ABSTRACT
Pulmonary embolism (PE) is a potentially life-threatening condition requiring prompt diagnosis and treatment. Recent advances have led to the development of newer techniques and drugs aimed at improving PE management, reducing its associated morbidity and mortality and the complications related to anticoagulation. This review provides an overview of the current knowledge and future perspectives on PE treatment. Anticoagulation represents the first-line treatment of hemodynamically stable PE, direct oral anticoagulants being a safe and effective alternative to traditional anticoagulation: these drugs have a rapid onset of action, predictable pharmacokinetics, and low bleeding risk. Systemic fibrinolysis is suggested in patients with cardiac arrest, refractory hypotension, or shock due to PE. With this narrative review, we aim to assess the state of the art of newer techniques and drugs that could radically improve PE management in the near future: (i) mechanical thrombectomy and pulmonary embolectomy are promising techniques reserved to patients with massive PE and contraindications or failure to systemic thrombolysis; (ii) catheter-directed thrombolysis is a minimally invasive approach that can be suggested for the treatment of massive or submassive PE, but the lack of large, randomized controlled trials represents a limitation to widespread use; (iii) novel pharmacological approaches, by agents inhibiting thrombin-activatable fibrinolysis inhibitor, factor Xia, and the complement cascade, are currently under investigation to improve PE-related outcomes in specific settings.
ABSTRACT
BACKGROUND AND PURPOSE: Ongoing disease activity during treatment has been associated to worse disability outcomes in patients with Multiple Sclerosis (MS). The aim of this study was to assess the 5-year response to fingolimod (FTY) treatment in patients with relapsing-remitting (RRMS) in a real-life setting. METHODS: We included RRMS patients who received FTY for at least 6 months and had a follow-up ≥ 60 months. Treatment response was assessed through the No Evidence of Disease Activity (NEDA)-3 status. RESULTS: Eighty-eight patients were included, of which 51 (58.0%) were NTZ-naïve and 37 (42.0%) NTZ-switchers. The mean age was 38.9 (9.5) years and 58 (65.9%) were females. The proportion of patients on FTY treatment who maintained the NEDA-3 status at 5 years was 55.9% among NTZ-naïve patients and 35.0% among NTZ-switchers (p=0.138). Predictors of NEDA-3 status were lower Expanded Disability Status Scale score at baseline (adjOR=0.28, 95% CI 0.10-0.77; p=0.013) in NTZ-naïve patients and fewer relapses in the 12 months before starting FTY in NTZ-switchers (adjOR=0.05, 95% CI 0.003-0.79; p=0.034). CONCLUSIONS: This study supports the potential of FTY as a disease-modifying treatment for the long-term management of RRMS patients. Patients with milder disability and fewer clinical relapses before treatment may achieve a better disease control.
