126
|
Li P, Ladage VP, Berger J, Chahin S, Jhaveri M, Geremakis C, Doshi JA. Disease-Modifying Therapy Adherence and Associated Factors in a National Sample of Medicare Patients With Multiple Sclerosis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:328-334. [PMID: 32197728 DOI: 10.1016/j.jval.2019.10.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/13/2019] [Accepted: 10/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Disease-modifying therapies (DMTs) reduce relapse rates and disability progression for relapsing multiple sclerosis (MS). Although 25% to 30% of all US patients with MS are Medicare beneficiaries, limited information exists on this population. This is the first study using national Medicare data to (1) describe characteristics of patients with MS using DMTs, (2) estimate adherence to DMTs over a 1-year and 3-year follow-up, and (3) examine factors associated with DMT adherence. METHODS This retrospective claims analysis used 2011-2014 100% Medicare files. Monthly adherence to MS DMTs was defined as the proportion of days covered ≥0.80 with any DMT in each month for 1-year (n = 36 593) and 3-year (n = 17 599) follow-up samples of MS DMT users. Generalized estimating equation logistic regressions were used to estimate factors associated with adherence to DMTs. RESULTS Over 90% of patients were eligible for Medicare owing to disability, and about three-quarters qualified for low-income subsidies. A downward trend in DMT adherence was observed over time in both samples. Monthly adherence dropped significantly between December of the prior year to January of the following year (from 76% to 65% in the 1-year follow-up sample and similar drops seen across all years in the 3-year follow-up sample). Multivariable regressions indicated characteristics such as being low-income, having a disability, and having high patient out-of-pocket DMT costs associated with poor adherence to DMTs. CONCLUSION Our study provides important insights into the characteristics and DMT adherence of Medicare patients with MS and highlights the need for interventions and policies mitigating barriers to adherence in this population.
Collapse
|
127
|
Conway DS, Hersh CM, Harris HC, Hua LH. Duration of natalizumab therapy and reasons for discontinuation in a multiple sclerosis population. Mult Scler J Exp Transl Clin 2020; 6:2055217320902488. [PMID: 32064117 PMCID: PMC6987494 DOI: 10.1177/2055217320902488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/05/2020] [Indexed: 11/15/2022] Open
Abstract
Objective To determine multiple sclerosis patient characteristics that predict a
shorter duration of natalizumab treatment. Methods The Tysabri Outreach: Unified Commitment to Health database was reviewed to
identify patients treated with natalizumab at our centers. Cox proportional
hazards models were used to evaluate patient characteristics associated with
shorter treatment durations on natalizumab. Associations were also assessed
with respect to specific reasons for stopping natalizumab. Results We identified 554 patients who began and stopped natalizumab treatment during
the observation period. The average disease duration at natalizumab
initiation was 7.6 years, and the average number of infusions was 30. The
multivariable Cox proportional hazards model identified greater age
(P = 0.035), longer disease duration
(P < 0.001), progressive relapsing multiple
sclerosis phenotype (P = 0.003), current smoking
(P = 0.031), and greater depression
(P = 0.026) as significant predictors for natalizumab
discontinuation. Greater disability levels (P = 0.022) and
gadolinium-enhancing lesions on baseline magnetic resonance imaging
(P < 0.001) were significantly associated with
longer natalizumab treatment. Individuals with progressive relapsing
multiple sclerosis had a 14-fold increased hazard of discontinuing
natalizumab due to inflammatory events (P < 0.001) than
those with relapsing–remitting multiple sclerosis. Smokers had an 80%
increased hazard of discontinuation due to intolerance
(P = 0.008). Conclusions Our results suggest that smoking, depression, and a progressive relapsing
multiple sclerosis phenotype are associated with shorter natalizumab
treatment durations.
Collapse
|
128
|
Gray C, Kenney JT. Outcomes-Based Contracting for Disease-Modifying Therapies in Multiple Sclerosis: Necessary Conditions for Paradigm Adoption. AMERICAN HEALTH & DRUG BENEFITS 2019; 12:390-398. [PMID: 32030115 PMCID: PMC6986548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/06/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND In therapeutic areas with uncertainty regarding clinical outcomes that are dependent on high-cost specialty medications, outcomes-based contracts can be a tool to reduce financial risk for payers and for drug manufacturers. With a high treatment cost, large number of therapy choices, and variability of responses to therapy across patients, multiple sclerosis is a compelling therapeutic area to support outcomes-based contracts. OBJECTIVE To identify the necessary conditions to support the widespread adoption of outcomes-based contracts for high-cost drug therapy, with a focus on disease-modifying therapies for multiple sclerosis. METHODS We conducted a series of in-depth, semi-structured phone interviews during fall 2018 with 17 healthcare stakeholders representing payers, manufacturers, and industry consultants, all of whom had some involvement in outcomes-based contract development or evaluation. The qualitative data management program from QSR International, N-VIVO 11, was used to store, organize, categorize, analyze, and produce visualization tools to explore, map ideas, and understand themes from the data. RESULTS Overall, payers and manufacturers agreed that outcomes-based contracts are an effective vehicle to mitigate financial risk and deliver value for disease-modifying therapies for multiple sclerosis, but they noted that the widespread adoption of outcomes-based contracts was tempered by 5 broad categories of challenges, including data-related issues, outcome measurement and confounding factors, regulatory barriers, levels of risk mitigation, and patient adherence. The majority of participants were receptive to using blood-based clinical biomarkers as outcomes-based contract end points, as long as the biomarkers are validated, accurately predict clinical outcomes, are well-established in the therapeutic area, and are readily accessible to various stakeholders. CONCLUSION Our findings indicate there is general support from payers and drug manufacturers to adopt outcomes-based contracts for disease-modifying therapies for multiple sclerosis. However, some conditions need to be met to allow their widespread adoption, including resolving data issues, ensuring patient adherence to therapy, having a level of risk mitigation that is significant for both parties to make the endeavor economically worthwhile, and fostering a supportive regulatory environment. Blood-based clinical biomarkers that meet certain criteria could be viable end points in outcomes-based contract for disease-modifying therapies for multiple sclerosis and can address many of the necessary conditions regarding data issues, including timeliness.
