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Immunmodulatorische Stufentherapie der Multiplen Sklerose

Aktuelle Therapieempfehlungen (September 2006)

Escalating immunomodulatory therapy of multiple sclerosis

Update (September 2006)

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Zusammenfassung

Die vorliegenden aktualisierten Empfehlungen zeigen neue Entwicklungen in Diagnostik, Immuntherapie sowie zur Versorgung von Patienten mit Multipler Sklerose (MS). Eine wichtige therapeutische Neuerung bieten monoklonale Antikörper. Ihr Einsatz in der Basistherapie ist jedoch durch ihr Nebenwirkungsprofil eingeschränkt. So ist Natalizumab zunächst nur zur Monotherapie bei Versagen einer Basisbehandlung oder bei rasch fortschreitender schubförmiger MS zugelassen. Dagegen zeigen Langzeitdaten zu den rekombinanten β-Interferonen und Glatirameracetat (Copaxone®), dass auch nach mehreren Jahren keine unerwarteten Nebenwirkungen auftreten und von einer anhaltenden therapeutischen Wirkung auszugehen ist, die bei den IFN-β-Präparaten mit der Dosis bzw. Frequenz der Therapie korreliert. Kürzlich erfolgte die Zulassung von IFN-β1b (Betaferon®) für die prophylaktische Behandlung nach dem 1. Schub (klinisch isoliertes Syndrom, CIS). Unter der Therapie mit β-Interferonen können jedoch neutralisierende Antikörper mit möglichem Wirkungsverlust auftreten. In der Therapie mit Glatirameracetat spielen Antikörper dagegen keine Rolle. Unter bzw. nach Therapie mit Mitoxantron zeigten sich in 0,2–0,4% schwere Nebenwirkungen (Kardiomyopathie, akute myeloische Leukämie). Die Plasmapherese bleibt auf individuelle Heilversuche in der Eskalationstherapie eines schweren Schubs beschränkt. Nach den revidierten McDonald-Kriterien kann die Diagnose einer MS nun schon früh nach Auftreten eines 1. Schubs (CIS) gestellt werden. Neu sind auch die Vorschläge zur optimierten Versorgung von MS-Patienten, womit ein Beschluss des europäischen Parlaments umgesetzt wurde.

Abstract

The updated recommendations presented here reflect new developments in the diagnostic work-up and immunotherapy of multiple sclerosis (MS) as well as optimization of medical care for MS patients. Monoclonal antibodies provide considerable improvement of treatment, but their use in basic therapy is restricted by their side effect profile. Thus, for the time being, natalizumab is only approved for monotherapy after basic treatment has failed or for rapidly progressive relapsing-remitting MS. In contrast, long-term data on recombinant β-interferons and glatiramer acetate (Copaxone®) show that even after several years no unexpected side effects occur and that a prolonged therapeutic effect can be assumed which correlates with the dose or frequency of treatment. Recently IFN-β1b (Betaferon®) was approved for prophylactic treatment after the first attack (clinically isolated syndrome, CIS). During treatment with β-interferons, neutralizing antibodies can emerge with possible loss of effectivity. In contrast, antibodies play no role in treatment with glatiramer acetate. During or after therapy with mitoxantrone, serious side effects (cardiomyopathy, acute myeloid leukemia) appeared in 0.2–0.4% of cases. Plasmapheresis is limited to individual curative attempts in escalating therapy of a severe attack. According to the revised McDonald criteria, the diagnosis of MS can be made as early as the occurrence of the first attack (CIS). Recommendations for optimized care of MS patients are also new, thus implementing a resolution of the European Parliament.

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Notes

  1. Durch die Natur der Konsensusfindung bestehen hier Abweichungen zu anderweitig publizierten Empfehlungen mancher Mitautoren dieses Reports [43]

  2. In Österreich ist dies das übliche Verfahren.

  3. Einige Zentren empfehlen, vor Therapie Liquor zu untersuchen und einzufrieren, um zum Vergleich mit späteren Untersuchungen Basisliquor zu asservieren.

  4. Glatirameracetat ist nach Auffassung der MSTKG eine den IFN-ß-Präparaten in etwa vergleichbare Basistherapie. Ohne erkennbaren Grund wurde es in den Zulassungsformulierungen der EMEA nicht erwähnt.

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  1. Klinische Forschungsgruppe für Multiple Sklerose und Neuroimmunologie, Neurologische Universitätsklinik, 97080, Josef-Schneider-Straße 11, Würzburg, Deutschland

    Peter Rieckmann

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Multiple Sklerose Therapie Konsensus Gruppe (MSTKG)

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Multiple Sklerose Therapie Konsensus Gruppe (MSTKG)., Rieckmann, P. Immunmodulatorische Stufentherapie der Multiplen Sklerose. Nervenarzt 77, 1506–1518 (2006). https://doi.org/10.1007/s00115-006-2220-x

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