Successful Treatment of Natalizumab Induced PML with CMX001 and the Side Effects Associated with Its Use (P07.060)

Abstract

Objective: To describe a case of natalizumab induced Progressive Multifocal Leukoencephalopathy (PML) in a multiple sclerosis (MS) patient that was successfully treated with CMX001 and to report the adverse events associated with its use. Background Natalizumab is an effective treatment for MS that has been associated with the risk of developing PML. CMX001 is an oral analogue of cidofovir which selectively inhibits viral DNA polymerase. Design/Methods: Retrospective clinical and laboratory evaluation of a patient with confirmed PML that was treated with CMX001. Results: 45 year old woman with MS on natalizumab 54 months diagnosed with PML on routine brain MRI. CSF revealed 783 copies/ml of JC virus. Five plasma exchanges were performed. Repeat CSF (day 8) revealed 9,511 copies/ml of JC virus. CMX001 was initiated on day 9 (200mg orally twice a week). After four doses, she experienced severe nausea, vomiting and diarrhea. The drug was held one week and restarted at 200mg twice a week. After two doses nausea, vomiting and diarrhea again became severe. Colonoscopy revealed eosinophilic colitis. She was started on mesalamine, cholestyramine and diphenoxylate/atropine. CMX001 was held one week and restarted at 150mg twice a week. Over the next three weeks she continued to have diarrhea and decreased appetite but less than at the higher dose. After six weeks on CMX001 150mg twice a week, she presented confused and had two observed seizures. Multiple electrolyte abnormalities were seen. CMX001 was discontinued and not restarted. JC virus in the CSF dropped while on CMX001 to 3133, 428, 140, and 78copies/ml at week 6, 9, 14, and 16 weeks respectively. Conclusions: CMX001 may have been effective for treatment of natalizumab induced PML but had significant gastrointestinal side effects at 200mg twice a week and may have contributed to two seizures. Disclosure: Dr. Hojnacki has received personal compensation for activities with Biogen Idec, Serono, Inc., Pfizer Inc, and Teva Neuroscience as a speaker and/or participant on scientific advisory boards. Dr. Zivadinov has received personal compensation for activities with Teva Neuroscience, Biogen Idec, EMD Serono, and Questcor Pharmaceuticals as a speaker and/or consultant. Dr. Zivadinov has received research support from Biogen Idec, Teva Neuroscience, Genzyme Corporation, Bracco, Questcor Pharmaceuticals and EMD Serono. Dr. Weinstock-Guttman has received personal compensation for activities with Acorda Therapeutics, Biogen Idec, Serono, Inc., Novartis, Pfizer Inc, Teva Neuroscience as a speaker and/or participant on an advisory board. Dr. Weinstock-Guttman has received research support from Acorda Therapeutics, Biogen Idec, Serono Inc., Novartis, Pfizer Inc, Teva Neuroscience, National Multiple Sclerosis Society, the National Institutes of Health, ITN, Teva Neuroscience, Aspreva-Roche, Acorda Therapeutics and Shire Pharmaceuticals.