53 %, the number of
gadolinium-enhancing lesions by 90 %, and of new or
enlarging T2 lesions by 85 % compared with the placebo
group. The cumulative probability of 3-month confirmed
EDSS worsening was 38 % lower. No new significant
safety issues were reported.
2.2.2.6 Vaccines
2.2.2.6.1 T-cell Vaccination. The concept of T-cell vac-
cination (TCV) was first introduced in 1981 in the EAE rat
model, using activated and irradiated MBP-specific T-cell
lines and clones [253]. The rationale was that vaccination
with attenuated myelin-responsive T cells should induce an
immune response against those cells which are probably
the ones responsible for the inflammation and demyelina-
tion in MS. TCV was found to suppress EAE and induced
the production of regulatory T cells (CD4 or CD8) specific
for the anti-myelin T-cell receptors of the vaccine T cells—
anti-idiotypic regulation [254].
There are at least seven different, small, phase II
clinical trials with TCV at various stages of MS already
reported in the literature [255–260] and six additional
studies that are in progress or have been recently com-
pleted, but not yet reported (reviewed by Vandenbark and
Abulafia-Lapid [261]. These studies showed a consistent
reduction in MBP-specific T cells following TCV and
revealed some indications of clinical efficacy, as reflected
by the prolongation of the time to EDSS progression in
both the RRMS and the SPMS patients. In another open-
label TCV study, 20 RRMS patients were vaccinated with
MBP and MOG (panel of peptides) T-cell lines with
similar results [262].
Our group recently performed a double-blind, sham-
controlled clinical trial with TCV in 26 progressive MS
patients, using multiple autologous injections of a mixture
of attenuated T-cell lines reactive to three or more myelin
peptides. This study, which is the first controlled, double-
blind trial with TCV in progressive MS, demonstrated the
feasibility and safety of TCV in MS, and provided signif-
icant indications of clinical efficacy. The changes in EDSS
and relapse rates were significantly better in the TCV
group. Of the 17 patients in the TCV group, 16 (94.3 %)
were relapse-free during the year of study [304].
2.2.2.6.2 T-cell Receptor Vaccination. A similar
approach to TCV is to vaccinate with only the relevant
anti-myelin antigen- responsive TCR and not the whole T
cells. Based on a meta-analysis of 1,000 genes from
myelin-specific T cells from MS subjects, TCR genes/
proteins were identified as candidate epitopes for vacci-
nation. On the basis of successful therapeutic vaccination
in the EAE model, a trivalent TCR vaccine using three
CDR2 peptides emulsified in incomplete Freund’s adjuvant
were developed. Several blinded studies using both single
and multiple TCR peptides demonstrated that TCR vacci-
nation could induce high frequencies of TCR-specific T
cells, along with indications of clinical benefit. TCR-spe-
cific T cells that are expanded by vaccination in vivo may
include a mixture of regulatory cell types, including Th2,
Th3, and Tr1 cells [263].
In a small open trial, a TCR peptide vaccine from the V
beta 5.2 sequence (which is expressed in MS plaques and
on MBP-specific T cells) boosted peptide-reactive T cells
in patients with progressive MS. Vaccine responders had a
reduced MBP response and remained clinically stable
without side effects during 1 year of therapy, whereas
nonresponders had an increased MBP response and pro-
gressed clinically. Peptide-specific Th2 cells directly
inhibited MBP-specific Th1 cells in vitro through the
release of IL-10, implicating a bystander suppression
mechanism that holds promise for treatment of MS and
other autoimmune diseases [264].
2.2.2.6.3 Altered Peptide Vaccination. The concept of
partial activation of T cells by stimulation of TCR with
peptide analogs of antigens evolved in the early 1990s to
that of altered peptide ligands (APLs) [265]. Two phase II
trials using APL vaccination came out simultaneously in
2000. The larger, placebo-controlled, multicenter trial,
using three weekly subcutaneous injections of the altered
peptide NBI-5788 (5, 20, and 50 mg), planned to include
144 patients [266]. The trial was discontinued because of
the appearance of hypersensitivity reactions, mainly at
higher doses of APL. MRI analysis of the patients who
completed the trial showed a reduction of MRI activity at
D. Karussis
the lower (5 mg) dose of APL. Immunologically APL-
reactive T cells of the Th2 phenotype, which were cross-
reactive with the native MBP peptide, were detected. In a
smaller trial using only the higher dose (50 mg) of APL, in
which eventually only eight patients were enrolled, treat-
ment-related exacerbations led to its termination [267].
