Intervention Review

Cyclophosphamide for multiple sclerosis

  1. Loredana La Mantia1,*,
  2. Clara Milanese1,
  3. Nerina Mascoli1,
  4. Roberto D'Amico2,
  5. Bianca Weinstock-Guttman3

Editorial Group: Cochrane Multiple Sclerosis Group

Published Online: 24 JAN 2007

Assessed as up-to-date: 14 NOV 2006

DOI: 10.1002/14651858.CD002819.pub2


How to Cite

La Mantia L, Milanese C, Mascoli N, D'Amico R, Weinstock-Guttman B. Cyclophosphamide for multiple sclerosis. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD002819. DOI: 10.1002/14651858.CD002819.pub2.

Author Information

  1. 1

    Fondazione I.R.C.C.S. - Istituto Neurologico C. Besta, MS Group, Milano, Italy

  2. 2

    University of Modena and Reggio Emilia, Department of Oncology and Hematology, Modena, Italy

  3. 3

    The Jacobs Neurological Institute, State University of New York at Buffalo, Baird MS Center, Buffalo, New York, USA

*Loredana La Mantia, MS Group, Fondazione I.R.C.C.S. - Istituto Neurologico C. Besta, Via Celoria, 11, Milano, 20133, Italy. msgroup@istituto-besta.it.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 24 JAN 2007

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Multiple sclerosis is a presumed cell-mediated autoimmune disease of the central nervous system. Cyclophosphamide (CFX) is a cytotoxic and immunosuppressive agent, used in systemic autoimmune diseases. Controversial results have been reported on its efficacy in MS. We conducted a systematic review of all relevant trials, evaluating the efficacy of CFX in patients with progressive MS.

Objectives

The main objective was to determine whether CFX slows the progression of MS.

Search methods

We searched the Cochrane MS Group Trials Register (June 2006), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2006), MEDLINE (PubMed)(January 1966 to June 2006), EMBASE (January 1988 to June 2006) and reference lists of articles. We also contacted researchers in the field.

Selection criteria

Randomised controlled trials (RCTs) evaluating the clinical effect of CFX treatment in patients affected by clinically definite progressive MS.
CFX had to be administered alone or in combination with adrenocorticotropic hormone (ACTH) or steroids. The comparison group had to be placebo or no treatment or the same co-intervention (ACTH or steroids)

Data collection and analysis

Two reviewers independently decided the eligibility of the study, assessed the trial quality and extracted data. We also contacted study authors for original data.

Main results

Of the 461 identified references, we initially selected 70: only four RCTs were included for the final analysis. Intensive immunosuppression with CFX (alone or associated with ACTH or prednisone) in patients with progressive MS compared to placebo or no treatment (152 participants) did not prevent the long-term (12, 18, 24 months) clinical disability progression as defined as evolution to a next step of Expanded Disability Status Scale (EDSS) score. However, the mean change in disability (final disability subtracted from the baseline) significantly favoured the treated group at 12 (effect size - 0.21, 95% confidence interval - 0.25 to -0.17) and 18 months (- 0.19, 95% confidence interval - 0.24 to - 0.14) but favoured the control group at 24 months (0.14, CI 0.07 to 0.21). We were unable to verify the efficacy of other schedules. Five patients died; sepsis and amenorrhea frequently occurred in treated patients (descriptive analysis).

Authors' conclusions

We were unable to achieve all of the objectives specified for the review. This review shows that the overall effect of CFX (administered as intensive schedule) in the treatment of progressive MS does not support its use in clinical practice.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

The effect of the immunosuppressive drug cyclophosphamide in people with multiple sclerosis

MS is a chronic disease of the nervous system affecting young and middle-aged adults. MS is supposed to be related to the immune system. CFX is an immunosuppressive drug used for various autoimmune diseases. As its use for MS is controversial, the Authors of this review aimed to assess CFX efficacy for patients with progressive MS. Among the pertinent literature, only five studies met the inclusion criteria of minimum methodological quality , with a total of 90 MS patients treated with CFX.
The data available were inadequate to attain all the objectives specified for the review. The Authors found poor evidence that CFX may slow progression in the medium-term. They found also that side effects such as alopecia, nausea, vomiting and menses interruption (amenorrhea) occurred at high frequency, while some evidences might suggest adverse effects also after two years .

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

cyclophosphamide對於多發性硬化的治療

多發性硬化推測是中樞神經系統的細胞免疫性疾病,cyclophosphamide(CFX)具有細胞毒性,是一種使用在系統性免疫疾病的免疫抑制藥物,對於多發性硬化的療效一直有爭議‧我們對所有相關試驗進行了系統性回顧,評估CFX對進行性多發性硬化的療效

目標

主要目的是決定CFX是否能延緩多發性硬化的進行

搜尋策略

我們搜尋了考科藍資料庫多發性硬化群組試驗登錄(2006年6月),考科藍對照試驗登錄中心(2006年議題3), MEDLINE(1966年1月至2006年6月), EMBASE(1988年1月至2006年6月)以及文章附註的參考文章列表,並且聯繫了此領域的研究者

選擇標準

選擇標準是隨機對照試驗,對於臨床確定為進行性多發性硬化的病人評估CFX的療效,單獨給予CFX或合併促腎上腺皮質激素(ACTH)或類固醇,和使用安慰劑組或無接受治療組比較或和雙藥物組(CFX合併ACTH或類固醇)比較

資料收集與分析

交由二位審稿者獨立決定研究合格與否,評估試驗的品質並摘錄資料,我們也聯繫原作者提供原始資料

主要結論

我們由461個參考資料先選擇了70個,最後只有4個RCT進入最後的分析,對進行性多發性硬化的病人使用密集免疫抑制藥物CFX(單獨或合併ACTH或腎上腺皮質素)和使用安慰劑組或無接受治療組比較,在12,18,24個月進行評估,發現不能預防長期失能(EDSS 進展至下一個階段)的進行,不過在12,18個月發現治療組的失能程度較輕有顯著差異,12個月時有效減輕0.21,95% CI  0.25 to −0.17, 18個月時有效減輕0.19, 95% CI  0.24 to  0.14, 不過24個月時對照組卻較佳(0.14, CI 0.07 to 0.21), 我們無法證實在其他時間的療效,有5位病人死亡,且治療期間常發生敗血症及停經(描述性研究)

作者結論

我們無法達到原先設定此篇回顧的所有目標,總結CFX的效果並不能用在進行性多發性硬化的臨床治療

翻譯人

本摘要由新光醫院吳亞縈翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

CFX無法避免進行性多發性硬化的惡化,並且常出現副作用,多發性硬化為主要侵犯年輕人及中年人的中樞神經系統的慢性免疫疾病,CFX是一種使用在自體免疫疾病的免疫抑制藥物,對於多發性硬化的療效一直有爭議,所以此篇回顧的作者希望評估CFX對進行性多發性硬化的療效,在合適的文獻中只有5個研究達到基本的方法學品質的要求,共有90位多發性硬化病人接受CFX治療,這些資料無法達成原先設定的目標,作者發現CFX可能在疾病中期時減緩惡化速度的證據薄弱,並常有副作用像是禿頭噁心嘔吐以及經期紊亂,有些證據則顯示這些副作用持續至2年後。