The First Case Series for Autologous Stem Cell Transplant in Multiple Sclerosis Patients in the United Arab Emirates
Authors: Abu Haleeqa Mohamed I. , Ali Ruaa Ballal , Mir Ruqqia , Brylev Lev , Ventura-Carmenate Yendry , al Kaabi Fatema , Castillo Aleman Yandy Marx , Alsaadawi Nameer , Dennison Jayakumar David , Atieh Mutaz , Ibrahim Asia , Wahdan Rasha , Al Karam Maysoon , Hernández-Ramírez Antonio , El-Najjar Inas 
Published: December 2024

Introduction:

Multiple Sclerosis (MS) is a chronic inflammatory demyelinating neurological disorder that. As per EBMT guidelines ASCT (autologous stem cell transplant) in MS is indicated for aggressive MS not previously treated with full course of DMT (Disease modifying therapy) and remitting relapsing MS (RRMS) failing 3 or more DMTs . We endeavored to make ASCT locally accessible to eligible patients living in the UAE, to avoid the need to travel abroad for this treatment. Establishing at Abu-Dhabi Stem Cell Center (ADSCC) the only transplant program in the Gulf region for Multiple sclerosis patients.

Objective:

We report the feasibility, safety and efficacy of ASCT in the first cohort of patients treated in Ab-Dhabi, United Arab Emirates.

Method:

Patients are assessed by both the neurology and hematology team for eligibility for ASCT. Following an appropriate wash out period from the last immunotherapy patients have received. Eligible patients proceed to stem cell mobilization utilizing: Cyclophosphamide priming 2.0g/m2, followed five days later by granulocyte colony stimulating factor (G-CSF) 5 mcg/kg/day for five days. A non-myeloablative (NMA) protocol is utilized. This includes cyclophosphamide 50 mg/kg/iv over 2 hours daily for four days along with MESNA 50 mg/kg/day continuous infusion. A total dose of Rabbit anti-thymocyte globulin (ATG) 6.0 mg/kg/day is administered in divided doses infused over five days. All patients are placed on appropriate antiviral, antibacterial and antifungal prophylaxis as per our standard protocol. Patients are monitored for CMV and EBV reactivation weekly until 3 months post engraftment.

Results:

Four patients underwent ASCT between (April 2023 and April 2024) Median age 26 (21-38) years. Male: Female 2:2, Expanded Disability Status Scale (EDSS) Median 6 (4.5-8.5). A median total stem cells 11.9 x 106 CD34 cells/Kg with a range of(7.19-17.7) was collected , processed and cryopreserved in ADSCC . Patients received a median of 6.99 x106 CD34cells/kg with a range of (5.18-8.6). Median engraftment for neutrophils 9 (8-10) days and for platelets 7 (0-9) days. No significant noninfectious complications happened during mobilization collection or post-transplant phase. Transfusion requirements: PRBC median of 2 (0-3) units, platelets median of 4 (0-8) units. Most patients in our cohort developed CMV reactivation, 3 of the 4 patients. The median time for reactivation was median 9.5 (0-17) days post stem cell infusion. All patients were treated successfully without complications with Valganciclovir. One patient had EBV reactivation only and was treated successfully with only a dose of rituximab. Regarding Neurological clinical assessment of EDSS post ASCT One patient had an impressive improvement of EDSS from 8.5 to 3. The remaining patients had a stable EDSS, do not currently require any immunotherapy and have not had any further relapses. All patients are alive and well; the program has had no mortality to date.

Conclusion:

We have successfully established the first local service in the Gulf region providing ASCT and access to a multidisciplinary team to all MS patients abrogating the need for travel for treatment. Although most patients developed viral reactivation, this was manageable and non-life threatening. This year we plan to expand our program and accommodate more patients from the region and beyond