Collapse
|
129
|
Abstract
Multiple sclerosis is a chronic, unpredictable, and disabling disease. Significant advances have been made in recent years supporting an earlier, more accurate, diagnosis and have led to more than 15 disease-modifying therapies approved by the Food and Drug Administration for relapsing forms of multiple sclerosis. Disease-modifying therapies are now being classified into categories based on level of efficacy. Strategies to use disease-modifying therapies earlier and in a more customizable manner are also emerging. A clinical case study will be used throughout this pearl to review the disease-modifying therapies and use patient-specific factors to develop and provide recommendations on therapeutic strategies for individuals with relapsing forms of multiple sclerosis.
Collapse
|
130
|
New Frontiers in Parkinson's Disease: From Genetics to the Clinic. J Neurosci 2019; 38:9375-9382. [PMID: 30381429 DOI: 10.1523/jneurosci.1666-18.2018] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/15/2018] [Accepted: 09/18/2018] [Indexed: 12/30/2022] Open
Abstract
The greatest unmet therapeutic need in Parkinson's disease (PD) is a treatment that slows the relentless progression of the symptoms and the neurodegenerative process. This review highlights the utility of genetics to understand the pathogenic mechanisms and develop novel therapeutic approaches for PD. The focus is on strategies provided by genetic studies: notably via the reduction and clearance of α-synuclein, inhibition of LRRK2 kinase activity, and modulation of glucocerebrosidase-related substrates. In addition, the critical role of precompetitive public-private partnerships in supporting trial design optimization, overall drug development, and regulatory approvals is illustrated. With these great advances, the promise of developing transformative therapies that halt or slow disease progression is a tangible goal.
Collapse
|
131
|
Baldassari LE, Feng J, Macaron G, Planchon SM, Alshehri E, Moss BP, Ontaneda D, Willis MA. Tuberculosis screening in multiple sclerosis: effect of disease-modifying therapies and lymphopenia on the prevalence of indeterminate TB screening results in the clinical setting. Mult Scler J Exp Transl Clin 2019; 5:2055217319875467. [PMID: 31588362 PMCID: PMC6740049 DOI: 10.1177/2055217319875467] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/09/2019] [Accepted: 08/14/2019] [Indexed: 01/31/2023] Open
Abstract
Background Tuberculosis screening is recommended in multiple sclerosis patients starting certain disease-modifying therapies. Disease-modifying therapies may affect interferon-gamma release assay results. Objective To determine the effects of multiple sclerosis disease-modifying therapies on interferon-gamma release assay results. Methods Indeterminate interferon-gamma release assay results among multiple sclerosis patients were compared across disease-modifying therapies by Fisher's exact test. Logistic regression evaluated the effects of lymphopenia on interferon-gamma release assay results. Results A total of 1058 patients underwent interferon-gamma release assay: 2.0% (21) positive, 6.1% (65) indeterminate, with 59.4% (628) on disease-modifying therapies. Results were significantly different across disease-modifying therapies (P = 0.002). Absolute lymphocyte count less than 0.5 k/μL had 9.39 times (95% confidence interval 5.2-17.0) increased odds of indeterminate interferon-gamma release assay results. Conclusions Disease-modifying therapies affecting lymphocytes had a higher risk of indeterminate interferon-gamma release assay results.
