Author Topic: (ECTRIMS) Plasma exchange and steroids in PML management  (Read 15 times)

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Offline agate

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(ECTRIMS) Plasma exchange and steroids in PML management
« on: September 21, 2016, 10:41:56 am »
 There are often questions wondering how those people who developed PML while taking Tysabri got along. This paper, presented at the annual ECTRIMS conference in London (September 14-17), gives a few clues:

Quote
To do or not to do? Plasma exchange and steroids in progressive multifocal leukoencephalopathy management

C. Scarpazza1, N. De Rossi1, C. Cordioli1, S. Gerevini2, R. Capra1, Italian PML Cohort Consortium

1Spedali Civili of Brescia, Brescia, 2San Raffaele Scientific Institute, Milano, Italy

Background:

 Progressive Multifocal Leukoencephalopathy (PML) is an uncommon side effect caused by the JC virus, emerging in natalizumab-treated multiple sclerosis (NTZ-MS) patients. Immune restoration at NTZ withdrawal often causes an Immune Reconstitution Inflammatory Syndrome (IRIS), which causes additional damage of the nervous tissues.

Goals:

To evaluate the impact of Plasma Exchange (PLEX) and use of steroids on the PML and PML-IRIS course.

Methods:

Clinical and MRI data of 40 patients who developed PML were retrospectively collected from 28 Italian sites. The data were centrally reviewed and established IRIS according with definite criteria was identified in each patient by two neuroradiologists and two neurologists. Patients' clinical course (measured with longitudinal EDSS score at NTZ beginning, i.e. baseline, PML onset, month 2, month 6 and month 12 follow-ups) was analyzed in the context of PLEX and steroids administration.

Results:

The survival rate was 92.5%. The number of viral copies in the CSF is highly correlated with the Δ EDSS from PML onset to month 6 follow-up (r=0.50, p=0.002).

Twenty-nine out of 40 patients (72.5%) manifested IRIS. Patients were divided into two groups basing on whether or not they were submitted to PLEX (PLEX+ and PLEX-, respectively). Their EDSS at baseline did not differ (t=0.28, p=0.77); no difference was found between the groups for the EDSS (mixed ANOVA Group x Time - non significant Group x Time interaction, p=0.23).

 However, PLEX speeds up IRIS (t=-2.19, p=0.03) and increases its duration (t=1.8, p=0.08).

Subsequently, patients were divided into two groups basing on whether the steroids were administered prior to  (NoIrSt) or during (IrSt) the established IRIS. A mixed ANOVA Group x Time (using PLEX and lesion size as covariates) revealed a Group x Time interaction (F[3,81]=2.77, p=0.04). Post hoc test revealed that NoIrSt EDSS scores worsened in the first months after diagnosis (p=0.002) and remained stable at 1 year follow-up (p=0.003), while the IrSt EDSS score did not significantly change over time (p>0.16).

The use of steroids [had no impact either] on the time elapsed between NTZ withdrawal and IRIS onset (t=-0.109, p=0.91), or on IRIS duration (t=-0.640, p=0.52).

Conclusions:

In this cohort, PLEX did not improve the clinical outcome and steroids administered [after] IRIS onset are associated with negative disability progression.

Disclosure:
Dr. De Rossi received speaker honoraria from Biogen and Teva and travel grants from Biogen, Teva and Merk Serono.
Dr. Cordioli received consulting fees from Novartis and Merk Serono.
Dr. Gerevini received speaker honoraria from Biogen-Idec.
Dr. Capra received consulting fees from Novartis, Biogen-Idec and lecture fees and/or travel grants from Novartis, Biogen-Idec, Genzyme and Sanofi-Aventis.
Dr. Scarpazza has nothing to disclose.





SPMS, diagnosed 1980. Avonex 2001-2004. Copaxone 2007-2010.

 

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