A Risk Score for Predicting Multiple Sclerosis

OBJECTIVE

Multiple sclerosis (MS) develops as a result of environmental influences on the genetically susceptible. Siblings of people with MS have an increased risk of both MS and demonstrating asymptomatic changes in keeping with MS. We set out to develop an MS risk score integrating both genetic and environmental risk factors. We used this score to identify siblings at extremes of MS risk and attempted to validate the score using brain MRI.

METHODS

78 probands with MS, 121 of their unaffected siblings and 103 healthy controls were studied. Personal history was taken, and serological and genetic analysis using the illumina immunochip was performed. Odds ratios for MS associated with each risk factor were derived from existing literature, and the log values of the odds ratios from each of the risk factors were combined in an additive model to provide an overall score. Scores were initially calculated using log odds ratio from the HLA-DRB1*1501 allele only, secondly using data from all MS-associated SNPs identified in the 2011 GWAS. Subjects with extreme risk scores underwent validation studies. MRI was performed on selected individuals.

RESULTS

There was a significant difference in the both risk scores between people with MS, their unaffected siblings and healthy controls (p<0.0005). Unaffected siblings had a risk score intermediate to people with MS and controls (p<0.0005). The best performing risk score generated an AUC of 0.82 (95%CI 0.75-0.88).

INTERPRETATIONS

The risk score demonstrates an AUC on the threshold for clinical utility. Our score enables the identification of a high-risk sibling group to inform pre-symptomatic longitudinal studies.

Ethnicity and prevalence of multiple sclerosis in east London

Background:

Incidence and prevalence rates of multiple sclerosis (MS) are generally higher in White populations than in other ethnic groups. Relevant studies in the United Kingdom were conducted over 30 years ago.

Objectives:

To provide updated ethnicity-specific MS prevalence rates in the United Kingdom.

Methods:

Electronic records from general practices (GPs) in four east London boroughs were queried for the number of people diagnosed with MS, grouped by ethnicity, into 5-year age bands. Compared against total registered GP patients in the area (c. 900,000), the age-standardised MS prevalence was calculated by ethnic group.

Results:

The overall age-standardised prevalence of MS was 111 per 100,000 (152 for women and 70 for men), and 180, 74 and 29 for the White, Black and South Asian populations, respectively. The sex ratios (female:male) were 2.2:1, 2.1:1 and 2.8:1, respectively.

Conclusion:

MS prevalence was considerably lower among Black and South Asian populations, compared to the White population, by 59% and 84%, respectively. However, compared to available data in Africa and South Asia, MS is several times more prevalent among Black people and South Asians living in the United Kingdom than their territorial ancestry.

Gender identity disorders and multiple sclerosis risk: A national record-linkage study

Background:

An altered balance of gonadal hormones in males with gender identity disorders (GIDs) may increase multiple sclerosis (MS) risk both inherently and secondary to treatment in undergoing male-to-female conversion.

Objective:

We investigated any association between GIDs and MS through analysis of record-linked hospital statistics.

Method:

Analysis of English Hospital Episode Statistics, 1999–2012.

Results:

The adjusted rate ratio (RR) of MS following GIDs in males was 6.63 (95% confidence interval (95% CI) = 1.81–17.01, p = 0.0002). The RR of MS following GIDs in females was 1.44 (95% CI = 0.47–3.37, p = 0.58).

Conclusion:

We report a strong association between GIDs and MS in male-to-females, supporting a potential role for low testosterone and/or feminising hormones on MS risk in males.

Switching patients at high risk of PML from natalizumab to another disease-modifying therapy

There are several options for switching people with multiple sclerosis (MS) who are at high risk of developing progressive multifocal leukoencephalopathy (PML) from natalizumab to alemtuzumab. However, some of these have risks that need to be managed, for example, the risks of carrying over asymptomatic PML from natalizumab on to the new therapy, and the risk of rebound disease activity associated with a prolonged washout after starting natalizumab. We propose a pragmatic bridging strategy, using another disease-modifying therapy (DMT), to reduce the risk of switching from natalizumab to alemtuzumab. We also discuss the caveats and subtleties associated with sequencing DMTs in MS and the complex decision making involved.

ETHNICITY AND MULTIPLE SCLEROSIS PREVALENCE IN EAST LONDON

Background

There is a perceived consensus that the incidence and prevalence rates of MS in countries with a White majority are lower in the minority ethnic population than in the White population. Often-cited UK-based studies relevant to this were conducted over twenty years ago. In our study we update the UK-based literature.

Methods

Electronic records from GPs in the four innermost east London boroughs were queried for the number of patients with an MS diagnosis, grouped by ethnicity, into 5-year age bands. Compared against total registered GP patients in the area (c.900K), we calculated the age-standardised MS prevalence separately, for White, Black and South Asian populations.