Considering the group as a whole, there were no clinical or
MRI differences before and after treatment with APL and
the treatment actually led to an increase in APL-reactive
T-cell lines, which were mainly skewed towards a Th1
phenotype.
2.2.2.7 Oral Tolerization with Myelin A unique approach
for specific downregulation of the myelin-reactive lym-
phocytes, which are considered the main responder cells
for the induction of demyelination, is oral tolerization
techniques. Based on animal studies [268, 269] and on the
recognition that oral administration of low doses of antigen
is an effective way of inducing tolerance, via the induction
of regulatory T cells capable of secreting Th2 and Th3
cytokines, trials of oral administration of bovine myelin
were initiated in the early 1990s. Administering whole
myelin had the advantage of circumventing the need to
identify the antigenic target for each particular patient. An
initial small-scale, 1-year, single-center, double-blind trial
with 30 early RRMS patients showed a trend to better
clinical outcomes, a reduction in MBP-reactive T cells in
myelin-treated patients, without any adverse effects [270].
A later study on patients in the continuation phase I/II trial
detected the presence in the peripheral blood of increased
frequencies of MBP and PLP-reactive T-cell lines with a
Th3 regulatory phenotype [271].
However, the phase III trial including 515 RRMS
patients did not confirm the efficacy of this therapy,
although only a single oral dose of myelin (300 mg, con-
taining 8 mg of MBP and 15 mg of PLP) was given, and a
large placebo effect was observed.
A different approach, the administration of synthetic
peptides derived from the sequence of myelin basic protein,
by intrathecal and intravenous routes, was used in an
attempt to tolerize patients. No adverse effects were
reported in two initial phase I trials with MBP peptides
75–95 [272, 273] in chronic progressive MS patients and
tolerance was inferred based on the reduction in CSF anti-
MBP antibodies, only after intravenous administration of
MBP85–96. A larger follow-up study using the MBP82–98
epitope included 56 patients, of which 41 received multiple
intravenous injections of MBP. Of the treated patients, 16
(39 %) failed to achieve long-term suppression of their
antibody levels, whereas 15 (36 %) achieved supression for
up to 1 year [274]. Unfortunately, no clinical or imaging
data were reported in these studies.
Finally, a multicenter study evaluated the safety, toler-
ability, and efficacy of a solubilized complex of DR2:
MBP84–102, which had been shown to reduce the prolif-
erative capacity of anti-MBP human T-cell lines, admin-
istered via three intravenous infusions in 33 SPMS patients
[275].
In the primary outcome measure—safety—there was an
exacerbation of MS in the low dose (2.0 mg/kg) group. All
clinical and MRI measures of efficacy did not show any
differences between the treatment and the placebo groups.
There was also no convincing evidence of reduced reac-
tivity to MBP or MOG peptides.
2.2.2.8 Stem Cells
2.2.2.8.1 Hematopoietic Stem Cell Transplanta-
tion. Hematopoietic stem cell transplantation (HSCT) for
MS (and autoimmune diseases in general) is based on the
principle of radical suppression of the immune system to
abrogate the inflammatory pathogenetic process in MS and
subsequently reset the immune system from scratch. The
autologous setting is usually used, where the immune
system is reconstituted by the patient’s own stem cells. The
rationale for this type of therapeutic approach in MS
derives from pivotal animal studies performed back in the
early 1990s [276, 277]. Open, uncontrolled clinical trials
have shown impressive effects on the suppression of
inflammation, induction of remission, and stabilization of
MS [278–281]. Worldwide, more than 500 patients with
MS have been treated with HSCT (reviewed by Karussis
and Vaknin-Dembinsky [282]). The different conditioning
protocols used in these studies complicate the uniform
interpretation of the data. In general, over the last 15 years,
more than 1,500 patients have received HSCT, mostly
autologous, for treatment of severe autoimmune diseases
(MS, systemic sclerosis, SLE, rheumatoid arthritis, juvenile
idiopathic arthritis and idiopathic cytopenic purpura). In
MS, an overall 85 % 5-year survival rate and 43 % pro-
gression-free survival have been recorded, with mean
100-day transplantation-related mortality ranging from 1 %
to 5 %. About 30 % of the patients had a complete
response, often durable despite full immune reconstitution.