Collapse
|
132
|
Cucarián JD, Berrío JP, Rodrigues C, Zancan M, Wink MR, de Oliveira A. Physical exercise and human adipose-derived mesenchymal stem cells ameliorate motor disturbances in a male rat model of Parkinson's disease. J Neurosci Res 2019; 97:1095-1109. [PMID: 31119788 DOI: 10.1002/jnr.24442] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 01/20/2023]
Abstract
Parkinson's disease (PD) is a disabling and highly costly neurodegenerative condition with worldwide prevalence. Despite advances in treatments that slow progression and minimize locomotor impairments, its clinical management is still a challenge. Previous preclinical studies, using mesenchymal stem cell (MSC) transplantation and isolated physical exercise (EX), reported beneficial results for treatment of PD. Therefore, this experimental randomized study aimed to elucidate the therapeutic potential of combined therapy using adipose-derived human MSCs (ADSCs) grafted into the striatum in conjunction with aerobic treadmill training, specifically in terms of locomotor performance in a unilateral PD rat model induced by 6-hydroxydopamine (6-OHDA). Forty-one male Wistar rats were categorized into five groups in accordance with the type of treatment to which they were subjected (Sham, 6-OHDA - injury, 6-OHDA + exercise, 6-OHDA + cells, and 6-OHDA + combined). Subsequently, dopaminergic depletion was assessed by the methylphenidate challenge and the specified therapeutic intervention was conducted in each group. The foot fault task was performed at the end of the experiment to serve as an assessment of motor skills. The results showed that despite disturbances in motor balance and coordination, locomotor dysfunction was ameliorated in all treatment categories in comparison to the injury group (sign test, p < 0.001, effect size: 0.71). The exercise alone and combined groups were the categories that exhibited the best recovery in terms of movement performance (p < 0.001). Overall, this study confirms that exercise is a powerful option to improve motor function and a promising adjuvant intervention for stem cell transplantation in the treatment of PD motor symptoms. OPEN PRACTICES: This article has been awarded Open Data. All materials and data are publicly accessible at https://figshare.com/s/18a543c101a17a1d5560. Learn more about the Open Practices badges from the Center for Open Science: https://osf.io/tvyxz/wiki.
Collapse
|
133
|
De Giglio L, Grimaldi AE, Fubelli F, Marinelli F, Pozzilli C. Advances in preventing adverse events during monoclonal antibody management of multiple sclerosis. Expert Rev Neurother 2019; 19:417-429. [PMID: 31094239 DOI: 10.1080/14737175.2019.1610393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Decades of pharmacological research in Multiple Sclerosis (MS) led to the development of therapeutic Monoclonal Antibodies (MAbs) with many different mechanisms of action (MoA), potentially able to improve disability outcome but also determining a more complex management of patients. Areas covered: When clinicians select MS treatments, they should consider adverse events (AEs) on individual basis to minimize patients' risks. Some AEs are common and can be easily handled, but rare complications should also be taken into account. The aim of this review is to summarize existing evidence and provide practical recommendations for the management of therapeutic MAbs in MS. Expert opinion: The introduction of MAbs revolutionized MS treatment with an improvement in effectiveness. Unfortunately, this has been coupled with a more complex array of AEs needing a tighter surveillance strategy. A close interaction between general practitioners, neurologists, and other specialists is the key for a safer use of such effective drugs.
Collapse
|
134
|
Kopp TI, Blinkenberg M, Chalmer TA, Petersen T, Ravnborg MH, Soelberg Sørensen P, Magyari M. Predictors of treatment outcome in patients with paediatric onset multiple sclerosis. Mult Scler 2019; 26:964-975. [PMID: 31081451 DOI: 10.1177/1352458519846100] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Disease-modifying therapies (DMT) are increasingly used for children with multiple sclerosis (MS) even though most double-blinded randomized controlled trials evaluating efficacy, safety and dosing strategy of a specific drug have included adults. OBJECTIVE To investigate predictors of treatment outcomes in patients with paediatric onset MS treated with DMTs. METHODS Prospective cohort study from the nationwide Danish Multiple Sclerosis Registry including all patients with a MS diagnosis who initiated treatment with an approved DMT before the age of 18 (N = 137) and followed until their 25th birthday. Selected baseline predictors were tested in univariate and multivariate regression models. RESULTS Multivariate analyses showed that being female and having disease duration for 2 or more years prior to DMT initiation predicted a higher relapse rate. In addition, disease duration and baseline expanded disability status scale (EDSS) predicted both confirmed disability worsening and improvement. We found no difference in treatment outcome between children with MS onset before and after the age of 13 years. CONCLUSIONS The efficacy of DMT in paediatric onset MS patients is comparable to that seen in adult onset MS patients. Earlier treatment start is associated with a beneficial prognosis in the paediatric cohort.
