Mitoxantrone (
Novantrone), a synthetic
anthracenedione derivative, is an
antineoplastic, immunomodulatory agent. Its presumed mechanism of action in patients with
multiple sclerosis (MS) is via immunomodulatory mechanisms, although these remain to be fully elucidated. Intravenous
mitoxantrone treatment improved neurological disability and delayed progression of MS in patients with worsening relapsing-remitting (RR) [also termed progressive-relapsing (PR) MS] or secondary-progressive (SP) disease. In a pivotal randomised, double-blind, multicentre trial,
mitoxantrone 12 mg/m(2) administered once every 3 months for 2 years provided significant improvements in neurological disability ratings, including Kurtzke Expanded Disability Status Scale (EDSS), Ambulatory Index (AI) and Standardised Neurological Status (SNS) scores, compared with placebo. The
drug also significantly reduced the mean number of
corticosteroid-treated relapses and prolonged the time to the first treated relapse, with the beneficial effects on
disease progression supported by magnetic resonance imaging. Post hoc analyses suggest that the benefits associated with
mitoxantrone treatment may be sustained for at least 12 months after
cessation of treatment, mean changes from baseline at 36 months in EDSS, AI and SNS scores of 0.10, 0.61 and 0.19, respectively, in the
mitoxantrone group versus 0.46, 1.13 and 3.38 with placebo. Concomitant intravenous
mitoxantrone 20mg plus intravenous
methylprednisolone 1g once every month for 6 months was more effective than intravenous
methylprednisolone monotherapy in preventing the development of new
gadolinium-enhanced lesions in patients with very active RRMS or SPMS. The
drug was generally well tolerated in patients with MS. Adverse events were generally mild to moderate in severity and usually resolved upon discontinuation of treatment or with appropriate
pharmacotherapy. At the recommended dosage,
mitoxantrone appears to have a low potential to cause
cardiotoxicity. In conclusion, intravenous
mitoxantrone reduces the relapse rate and slows progression of the disease in patients with worsening RRMS, PRMS or SPMS; thus providing a new option for the management of these patients. The
drug was generally well tolerated at the recommended dosage, although potential
cardiotoxicity limits the total cumulative dose to 140 mg/m(2). Further studies are warranted to determine which patients with worsening RRMS, PRMS or SPMS are most likely to benefit from
mitoxantrone treatment and to more fully define the long-term safety and tolerability of
mitoxantrone, including the use of concomitant cardioprotectants to extend the therapeutic lifespan of the
drug. Pharmacodynamic Profile.
Mitoxantrone, a synthetic
anthracenedione derivative, is an established cytotoxic,
antineoplastic agent. Its presumed mechanism of action in
multiple sclerosis (MS) is immunosuppression. In
antineoplastic studies, the
drug showed several immunomodulatory effects, inducing macrophage-mediated suppression of B-cell, T-helper and T-cytotoxic lymphocyte function. Currently, the pharmacodynamic properties of
mitoxantrone have not been investigated to any extent in patients with MS. In one study, 6 months' treatment with intravenous
mitoxantrone generally had no effect on the distribution of
cytokine-positive peripheral blood monocyte cells in patients with MS. In an animal model of the disease,
mitoxantrone suppressed the development and progression of both actively and passively induced acute
experimental allergic encephalomyelitis (EAE). It appeared to be 10-20 times more effective than
cyclophosphamide in the suppression of EAE. Moreover,
mitoxantrone approximately doubled the mean time to onset of EAE versus control animals (279 vs 148 days after immunisation; p < 0.00005). In vitro,
mitoxantrone 10 and 100 micro g/L inhibited myelin degradation by leucocytes and peritoneal macrophages derived from mice with acute EAE by approximately 60% and 100%. Pharmacokinetic Profile. Currently, there are no published pharmacokinetic data for intravenous
mitoxantrone in pitoxantrone in patients with MS, paediatric patients or in those with renal impairment. All studies, to date, have been in patients with
cancer receiving a single, approximately 30-minute
intravenous infusion of
mitoxantrone 5-14 mg/m(2). The
drug exhibits triexponential pharmacokinetics, with a rapid initial distribution (alpha) phase, an intermediate distribution (beta) phase and a much slower elimination (gamma) phase. The mean half-life of the alpha phase appears to be 6-12 minutes and that of the beta phase 1.1-3.1 hours.
Mitoxantrone has a high affinity for tissue, with a volume of distribution of up to 2248 L/m(2).