2.2.2.8.2 Other Stem Cells. Pivotal studies with neuronal
stem cells have shown a significant beneficial clinical
effect in mice with EAE (the animal model of MS) [283–
285]. Subsequently, embryonic and other types of adult
stem cells, especially mesenchymal stem cells, were tested
in various models of EAE [286–288]. MSC injection, either
intravenous or into the CSF, strongly suppressed the clin-
ical and pathological signs of EAE and reversed disability.
Most importantly, remyelination was evident in these
Immunotherapy of MS
MSC-treated animals, accompanied by impressive neuro-
protection [288].
The additional scientific rationale for using MSC in EAE
and MS derives from the reported strong immunomodula-
tory effects of these cells [289–291]. Phase I/II safety
studies with MSC or bone marrow-derived cells have been
performed in MS [282, 292]. Overall, MSCs given intra-
venously or intrathecally were well tolerated, with some
preliminary evidence of efficacy [282]. In the latter study,
from our group, MSC were labeled with paramagnetic iron
particles and hypointense signals were detected in the cer-
vical spine MRI, providing some indication of the migration
of the injected cells into the CNS parenchyma. In addition,
in vivo immunomodulatory effects were shown to be
induced in these MSC-injected patients [282].
A more recent phase IIa study [293] in ten patients with
secondary progressive MS showed an improvement in
visual acuity and visual evoked response latency,
accompanied by an increase in optic nerve area, following
intravenous transplantation of autologous MSC. Although
no significant effects on other visual parameters, retinal
nerve fiber layer thickness, or optic nerve magnetization
transfer ratio were observed, this study provides a strong
indication of induction of tissue repair with MSC trans-
plantation in humans.
3 A Suggested Algorithm for MS Immunotherapy
MS is not an homogenous disease and distinct types of
immune pathogenesis seem to be involved in different
subgroups [12]. Its course and prognosis greatly varies
among patients. It would be therefore too pretentious to
suggest a common treatment algorithm that could fit all the
patients with MS. The use of neuroimaging markers (such
as the type, the number and activity of the lesions in MRI at
CIS
Highly active disease in MRI
McDonald criteria +Clinical-MRI
follow up every 3-6 m
McDonald criteria -
RIS
BIOMARKERS (OCB, anti-glycans etc)
Low activity in MRI
CDMS
Glatiramer acetate
High-dose IFNβ
Low-dose IFNβ
natalizumab, fingolimod, teriflunomide, light immunosuppressants (azathioprine, lowdose methotrexate,mycophenolate), chronic steroids,
plasmapheresis
Sub-optimal response or side
effects
Sub-optimal response or side effects
Sub-optimal response or side-effects or JCV abs
positivity
FIRST-LINE IMMUNOTHERAPIES
SECOND-LINE IMMUNOTHERAPIES
More aggressive immunosuppression: mitoxantrone, cyclophosphamide, other monoclonal antibodies (anti-
CD20, anti-CD52)
THIRD-LINE IMMUNOTHERAPIES
Experimental modalities/Clinical trials : TCV, laquinimod, HSCT, stem cells, etc
First line immunotherapies plus immunosuppressants
or steroids
COMBINATION IMMUNOTHERAPY
RESCUE IMMUNOTHERAPY
Sub-optimal response or side
effects
natalizumab, mitoxanthrone, steroid pulses, plasmapheresis, cyclophosphamide,
alemtuzumab, rituximab
MAINTENANCEIMMUNOTHERAPY
Active disease-fast prgression
Slowly progressive disease
azathioprine, steroid pulses, plasmapheresis, natalizumab
alemtuzumab, rituximab
Progressive MS
Highly active disease-with
relapses
Low activity
with relapses
Fig. 3 A suggested treatment algorithm for multiple sclerosis (MS)
immunotherapy. CDMS clinically definite MS, CIS clinically isolated
syndrome, HSCT hematopoietic stem cell transplantation, IFNbinterferon beta, JCV John Cunningham virus, MMF mycofenolate
mofenil, MTX methotrexate, NMO neuromyelitis optica, OCBoligoclonal antibodies, RIS radiologically isolated syndrome, TCVT-cell vaccination
D. Karussis
the early stages of MS) [294–296] and immunological bio-
markers (such as the presence of oligoclonal antibodies in the
CSF and anti-myelin antibodies and anti-glycan antibodies in
the serum, at the first stages of MS) [297–300] would help to
tailor/personalize immunotherapy for each individual case.
