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#Post#: 1374--------------------------------------------------
(ECTRIMS) Plasma exchange and steroids in PML management
By: agate Date: September 21, 2016, 2:41 pm
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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.[/quote]
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