Natalizumab: Wikis

  

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Natalizumab ?
Monoclonal antibody
Source Humanized
Target Alpha-4 integrin
Identifiers
CAS number 189261-10-7
ATC code L04AA23
PubChem  ?
DrugBank BTD00083
Chemical data
Formula  ?
Mol. mass 149 kDa
Pharmacokinetic data
Bioavailability n/a
Metabolism  ?
Half life 11 ± 4 days
Excretion  ?
Therapeutic considerations
Licence data

EU EMEA:linkUS FDA:link

Pregnancy cat. C(AU) C(US)
Legal status Prescription only
Routes Intravenous infusion

Natalizumab is a humanized monoclonal antibody against the cellular adhesion molecule α4-integrin. Natalizumab is used in the treatment of multiple sclerosis and Crohn's disease. It is co-marketed by Biogen Idec and Élan as Tysabri, and was previously named Antegren. Natalizumab is administered by intravenous infusion every 28 days. The drug is believed to work by reducing the ability of inflammatory immune cells to attach to and pass through the cell layers lining the intestines and blood-brain barrier. Natalizumab has proven effective in treating the symptoms of both diseases, preventing relapse, vision loss, cognitive decline and significantly improving quality of life in people with multiple sclerosis, as well as increasing rates of remission and preventing relapse in Crohn's disease.

Natalizumab was approved in 2004 by the U.S. Food and Drug Administration (FDA). It was subsequently withdrawn from the market by its manufacturer after it was linked with three cases of the rare neurological condition progressive multifocal leukoencephalopathy (PML) when administered in combination with interferon beta-1a, another immunosuppressive drug often used in the treatment of multiple sclerosis. After a review of safety information and no further deaths, the drug was returned to the US market in 2006 under a special prescription program. As of June 2009, ten cases of PML were known. However, twenty-four cases of PML had been reported since its reintroduction by October 2009, showing a sharp rise in the number of fatalities and prompting a review of the chemical for human use by the European Medicines Agency.[1][2][3] In the European Union, it has been approved for human use only for the treatment of multiple sclerosis and only then as a monotherapy because the initial cases of PML, and later the fatalities, were said by the manufacturers to be linked to the use of previous medicines by the deceased customers.

Biogen Idec announced the initiation of the first clinical trial of Tysabri as a potential cancer treatment as of September 5, 2008.[4]

Contents

Indications

Natalizumab is FDA-approved for the treatment of multiple sclerosis and Crohn's disease and approved for treatment of multiple sclerosis in Europe, but is currently under review by the EMEA.[5][6]

Multiple sclerosis

Natalizumab was evaluated in two randomized, double-blind, placebo-controlled trials in people with multiple sclerosis. Both studies enrolled individuals with MS who experienced at least one clinical relapse during the prior year and had a Kurtzke EDSS score between 0 and 5. In these trials natalizumab was shown to reduce relapses in individuals with MS by 68% vs. placebo, a margin far greater than had been seen for other approved MS therapies.[7] Natalizumab also slowed the progression of disability in patients with relapsing MS.[7][8] In combination with interferon beta-1a (IB1A), relapsing and disability progression were reduced more than IB1A alone.[9] Other benefits of natalizumab use by patients with relapsing MS included reduced visual loss,[10] a significant increase in the proportion of disease-free individuals,[11] significantly improved assessments of health-related quality of life in relapsing individuals,[12][13] reduced cognitive decline of a portion of individuals with MS,[14] reduced hospitalizations and steroid use,[15] and prevention of the formation of new lesions.[7][16] Approximately 6% of individuals receiving natalizumab have been found to develop persistent antibodies to the drug, which reduces its efficacy[9][17][18] and produce reactions during the infusion of the drug, as well as hypersensitivity.[9] Natalizumab is approved in the United States and the European Union. It is indicated as monotherapy (not combined with other drugs) for the treatment of highly active relapsing remitting MS in spite of prior treatments.[8] Natalizumab offers a limited improvement in efficacy compared to other treatments for MS, but due to the lack of information about long-term use, as well as potentially fatal adverse events, reservations have been expressed over the use of the drug outside of comparative research with existing medications.[9]

Crohn's disease

Several randomized controlled trials have demonstrated that natalizumab is effective in increasing rates of remission[19] and maintaining symptom-free status[20] in patients with Crohn's disease. Natalizumab may be appropriate in patients who do not respond to medications that block tumor necrosis factor-alpha such as infliximab,[21] with some evidence to support combination treatment of Crohn's disease with natalizumab and infliximab may be helpful in inducing remission.[22] Treatment of adolescent patients with natalizumab demonstrates an effectiveness similar to that of adult patients.[23]

