Abstract General Information
The association of secukinumab and ofatumumab: concomitant ankylosing spondylitis and multiple sclerosis
CASE PRESENTATION: A 53-year-old woman has dealt with back pain and uveitis episodes since she was a teenager, condition that got worse over time. In 1997 (at 28), she presented an episode of left hemiparesis, diagnosed as stroke. In February 2017 (at 48) she was diagnosed with ankylosing spondylitis (AS), after evidence of bilateral sacroiliitis. She started treatment with tumor necrosis factor blocking agent (anti-TNF) in July 2017. In September 2017, under Adalimumab, she developed other focal neurological episode. Brain and spinal cord MRI confirmed the diagnosis of relapsing-remitting multiple sclerosis (MS) and the anti-TNF was switched to Secukinumab (anti interleukin-17A). In parallel, MS treatment was introduced: glatiramer and then dimethyl fumarate (DMF) (2017-2018). AS remission occurred under Secukinumab. However, in April 2019, she presented MS activity (new relapses and new lesions) leading to the initiation of Natalizumab in July 2019. Given the risk of association of 2 monoclonal antibodies and due to positive serology for JC virus, Secukinumab was discontinued. AS symptoms reactivated, treated with anti-inflammatories, sulfasalazine, and low-dose prednisone, with no response. At 22 infusions, Secukinumab was reinitiated. After 24 infusions, Natalizumab was switched, aiming to maintain a high-efficacy drug but also a reasonable safety level. Ofatumumab was chosen, owing to faster B-cell repletion in case of adverse effects. Since starting with Secukinumab and Ofatumumab in 2021, she has been stable, with no AS or MS reactivation, and no clinically significant adverse events.
DISCUSSION: Anti-TNF must be avoided in MS patients (in this case, adalimumab reactivated a previous misdiagnosed MS). Although anti-IL-17A agents have already been studied in MS, data are limited and Sekukinumab was not suitable to stabilize MS, even in association with DMF.
FINAL COMMENTS: The association of Secukinumab and Ofatumumab showed high efficacy in stabilizing both conditions, with a reasonable safety profile.
Letícia Pieroni Cavaglieri, Mateus Boaventura