News in brief: Fewer relapses in RRMS with off-label rituximab; Antihistamines better than benzos for vertigo; Gender disparity in stroke management

19 Jul 2022

Fewer relapses in RRMS with off-label rituximab

Although rituximab is not approved for use in patients with multiple sclerosis, treatment with the B-cell depleting therapy was associated with a significantly lower risk of relapse compared with standard treatment of dimethyl fumarate, a study has shown.

Published in The Lancet Neurology, the results come from a phase 3 clinical trial involving 195 patients in Sweden with newly diagnosed relapsing-remitting MS.

During the 24-month follow-up, patients treated with rituximab had a five-fold lower risk of relapse compared to those who received dimethyl fumarate.

Only three out of 98 patients who received rituximab suffered relapses, compared to 16 out of 97 patients who received dimethyl fumarate. Magnetic resonance imaging (MRI) also showed that those who received rituximab had fewer new MS plaques.

“The excellent efficacy and low cost of rituximab could make it an attractive first choice for newly diagnosed MS patients, not least in resource-poor areas. But more and larger studies are needed to confirm the drug’s efficacy, long-term safety and cost-effectiveness for MS,” says the study’s first author Anders Svenningsson, adjunct professor at the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet and chief physician at the neurology clinic at Danderyd Hospital.

However, since the patent has expired, there is no incentive from the pharmaceutical company holding the marketing rights to apply for a new indication, said Dr Svenningsson.

“But now, in addition to accumulated clinical experience, we also have the documentation that is usually required to apply for an indication. Our study is an important step on the way for rituximab to become an approved MS drug,” he said.

Antihistamines better than benzos for vertigo

Antihistamines, rather than benzodiazepines, should be the preferred choice when pharmacotherapy is indicated for patients with acute vertigo, a new systematic review and meta-analysis has concluded.

Published in JAMA Neurology, the review identified seven trials with a total of 802
participants that evaluated the primary outcome of interest of symptom control of vertigo at two hours measured by a visual analogue score (VAS).

It found that single-dose antihistamines resulted in significantly more improvement on 100-point VAS scores compared with benzodiazepines (difference, 16.1) but not compared with other therapies such as ondansetron, droperidol, metoclopramide, and piracetam.

For the secondary outcomes of symptom control at one week and one month, neither daily benzodiazepines nor antihistamines were found to be superior to placebo.

The authors said the review found no evidence to support an association of benzodiazepine
use with improvement in any outcomes for patients with acute vertigo and therefore the use of benzodiazepines should be discouraged.

Gender disparity in stroke management

Women hospitalised with acute stroke are more likely than men to arrive by ambulance, but less likely to receive stroke-specific management during their journey, an Australian study has found.

Among people under 70, women with stroke were less likely than men to be assessed by paramedics as having a stroke (adjusted Odds Ratio 0.89), a review of more than 200,000 hospitalisations in NSW found.

Women were more likely than men to be assessed by paramedics as having migraine, other headache, anxiety, unconsciousness, hypertension, or nausea.

Women with stroke were also less likely than men to be managed according to the NSW Ambulance pre-hospital stroke care protocol, the study at the George Institute for Global Health, University of NSW found, but the likelihood of basic pre-hospital care was similar for both sexes.

Senior Research Fellow and Academic Lead of the George Institute’s Global Brain Health Initiative, Dr Cheryl Carcel said that missing stroke diagnosis in women could be due to different symptoms, but there was possible implicit sex bias amongst healthcare providers.

“Procedures for in-ambulance stroke care ensure patients with stroke symptoms are brought to a high-level specialised facility quickly to receive life-saving treatment,” she said.

“While there aren’t any studies looking at clinician sex bias in stroke, we have evidence from other countries where it is happening in coronary artery disease. Greater awareness amongst all health professionals about differences in symptom presentation between men and women could help address this bias,” she added.

The findings are published in the MJA

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