Incidence and prevalence of NMOSD in Australia and New Zealand

OBJECTIVES

We have undertaken a clinic-based survey of neuromyelitis optica spectrum disorders (NMOSDs) in Australia and New Zealand to establish incidence and prevalence across the region and in populations of differing ancestry.

BACKGROUND

NMOSD is a recently defined demyelinating disease of the central nervous system (CNS). The incidence and prevalence of NMOSD in Australia and New Zealand has not been established.

METHODS

Centres managing patients with demyelinating disease of the CNS across Australia and New Zealand reported patients with clinical and laboratory features that were suspicious for NMOSD. Testing for aquaporin 4 antibodies was undertaken in all suspected cases. From this group, cases were identified who fulfilled the 2015 Wingerchuk diagnostic criteria for NMOSD. A capture-recapture methodology was used to estimate incidence and prevalence, based on additional laboratory identified cases.

RESULTS

NMOSD was confirmed in 81/170 (48%) cases referred. Capture-recapture analysis gave an adjusted incidence estimate of 0.37 (95% CI 0.35 to 0.39) per million per year and a prevalence estimate for NMOSD of 0.70 (95% CI 0.61 to 0.78) per 100 000. NMOSD was three times more common in the Asian population (1.57 (95% CI 1.15 to 1.98) per 100 000) compared with the remainder of the population (0.57 (95% CI 0.50 to 0.65) per 100 000). The latitudinal gradient evident in multiple sclerosis was not seen in NMOSD.

CONCLUSIONS

NMOSD incidence and prevalence in Australia and New Zealand are comparable with figures from other populations of largely European ancestry. We found NMOSD to be more common in the population with Asian ancestry.

Therapeutic approaches to disease modifying therapy for multiple sclerosis in adults: an Australian and New Zealand perspective: part 1 historical and established therapies. MS Neurology Group of the Australian and New Zealand Association of Neurologists

Multiple sclerosis (MS) is a potentially life-changing immune mediated disease of the central nervous system. Until recently, treatment has been largely confined to acute treatment of relapses, symptomatic therapies and rehabilitation. Through persistent efforts of dedicated physicians and scientists around the globe for 160 years, a number of therapies that have an impact on the long term outcome of the disease have emerged over the past 20 years. In this three part series we review the practicalities, benefits and potential hazards of each of the currently available and emerging treatment options for MS. We pay particular attention to ways of abrogating the risks of these therapies and provide advice on the most appropriate indications for using individual therapies. In Part 1 we review the history of the development of MS therapies and its connection with the underlying immunobiology of the disease. The established therapies for MS are reviewed in detail and their current availability and indications in Australia and New Zealand are summarised. We examine the evidence to support their use in the treatment of MS.

Therapeutic approaches to disease modifying therapy for multiple sclerosis in adults: an Australian and New Zealand perspective: part 3 treatment practicalities and recommendations. MS Neurology Group of the Australian and New Zealand Association of Neurologists

In this third and final part of our review of multiple sclerosis (MS) treatment we look at the practical day-to-day management issues that are likely to influence individual treatment decisions. Whilst efficacy is clearly of considerable importance, tolerability and the potential for adverse effects often play a significant role in informing individual patient decisions. Here we review the issues surrounding switching between therapies, and the evidence to assist guiding the choice of therapy to change to and when to change. We review the current level of evidence with regards to the management of women in their child-bearing years with regards to recommendations about treatment during pregnancy and whilst breast feeding. We provide a summary of recommended pre- and post-treatment monitoring for the available therapies and review the evidence with regards to the value of testing for antibodies which are known to be neutralising for some therapies. We review the occurrence of adverse events, both the more common and troublesome effects and those that are less common but have potentially much more serious outcomes. Ways of mitigating these risks and managing the more troublesome adverse effects are also reviewed. Finally, we make specific recommendations with regards to the treatment of MS. It is an exciting time in the world of MS neurology and the prospects for further advances in coming years are high.

Gain and loss of gastrointestinal symptoms in diabetes mellitus: associations with psychiatric disease, glycemic control, and autonomic neuropathy over 2 years of follow-up

OBJECTIVE

To prospectively determine the turnover (gain or loss) of gastrointestinal (GI) symptoms in diabetic subjects in relation to glycemic control, autonomic neuropathy and psychiatric disease over a 2-year follow-up.

METHODS

Type 1 and type 2 diabetic subjects were recruited from the community, as were community controls. Individual GI symptoms were examined by a validated questionnaire and classified as diarrhea, irritable bowel syndrome, upper GI symptoms, and any GI symptoms at baseline, 12 and 24 months. Glycemic control (glycated hemoglobin), autonomic function (using standardized tests), and psychiatric disease (using the Composite International Diagnostic Interview) were also assessed at these time points.

RESULTS

Baseline and 2-year follow-up data were available for 139 diabetic subjects and 55 controls. Glycated hemoglobin at baseline was 7.7% (+/-1.36) in the diabetic group; 5% had severe autonomic dysfunction. There was a significantly higher prevalence of diarrhea in the diabetic subjects. GI symptom turnover varied between 15% and 25% in the diabetic group and was not significantly different from the controls. There was no clear association between turnover of GI symptoms and either glycemic control or autonomic neuropathy. The appearance of depression was associated with gaining of most symptoms apart from irritable bowel syndrome, although the associations did not always reach significance. The univariate results were confirmed after adjusting for age, gender, body mass index, and metformin use.

CONCLUSION

The turnover of GI symptoms in diabetic subjects was not associated with glycemic control but there was a positive association with change in depression.

Effect of leflunomide on the peripheral nerves in rheumatoid arthritis

BACKGROUND

The objective of this study was to determine the neurophysiological effects of leflunomide on peripheral nerves in rheumatoid arthritis.

METHODS

We conducted a prospective cohort trial of 32 patients with rheumatoid arthritis with 16 patients receiving leflunomide treatment and 16 receiving other disease-modifying anti-rheumatic drug therapies. Clinical, laboratory and neurophysiological measurements were used to determine the presence of a peripheral neuropathy in these patients at study entry and then after a further 3 and 6 months.

RESULTS

Fifty-four per cent of the leflunomide group and 8% of the control group had an increase in their neuropathy symptom score 6 months into the study (P = 0.01). No correlation was found between the electrophysiological findings and the clinical symptoms. There was no significant difference between the two groups in upper and lower limb sensory and motor amplitudes and conduction velocities recorded at 3 and 6 months. One patient developed both clinical and neurophysiological evidence of a peripheral neuropathy 5 months into the study that improved after cessation of leflunomide therapy and cholestyramine washout.

CONCLUSION

After 6 months of exposure we found that leflunomide was associated with an apparent increase in the clinical symptoms of peripheral neuropathy in patients with rheumatoid arthritis. These symptoms did not correlate with neurophysiological studies.