Collapse
|
135
|
Wilkie DD, Solari A, Nicholas R. Initiating disease-modifying treatments in multiple sclerosis: Measuring the decision process using decisional conflict and decisional regret scales. Mult Scler J Exp Transl Clin 2019; 5:2055217319833006. [PMID: 30834139 PMCID: PMC6393834 DOI: 10.1177/2055217319833006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/08/2019] [Accepted: 01/27/2019] [Indexed: 11/15/2022] Open
Abstract
Introduction Initiating disease-modifying treatments (DMTs) in multiple sclerosis (MS) is a major decision for people with (pw)MS but little is known about how the decision is perceived by the individual. Objectives The aim of the study was to determine if decisional conflict (DC) and decisional regret reflect different stages of the decision-making process when initiating DMTs. Methods This was a cross-sectional study of three cohorts of pwMS (n = 254), a 'MS conference attendees', 'on treatment' and an 'offered treatment' cohort. Questionnaires assessing DC, decisional regret and control preference were performed. Results Forty-four per cent (113/254) of pwMS were dissatisfied with their treatment status and 53% (135/254) had DC. DC (p = 0.013) and decisional regret (p = 0.027) increase in treatment-naïve pwMS and also in those 'offered treatment' dissatisfied with their treatment status (p < 0.0001), whilst those 'on treatment' have low Decisional Regret Scale (DRS) score (p = 0.0005). DC and DRS were only correlated with treatment status in those on treatment and not in treatment-naïve patients. F (58/135) pwMS satisfied with treatment had DC. DC (n = 236, adjusted R 2 0.137, p = 0.000) and DRS (n = 235, adjusted R 2 0.232, p = 0.000) were increased by dissatisfaction with treatment, lower potency treatment, being from the 'MS conference attendees' cohort and reliance on the doctor's decision, with DC additionally associated with being employed. Conclusions DC and decisional regret vary in populations at different stages of initiating DMTs and are impacted by non-treatment issues.
Collapse
|
136
|
Sotirchos ES, Gonzalez-Caldito N, Dewey BE, Fitzgerald KC, Glaister J, Filippatou A, Ogbuokiri E, Feldman S, Kwakyi O, Risher H, Crainiceanu C, Pham DL, Van Zijl PC, Mowry EM, Reich DS, Prince JL, Calabresi PA, Saidha S. Effect of disease-modifying therapies on subcortical gray matter atrophy in multiple sclerosis. Mult Scler 2019; 26:312-321. [PMID: 30741108 DOI: 10.1177/1352458519826364] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The effects of disease-modifying therapies (DMTs) on region-specific brain atrophy in multiple sclerosis (MS) are unclear. OBJECTIVE To determine the effects of higher versus lower efficacy DMTs on rates of brain substructure atrophy in MS. METHODS A non-randomized, observational cohort of people with MS followed with annual brain magnetic resonance imaging (MRI) was evaluated retrospectively. Whole brain, subcortical gray matter (GM), cortical GM, and cerebral white matter (WM) volume fractions were obtained. DMTs were categorized as higher (DMT-H: natalizumab and rituximab) or lower (DMT-L: interferon-beta and glatiramer acetate) efficacy. Follow-up epochs were analyzed if participants had been on a DMT for ⩾6 months prior to baseline and had at least one follow-up MRI while on DMTs in the same category. RESULTS A total of 86 DMT epochs (DMT-H: n = 32; DMT-L: n = 54) from 78 participants fulfilled the study inclusion criteria. Mean follow-up was 2.4 years. Annualized rates of thalamic (-0.15% vs -0.81%; p = 0.001) and putaminal (-0.27% vs -0.73%; p = 0.001) atrophy were slower during DMT-H compared to DMT-L epochs. These results remained significant in multivariate analyses including demographics, clinical characteristics, and T2 lesion volume. CONCLUSION DMT-H treatment may be associated with slower rates of subcortical GM atrophy, especially of the thalamus and putamen. Thalamic and putaminal volumes are promising imaging biomarkers in MS.
Collapse
|
137
|
Linden J, Granåsen G, Salzer J, Svenningsson A, Sundström P. Inflammatory activity and vitamin D levels in an MS population treated with rituximab. Mult Scler J Exp Transl Clin 2019; 5:2055217319826598. [PMID: 30800416 PMCID: PMC6378455 DOI: 10.1177/2055217319826598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 12/17/2018] [Accepted: 01/06/2019] [Indexed: 01/09/2023] Open
Abstract
Background Most multiple sclerosis patients on disease-modifying treatment at Umeå University Hospital are treated with rituximab and the prevalence of vitamin D supplementation has increased over time. Follow-up studies of these off-label treatments are needed. Objective To study inflammatory activity and adverse effects in rituximab-treated multiple sclerosis patients, and associations with 25-hydroxy-vitamin D levels. Methods Retrospectively collected data on repeated estimates of relapses, disability, side effects, magnetic resonance imaging, laboratory measures including 25-hydroxy-vitamin D levels and self-perceived health. Results In 272 multiple sclerosis patients with a mean follow-up of 43 months, we identified seven possible relapses during active rituximab treatment. On magnetic resonance imaging examination, new T2 lesions were seen in 1.3% (10 out of 792 scans), and 0.25% (two out of 785 scans) showed contrast enhancement. Adjusted 25-hydroxy-vitamin D levels in samples drawn close to all magnetic resonance images with new T2 lesions were lower compared to the remainder (62 vs. 81 nmol/l; P = 0.030). Levels of 25-hydroxy-vitamin D were associated with self-perceived health (r = 0.18, P = 0.041, n = 130) and C-reactive protein (r = -0.13, P = 0.042) but not with the risk of side effects. Conclusion The inflammatory activity in this rituximab-treated multiple sclerosis population that increasingly used vitamin D supplementation was extremely low. Higher 25-hydroxy-vitamin D levels were associated with beneficial outcomes.
