switching therapy: sins santiago 2014
DESCRIPTION
My slides from a talk to Chilean neurologists on switching DMTs.TRANSCRIPT
SWITCHING THERAPIES
CONSIDERATIONS REGARDING ALEMTUZUMAB
Professor Gavin Giovannoni
Blizard Institute, Barts and The London School of Medicine and Dentistry
Disclosures
Professor Giovannoni has received personal compensation for participating on
Advisory Boards in relation to clinical trial design, trial steering committees and
data and safety monitoring committees from: Abbvie, Bayer-Schering Healthcare,
Biogen-Idec, Canbex, Eisai, Elan, Fiveprime, Genzyme, Genentech, GSK, GW
Pharma, Ironwood, Merck-Serono, Novartis, Pfizer, Roche, Sanofi-Aventis,
Synthon BV, Teva, UCB Pharma and Vertex Pharmaceuticals.
Professor Giovannoni would like to acknowledge and thank Genzyme for making
available data slides on alemtuzumab for this presentation.
No evident disease activity: NEDA
Gd, gadolinium. 1. Havrdova E, et al. Lancet Neurol 2009; 8:254–260; 2. Giovannoni G, et al. Lancet Neurol 2011; 10:329–337.
Treat-2-target
No evidence of disease activity defined as:1,2
× No relapses
× No sustained disability progression
× No MRI activity
× No new or enlarging T2 lesions
× No Gd-enhancing lesions
Treating-2-target
Choosing therapy
X Y Z
Define the
Individual’s MS
No
Treatment failure? Yes
• Patient’s preferences?
• Your choice?
Individual measures:
• Evidence of disease activity?
• Tolerability/safety?
• Adherence?
• Drug or inhibitory markers?
Monitoring
• MS prognosis
• Life style and goals
• Shared goals for therapy
Rebaseline
Rebaseline:
• IFNβ, natalizumab, fingolimod,
teriflunomide, DMF=3-6 months
• Glatiramer acetate=9 months
• Alemtuzumab=24 months
DMF=dimethyl fumarate.
Alemtuzumab for the treatment of RRMS
• Alemtuzumab is indicated for adult patients with
relapsing remitting multiple sclerosis (RRMS) with
active disease defined by clinical or imaging
features1.
• Alemtuzumab is a humanized monoclonal antibody
that selectively targets CD52, a protein abundant
on the surface of B and T lymphocytes2
• A phase 2 & 3 clinical trial program was
implemented to establish efficacy and safety in MS
patients
• Completed 3 head-to-head trials vs. high-dose
subcutaneous interferon beta-1a (SC IFNB-1a)
in patients with active relapsing-remitting
multiple sclerosis (RRMS) 3-6
1. SMPC – EMA label; 2. Hu Y et al. Immunology 2009;128:260-70; 3. Coles AJ et al. N Engl J Med 2008;359:1786-801; 4. Coles AJ et al. Lancet
2012;380:1819-1828; 5. Coles AJ et al. Lancet 2012;380(1829-1839); 6. Brinar V et al. Presented at 21st Meeting of the European Neurological
Society, 2011.
CARE-MS II: Subgroup analysis by previous DMT use
• CARE-MS II study enrolled patients with relapsing-remitting MS
(RRMS) who had experienced continued disease activity on
disease-modifying therapies (DMTs)
Patient Subgroups According to DMT Type, or Number of Courses
Freedman MS, et al. Presented at ECTRIMS; 2012; France; P483.
Efficacy outcomes - Relapses Relapse Rate in Patients Stratified by Prior DMT Usage
• Alemtuzumab was superior to SC IFNB-1a at reducing relapse rate
regardless of the type of prior therapy
• The patient group who received SC IFNB-1a prior to study entry had
a higher relapse rate, if treated with SC IFNB-1a, than those who
had no prior SC IFNB-1a use
Freedman MS, et al. Presented at ECTRIMS; 2012; France; P483.