In January 2008, the FDA approved natalizumab for both induction of remission and maintenance of remission for moderate to severe Crohn's disease,[24] though it has not been approved for this use in the European Union due to concerns over its risk/benefit ratio.[25]

Adverse effects

Common adverse effects include fatigue and allergic reactions with a low risk of anaphylaxis,[26] headache, nausea, colds and exacerbation of Crohn's disease in a minority of patients with the condition.[22] Adolescents with Crohn's disease experience headache, fever and exacerbation of Crohn's disease.[23] Natalizumab is contraindicated for people with known hypersensitivity to the drug or its components and in patients with a history of PML (see interactions).

Postmarketing surveillance in early 2008 revealed that 0.1% of people taking natalizumab experience clinically significant liver injury, leading to the FDA, EMEA and manufacturers recommending that the medication be discontinued in patients with jaundice or other evidence of significant liver damage.[27 ][28][29] This rate is comparable to other immune-suppressing drugs. [30] Evidence of hepatotoxicity in the form of elevated blood levels of bilirubin and liver enzymes can appear as soon as six days after an initial dose; reactions are unpredictable and may appear even if the patient does not react to previous treatment.[31] Such signs reoccur upon rechallenge in some patients, indicating that damage is not coincidental.[31] In the absence of any blockage these liver function tests are predictors of severe liver injury with possible sequelae of liver transplantation or death.[31]

Natalizumab has also been linked to melanoma, though the association is unclear.[32] The long-term effects of the drug are unknown[33] and concern has been expressed over the risks of infection and cancer.[9]

Progressive multifocal leukoencephalopathy, an opportunistic infection caused by the JC virus, and that typically occurs in patients who are immunocompromised, developed in seven patients who received natalizumab [34]; three cases were noted in clinical trials in 2006[35] leading to the drug being temporarily pulled from the market; two cases were reported to the FDA in August 2008 [36]; and, two cases were announced in December 2008 [34]. A recent preliminary study suggests that patients on this drug for more than 12 months are at elevated risk for PML (Chen Y et al. Asymptomatic reactivation of JC virus in patients treated with natalizumab. N Engl J Med 2009 Sep 10; 361:1067.)

Mechanism of action

Structure of a generic antibody

Natalizumab is a humanized monoclonal antibody against alpha-4 (α4) integrin, the first drug developed in the class of selective adhesion molecule inhibitors. α4-integrin is required for white blood cells to move into organs; natalizumab's mechanism of action is believed to be the inhibition these immune cells from crossing blood vessel walls to reach affected organs.[37]

In multiple sclerosis

The symptom-causing lesions of MS are believed to be caused when inflammatory cells such as T-lymphocytes pass through the blood-brain barrier through interaction with receptors on the endothelial cells. Natalizumab appears to reduce the transmission of immune cells into the central nervous system by interfering with the α4β1-integrin receptor molecules on the surfaces of cells. The effect appears to occur on endothelial cells expressing the VCAM-1 gene, and in parenchymal cells expressing the osteopontin gene. In animals used to model MS and test therapies, repeated administration of natalizumab reduced migration of leukocytes into the brain's parenchyma, and also reduced lesioning, though it is uncertain if this is clinically significant for humans.[38]

Individuals with MS dosed with natalizumab demonstrated increased CD34-expressing cells, with research suggesting a peak in expression after 72 hours.[39]

In Crohn's disease

The interaction of the α4β7 integrin and the addressin (also known as MADCAM1) endothelial cell receptor is believed to contribute to the chronic bowel inflammation that causes Crohn's disease. Addressin is primarily expressed in the endothelium of venules in the small intestine and are critical in guiding T-lymphocytes to lymphatic tissues in Peyer's patches. In CD patients, sites of active inflammation of the bowel in CD patients have increased expression of addressin, suggesting a connection between the inflammation and the receptor. Natalizumab may block interaction between the α4β7 integrin and addressin at sites of inflammation. Animal models have found higher levels of VCAM-1 expression in mice with irritable bowel syndrome and the VCAM-1 gene may also play a part in CD but its role is not yet clear.[38]