Collapse
|
138
|
Minden SL. Use and cost of disease-modifying therapies by Sonya Slifka Study participants: has anything really changed since 2000 and 2009? Mult Scler J Exp Transl Clin 2019; 5:2055217318820888. [PMID: 30815276 PMCID: PMC6385335 DOI: 10.1177/2055217318820888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/06/2018] [Accepted: 11/23/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Disease-modifying therapies benefit individuals with relapsing forms of multiple sclerosis, but their utility remains unclear for those without relapses. OBJECTIVE To determine disease-modifying therapy use and costs in 2009, compare use in 2009 and 2000, and examine compliance with evidence-based guidelines. METHODS We determined the extent and characteristics of disease-modifying therapy use by participants in the Sonya Slifka Longitudinal Multiple Sclerosis Study (Slifka) in 2000 (n=2156) and 2009 (n=2361) and estimated out-of-pocket and total (payer) costs for 2009. Two multivariable logistic regressions predicted disease-modifying therapy use. RESULTS Disease-modifying therapy use increased from 55.3% in 2000 to 61.5% in 2009. In 2009, disease-modifying therapy use was reported by 76.5% of participants with relapsing-remitting multiple sclerosis, 73.2% with progressive-relapsing multiple sclerosis, 62.5% with secondary progressive multiple sclerosis, and 41.8% with primary progressive multiple sclerosis. Use was significantly associated with relapsing-remitting multiple sclerosis, shorter duration of illness, one to two relapses per year, non-ambulatory symptoms, using a cane, younger age, higher family income, and having health insurance. Average annual costs in 2009 were US$939-3101 for patients and US$16,302-18,928 for payers. CONCLUSION Use rates were highest for individuals with relapsing-remitting multiple sclerosis, but substantial for those with progressive courses although clinical trials have not demonstrated significant benefits for them.
Collapse
|
139
|
Aouad P, Yiannikas C, Fernando SL, Parratt J. A case of autoimmune myositis after treatment with alemtuzumab for multiple sclerosis. Mult Scler J Exp Transl Clin 2018; 4:2055217318819012. [PMID: 30622727 PMCID: PMC6302273 DOI: 10.1177/2055217318819012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 11/04/2018] [Accepted: 11/14/2018] [Indexed: 12/02/2022] Open
Abstract
Alemtuzumab is a high-efficacy disease-modifying therapy for the treatment of relapsing forms of multiple sclerosis and is associated with secondary autoimmune adverse events. We report a novel case of secondary autoimmune myositis that occurred seven months after the initial treatment cycle and achieved full recovery with oral corticosteroids. This particular form of myositis appears to be unique, and is likely to be a distinct entity from the other four types of immune-mediated myositis.
Collapse
|
140
|
Dumitrescu L, Constantinescu CS, Tanasescu R. Siponimod for the treatment of secondary progressive multiple sclerosis. Expert Opin Pharmacother 2018; 20:143-150. [PMID: 30517042 DOI: 10.1080/14656566.2018.1551363] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic central nervous system immune-mediated disease with an important inflammatory component associated with focal demyelination and widespread neurodegeneration. In most cases, the clinical presentation is relapsing-remitting, followed by a secondary progressive phase, characterized by disability accrual unrelated to relapses. In a minority, the phenotype is progressive from the beginning. Major therapeutic achievements have been made concerning the relapsing phase but modifying the evolution of progressive MS remains an unmet need. Areas covered: This review covers siponimod (BAF312), a new sphingosine 1-phosphate receptor modulator, and its role in the treatment of secondary progressive MS. The authors reviewed PubMed English literature using the keywords 'siponimod' or 'BAF312' and 'multiple sclerosis.' They also present the pharmacological profile of siponimod, as well as clinical efficacy and safety, with emphasis on the recently published results of a Phase III trial. Phase II data in relapsing MS are also summarized. Expert opinion: Siponimod may reduce the activity of the disease and has a modest effect on the gradual disability accrual. If approved, it may become one of the few available therapy options for secondary progressive MS.
Collapse
|
141
|
Fox EJ, Markowitz C, Applebee A, Montalban X, Wolinsky JS, Belachew S, Fiore D, Pei J, Musch B, Giovannoni G. Ocrelizumab reduces progression of upper extremity impairment in patients with primary progressive multiple sclerosis: Findings from the phase III randomized ORATORIO trial. Mult Scler 2018; 24:1862-1870. [PMID: 30415593 PMCID: PMC6282157 DOI: 10.1177/1352458518808189] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Upper extremity (UE) impairment is common with primary progressive multiple
sclerosis (PPMS). Objective: This exploratory analysis examined the effects of ocrelizumab on confirmed
progression (CP) and confirmed improvement (CI) in UE impairment in patients
from ORATORIO. Methods: Patients with PPMS received ocrelizumab 600 mg or placebo every 24 weeks for
⩾120 weeks. The Nine-Hole Peg Test (9HPT) was administered at baseline (BL)
and every 12 weeks thereafter. Prespecified exploratory endpoints included
change in 9HPT time and proportion of patients with CP of ⩾20% in 9HPT.
