Author’s Accepted Manuscript

Marked neutropenia: significant but rare in people

with multiple sclerosis after alemtuzumab treatment

David Baker, Gavin Giovannoni, Klaus Schmierer

www.elsevier.com/locate/msard

PII: S2211-0348(17)30238-9
DOI: http://dx.doi.org/10.1016/j.msard.2017.09.028
Reference: MSARD667
To appear in: Multiple Sclerosis and Related Disorders
Received date: 23 July 2017
Accepted date: 23 September 2017
Cite this article as: David Baker, Gavin Giovannoni and Klaus Schmierer,
Marked neutropenia: significant but rare in people with multiple sclerosis after
alemtuzumab treatment, Multiple Sclerosis and Related Disorders,
http://dx.doi.org/10.1016/j.msard.2017.09.028
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Marked neutropenia: significant but rare in people with multiple sclerosis after
alemtuzumab treatment

David Baker*, Gavin Giovannoni, Klaus Schmierer

Blizard Institute, Barts and the London School of Medicine and Dentistry. Queen Mary
University of London, London E1 2AT, United Kingdom

*Correspondence: Prof. David Baker. BartsMS, Blizard Institute, Barts and the London School
of Medicine and Dentistry (Neuroscience), Queen Mary University of London, 4 Newark Street,
London E1 2AT, United Kingdom. Email: david.baker@qmul.ac.uk Tel: +44 20 7882 2485.

ABSTRACT

Background:

Alemtuzumab is a CD52-specific monoclonal antibody that markedly depletes T and B

lymphocytes and inhibits relapsing multiple sclerosis (MS). However, polymorphonuclear
neutrophils also express CD52 and can be depleted by alemtuzumab, thereby potentially
contributing to the infections that develop post-alemtuzumab treatment. Surprisingly,
however, the degree of neutrophil depletion in MS was not included in the pivotal trial reports.

Methods:
The regulatory submission of the Comparison of Alemtuzumab and Rebif® Efficacy in MS 1 and
2 trials was obtained from the European Medicines Agency through Freedom of Information.
The data relating to neutrophils was extracted.
Results:
Data extraction from the submission was straightforward. In year one 72/811 (8.9%) and in
year two 116/808 (14.4%) people with MS (pwMS) developed neutropenia. The degree of
neutropenia was generally mild, and only 5/811 (0.6%) in year 1 and 12/808 (1.5%) in year 2
developed grade 3-4 toxicity (<1.0 x 109/L). Two pwMS developed severe neutropenia-related
adverse events.
Conclusions:
Treatment with alemtuzumab induces neutropenia, which is mild in the large majority of pwMS
treated. Leucocyte levels following alemtuzumab should be monitored as a marker of efficacy
and safety; persistent neutropenia may require treatment.
KEYWORDS

Alemtuzumab, Multiple sclerosis, polymorphonuclear neutrophils, neutropenia

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INTRODUCTION

Multiple sclerosis (MS) is the major, immune-mediated demyelinating disease of the central
nervous system, which responds to a number of immunomodulatory agents. Alemtuzumab is a
humanised CD52-depleting monoclonal antibody, which exhibits high activity in controlling
relapsing multiple sclerosis (Willis et al. 2016a). Although alemtuzumab is considered to be a
lymphocyte depleting agent, CD52 is expressed by a number of leucocyte subtypes including
monocytes and polymorphonuclear neutrophils (Ambrose et al. 2009; Willis et al 2017).
Recently, cases of marked neutropenia in people with MS (pwMS) have been reported following
alemtuzumab treatment (Gaitán et al. 2017). Although data relating to leucocyte subsets were
not reported from the pivotal alemtuzumab trials (Cohen et al. 2012, Coles et al. 2012), we
recently reported the influence on lymphocyte subsets based on data contained in the
European Medicines Agency (EMA) regulatory submission (Baker et al 2017a, Baker et al
2017b). Here, we report the neutrophil data from these trial datasets.

METHODS

The regulator submission relating to the Comparison of Alemtuzumab and Rebif® Efficacy in
Multiple Sclerosis 1 (CARE-MS I) and 2 (CARE-MS II) trials of alemtuzumab was obtained
through a Freedom of Information request from the EMA (Baker et al. 2017b). Data relating to
neutrophil numbers, following treatment in drug-naive pwMS (CARE-MS I), or pwMS previously
treated with a disease modifying drug (CARE-MS II), was extracted from the tabulated
datasets obtained.