Interactions

Natalizumab appears to interact with other immune-modulating drugs to increase the risk of progressive multifocal leukoencephalopathy (PML), an often-fatal opportunistic infection caused by JC virus. In 2005, two people taking natalizumab in combination with interferon beta-1a developed PML. One died, and the other recovered with disabling sequelae.[40][41] A third fatal case initially attributed to an astrocytoma was reported in a patient being treated for Crohn's disease.[42] Though the patient was being treated with natalizumab in combination with azathioprine, corticosteroids and infliximab, indications of PML infection appeared only after natalizumab monotherapy was re-introduced.[42] No deaths have been linked to natalizumab when it was not combined with other immune-modulating drugs[43] and other rates of opportunistic infections are not increased in patients taking natalizumab[44] possibly due to the drug’s mechanism of action.[45] Other than a prior history of PML, there is no known method to identify patients at risk of developing PML.[46] Natalizumab's label indicates that it is contraindicated for immunosuppressed individuals or those with a history of PML.[38] Due to the uncertain risk of PML, natalizumab is only available through a restricted distribution program.[38] As of June 2009, ten cases of PML associated with natalizumab have been reported.[3] At least one of them had not previously taken any other inmunomodulator therapy.[47]

Though the small number of cases precludes conclusion on the ability of natalizumab alone to induce PML, its black box warning states that the drug has only been linked to PML when combined with other immune-modulating drugs and natalizumab is contraindicated for use with other immunomodulators.[38] Corticosteroids may produce immunosuppression, and the Tysabri prescribing information recommends that people taking corticosteroids for the treatment of Crohn's disease have their doses reduced before starting natalizumab treatment.[38] The risk of developing PML was later estimated to be 1 in 1,000 (0.1%) over 18 months[17][44][48] though the longer term risks of PML are unknown.[17]

Legal status

Natalizumab was originally approved for treatment of multiple sclerosis in 2004, through the FDA's accelerated Fast Track program, due to the drug's efficacy in one-year clinical trials. In February 2005, four months after its approval, natalizumab was withdrawn voluntarily by the manufacturer after two cases of progressive multifocal leukoencephalopathy. Groups representing individuals with MS lobbied to have the drug returned to the US market[49] and in June, 2006, after recommendation by an advisory committee and a review of two years of safety and efficacy data, the FDA re-approved natalizumab for patients with all relapsing forms of MS (relapse-remitting, secondary-progressive, and progressive-relapsing) as a first-line or second-line therapy.[50][51] Patients taking natalizumab must enter into a registry for monitoring.[49] Natalizumab is the only drug after alosetron withdrawn for safety reasons that returned to the US market.

In April, 2006 the Committee for Medicinal Products for Human Use recommended authorizing natalizumab to treat relapsing-remitting MS, and several weeks later the European Medicines Agency approved natalizumab in the European Union for highly-active relapsing remitting MS.[6]

Health Canada added natalizumab to Schedule F of the Food and Drug Regulations on April 3rd, 2008 as a prescription drug requiring oversight from a physician.[52]

