Eculizumab treatment has raised the special concern of meningococ

Eculizumab treatment has raised the special concern of meningococcal infections [27]. Data on specific biomarkers for most of the agents described are widely lacking. Repopulation of B cells via find protocol detection of CD19+ and CD20+ cells is sometimes used to determine reinfusion intervals for rituximab treatment, as it may be correlated with disease activity [103]. FTY entails peripheral immunomodulatory effects and direct interactions within the CNS resulting from modulation of sphingosin-phosphate receptors (S1PR) [104]. Approval of Gilenya® for treatment of RRMS differs substantially between FDA and EMA [105, 106], reflecting divergent evaluations of its risk–benefit

profile. Whereas, in the United States, FTY is approved as first-line therapy, in the European Union it is considered second-line therapy predominantly after a failure of IFN-beta or glatirameracetate. This approach is supported, at least in part, by subgroup

analyses of the TRANSFORMS (TRial Assessing injectable interferoN vS FTY720 Oral in RrMS) study, especially for patients with high disease activity on IFN-beta therapy [107]. Ongoing studies investigate the use of FTY in PPMS ( NCT00731692), in paediatric MS ( NCT01892722) and in CIDP ( NCT01625182). Siponimod, a specific modulator of S1PR subtypes 1 and 5, [108] is being evaluated in a trial in SPMS patients ( NCT01665144). Specific risk populations comprise patients with predisposing conditions for the development of macula oedema such as diabetes mellitus and (recurrent) uveitis. Patients with pre-existing

cardiac arrhythmia, negative dromo- and chronotropic co-medication and pre-existing pulmonary disease should be evaluated closely. In addition, assessment of varizella zoster (VZV) immune status is mandatory [106]. FTY is administered orally as a 0·5-mg capsule once daily. Before treatment Metalloexopeptidase initiation, laboratory investigations including differential blood count, liver enzymes, pregnancy test and VZV status have to be performed. VZV-IgG-negative patients should be vaccinated. Electrocardiography (ECG) and continuous ECG monitoring are recommended during first-dose administration and selectively afterwards. Ophthalmological and dermatological screening are recommended as routine pretreatment investigation, most importantly in risk populations (see Patient selection). Routine laboratory testing, especially for lymphopenia, is required at close intervals; dermatological, opthalmological and pneumological check-up should be implied in bigger, but regular, intervals or by clinical indication [106]. Because FTY can moderately raise blood pressure, especially in hypertensive patients, blood pressure measurements should be performed regularly.

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