Teriflunomide reduces relapse-related neurological sequelae, hospitalizations and steroid use

Multiple sclerosis (MS) relapses impose a substantial clinical and economic burden. Teriflunomide is a new oral disease-modifying therapy approved for the treatment of relapsing MS. We evaluated the effects of teriflunomide treatment on relapse-related neurological sequelae and healthcare resource use in a post hoc analysis of the Phase III TEMSO study. Confirmed relapses associated with neurological sequelae [defined by an increase in Expanded Disability Status Scale/Functional System (sequelae-EDSS/FS) ≥ 30 days post relapse or by the investigator (sequelae-investigator)] were analyzed in the modified intention-to-treat population (n = 1086). Relapses requiring hospitalization or intravenous (IV) corticosteroids, all hospitalizations, emergency medical facility visits (EMFV), and hospitalized nights for relapse were also assessed. Annualized rates were derived using a Poisson model with treatment, baseline EDSS strata, and region as covariates. Risks of sequelae and hospitalization per relapse were calculated as percentages and groups were compared with a χ(2) test. Compared with placebo, teriflunomide reduced annualized rates of relapses with sequelae-EDSS/FS [7 mg by 32 % (p = 0.0019); 14 mg by 36 % (p = 0.0011)] and sequelae-investigator [25 % (p = 0.071); 53 % (p < 0.0001)], relapses leading to hospitalization [36 % (p = 0.015); 59 % (p < 0.0001)], and relapses requiring IV corticosteroids [29 % (p = 0.001); 34 % (p = 0.0003)]. Teriflunomide-treated patients spent fewer nights in hospital for relapse (p < 0.01). Teriflunomide 14 mg also decreased annualized rates of all hospitalizations (p = 0.01) and EMFV (p = 0.004). The impact of teriflunomide on relapse-related neurological sequelae and relapses requiring healthcare resources may translate into reduced healthcare costs.

Constructing an adaptive care model for the management of disease-related symptoms throughout the course of multiple sclerosis—performance improvement CME

Background:

Symptom management remains a challenging clinical aspect of MS.

Objective:

To design a performance improvement continuing medical education (PI CME) activity for better clinical management of multiple sclerosis (MS)-related depression, fatigue, mobility impairment/falls, and spasticity.

Methods:

Ten volunteer MS centers participated in a three-stage PI CME model: A) baseline assessment; B) practice improvement CME intervention; C) reassessment. Expert faculty developed performance measures and activity intervention tools. Designated MS center champions reviewed patient charts and entered data into an online database. Stage C data were collected eight weeks after implementation of the intervention and compared with Stage A baseline data to measure change in performance.

Results:

Aggregate data from the 10 participating MS centers (405 patient charts) revealed performance improvements in the assessment of all four MS-related symptoms. Statistically significant improvements were found in the documented assessment of mobility impairment/falls ( p=0.003) and spasticity ( p<0.001). For documentation of care plans, statistically significant improvements were reported for fatigue ( p=0.007) and mobility impairment/falls ( p=0.040); non-significant changes were noted for depression and spasticity.

Conclusions:

Our PI CME interventions demonstrated performance improvement in the management of MS-related symptoms. This PI CME model (available at www.achlpicme.org/ms/toolkit ) offers a new perspective on enhancing symptom management in patients with MS.

Pre-specified subgroup analyses of a placebo-controlled phase III trial (TEMSO) of oral teriflunomide in relapsing multiple sclerosis

Background:

The Teriflunomide Multiple Sclerosis Oral (TEMSO) trial, a randomized, double-blind, placebo-controlled phase III study, demonstrated that teriflunomide significantly reduced annualized relapse rate (ARR), disease progression and magnetic resonance imaging (MRI) activity, with a favorable safety profile in relapsing multiple sclerosis (RMS) patients.

Objective:

The purpose of this study was to report the effects of teriflunomide on ARR and disability progression in pre-specified subgroups.

Methods:

RMS patients (n=1088) were randomized to placebo or teriflunomide, 7 mg or 14 mg, once daily, for 108 weeks. Subgroup analyses were performed for ARR and disability progression by baseline demographics (gender, race, age), disease characteristics (Expanded Disability Status Scale (EDSS) strata, relapse history, multiple sclerosis (MS) subtype), MRI parameters (gadolinium-enhancing lesions, total lesion volume) and prior use of MS drugs. A generalized estimating equation method and Cox regression model were used to assess consistency of the treatment effect across subgroups, utilizing a treatment-by-subgroup interaction test for each factor separately.

Results:

Reductions in ARR and disability progression were consistent across subgroups in favor of teriflunomide, with no treatment-by-subgroup interaction test reaching statistical significance.

Conclusion:

The positive effects of teriflunomide were demonstrated consistently across subgroups in TEMSO.

Practice patterns of US neurologists in patients with CIS, RRMS, or RIS: A consensus study

We assess current practice patterns of US neurologists in patients with clinically isolated syndrome (CIS), relapsing-remitting multiple sclerosis (RRMS), and radiologically isolated syndrome (RIS) using case-based surveys. For CIS, 87% recommended initiation of disease-modifying therapy (DMT) with MRI brain lesions. An injectable DMT was recommended by 90%-98% for treatment-naive, mild RRMS patients. There was 97% consensus to treat highly active RRMS, but no consensus on therapy choice. With RIS, there was consensus not to initiate treatment with brain but no spinal MRI lesions. Current US treatment patterns emphasize MRI in MS diagnosis and subsequent treatment decisions, treatment of early disease, aggressive initial treatment of highly active MS, and close patient monitoring.