References

  1. ^ European Medicines Agency, Press Office, Committee for Medicinal Products for Human Use Oct 22 2009
  2. ^ REUTERS EU agency reports 24th case of Tysabri infection
  3. ^ a b Clarke, Toni with Steve Orlofsky and Lisa Von Ahn (29 June 2009). "Biogen reports 10th case of PML brain infection". Reuters. http://news.yahoo.com/s/nm/20090629/hl_nm/us_biogen.  
  4. ^ "Biogen Idec testing Tysabri as a cancer treatment". 2008-09-05. http://www.boston.com/business/ticker/2008/09/biogen_idec_tes.html. Retrieved 2008-09-05.  
  5. ^ http://www.fiercepharma.com/story/tysabri-safety-falls-under-emea-scrutiny/2009-10-26
  6. ^ a b "Press release - European Medicines Agency: Committee for Medicinal Products for Human Use 24-27 April 2006" (PDF). European Medicines Agency. 2006-04-28. http://www.emea.europa.eu/pdfs/human/press/pr/15260806en.pdf. Retrieved 2008-04-02.  
  7. ^ a b c Polman CH, O'Connor PW, Havrdova E, et al. (2006). "A randomized, placebo-controlled trial of natalizumab for relapsing forms of multiple sclerosis". N. Engl. J. Med. 354 (9): 899–910. doi:10.1056/NEJMoa044397. PMID 16510744.  
  8. ^ a b "TYSABRI: ANNEX I – SUMMARY OF PRODUCT CHARACTERISTICS" (PDF). European Medicines Agency. http://www.emea.europa.eu/humandocs/PDFs/EPAR/tysabri/H-603-PI-en.pdf. Retrieved 2008-03-09.  
  9. ^ a b c d e "Natalizumab: new drug. Multiple sclerosis: risky market approval". Prescrire Int 17 (93): 7–10. 2008. PMID 18354844.  
  10. ^ Balcer LJ, Galetta SL, Calabresi PA, et al. (2007). "Natalizumab reduces visual loss in patients with relapsing multiple sclerosis". Neurology 68 (16): 1299–304. doi:10.1212/01.wnl.0000259521.14704.a8. PMID 17438220.  
  11. ^ Galetta, S; et al. (2008-04-18). "Natalizumab Increases the Proportion of Patients Free of Clinical or MRI Disease Activity in Relapsing Multiple Sclerosis". unpublished/unpresented conference poster. http://www.abstracts2view.com/aan2008chicago/view.php?nu=AAN08L_P02.156. Retrieved 2008-03-11.  ; industry publication - "New TYSABRI Data to Be Presented at the European Committee for Treatment and Research in Multiple Sclerosis". Élan. 2007-10-11. http://www.elan.com/news/full.asp?ID=1061738. Retrieved 2008-03-09.  
  12. ^ Rudick RA, Miller DM (2008). "Health-related quality of life in multiple sclerosis : current evidence, measurement and effects of disease severity and treatment". CNS drugs 22 (10): 827–39. doi:10.2165/00023210-200822100-00004. PMID 18788835.  
  13. ^ Rudick RA, Miller D, Hass S, et al. (2007). "Health-related quality of life in multiple sclerosis: effects of natalizumab". Ann. Neurol. 62 (4): 335–46. doi:10.1002/ana.21163. PMID 17696126.  
  14. ^ "New Data on Natalizumab Demonstrate Significant Improvement in Cognitive Function in Patients With Multiple Sclerosis". Doctor's Guide. 2006-09-28. http://www.pslgroup.com/dg/265832.htm. Retrieved 2008-03-09.  
  15. ^ "New Pharmacoeconomic Data On TYSABRI Demonstrate Significant Reduction In Steroid Use And Hospitalizations In Patients With Multiple Sclerosis". webwire. 2006-10-06. http://www.webwire.com/ViewPressRel.asp?aId=21727. Retrieved 2008-03-09.  
  16. ^ Miller DH, Soon D, Fernando KT, et al. (2007). "MRI outcomes in a placebo-controlled trial of natalizumab in relapsing MS". Neurology 68 (17): 1390–401. doi:10.1212/01.wnl.0000260064.77700.fd. PMID 17452584.  
  17. ^ a b c Hutchinson M (2007). "Natalizumab: A new treatment for relapsing remitting multiple sclerosis". Ther Clin Risk Manag 3 (2): 259–268. doi:10.2147/tcrm.2007.3.2.259. PMID 18360634. PMC 1936307. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18360634. Retrieved 2008-04-22.  
  18. ^ Calabresi PA, Giovannoni G, Confavreux C, et al. (2007). "The incidence and significance of anti-natalizumab antibodies: results from AFFIRM and SENTINEL". Neurology 69 (14): 1391–403. doi:10.1212/01.wnl.0000277457.17420.b5. PMID 17761550.  
