Tagalemtuzumab

Mortality: what risk would you be prepared to take?

Barts-MS rose-tinted-odometer: ZERO-★’S (Black Tuesday – a tear for my beloved country #000000) As you are aware by now I am a proponent of flipping the pyramid and using high-efficacy DMTs first-line including immune-reconstitution therapies (IRTs) such as alemtuzumab and AHSCT. I justify the latter two options based on the fact that given sufficient time the vast majority of pwMS will...

A no-brainer?

Barts-MS rose-tinted-odometer: ★★★★★ (aquamarine on a very rainy Friday in London, #00FFBF)  I recently had a patient of mine who has been desperate to be treated with alemtuzumab actually ask if he can change his mind and rather be referred for AHSCT (autologous hematopoietic stem cell transplantation). Why? Because the chances of being put into long term remission, and hence potentially...

Which side of the fence are you on?

Barts-MS rose-tinted-odometer: zero-★s (still seeing red) Apologies some more definitions:  Side of the fence: used to refer to either of the opposing positions or interests involved in a particular situation. Status quo: the current situation; the way things are now. The MS community, i.e. patients and HCPs are content with the status quo and aren’t looking for a change.  NEDA: no...

To switch or not to switch that is the question

Barts-MS rose-tinted-odometer: ★★★ The one good thing about thinking aloud is that your colleagues’ chip in and provide feedback. Case 2 from my ‘ethical quandary post‘ is generating an important debate about whether to support this patient’s decision to switch therapy or not. As a reminder, this is the 40-year old woman who started natalizumab as a first-line therapy 11...

Regrets

Barts-MS rose-tinted-odometer: ★★ Shortly after leaving Queen Square to take up my current position at Barts and The London Juliet Solomon, a good friend, and one of the research managers who had an office opposite me on the 6th floor of the Institute of Neurology sent me a signed copy of the ‘The Book of Regrets’ she had compiled as a present. She has asked celebrities to write essays on...

An ethical quandary

Barts-MS rose-tinted-odometer: ★★ The two case studies below are creating an ethical quandary in my MS practice. Can you help me please? Case 1The first is the 40-year old woman with MS who is NEDA-2 (no evident disease activity) on DMF (Tecfidera) with no documented relapses in the last 4 years and a series of annual MRI scans with no new or enlarging T2 MS lesions. However, there has been a...

Refusenik

Barts-MS rose-tinted-odometer: ★★ She is only 24 years of age; a graduate trainee in a marketing company. She has a promising future ahead of her. She lives in London and has a long term partner; they met at University. She knows he is the one for her and they are planning to get engaged in the next 1 to 2 years. Like most graduate trainees they find London expensive and share a house with four...

The far reaching arm of alemtuzumab

The immune system (image from Novus Biologicals) Whilst we talk about targeted B cell treatments, alemtuzumab possibly is what I’d term a ‘Domestos’ style drug. This type of drug is useful when your aim is to control the entire immune system quickly. Drugs similar to this are cyclophosphamide, cysclosporin and mitoxantrone; which are all considered highly active therapies. Many...

#MSCOVID19: ABN Guidance Update

Barts-MS rose-tinted-odometer: ★★★ The ABN have updated their COVID-19 guidelines, which are beginning to move towards the evidence. However, the guidance on cladribine is not supported by the evidence nor the science, i.e. how cladribine actually works and its impacts the immune system. The latest guidance states “the risk of severe COVID-10 disease is increased for many months after...

Journal Club: whack-a-mole

The latest Barts-MS journal club describes and discusses the Whack-A-Mole strategy dealing with secondary autoimmunity post-alemtuzumab treatment. It is based on the paper below. Meltzer et al. Mitigating alemtuzumab-associated autoimmunity in MS: A “whack-a-mole” B-cell depletion strategy. Neurol Neuroimmunol Neuroinflamm. 2020 Aug 7;7(6):e868. doi: 10.1212/NXI.0000000000000868...

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