Results

Overall prevalence was 111 per 100K (152 for women, 70 for men). This was 180, 74, and 29 for the White, Black and South Asian populations respectively. The sex ratios (female:male) were 2.2:1, 2.1:1 and 2.8:1 respectively.

Conclusion

Inner east London is an ideal area to study ethnicity-specific prevalence, with a population that is 36% White, 16% Black, 30% South Asian and 18% Other. MS prevalence was considerably lower amongst Black and South Asian populations, compared to the White population, by 59% and 84% respectively. Our findings are consistent with previous studies.

DESIGNING AN INFORMATION RESOURCE TO EXPLAIN DIAGNOSTIC LUMBAR PUNCTURE AND PROMOTE BEST PRACTICE

Introduction

The lumbar puncture (LP) procedure is an important test in neurological practice. Appropriate information is key to both preparing patients for this invasive procedure and facilitating use of atraumatic LP needles to minimize adverse effects such as local pain and post-LP headache.

Methods

A cross-disciplinary team (designers, clinicians and people with multiple sclerosis (pwMS)) developed a website to explain the LP procedure at The Royal London Hospital (Barts Health NHS Trust, UK). User testing was carried out to review both the visual design and functionality of the resource for people with visual and cognitive limitations.

Results

After successful testing www.clinicspeak.com/LumbarPuncture is being used in the informed consent process for clinical trials involving pwMS at our institution and is being piloted in our day unit and A&E departments. The website includes what to expect, how to deal with adverse effects, why cerebrospinal fluid is examined and information on the atraumatic needle.

Conclusion

The resource provides an appropriate way of communicating sensitive, yet important information to patients. It also demonstrates an innovative way of spreading best practice and encourages the widespread adoption of atraumatic needles for LP in both clinical and research settings. The resource will be demonstrated at the meeting.

No evidence for higher risk of cancer in patients with multiple sclerosis taking cladribine

Objective:

To compare the cancer risk of cladribine and other disease-modifying drugs (DMDs) in trials of people with relapsing multiple sclerosis (pwRMS).

Methods:

Meta-analysis of phase III trials of licensed DMDs for pwRMS and a phase III trial of cladribine (CLARITY). Cancer rates were compared using Fisher exact test.

Results:

Eleven trials were included. Investigated treatments included cladribine, dimethyl fumarate, fingolimod, teriflunomide, natalizumab, alemtuzumab, and glatiramer acetate. The cancer rate in the CLARITY treatment group (0.34%) was not increased compared to all other treatment groups, whether including placebo-controlled trials only (0.6%, p = 0.4631) or all trials, i.e., including those with an active comparator arm (0.67%, p = 0.3669). No cancer was reported in the CLARITY placebo group, whereas the combined cancer rate of all other placebo groups was 1.19% (p = 0.0159). The cancer rate of zero in the CLARITY placebo group was also lower than that in the phase III trial of cladribine in people with clinically isolated syndrome (ORACLE MS, 2.91%, p = 0.0012). In fact, no difference was detected between cancer rates in the treatment groups of CLARITY (0.34%) and ORACLE MS (0.49%) (p = 0.6546).

Conclusions:

Our study does not support an increased cancer risk from cladribine in the doses used in CLARITY and ORACLE MS, which previously contributed to refusal of market authorization of cladribine in Europe. Longer-term follow-up is required to assess the safety profile of cladribine, as well as currently licensed DMDs, to definitively assess cancer risk.

Is it time to target no evident disease activity (NEDA) in multiple sclerosis?

The management of multiple sclerosis is becoming increasingly complex with the emergence of new and more effective disease-modifying therapies (DMT). We propose a new treatment paradigm that individualises treatment based on a choice between two interchangeable therapeutic strategies of maintenance-escalation or induction therapy. We propose treating- to-target of no evident disease activity (NEDA) as defined using clinical and MRI criteria. This algorithm requires active monitoring with a rebaselining MRI, at a point in time after the specific DMT concerned has had sufficient time to work, and at least annual MRI studies to monitor for subclinical relapses. Disease activity on the maintenance-escalation therapy arm of the algorithm indicates a sub-optimal treatment response and should trigger a discussion about switching, or escalating, therapy or the consideration of switching to the induction therapy arm of the algorithm. In comparison, disease activity on an induction therapy arm would be an indication for retreatment or a switch to the maintenance-escalation therapy arm. We envisage the definition of NEDA evolving with time as new technological innovations are adopted into clinical practice, for example the normalisation of whole, or regional, brain atrophy rates and cerebrospinal fluid neurofilament levels.

