Treatment of multiple sclerosis with cyclophosphamide: critical review of clinical and immunologic effects.
Cyclophosphamide is an alkylating agent used to treat malignancies and immune-mediated inflammatory non-malignant processes such as lupus nephritis and immune-mediated neuropathies. It has been studied as a treatment for multiple sclerosis (MS) for the past 30 years and is used by physicians in selected cases of progressive or worsening MS. Review of published reports suggests that it is efficacious in cases of worsening MS that have an inflammatory component as evidenced by relapses and/or gadolinium (Gd)-enhancing lesions on magnetic resonance imaging (MRI) or in patients in earlier stages of disease where inflammation predominates over degenerative processes in the central nervous system (CNS). There is no evidence of efficacy in primary progressive MS or later stages of secondary progressive MS. Although a general immunosuppressant that affects both T- and B-cell function, cyclophosphamide has selective immune effects in MS by suppressing IL-12 and Th1-type responses and enhancing Th2/Th3 responses (IL-4, IL-10, TGF-beta; eosinophils in peripheral blood). Side effects include nausea, alopecia, infertility, bladder toxicity and risk of malignancy. The most commonly used regimens involve every 4- to 8-week outpatient i.v. pulse therapy given with or without corticosteroids and are usually well-tolerated by patients. Cyclophosphamide is currently used in patients whose disease is not controlled by beta-interferon or glatiramer acetate and those with rapidly worsening MS.
Weiner
H L
HL
Multiple Sclerosis Center, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston 02115, USA. hweiner@rics.bwh.harvard.edu
Cohen
J A
JA
D000328:Adult; D000477:Alkylating Agents / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use*; D000818:Animals; D001327:Autoimmune Diseases / Q000188:drug therapy*; D002986:Clinical Trials as Topic; D003520:Cyclophosphamide / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use*; D004334:Drug Administration Schedule; D004681:Encephalomyelitis, Autoimmune, Experimental / Q000188:drug therapy; D005260:Female; D005544:Forecasting; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use*; D007246:Infertility / Q000139:chemically induced; D018664:Interleukin-12 / Q000378:metabolism; D008297:Male; D051379:Mice; D015337:Multicenter Studies as Topic; D009103:Multiple Sclerosis / Q000145:classification / Q000188:drug therapy*; D009325:Nausea / Q000139:chemically induced; D016032:Randomized Controlled Trials as Topic; D051381:Rats; D018417:Th1 Cells / Q000187:drug effects / Q000276:immunology / Q000378:metabolism
D000477:Alkylating Agents; D007166:Immunosuppressive Agents; D018664:Interleukin-12; D003520:Cyclophosphamide