Counseling Points Multiple Sclerosis - Spring 2015 - 7

disorder, progressive multifocal leukoencepha-

Infectious complications associated with MS
therapies are summarized in Table 2. For some
drugs, the reported infectious complications have
been observed mainly in other disease states such as
rheumatoid arthritis or leukemia.
Use of interferons or glatiramer acetate are
not associated with increased risk of infections,
as demonstrated through more than 20 years of
use. 23,37 Treatment with interferon may result
in mild leukopenia, but there are no reports of
opportunistic infections in patients with MS
treated with these agents.38,39 A study by Miller
and colleagues to determine whether treatment
with any interferon or glatiramer acetate would
decrease expression of JC virus did not show an

lopathy (PML). PML is a demyelinating white
matter disease caused when the JC polyomavirus
(JCV) proliferates in the CNS. The virus infects
the oligodendrocytes and causes their death by
necrosis and demyelination.20 PML may develop
in patients with underlying immunosuppressive
conditions (e.g., Hodgkin's lymphoma, AIDS),
but its incidence has been steadily increasing in
people with MS treated with monoclonal antibodies such as natalizumab.21 PML risk stratification has been discussed extensively in other literature, including a comprehensive Supplement to
the International Journal of MS Care.22

Table 2. Risk of Infectious Complications from MS Therapies
Therapy

Potential Infectious Complications in MS

Interferon beta-1a
Interferon beta-1b

May cause neutropenia or lymphopenia. Rarely of clinical significance in MS.23

Glatiramer acetate

None1

Mitoxantrone

Risk of opportunistic infection from severe leukopenia.24
Urinary tract infection, pneumonia, varicella zoster, herpes simplex (0.6% of treated patients)

Fingolimod

Varicella zoster encephalitis and vasculopathy, herpes simplex encephalitis, PML (rare; cases
may be associated with prior natalizumab use)25-27

Natalizumab

PML, herpes simplex, varicella zoster, CNS and ocular toxoplasmosis, human herpesvirus 6
(HHV6) reactivation22,28-31

Rituximab*

Hepatitis B reactivation, Pneumocystis pneumonia, about 80 cases of PML. Serious infections
are rare among large populations treated for RA32,33

Teriflunomide

Similar to placebo34

Dimethyl fumarate

None noted in pivotal trials. Rare cases of PML in psoriasis patients treated with fumarate.
One PML case in patient with MS taking drug for 4.5 years (lymphopenia 3.5 years)35,36

Alemtuzumab**

In organ transplant population, 50% greater risk of opportunistic infection; 2X risk of
CMV reactivation; increased risk of fungal infections; 7 cases of PML in patients with
immunosuppression (lung transplant, chronic lymphocytic leukemia). Prophylaxis is
recommended to limit varicella zoster or herpes simplex activation or reactivation. 7-9

CMV=cytomegalovirus; PML= progressive multifocal leukoencephalopathy; RA=rheumatoid arthritis
*Not approved for use in MS; data based on use in rheumatoid arthritis
**Infectious complications based on use in organ transplant population

7

Spring 2015
Counseling Points Multiple Sclerosis - Spring 2015

Table of Contents for the Digital Edition of Counseling Points Multiple Sclerosis - Spring 2015