The problem with repurposing: Is there really an alternative to Big Pharma for developing new drugs for multiple sclerosis?

If it is not feasible to develop licensed drugs to the stage that they can actually be prescribed for a new indication, can we justify, either ethically or economically, the undertaking of proof-of-concept studies using off-patent medications? Without a financial incentive it is very difficult to repurpose off patent drugs for a new indication. Therefore, we need a political solution to allow the repurposing of off-patent drugs by other stakeholders or Big Pharma.

Testicular hypofunction and multiple sclerosis risk: a record-linkage study

The influence of gonadal hormones on multiple sclerosis (MS) is not well characterized and has thus far been investigated primarily in animal models or as a proposed therapeutic approach. We investigated a potential association between testicular hypofunction, as a proxy for low testosterone levels, and MS risk through analysis of linked English national Hospital Episode Statistics from 1999 to 2011. We report a strong positive association between testicular hypofunction and subsequent MS (rate ratio = 4.62, 95% confidence interval = 2.3-8.24, p < 0.0001). Future work should aim more directly to elucidate the relationship between testosterone levels and MS in both males and females.

A rare presentation of atypical demyelination: tumefactive multiple sclerosis causing Gerstmann's syndrome

Background

Tumefactive demyelinating lesions are a rare manifestation of multiple sclerosis (MS). Differential diagnosis of such space occupying lesions may not be straightforward and sometimes necessitate brain biopsy. Impaired cognition is the second most common clinical manifestation of tumefactive MS; however complex cognitive syndromes are unusual.

Case presentation

We report the case of a 30 year old woman who presented with Gerstmann’s syndrome. MRI revealed a large heterogeneous contrast enhancing lesion in the left cerebral hemisphere. Intravenous corticosteroids did not stop disease progression. A tumour or cerebral lymphoma was suspected, however brain biopsy confirmed inflammatory demyelination. Following diagnosis of tumefactive MS treatment with natalizumab effectively suppressed disease activity.

Conclusions

The case highlights the need for clinicians, radiologists and surgeons to appreciate the heterogeneous presentation of tumefactive MS. Early brain biopsy facilitates rapid diagnosis and management. Treatment with natalizumab may be useful in cases of tumefactive demyelination where additional evidence supports a diagnosis of relapsing MS.

Assessing treatment response to interferon-β: is there a role for MRI?

OBJECTIVE

Interferon-β (IFN-β) has been shown to reduce relapse rates in multiple sclerosis; however, the clinical response appears to vary among individuals. Can early MRI be used to identify those patients who have a poor response to treatment?

METHODS

A systematic review of studies examining differential treatment response and clinical endpoints in groups defined as responders or nonresponders to IFN-β was performed. Meta-analytic techniques were used to combine study results where appropriate.

RESULTS

Patients with MRI evidence of poor response to IFN-β treatment as defined by either ≥2 new hyperintense T2 lesions or new gadolinium-enhancing lesions had significantly increased risk of both future relapses and progression as defined by the Expanded Disability Status Scale. There appeared to be an increased risk of poor outcomes 16 years after treatment initiation in those with an initial poor response to treatment. Previous evidence has shown this not to be the case in placebo arms of clinical trials.

CONCLUSIONS

For those patients starting IFN-β, early MRI, within 6 to 24 months after starting treatment, has the potential to provide important information when counseling patients about the likelihood of future treatment failure. This can inform treatment decisions before clinical relapses or disease progression.

Sample sizes for lesion magnetisation transfer ratio outcomes in remyelination trials for multiple sclerosis

BACKGROUND

Enhancing remyelination in MS might improve function and protect axons from future damage. Lesion magnetisation transfer ratio (MTR) is sensitive to myelin content, and may be a useful measure for trials evaluating potential remyelinating agents.

OBJECTIVE

Estimating sample sizes required for a parallel group, placebo-controlled trial in MS using change in mean MTR of all T2lesions as a primary outcome measure.

METHODS

The primary sample size calculation was derived from data from a natural history study of relapsing remitting MS (n=18). The MTR values observed in demyelinated and remyelinated lesions in an ex vivo study were used to estimate the effect of remyelination on lesion MTR. The ex vivo data were also used to independently calculate sample sizes in order to inform the robustness of the in vivo estimates.

RESULTS

Calculations suggest that 30% remyelination of T2 lesions could be detected with 80% power in 38 (95% confidence interval 12-96) patients per arm based on the in vivo data, and in 66 per arm based on the ex vivo data.

CONCLUSION

The sample sizes derived are in a range that makes MTR a feasible outcome measure for proof-of-concept trials of putative therapies achieving remyelination in MS lesions.