  19. ^ Ghosh S, Goldin E, Gordon F, Malchow H, Rask-Madsen J, Rutgeerts P, Vyhnálek P, Zádorová Z, Palmer T, Donoghue S (2003). "Natalizumab for active Crohn's disease". N. Engl. J. Med. 348 (1): 24–32. doi:10.1056/NEJMoa020732. PMID 12510039.  
  20. ^ Feagan BG, Sandborn WJ, Hass S, Niecko T, White J (2007). "Health-related quality of life during natalizumab maintenance therapy for Crohn's disease". Am. J. Gastroenterol. 102 (12): 2737–46. doi:10.1111/j.1572-0241.2007.01508.x. PMID 18042106.  
  21. ^ Michetti P, Mottet C, Juillerat P, et al. (2007). "Severe and steroid-resistant Crohn's disease". Digestion 76 (2): 99–108. doi:10.1159/000111023. PMID 18239400.  
  22. ^ a b Sands BE, Kozarek R, Spainhour J, et al. (2007). "Safety and tolerability of concurrent natalizumab treatment for patients with Crohn's disease not in remission while receiving infliximab". Inflamm. Bowel Dis. 13 (1): 2–11. doi:10.1002/ibd.20014. PMID 17206633.  
  23. ^ a b Hyams JS, Wilson DC, Thomas A, et al. (2007). "Natalizumab therapy for moderate to severe Crohn disease in adolescents". J. Pediatr. Gastroenterol. Nutr. 44 (2): 185–91. doi:10.1097/01.mpg.0000252191.05170.e7. PMID 17255829. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?an=00005176-200702000-00006.  
  24. ^ "FDA Approves Tysabri to Treat Moderate-to-Severe Crohn's Disease". Food and Drug Administration. 2008-01-14. http://www.fda.gov/bbs/topics/NEWS/2008/NEW01775.html. Retrieved 2008-03-09.  
  25. ^ "Refusal CHMP assessment report for natalizumab" (PDF). European Medicines Agency. 2007-11-15. http://www.emea.europa.eu/humandocs/PDFs/EPAR/natalizumab/H-624-RAR-en.pdf. Retrieved 2008-04-02.   lay-summaryPDF (78.5 KB)
  26. ^ Horga A, Horga de la Parte JF (2007). "[Natalizumab in the treatment of multiple sclerosis]" (in Spanish; Castilian). Rev Neurol 45 (5): 293–303. PMID 17876741.  
  27. ^ "FDA MedWatch - 2008 Safety Information Alerts". Food and Drug Administration. 2008-02-28. http://www.fda.gov/medwatch/safety/2008/safety08.htm#Tysabri. Retrieved 2008-04-05.  
  28. ^ "EMEA concludes new advice to doctors and patients for Tysabri (natalizumab) needed" (in English) (PDF). European Medicines Agency. 2008-03-20. http://emea.europa.eu/humandocs/PDFs/EPAR/tysabri/PR_Tysabri_13948908en.pdf. Retrieved 2008-04-05.  
  29. ^ "Questions and answers on Tysabri and liver injury" (PDF). European Medicines Agency. 2008-03-20. http://emea.europa.eu/humandocs/PDFs/EPAR/tysabri/Q&A_Tysabri_14590808en.pdf. Retrieved 2008-04-14.  ; lay-summary, second summary
  30. ^ Kenneth Gross, M.D. (2008-03-03). "Multiple Sclerosis - Natalizumab (Tysabri) Can Rarely Cause Liver Problems". http://www.healthcentral.com/multiple-sclerosis/c/6639/21073/liver/. Retrieved 2008-04-05.  
  31. ^ a b c Panzara, M; Francis V (2008-02-01). "Important safety information: Dear Healthcare Practitioner letter" (PDF). Biogen Idec and Élan. http://www.fda.gov/medwatch/safety/2008/Tysabri_dhcp_letter.pdf. Retrieved 2008-04-11.  ; lay summary
  32. ^ Mullen JT, Vartanian TK, Atkins MB (2008). "Melanoma complicating treatment with natalizumab for multiple sclerosis". N. Engl. J. Med. 358 (6): 647–8. doi:10.1056/NEJMc0706103. PMID 18256405.  
  33. ^ van Bronswijk H, Dubois EA, van Gerven JM, Cohen AF (2008). "[New drugs; natalizumab]" (in Dutch; Flemish). Ned Tijdschr Geneeskd 152 (9): 499–500. PMID 18389881.  
  34. ^ a b Greene, Robert T. (December 15, 2008). "Biogen, Elan Report Brain Illness in Tysabri Patient" (in English). Bloomberg.com. http://www.bloomberg.com/apps/news?pid=20601087&sid=ahUhAZaAQqgs&refer=home. Retrieved December 21, 2008.  
  35. ^ Van Assche G, Van Ranst M, Sciot R, et al. (July 2005). "Progressive multifocal leukoencephalopathy after natalizumab therapy for Crohn's disease". N. Engl. J. Med. 353 (4): 362–8. doi:10.1056/NEJMoa051586. PMID 15947080.  