Mitoxantrone persists for prolonged periods in tissues and was detectable in autopsy tissue from patients who last received the
drug up to 272 days before death. At concentrations of 10-10000 ng/mL, the
drug was 70-80 % bound to
plasma proteins in dogs. Elimination of
mitoxantrone occurs predominantly through biliary excretion and may be impaired in patients with hepatic dysfunction or third space abnormalities (e.g.
ascites). The mean terminal elimination half-life of
mitoxantrone ranged from 23 hours to 215 hours. Renal clearance accounts for 10 % of the total clearance of the
drug. Total clearance of
mitoxantrone ranged from 13 to 34.2 L/h/m(2) and renal clearance from 0.9 to 2.7 L/h/m(2). The
drug appears to have a low potential for interaction with other concomitantly administered agents. Therapeutic Efficacy. Intravenous
mitoxantrone (infusion of > or = 5 minutes), either as monotherapy or in combination with intravenous
methylprednisolone, delayed the progression of the disease in patients with secondary-progressive (SP) or worsening relapsing-remitting (RR) MS (the latter is also termed progressive-relapsing MS) in comparative, randomised, multicentre trials. In a double-blind, monotherapy trial (
Mitoxantrone In
Multiple Sclerosis [MIMS] trial),
mitoxantrone 12 mg/m(2) (n = 60) once every 3 months for 2 years significantly improved neurological disability relative to placebo (n = 64), as assessed by changes in mean Kurtzke Expanded Disability Status Scale (EDSS) score, mean Ambulatory Index (AI) score and mean Standardised Neurological Status (SNS) score. The
drug also significantly reduced the mean number of
corticosteroid-treated relapses per patient and prolonged the time to the first treated relapse. A Wei-Lachin multivariate analysis of these five efficacy variables indicated that the global difference between the two treatment groups was 0.30 (p < 0.0001). Mitroxantrone was also more effective than placebo according to secondary endpoints in this study, with fewer
mitoxantrone recipients experiencing a relapse, a deterioration of > or =1 EDSS point or a confirmed deterioration in EDSS score over a 3-month period.
Mitoxantrone recipients also showed less deterioration in quality-of-life ratings and had fewer hospital admissions, whereas more placebo recipients had new
gadolinium-enhanced lesions at study end (the latter parameter was assessed using magnetic resonance imaging [MRI] in a subgroup of 110 patients, including 40 patients who received an exploratory 5 mg/m(2) dose). Furthermore, post hoc analyses indicated that the beneficial effects of
mitoxantrone treatment on EDSS, SNS and AI scores were sustained for at least 12 months after
cessation of treatment, with mean changes from baseline at 36 months in EDSS, AI and SNS scores of 0.10, 0.61 and 0.19, respectively, in the
mitoxantrone group versus 0.46, 1.13 and 3.38 with placebo. Preliminary data from a cost-minimisation analysis based on results from the MIMS trial indicated that approximately half of the cost of
mitoxantrone was offset by cost savings in other areas associated with the treatment of MS (direct and indirect major costs), with a total annual incremental cost for
mitoxantrone of dollar 1661 per patient. Combination
therapy once-monthly with intravenous
mitoxantrone 20mg plus intravenous
methylprednisolone 1g was more effective than intravenous
methylprednisolone 1g once every month in preventing the development of
gadolinium-enhanced lesions in patients with very active RRMS or SPMS (double-blind assessment using MRI scans). After 6 months, significantly more combination
therapy recipients had no new
gadolinium-enhanced lesions (90.5% vs 31.3% with monotherapy; p < 0.001) [primary endpoint]. There were also significant reductions in both the mean number of new enhancing lesions and the total number of
gadolinium-enhanced lesions in patients receiving combination
therapy versus
methylprednisolone monotherapy.Tolerability.
Mitoxantrone was generally well tolerated in patients with MS. Treatment-emergent adverse events occurring significantly more frequently with
mitoxantrone (12 mg/m(2) once every 3 months for 2 years) than placebo were
nausea,
alopecia, menstrual disorders,
urinary tract infection, amenorrhoea, leucopenia and elevated gamma-glutamyltranspeptidase levels. Adverse events were usually mild to moderate in severity and generally resolved with discontinuation of treatment or when treated with appropriate
pharmacotherapy. Eight percent of patients discontinued treatment in the
mitoxantrone 12 mg/m(2) group due to an adverse event versus 3% of placebo recipients. The incidence of
drug-related acute myelogenous leukaemia was very low (0.12%) in a cohort of 802 patients with MS receiving
mitoxantrone. Evidence suggests that the risk of
cardiotoxicity is low in patients with MS. After 1 year of monotherapy, 3.4% of
mitoxantrone recipients had a reduction in left ventricular ejection fraction (LVEF) to < or =50% compared with 0% of placebo recipients; at the end of the second year, respective incidences were 1.9% and 2.9% (total cumulative dose of
mitoxantrone per patient was 96 mg/m(2) after 2 years' treatment). (ABSTRACT TRUNCATED)