For instance, patients with type II MS immunopathogenesis,
i.e. more prominently antibody-mediated disease, or with the
neuromyelitic variants of demyelination (NMO spectrum of
demyelination, associated with anti-aquaporin antibodies),
may not only not respond well but even deteriorate under
some of the first-line treatments (such as IFNs). The unique
spinal cord extensive lesions in the NMO spectrum of
demyelinating diseases may also help to distinguish these
cases from classical MS. It would be therefore crucial to use
immunological and imaging biomarkers, not only to correctly
diagnose these MS variants, but also to identify the patients
with CIS or RIS who, according to their MRI findings, have
greater risks for disability progression (worse prognosis) or,
on the contrary, to predict a benign MS course. This will allow
the very early introduction of immunotherapy only in the
patients where such an early intervention is justified.
A summary of the existing knowledge from published and
ongoing trials and suggestions of some common treatment
recommendations is presented in Fig. 3. This ‘algorithm’
with all the above-mentioned reservations is also based on
previously published recommendations formulated by
expert forums (some of which the author of this review has
participated in) [301], and in which a suboptimal response to
therapies was defined and a treatment-escalation model for
the management of patients with such insufficient response
was suggested [301, 302]. This model is based on the prin-
ciple of starting with a ‘first-line’ treatment (IFNb or GA)
and then, if the response is not sufficient, escalate first to a
higher dose of IFN, then to natalizumab or fingolimod, and/
or to immunosuppressive medications. The suggested algo-
rithm incorporates an additional option for the severe MS
cases, that of short-term aggressive immunotherapy (cyclo-
phosphamide, mitoxanthrone, natalizumab, alemtuzumab,
rituximab, HSCT) followed by maintenance treatment with
the regular modalities as in the previous scheme. As already
mentioned, early treatment of CIS and RIS should be based
on identification of the patients with poor prognosis. Con-
cerning progressive MS, indications from the IFN (and
other) studies support the conception of dividing the pro-
gressive MS patients into those with active inflammatory
disease (manifested either by clinical relapses or by pro-
gression in disability or active lesions in MRI) and those with
no active inflammation (chronic, purely degenerative phase,
usually secondary to the inflammatory one; ‘burnt-out dis-
ease’). In the first group, it seems that immunotherapy
strategies may be more effective and in general should target
the putative compartmentalized inflammation, and espe-
cially B cells.
4 Conclusions
Until 1993, no specific immunotherapy was registered for
MS. Since the introduction of IFNb, huge steps have been
made and increasingly more specific and efficious (Fig. 2)
modalities have been introduced and registered. However,
along with the seemingly increasing efficacy of the newly
introduced and more targeted immunotherapies, more
safety issues have arisen. The cumulative experience
obtained from the numerous clinical trials in MS with
various types of immunotherapies allows one to draw the
conclusion that inflammation, most probably initiated in
the peripheral immune system, is crucial for the formation
of new demyelinating lesions and, with time, appears to be
the main cause for the resulting axonal damage and neu-
ronal tissue atrophy. Immunological therapies, ideally
applied as early as possible, might, therefore, prevent
progression of disability if given before the cascade of
events leading to irreversible tissue loss. The reported
lower efficacy of most of the known immunotherapies in
patients with progressive forms of MS might be explained
by the possibility that inflammation is less pronounced or
only compartmentalized in the CNS at these stages of the
disease. More effective modalities that exert strong local
immunomodulation in the CNS might be more beneficial
for progressive MS. The additional goals of future MS
therapy should include neuroprotective modalities and
techniques that may enhance neuroregeneration and re-
myelination. High expectations of this direction are
focused on stem cell-related treatments, but these have to
be substantiated in future controlled trials.
Disclosures Prof. Karussis has received honoraria from Biogen,
Teva, Serono, Novartis and Bayer for lectures. He has no conflicts of
interest that are directly relevant to the content of this article.
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