Analysis populations included intention-to-treat (ITT) patients and
subgroups stratified by BL 9HPT time and Expanded Disability Status Scale.
Post hoc analyses included the proportion of patients achieving more severe
thresholds of CP and the proportion achieving CI in 9HPT. Results: Among ITT patients, ocrelizumab significantly reduced the change in 9HPT time
over 120 weeks, the risk of CP of ⩾20% in 9HPT time for both hands and the
risk of more severe 9HPT progression versus placebo. Numerical trends also
favoured ocrelizumab versus placebo with respect to achieving CI. Consistent
directional trends were observed in subgroup analyses. Conclusion: Ocrelizumab reduces the risk of UE disability progression and may increase
the possibility of improvement versus placebo in PPMS.
Collapse
|
142
|
Voortman MM, Greiner P, Moser D, Stradner MH, Graninger W, Moser A, Haditsch B, Enzinger C, Fuchs S, Fazekas F, Fessler J, Khalil M. The effect of disease modifying therapies on CD62L expression in multiple sclerosis. Mult Scler J Exp Transl Clin 2018; 4:2055217318800810. [PMID: 30263146 PMCID: PMC6149021 DOI: 10.1177/2055217318800810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/09/2018] [Accepted: 08/22/2018] [Indexed: 12/04/2022] Open
Abstract
Background The increasing armamentarium of disease-modifying therapies in
multiple sclerosis is accompanied by potentially severe adverse
effects. The cell-adhesion molecule CD62L, which facilitates
leukocyte extravasation, has been proposed as a predictive
marker for treatment tolerability. However, pre-analytical
procedures might impact test results, thereby limiting its
clinical usability. Whether the immediate analysis of CD62L
expression of peripheral blood mononuclear cells can aid
treatment decision making is yet unclear. Objective To investigate the effect of various disease-modifying therapies in
multiple sclerosis on CD62L expression of
CD3+CD4+ peripheral blood
mononuclear cells in freshly collected blood samples. Methods We collected peripheral blood samples from patients with clinically
isolated syndrome and multiple sclerosis (baseline/follow up
n = 234/n = 98) and
healthy controls (n = 51).
CD62L+CD3+CD4+ expression
was analysed within 1 hour by fluorescence-activated cell
sorting. Results CD62L+CD3+CD4+ expression was
significantly decreased in patients treated with natalizumab
(n = 26) and fingolimod
(n = 20) and increased with
dimethyl-fumarate (n = 15) compared to patients
receiving interferon/glatiramer acetate
(n = 90/30) or no disease-modifying therapies
(n = 53) and controls
(n = 51) (p<0.001). CD62L
expression showed temporal stability during unchanged
disease-modifying therapy usage, but increased after natalizumab
withdrawal and decreased upon fingolimod introduction. Conclusion CD62L+CD3+CD4+ expression is
altered in patients treated with different disease-modifying
therapies when measured in freshly collected samples. The
clinical meaning of CD62L changes under disease-modifying
therapies warrants further investigation.
Collapse
|
143
|
Sellebjerg F, Royen L, Soelberg Sørensen P, Oturai AB, Jensen PEH. Prognostic value of cerebrospinal fluid neurofilament light chain and chitinase-3-like-1 in newly diagnosed patients with multiple sclerosis. Mult Scler 2018; 25:1444-1451. [PMID: 30113249 DOI: 10.1177/1352458518794308] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neurofilament light chain (NFL) and chitinase-3-like-1 (CHI3L1) concentrations in cerebrospinal fluid (CSF) may have prognostic value in clinically isolated syndromes (CIS) and relapsing-remitting multiple sclerosis (RRMS). OBJECTIVES To compare the prognostic value of CSF concentrations of NFL and CHI3L1 in newly diagnosed CIS and RRMS patients. METHODS NFL and CHI3L1 were measured in CSF in 177 newly diagnosed patients with CIS or RRMS who were followed clinically for a mean of 5.7 years. RESULTS At baseline CSF concentrations of NFL correlated with CSF concentrations of CHI3L1, relapses in the previous year, time from last relapse, and the Expanded Disability Status Scale (EDSS) score. CSF concentrations of NFL and CHI3L1 were both associated with increased relapse risk during the first 2 years in univariate analyses, but only the CSF concentration of NFL was independently associated with relapse risk in a multivariable analysis. There was no relationship between CSF concentrations of NFL or CHI3L1 and risk of conversion to secondary progressive MS or development of disability. CONCLUSION CSF concentrations of NFL are associated with 2-year relapse risk but not with disease progression or clinical worsening in newly diagnosed CIS and RRMS patients. This may be due to confounding by the effect of disease-modifying therapies.