Practice patterns of US neurologists in patients with SPMS and PPMS: A consensus study

A modified Delphi process assessed current multiple sclerosis (MS) practice patterns for secondary and primary progressive MS (secondary progressive MS [SPMS] and primary progressive MS [PPMS]). In early 2011, 2 sequential, case-based surveys were administered to 75 US MS specialists to assess treatment practices and patient management. Respondents were from geographically diverse US academic (42%) and community (58%) treatment centers. There was consensus (≥75% agreement in responses) to switch disease-modifying therapies for a patient with SPMS with both MRI activity and disability progression (95%), but no consensus on treatment selection. For PPMS, responses supported diagnosis using spinal MRI (100%) and lumbar puncture (75%) and treatment initiation in patients with brain gadolinium-enhancing lesions with or without spinal cord lesions (85%); however, there was no consensus on treatment initiation with spinal cord lesions alone or initial therapy. The lack of agreement among US MS experts on the best treatment approaches for SPMS or PPMS highlights the need for effective therapies.

Multiple sclerosis: where will we be in 2020?

The past decade has seen a surge of research interest in multiple sclerosis and an accelerated expansion of investigative efforts into multiple sclerosis therapeutics. Investigators have continued dissecting the complex immunological perturbations that may contribute to the disease and made major advances in understanding the genetics of multiple sclerosis. This article addresses current investigative issues and offers predictions about where the understanding and treatment of multiple sclerosis may stand at the end of the 21st century's second decade.

A NEW METHOD FOR THE GENERATION AND USE OF FOCUSED ULTRASOUND IN EXPERIMENTAL BIOLOGY

1. An efficient generator of focused ultrasound has been designed, built, and successfully operated. 2. The generator has been used to produce focal heating in the centers of paraffin blocks, and in a similar manner, focal areas of destruction were obtained deep in fresh liver tissue with minimal effects at the surface and no effects on the intervening tissue. 3. In animals, focused ultrasound of high intensity produced local cerebral changes as inferred from behavior disabilities and as demonstrated at autopsy. This local brain effect was achieved through intervening scalp, skull, and meninges. The resulting behavior disabilities disappeared in from 2 to 16 hours. 4. To date, it has not been possible to produce such brain changes without incidental injury to the skin and subcutaneous tissue lying at the base of the cone of radiation. 5. Improvements in generation and application of the focused supersonic beam are suggested whereby it should be possible to increase still further the focal effects in the brain, with a corresponding decrease or elimination of complicating surface injury.

Assessing disability progression with the Multiple Sclerosis Functional Composite

BACKGROUND

The initial Multiple Sclerosis Functional Composite (MSFC) proposal was a three-part composite of quantitative measures of ambulation, upper extremity function, and cognitive function expressed as a single composite Z-score. However, the clinical meaning of an MSFC Z-score change is not obvious. This study instead used MSFC component data to define a patient-specific disease progression event.

OBJECTIVE

Evaluate a new method for analyzing disability progression using the MSFC.

METHODS

MSFC progression was defined as worsening from baseline on scores of at least one MSFC component by 20% (MSFC Progression-20) or 15% (MSFC Progression-15), sustained for >or=3 months. Progression rates were determined using data from natalizumab clinical studies (Natalizumab Safety and Efficacy in Relapsing Remitting Multiple Sclerosis [AFFIRM] and Safety and Efficacy of Natalizumab in Combination With Interferon Beta-1a in Patients With Relapsing Remitting Multiple Sclerosis [SENTINEL]). Correlations between MSFC progression and other clinical measures were determined, as was sensitivity to treatment effects.

RESULTS

Substantial numbers of patients met MSFC progression criteria, with MSFC Progression-15 being more sensitive than MSFC Progression-20, at both 1 and 2 years. MSFC Progression-20 and MSFC Progression-15 were related significantly to Expanded Disability Status Scale (EDSS) score change, relapse rate, and the SF-36 Physical Component Summary (PCS) score change. MSFC Progression-20 and MSFC Progression-15 at 1 year were predictive of EDSS progression at 2 years. Both MSFC progression end points demonstrated treatment effects in AFFIRM, and results were replicated in SENTINEL.

CONCLUSION

MSFC Progression-20 and MSFC Progression-15 are sensitive measures of disability progression; correlate with EDSS, relapse rates, and SF-36 PCS; and are capable of demonstrating therapeutic effects in randomized, controlled clinical studies.

Microbial activity and diversity during extreme freeze-thaw cycles in periglacial soils, 5400 m elevation, Cordillera Vilcanota, Perú

High-elevation periglacial soils are among the most extreme soil systems on Earth and may be good analogs for the polar regions of Mars where oligotrophic mineral soils abut with polar ice caps. Here we report on preliminary studies carried out during an expedition to an area where recent glacial retreat has exposed porous mineral soils to extreme, daily freeze-thaw cycles and high UV fluxes. We used in situ methods to show that inorganic nitrogen (NO(3) (-) and NH(4) (+)) was being actively cycled even during a period when diurnal soil temperatures (5 cm depth) ranged from -12 to 27 degrees C and when sub-zero, soil cooling rates reached 1.8 degrees C h(-1) (the most rapid soil cooling rates recorded to date). Furthermore, phylogenetic analyses of microbial phylotypes present at our highest sites (5410 m above sea level) showed the presence of nitrifying bacteria of the genus Nitrospira and newly discovered nitrite-oxidizing Betaproteobacteria. These soils were overwhelmingly dominated (>70% of phylotypes) by photosynthetic bacteria that were related to novel cyanobacteria previously found almost exclusively in other plant-free, high-elevation soils. We also demonstrated that soils from our highest sites had higher potential for mineralizing glutamate and higher microbial biomass than lower elevation soils that had been more recently covered by ice. Overall, our findings indicate that a diverse and robustly functioning microbial ecosystem is present in these previously unstudied high-elevation soils.