Effect of Nonmyeloablative HSCT vs Disease-Modifying Therapy on Relapsing-Remitting MS Disease Progression | Stem Cell Transplantation | JN Learning | AMA Ed Hub [Skip to Content]
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Effect of Nonmyeloablative Hematopoietic Stem Cell Transplantation vs Continued Disease-Modifying Therapy on Disease Progression in Patients With Relapsing-Remitting Multiple SclerosisA Randomized Clinical Trial

Educational Objective
To understand therapeutic strategies for patients with multiple sclerosis.
1 Credit CME
Key Points

Question  Is nonmyeloablative autologous hematopoietic stem cell transplantation (HSCT) more effective than disease-modifying therapy for patients with highly active relapsing-remitting multiple sclerosis (MS)?

Findings  In this randomized clinical trial that included 110 patients with relapsing-remitting MS, treatment with nonmyeloablative HSCT compared with disease-modifying therapy resulted in a significantly prolonged time to disease progression (hazard ratio, 0.07).

Meaning  In this preliminary study, nonmyeloablative HSCT was more effective than disease-modifying therapy for patients with relapsing-remitting MS.

Abstract

Importance  Hematopoietic stem cell transplantation (HSCT) represents a potentially useful approach to slow or prevent progressive disability in relapsing-remitting multiple sclerosis (MS).

Objective  To compare the effect of nonmyeloablative HSCT vs disease-modifying therapy (DMT) on disease progression.

Design, Setting, and Participants  Between September 20, 2005, and July 7, 2016, a total of 110 patients with relapsing-remitting MS, at least 2 relapses while receiving DMT in the prior year, and an Expanded Disability Status Scale (EDSS; score range, 0-10 [10 = worst neurologic disability]) score of 2.0 to 6.0 were randomized at 4 US, European, and South American centers. Final follow-up occurred in January 2018 and database lock in February 2018.

Interventions  Patients were randomized to receive HSCT along with cyclophosphamide (200 mg/kg) and antithymocyte globulin (6 mg/kg) (n = 55) or DMT of higher efficacy or a different class than DMT taken during the previous year (n = 55).

Main Outcomes and Measures  The primary end point was disease progression, defined as an EDSS score increase after at least 1 year of 1.0 point or more (minimal clinically important difference, 0.5) on 2 evaluations 6 months apart, with differences in time to progression estimated as hazard ratios.

Results  Among 110 randomized patients (73 [66%] women; mean age, 36 [SD, 8.6] years), 103 remained in the trial, with 98 evaluated at 1 year and 23 evaluated yearly for 5 years (median follow-up, 2 years; mean, 2.8 years). Disease progression occurred in 3 patients in the HSCT group and 34 patients in the DMT group. Median time to progression could not be calculated in the HSCT group because of too few events; it was 24 months (interquartile range, 18-48 months) in the DMT group (hazard ratio, 0.07; 95% CI, 0.02-0.24; P < .001). During the first year, mean EDSS scores decreased (improved) from 3.38 to 2.36 in the HSCT group and increased (worsened) from 3.31 to 3.98 in the DMT group (between-group mean difference, −1.7; 95% CI, −2.03 to −1.29; P < .001). There were no deaths and no patients who received HSCT developed nonhematopoietic grade 4 toxicities (such as myocardial infarction, sepsis, or other disabling or potential life-threatening events).

Conclusions and Relevance  In this preliminary study of patients with relapsing-remitting MS, nonmyeloablative HSCT, compared with DMT, resulted in prolonged time to disease progression. Further research is needed to replicate these findings and to assess long-term outcomes and safety.

Trial Registration  ClinicalTrials.gov Identifier: NCT00273364

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Article Information

Corresponding Author: Richard K. Burt, MD, Division of Immunotherapy, Northwestern University Feinberg School of Medicine, 446 E Ontario St, Axis Bldg, Ste 10-1000, Chicago, IL 60611 (rburt@northwestern.edu).

Accepted for Publication: December 5, 2018.

Author Contributions: Drs Burt and Helenowski had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Burt, Balabanov, Jovanovic.

Acquisition, analysis, or interpretation of data: Burt, Balabanov, Burman, Sharrack, Snowden, Oliveira, Fagius, Rose, Nelson, Barreira, Carlson, Han, Moraes, Morgan, Quigley, Yaung, Buckley, Alldredge, Clendenan, Calvario, Henry, Jovanovic.

Drafting of the manuscript: Burt, Sharrack, Snowden, Rose, Han, Quigley, Yaung, Clendenan, Calvario, Henry.

Critical revision of the manuscript for important intellectual content: Burt, Balabanov, Burman, Sharrack, Snowden, Oliveira, Fagius, Nelson, Barreira, Carlson, Han, Moraes, Morgan, Buckley, Alldredge, Clendenan, Calvario, Henry, Jovanovic.

Statistical analysis: Burt, Balabanov, Sharrack, Han, Jovanovic.

Obtained funding: Burt.

Administrative, technical, or material support: Burt, Burman, Sharrack, Fagius, Nelson, Carlson, Han, Buckley, Alldredge, Clendenan, Calvario, Henry.

Supervision: Burt, Rose, Morgan, Henry.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Balabanov reported receipt of personal fees from Biogen and Sanofi Genzyme and grants from Biogen. Dr Burman reported receipt of grants from the Swedish Society for Medical Research and the Swedish Society for Medicine. Dr Snowden reported receipt of speaking honoraria from Sanofi and Jazz. Dr Fagius reported receipt of personal fees from Sanofi OY, Biogen, and Novartis. Dr Rose reported receipt of grants from the National Multiple Sclerosis Society, the Guthy Jackson Foundation, Biogen, and Teva Neuroscience. Dr Nelson reported receipt of grants from Alkermes, Novartis, Biogen, Genentech, Sanofi Genzyme, and the National Multiple Sclerosis Society; receipt of speakers bureau fees from Genentech, Sanofi Genzyme, Acorda, and the Consortium of Multiple Sclerosis Centers; advisory board membership for Sanofi Genzyme; and chairing a review panel for an MS research program for the US Department of Defense. No other disclosures were reported.

Funding/Support: This study was made possible by financial support from the Danhakl family, the Cumming Foundation, the McNamara Purcell Foundation, Morgan Stanley, and the National Institute for Health Research Sheffield Clinical Research Facility. There was no industry support or pharmaceutical support for the study.

Role of the Funder/Sponsor: None of the organizations that provided financial support had a role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

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