Collapse
|
144
|
Cohen JA, Comi G, Arnold DL, Bar-Or A, Selmaj KW, Steinman L, Havrdová EK, Cree BA, Montalbán X, Hartung HP, Huang V, Frohna P, Skolnick BE, Kappos L. Efficacy and safety of ozanimod in multiple sclerosis: Dose-blinded extension of a randomized phase II study. Mult Scler 2018; 25:1255-1262. [PMID: 30043658 PMCID: PMC6681431 DOI: 10.1177/1352458518789884] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background: Ozanimod, an oral immunomodulator, selectively targets sphingosine
1-phosphate receptors 1 and 5. Objective: Evaluate efficacy, safety, and tolerability of ozanimod in relapsing multiple
sclerosis. Methods: In the RADIANCE Part A phase II study (NCT01628393), participants with
relapsing multiple sclerosis were randomized (1:1:1) to once-daily ozanimod
hydrochloride (0.5 or 1 mg) or placebo. After 24 weeks, participants could
enter a 2-year, dose-blinded extension. Ozanimod-treated participants
continued their assigned dose; placebo participants were re-randomized (1:1)
to ozanimod hydrochloride 0.5 or 1 mg (equivalent to ozanimod 0.46 and
0.92 mg). Results: A total of 223 (89.6%) of the 249 participants completed the blinded
extension. At 2 years of the extension, the percentage of participants who
were gadolinium-enhancing lesion-free ranged from 86.5% to 94.6%. Unadjusted
annualized relapse rate during the blinded extension (week 24—end of
treatment) was 0.32 for ozanimod hydrochloride 0.5 mg → ozanimod
hydrochloride 0.5 mg, 0.18 for ozanimod hydrochloride 1 mg → ozanimod
hydrochloride 1 mg, 0.30 for placebo → ozanimod hydrochloride 0.5 mg, and
0.18 for placebo → ozanimod hydrochloride 1 mg. No second-degree or higher
atrioventricular block or serious opportunistic infection was reported. Conclusion: Ozanimod demonstrated sustained efficacy in participants continuing treatment
up to 2 years and reached similar efficacy in participants who switched from
placebo; no unexpected safety signals emerged.
Collapse
|
145
|
Zaratin P, Comi G, Leppert D. 'Progressive MS - macro views': The need for novel clinical trial paradigms to enable drug development for progressive MS. Mult Scler 2018; 23:1649-1655. [PMID: 29041866 DOI: 10.1177/1352458517729457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article outlines the principal challenges to establish a standard phase-2 approach for progressive multiple sclerosis (PMS) and presents referring strategies to accelerate the registration process via a guidance approved by regulatory agencies. Accordingly, the contribution of 'big datasets' for a better understanding of the natural history of primary-progressive multiple sclerosis (PPMS) and secondary-progressive multiple sclerosis (SPMS) and of their prognostic factors and the value of novel biomarkers are discussed. The establishment of new industry-academic initiatives, such as independent consortia under the umbrella of Progressive MS Alliance (PMSA), with the endorsement of MS organizations and Scientific Societies (e.g. European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS)) may be crucial to overcome some of the current challenges. Within this frame, the continuous interaction with regulatory agencies is instrumental for the formal validation of the many developments suitable to improve clinical trialling in PMS.
Collapse
|
146
|
Conway DS, Cecilia Vieira M, Thompson NR, Parker KN, Meng X, Fox RJ. Patient-Reported Disease-Modifying Therapy Adherence in the Clinic: A Reliable Metric? Mult Scler J Exp Transl Clin 2018; 4:2055217318777894. [PMID: 29854415 PMCID: PMC5971395 DOI: 10.1177/2055217318777894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/20/2018] [Accepted: 04/22/2018] [Indexed: 11/17/2022] Open
Abstract
Background Adherence to multiple sclerosis (MS) disease-modifying therapy (DMT) is commonly assessed through patient reporting, but patient-reported adherence is rarely studied. Objective To determine rates of DMT adherence reported from patient to clinician, reasons for nonadherence, and relationships between adherence and outcomes. Methods We identified relapsing-remitting MS patients on DMT for ≥3 months. DMT adherence was defined as taking ≥80% of doses. Linear and logistic regression models were created used to determine the association of baseline adherence with several patient reported outcomes and the timed 25-foot walk at 6 months, 1 year, 2 years, and 3 years after the index visit. Results The analysis included 1148 patients, of whom 501 had data at 6 months, 544 at 1 year, 331 at 2 years, and 247 at 3 years. Baseline adherence was 94.9% and overall adherence was 93.1%. Forgetting was the most common reason for missed doses. In the adjusted models, adherence was not associated with the outcomes. Conclusions Higher than expected adherence and a lack of association between adherence and outcomes suggests patient reported adherence may not be reliable. Further research is needed to clarify the relationship between patient-reported adherence and relapses or new lesion formation.