RESULTS

The mean and median neutrophil counts change slightly over time and there was a small drop
in the number (0.75 ± 1.81 x 109/L. n = 353) in neutrophil numbers within a month of first
infusion in treatment-naive pwMS enrolled in CARE-MS I. However, cell counts remained within
the normal range after both treatment cycles (Figure 1). The maximum level of neutrophils
fluctuated (Figure 1) perhaps reflecting response to infections (Figure 1), which can occur after
alemtuzumab administration (Cohen et al. 2012, Coles et al. 2012). Without access to the raw
data, however, we were unable to draw a definitive conclusion about this issue. Only 93/376
(24.7%) pwMS developed neutrophil levels below the lower limit of normal. Of the 93 subjects
with neutropenia 85 (91.4%) did not report any neutropenia-related adverse events. The
percentage of pwMS to have post-baseline values below the lower limits of normal, or a
neutropenia-related adverse event over a two year trial period was 25% in CARE-MS I and
20.5% in CARE-MS II. In the trial of treatment-naive pwMS (CARE-MS I), 10 participants
treated with alemtuzumab group had grade 3 or 4 neutropenia (<1.0 x 109/L. Table 1)
according to the National Cancer Institute, Common Terminology Criteria for Adverse Events
V3, and 3/10 had related adverse events. One/10 developed agranulocytosis, and 6/10 had
grade 3 neutropenia that occurred at a single time-point only. Within the clinical database of
neutropenia-related adverse events, 2/376 (0.5%) developed agranulocytosis, and one of
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these, who also had Grave’s disease, developed febrile neutropenia. This latter participant was
treated with plasma exchange following which neutrophil numbers recovered. The other
participant was treated with lenograstim; within nine days the neutrophil count had risen from
0.23 x109/L to 20.2 x 109/L. The case of agranulocytosis recovered within 36 days of onset.
Only 7/429 participants of CARE MS II treated with alemtuzumab developed neutropenia
>grade 2 (Table 1).

DISCUSSION

Our study indicates that whilst neutropenia does occur following treatment with alemtuzumab,
known to markedly deplete lymphocytes (Baker et al. 2017b), the degree of neutropenia was
generally mild. Although neutrophil numbers increase within a day of first infusion of
alemtuzumab prior to normalising by the end of the infusion cycle (Thomas et al 2016), severe
neutropenia can occur in pwMS within one month post-infusion.

It is known that neutrophils express CD52 and are sensitive to complement mediated lysis,
and that neutropenia can occur in following alemtuzumab treatment in pwMS and people with
other conditions (Fabian et al. 1993; Ambrose et al. 2009; Smith al. 2014, Gaitán et al. 2017).
However, as shown here, neutropenia is not a major complication for most pwMS taking
alemtuzumab. It does occur in some individuals though thereby leaving them vulnerable to
infection and other complications (Gaitán et al. 2017).

One pwMS with a normal neutrophil level at baseline developed agranulocytosis. This was
successfully treated, as was reported in a recent case study of alemtuzumab-induced
neutropenia (Gaitán et al. 2017). Although rare, such severe adverse effects indicate that
monitoring of leucocyte subsets is important for early detection. Neutropenia may also occur
due to secondary autoimmunity after alemtuzumab. In such cases neutropenia is typically
delayed and occurs after immune reconstitution (Willis et al. 2016b).

DISCLOSURES:
None considered relevant to the contents of this paper. However, DB is a founder and
consultant to Canbex therapeutics and has received research funds from Canbex therapeutics,
Sanofi-Genzyme in the past 3 years. GG has received fees for participation in advisory board
for AbbVie Biotherapeutics, Biogen, Canbex, Ironwood, Novartis, Merck, Merck Serono, Roche,
Sanofi Genzyme, Synthon, Teva and Vertex; speaker fees from AbbVie, Biogen, Bayer
HealthCare, Genzyme, Merck Serono, Sanofi-Aventis and Teva. Research support from Biogen,
Genzyme, Ironwood, Merck, Merck Serono and Novartis. KS has been a PI of trials sponsored
by Novartis, Roche, Teva, Medday, involved in trials sponsored by Biogen, Sanofi-Genzyme,
BIAL, Cytokinetics, and Canbex, and has received speaking honoraria for lecturing and
advisory activity, and/or meeting support from Biogen, Merck Serono, Novartis, Roche, Sanofi-
Genzyme, and Teva.
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STUDY FUNDING:

This research received no specific grant from any funding agency in the public, commercial or
not-for-profit sectors.

ACKNOWLEDGEMENT:

We thank the European Medicines Agency for supplying the regulatory submissions. KS & DB
had full access to all the data in the study and take responsibility for the integrity of the data
and the accuracy of the data analysis.

CONTRIBUTIONS

Concept DB, KS, GG; FOI request KS; data analysis DB, KS; figures DB; writing of manuscript
DB, GG, KS.

