Memorial Healthcare System
Neuroscience Institute

Author Of 2 Presentations

Disease Modifying Therapies – Risk Management Poster Presentation

P0271 - A Case of Drug Induced Myocarditis Associated With the Administration of Alemtuzumab (ID 1233)

Speakers
Presentation Number
P0271
Presentation Topic
Disease Modifying Therapies – Risk Management

Abstract

Background

Over the past decade, a number of Disease Modifying Therapies (DMTs) for Multiple Sclerosis (MS) have been made available to help slow the progression of MS. The efficacy of these therapies depends on the extent of lymphocyte suppression, offering favorable outcomes in disease suppression, but present safety concerns that should be balanced. Alemtuzumab has been FDA approved for aggressive forms of Relapsing Remitting MS (RRMS) since 2014. It acts on the CD52 antigen present on B and T cells, thereby achieving lymphopenia. while it is highly efficacious, it has several warnings of autoimmunity, infusion reactions, strokes, and malignancies.

Objectives

The purpose of this abstract is to highlight a novel case study of possible alemtuzumab induced myocarditis. A quick literature review did not yield any findings of prior reports.

Methods

We present a 27 year old woman with a 10-year history of MS who had previously been treated with interferon, dimethyl fumarate, and fingolimod – all switched for either disease activity or intolerance. Alemtuzumab was initiated following these DMT failures.

Alemtuzumab was administered in January 2020 with pre-medications as per the package insert. On day 2 of her infusion, she developed asymptomatic bradycardia. Upon arrival on day 3, she reported intermittent epigastric pain overnight. Facial flushing was noted by the nurse and the infusion was held. In addition, she was having palpitations with fluctuations in heart rate. The RN hooked her up to EKG, which was significant for multiple PVCs, ST abnormalities and a right bundle branch block. At this point she was quickly transferred to the Emergency Department.

While in the ED, she quickly developed dyspnea and a productive cough. Due to desaturation, tachycardia and hypotension, she was admitted to the Intensive Care Unit for cardiogenic shock. Repeat chest Xray showed bilateral pulmonary edema. Troponins were uptrending and echocardiogram showed an ejection fraction of 10%. The diagnosis of acute drug induced myocarditis was made.

Results

The patient was treated with bipap and diuretics, after which heart rate and saturation progressively improved. Initial Cardiac MRI revealed an EF of 42%. Diffuse "mild" Late Gadolinium Enhancement, more consistent with inflammation and edema than myocardial fibrosis (scar).She was discharged home with a lifevest and on Digoxin, Toprol XL, Aldactone, and Losartan.

At four month follow up, repeat cardiac MRI showed improved EF to 54% with resolution of myocardial edema.

Conclusions

To our knowledge this is the first report of alemtuzumab induced myocarditis and while an isolated event, prescribers should be aware of this potential adverse effect.

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Observational Studies Poster Presentation

P0926 - Therapeutic Practices in Multiple Sclerosis (MS) Amongst General Neurologists and MS Specialists (ID 1365)

Speakers
Presentation Number
P0926
Presentation Topic
Observational Studies

Abstract

Background

The rapid development of MS disease modifying therapies (DMTs) has substantially complicated decision-making for clinicians. Despite the availability of 18 DMTs spanning nine therapeutic classes, few of these agents have been compared head-to-head and only recently were consensus-based guidelines published on their use. Almost no publicly available information exists about how practicing neurologists are approaching the contemporary management of this population.

Objectives

To assess potential discrepancies in clinical decisions between neurologists who specialize in MS and those who treat MS but do not subspecialize.

Methods

An online survey was conducted in May 2020. US and Canadian neurologists practicing in academic or specialized MS centers were invited to participate. A random sample of US generalists who practice in community-based, non-specialized settings but see 5-20 MS patients each week were also recruited. Questions were formulated to assess differences regarding strategic approaches to case-based scenarios.

Results

A total of 25 experts and 100 general neurologists completed the assessment. Experts were more likely to offer high efficacy DMTs across a variety of clinical presentations (e.g. CIS by age, RRMS, pregnancy, PPMS). For a 25-year-old female patient with CIS, the largest cohort of experts prioritized ocrelizumab (30%) vs. 2% of generalists (p<0.001). Generalists preferred glatiramer acetate (GA) (34%) vs. 0% of experts (p<0.001). For a 29-year-old female (JCV negative) with moderate risk disease, 84% of experts selected either natalizumab or ocrelizumab, compared to 43% of generalists (p<0.001). For a 29-year-old with higher risk MS and plans to become pregnant, 76% of experts chose ocrelizumab (8% of generalists, p<0.001) while 44% of generalists recommended GA (0% of experts, p<0.001). Both groups trended more towards high efficacy therapies in response to radiologic disease activity vs. clinical relapses with stable imaging.

Conclusions

There were several group commonalities including DMT initiation, the impact of race, and therapeutic response to breakthrough disease. However, substantial differences were seen in DMT choice, switching behavior, use in patients contemplating pregnancy, and age variation. Experts typically prioritized higher efficacy agents while generalists typically prioritized safety profile. This suggests that approaches are heterogenous and greater education among generalists may be warranted.

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Presenter Of 1 Presentation

Observational Studies Poster Presentation

P0926 - Therapeutic Practices in Multiple Sclerosis (MS) Amongst General Neurologists and MS Specialists (ID 1365)

Speakers
Presentation Number
P0926
Presentation Topic
Observational Studies

Abstract

Background

The rapid development of MS disease modifying therapies (DMTs) has substantially complicated decision-making for clinicians. Despite the availability of 18 DMTs spanning nine therapeutic classes, few of these agents have been compared head-to-head and only recently were consensus-based guidelines published on their use. Almost no publicly available information exists about how practicing neurologists are approaching the contemporary management of this population.

Objectives

To assess potential discrepancies in clinical decisions between neurologists who specialize in MS and those who treat MS but do not subspecialize.

Methods

An online survey was conducted in May 2020. US and Canadian neurologists practicing in academic or specialized MS centers were invited to participate. A random sample of US generalists who practice in community-based, non-specialized settings but see 5-20 MS patients each week were also recruited. Questions were formulated to assess differences regarding strategic approaches to case-based scenarios.

Results

A total of 25 experts and 100 general neurologists completed the assessment. Experts were more likely to offer high efficacy DMTs across a variety of clinical presentations (e.g. CIS by age, RRMS, pregnancy, PPMS). For a 25-year-old female patient with CIS, the largest cohort of experts prioritized ocrelizumab (30%) vs. 2% of generalists (p<0.001). Generalists preferred glatiramer acetate (GA) (34%) vs. 0% of experts (p<0.001). For a 29-year-old female (JCV negative) with moderate risk disease, 84% of experts selected either natalizumab or ocrelizumab, compared to 43% of generalists (p<0.001). For a 29-year-old with higher risk MS and plans to become pregnant, 76% of experts chose ocrelizumab (8% of generalists, p<0.001) while 44% of generalists recommended GA (0% of experts, p<0.001). Both groups trended more towards high efficacy therapies in response to radiologic disease activity vs. clinical relapses with stable imaging.

Conclusions

There were several group commonalities including DMT initiation, the impact of race, and therapeutic response to breakthrough disease. However, substantial differences were seen in DMT choice, switching behavior, use in patients contemplating pregnancy, and age variation. Experts typically prioritized higher efficacy agents while generalists typically prioritized safety profile. This suggests that approaches are heterogenous and greater education among generalists may be warranted.

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