Efficacy outcomes - Relapses Relapse Rate in Patients Stratified by (A) Median Duration of Prior DMT Use and (B)
Number of Prior DMT Courses
• Alemtuzumab was superior to SC IFNB-1a at reducing relapse rate
regardless of the duration of the previous treatment or the number of prior
DMT courses (1 or ≥2)
• The patient group who received more than 1 DMT course prior to study
entry had a higher relapse rate, if treated with SC IFNB-1a, than those who
had just 1 prior DMT course
Freedman MS, et al. Presented at ECTRIMS; 2012; France; P483.
Efficacy outcomes - Sustained Accumulation of Disability
Freedman MS, et al. Presented at ECTRIMS; 2012; France; P483.
SAD in Patients Stratified by Prior DMT Usage
• Alemtuzumab showed a consistent trend toward greater efficacy than SC
IFNB-1a in reducing the risk of SAD regardless of the type of previous
treatment
Freedman MS, et al. Presented at ECTRIMS; 2012; France; P483.
Sustained Accumulation of Disability in Patients Stratified by (A) Median Duration of Prior
DMT Use and (B) Number of Prior DMT Courses
• Alemtuzumab showed a consistent trend toward greater efficacy than SC
IFNB-1a in reducing the risk of SAD regardless of the the duration of prior
DMT use or number of prior DMTs
Efficacy outcomes - Sustained Accumulation of Disability
Previous treatment with Natalizumab
• The number of adverse events among patients who received
natalizumab prior to study entry is too small to draw any
meaningful conclusions
• In patients with prior natalizumab use:
• Relapses occurred in 4 of 7 SC IFNB-1a and 5 of 15
alemtuzumab 12 mg patients
• SAD occurred in 0 of 7 SC IFNB-1a and 1 of 15
alemtuzumab 12 mg patients
Freedman MS, et al. Presented at ECTRIMS; 2012; France; P483.
Important considerations
• Switching from natalizumab
• Carry-over PML
• Rebound post-alemtuzumab
• Switching from fingolimod
• Persistent lymphopaenia
• Rebound post-fingolimod
• Switching from other agents
• Persistent lymphopaenia
BARTS-MS www.ms-res.org
Switching from Nz to Az
Natalizumab
Natalizumab
Alemtuzumab
Asymptomatic PML? LP-JCV DNA & MRI
Alemtuzumab
Natalizumab Alemtuzumab Oral bridging agent (Teriflunomide, DMF or Fingolimod)
Rebaseline MRI **
Asymptomatic PML? LP-JCV DNA & MRI
3-6 MONTH WASHOUT
Asymptomatic PML?* LP-JCV DNA & MRI
Rebaseline MRI
Option 1: Immediate switch (high risk if carry-over PML develops)
Option 2: Washout (intermediate risk; mainly related to rebound of MS disease activity)
Option 3: Bridging (low risk; mainly related to using a low efficacy bridging agent and using alemtuzumab after the bridging agent)
6-12 MONTHS
* For this option the shorter the washout the more important the screen for asymptomatic PML becomes. ** PML screening and baseline MRI studies are don’t use the same types of scans hence the need for both.
Temporal profile of lymphocyte counts with fingolimod therapy
Francis et al. MSJ 2013
Switching from Fingo to Az
Fingolimod
Fingolimod
Alemtuzumab
Alemtuzumab
Fingolimod Alemtuzumab Bridging agent (IFN-beta, GA, Teriflunomide or DMF)
Only treat with alemtuzumab once lymphocyte counts normalize*
2 to 6 12 MONTH WASHOUT
Only treat with alemtuzumab once lymphocyte counts normalize*
Option 1: Immediate switch (high-risk if persistent lymphopaenia occurs)
Option 2: Washout (intermediate risk; mainly related to rebound of MS disease activity)
Option 3: Bridging (low risk; mainly related to MS rebound as a result of using a low efficacy bridging agent after fingolimod)
3-12 MONTHS
* What constitutes a normal level post-fingolimod needs to be defined; I would be reluctant to give alemtuzumab to anyone with a total lymphocyte count below 1.0x109 .
Treat with alemtuzumab before lymphocyte counts normalize
* What constitutes a normal level in this situation needs to be defined; I would be reluctant to give alemtuzumab to anyone with a total lymphocyte count below 1.0x109 .
Questions