  36. ^ U.S. Food and Drug Administration (August 2008). "Natalizumab Injection for Intraveneous [''sic''] Use (marketed as Tysabri)". http://www.fda.gov/cder/drug/InfoSheets/HCP/natalizumab2008HCP.htm. Retrieved December 22, 2008.  
  37. ^ Rice GP, Hartung HP, Calabresi PA (2005). "Anti-alpha4 integrin therapy for multiple sclerosis: mechanisms and rationale". Neurology 64 (8): 1336–42. doi:10.1212/01.WNL.0000158329.30470.D0 (inactive 2008-06-23). PMID 15851719.  
  38. ^ a b c d e f "Final TYSABRI PI" (PDF). http://tysabri.com/en_US/tysb/footer/TYSABRI-pi.pdf. Retrieved 2008-03-13.  
  39. ^ Zohren F, Toutzaris D, Klarner V, Hartung HP, Kieseier B, Haas R (2008). "The monoclonal anti-VLA4 antibody natalizumab mobilizes CD34+ hematopoietic progenitor cells in humans". Blood 111 (7): 3893. doi:10.1182/blood-2007-10-120329. PMID 18235044. http://www.bloodjournal.org/cgi/pmidlookup?view=long&pmid=18235044.  
  40. ^ Kleinschmidt-DeMasters BK, Tyler KL (2005). "Progressive multifocal leukoencephalopathy complicating treatment with natalizumab and interferon beta-1a for multiple sclerosis". N. Engl. J. Med. 353 (4): 369–74. doi:10.1056/NEJMoa051782. PMID 15947079.  
  41. ^ Langer-Gould A, Atlas SW, Green AJ, Bollen AW, Pelletier D (2005). "Progressive multifocal leukoencephalopathy in a patient treated with natalizumab". N. Engl. J. Med. 353 (4): 375–81. doi:10.1056/NEJMoa051847. PMID 15947078.  
  42. ^ a b Van Assche G, Van Ranst M, Sciot R, et al. (2005). "Progressive multifocal leukoencephalopathy after natalizumab therapy for Crohn's disease". N. Engl. J. Med. 353 (4): 362–8. doi:10.1056/NEJMoa051586. PMID 15947080. http://content.nejm.org/cgi/content/full/353/4/362.  
  43. ^ Yousry TA, Major EO, Ryschkewitsch C, et al. (2006). "Evaluation of patients treated with natalizumab for progressive multifocal leukoencephalopathy". N. Engl. J. Med. 354 (9): 924–33. doi:10.1056/NEJMoa054693. PMID 16510746.  
  44. ^ a b Berger JR (2006). "Natalizumab". Drugs Today 42 (10): 639–55. doi:10.1358/dot.2006.42.10.1042190. PMID 17136224.  
  45. ^ Ransohoff RM (2007). ""Thinking without thinking" about natalizumab and PML". J. Neurol. Sci. 259 (1-2): 50–2. doi:10.1016/j.jns.2006.04.011. PMID 17521672.  
  46. ^ Aksamit AJ (2006). "Review of progressive multifocal leukoencephalopathy and natalizumab". Neurologist 12 (6): 293–8. doi:10.1097/01.nrl.0000250948.04681.96. PMID 17122725.  
  47. ^ "Brain Infections Return for Multiple Sclerosis Drug Tysabri". 2008-08-01. http://blogs.wsj.com/health/2008/08/01/brain-infections-return-for-multiple-sclerosis-drug-tysabri/?mod=googlenews_wsj. Retrieved 2008-08-01.  
  48. ^ Kappos L, Bates D, Hartung HP, et al. (2007). "Natalizumab treatment for multiple sclerosis: recommendations for patient selection and monitoring". Lancet Neurol 6 (5): 431–41. doi:10.1016/S1474-4422(07)70078-9. PMID 17434098.  
  49. ^ a b Pollack, A (2006-03-09). "F.D.A. Panel Recommends M.S. Drug Despite Lethal Risk". The New York Times. http://www.nytimes.com/2006/03/09/business/09drug.html?_r=1&scp=2&sq=natalizumab&st=nyt&oref=slogin. Retrieved 2008-03-13.  
  50. ^ "Errata to FDA Background document for the Tysabri (natalizumab) Advisory Committee on July 31, 2007" (PDF). Food and Drug Administration. 2007-07-20. http://www.fda.gov/ohrms/dockets/ac/07/briefing/2007-4313b1-02-FDA-Errata.pdf. Retrieved 2008-03-09.  
  51. ^ Fiore D (2007). "Multiple sclerosis and Natalizumab". Am J Ther 14 (6): 555–60. doi:10.1097/MJT.0b013e31804bfa6a. PMID 18090880.  
  52. ^ "Regulations Amending the Food and Drug Regulations (1528 — Schedule F)". Canada Gazette. 2008-04-16. http://canadagazette.gc.ca/partII/2008/20080416/html/sor101-e.html#1. Retrieved 2008-04-23.  

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