REFERENCES

Ambrose LR, Morel AS, Warrens AN. Neutrophils express CD52 and exhibit complement-
mediated lysis in the presence of alemtuzumab. Blood. 200; 114:3052-3055

Smith A, Couvillion R, Zhang R, Killackey M, Buell J, Lee B, Saggi BH, Paramesh AS. Incidence
and management of leukopenia/neutropenia in 233 kidney transplant patients following single
dose alemtuzumab induction. Transplant Proc. 2014; 46:3400-3404.

Baker D, Herrod SS, Alvarez-Gonzalez C, Zalewski L, Albor C, Schmierer K. Both cladribine and
alemtuzumab may affect MS via B-cell depletion. Neurol Neuroimmunol Neuroinflamm. 2017a
5;4(4):e360.

Baker D, Herrod SS, Alvarez-Gonzalez C, Giovannoni G, Schmierer K.Interpreting Lymphocyte

Reconstitution Data From the Pivotal Phase 3 Trials of Alemtuzumab. JAMA Neurol. 2017b. doi:
10.1001/jamaneurol.2017.0676. [Epub]

Cohen JA, Coles AJ, Arnold DL, Confavreux C, Fox EJ, Hartung HP, Havrdova E, Selmaj KW,
Weiner HL, Fisher E, Brinar VV, Giovannoni G, Stojanovic M, Ertik BI, Lake SL, Margolin DH,
Panzara MA, Compston DA; CARE-MS I investigators.Alemtuzumab versus interferon beta 1a
as first-line treatment for patients with relapsing-remitting multiple sclerosis: a randomised
controlled phase 3 trial. Lancet. 2012;380:1819-1828.

Coles AJ, Twyman CL, Arnold DL, Cohen JA, Confavreux C, Fox EJ, Hartung HP, Havrdova E,
Selmaj KW, Weiner HL, Miller T, Fisher E, Sandbrink R, Lake SL, Margolin DH, Oyuela P,
Panzara MA, Compston DA; CARE-MS II investigators.Alemtuzumab for patients with relapsing
multiple sclerosis after disease-modifying therapy: a randomised controlled phase 3
trial.Lancet. 2012;380: 1829-1839.

Fabian I, Flidel O, Gadish M, Kletter Y, Slavin S, Nagler A. Effects of CAMPATH-1 antibodies on

the functional activity of monocytes and polymorphonuclear neutrophils. Exp Hematol. 1993;
21:1522-7.
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Gaitán MI, Ysraelit MC, Correale J. Neutropenia in patients with multiple sclerosis treated with
alemtuzumab. JAMA Neurol. 2017 doi: 10.1001/jamaneurol.2017. 1456.

Thomas K, Eisele J, Rodriguez-Leal AF, Hainke U, Ziemssen T. Acute effects of alemtuzumab

infusion in patients with active relapsing-remitting MS. Neurol Neuroimmunol
Neuroinflamm 2016; 29:e228.

Willis MD, Robertson NP. Alemtuzumab for multiple sclerosis.Curr Neurol Neurosci Rep. 2016a
16:84.

Willis MD, Harding KE, Pickersgill TP, Wardle M, Pearson OR, Scolding NJ, Sme J, Robertson
NP. Mult Scler 2016: 22:1215-1223.

Figure 1. Number of peripheral blood neutrophils following alemtuzumab administration. Mean

± standard deviation, median, maximum and minimum levels of neutrophils in the CARE-MS I
trial. Alemtuzumab was administered at baseline and at month 12. n = 349-373 per time
point.

25

Mean
Mean number of neutrophils x 10 9/L

Median
20 Minimum
Maximum

15

10

0
0 3 6 9 12 15 18 21 24
Time (months)
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Table 1. Neutropenia following treatment with alemtuzumab

Neutropenia Grade (Cell number) Baseline Year 1 Year 2

Grade 0 ≥ Lower limits of normal (LLN) 364/429 304/375 318/374
Grade 1 (≥1.5 - <LLN x 109/L) 5/5 39/39 33/32
Grade 2 (≥1.0 - <1.5x 109/L) 4/0 30/19 17/22
Grade 3 (≥0.5 - <1.0 x 109/L) 0/1 2/2 6/5
Grade 4 <0.5 x 109/L) 0/0 1/0 1/0
Neutrophil counts according to the Common Terminology Criteria for Adverse Events at
baseline and the worst post-baseline neutrophil count in people with MS receiving 12mg/day
alemtuzumab for 5 days in year 1, and 3 days in year 2 in CARE-MS I and CARE-MS II.

HIGHLIGHTS

 Neutropenia occurred in 20-25% of people in the 2 year phase III, pivotal trials of
alemtuzumab.
 However, grade 3-4 neutropenia (neutrophils <1.0 x 109/L) occurred in only 5/811 people
with MS (0.6%) in the year following the first infusion cycle and in 12/808 people (1.5%)
in the year following the second infusion cycle.
 Agranulocytosis was a rare occurrence but this responded to treatment.