Collapse
|
147
|
Mills EA, Mao-Draayer Y. Aging and lymphocyte changes by immunomodulatory therapies impact PML risk in multiple sclerosis patients. Mult Scler 2018; 24:1014-1022. [PMID: 29774781 DOI: 10.1177/1352458518775550] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
New potent immunomodulatory therapies for multiple sclerosis (MS) are associated with increased risk for progressive multifocal leukoencephalopathy (PML). It is unclear why a subset of treated patients develops PML, but patient age has emerged as an important risk factor. PML is caused by the JC virus and aging is associated with immune senescence, which increases susceptibility to infection. With the goal of improving PML risk stratification, we here describe the lymphocyte changes that occur with disease-modifying therapies (DMTs) associated with high or moderate risk toward PML in MS patients, how these changes compare to immune aging, and which measures best correlate with risk. We reviewed studies examining how these therapies alter patient immune profiles, which revealed the induction of changes to lymphocyte number and/or function that resemble immunosenescence. Therefore, the immunosuppressive activity of these MS DMTs may be enhanced in the context of an immune system that is already exhibiting features of senescence.
Collapse
|
148
|
Schee JP, Viswanathan S. Pure spinal multiple sclerosis: A possible novel entity within the multiple sclerosis disease spectrum. Mult Scler 2018; 25:1189-1195. [PMID: 29771191 DOI: 10.1177/1352458518775912] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We identified five female patients retrospectively with relapsing short-segment partial myelitis whose clinical and paraclinical features were suggestive of cord involvement of multiple sclerosis (MS)-type albeit not rigidly fulfilling the 2017 McDonald criteria. Notably, these patients had not developed any typical MS-like brain lesions despite repeated neuroimaging assessments over years. Comprehensive work-up for differential diagnoses of MS and other causes of transverse myelitis particularly neuromyelitis optica spectrum disorders had been consistently negative on longitudinal follow-up. Thus, we postulate a possible entity of pure spinal MS which may represent a novel forme fruste within the MS disease spectrum.
Collapse
|
149
|
Durozard P, Maarouf A, Boutiere C, Ruet A, Brochet B, Vukusic S, Carra-Dalliere C, Labauge P, Mathey G, Debouverie M, Papeix C, Maillart E, Lubetzki C, Bensa C, Gout O, Giannesini C, Stankoff B, Ciron J, Brassat D, Pelletier J, Rico Lamy A, Audoin B. Efficacy of rituximab in refractory RRMS. Mult Scler 2018; 25:828-836. [PMID: 29722639 DOI: 10.1177/1352458518772748] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the efficacy of rituximab as rescue therapy in patients with relapsing-remitting multiple sclerosis (RRMS) and persistent disease activity confirmed by magnetic resonance imaging (MRI) despite immunosuppressive disease-modifying therapy (DMT). METHODS In this observational nationwide retrospective multicenter study, we first identified 351 off-label rituximab-treated patients through a cohort of 15,984 RRMS patients. In this group, we identified patients with disease activity prior to rituximab confirmed by MRI (one or more new T2 lesion and/or gadolinium-enhancing lesion) despite immunosuppressive DMT (fingolimod, natalizumab, or mitoxantrone) with a follow-up after rituximab initiation longer than 6 months. Outcome data were collected from the French Observatory of Multiple Sclerosis (OFSEP) register and medical charts. RESULTS A total of 50 patients were identified. Median rituximab treatment duration was 1.1 (0.5-6.4) year. Mean annualized relapse rate significantly decreased from 0.8 during last immunosuppressive DMT to 0.18 after rituximab ( p < 0.0001). While 72% of patients showed gadolinium-enhancing lesions on the last MRI performed during last immunosuppressive DMT, 8% of them showed gadolinium-enhancing lesions on the first MRI performed 6.1 (range 1.4-18.4) months after rituximab ( p < 0.0001). CONCLUSION This study provides level IV evidence that rituximab reduces clinical and MRI disease activity in patients with active RRMS despite immunosuppressive DMT.
Collapse
|
150
|
Coret F, Pérez-Miralles FC, Gascón F, Alcalá C, Navarré A, Bernad A, Boscá I, Escutia M, Gil-Perotin S, Casanova B. Onset of secondary progressive multiple sclerosis is not influenced by current relapsing multiple sclerosis therapies. Mult Scler J Exp Transl Clin 2018; 4:2055217318783347. [PMID: 30090637 PMCID: PMC6077906 DOI: 10.1177/2055217318783347] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/19/2018] [Accepted: 05/10/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Disease-modifying therapies are thought to reduce the conversion rate to secondary progressive multiple sclerosis. OBJECTIVE To explore the rate, chronology, and contributing factors of conversion to the progressive phase in treated relapsing-remitting multiple sclerosis patients. METHODS Our study included 204 patients treated for relapsing-remitting multiple sclerosis between 1995 and 2002, prospectively followed to date. Kaplan-Meier analysis was applied to estimate the time until secondary progressive multiple sclerosis conversion, and multivariate survival analysis with a Cox regression model was used to analyse prognostic factors. RESULTS Relapsing-remitting multiple sclerosis patients were continuously treated for 13 years (SD 4.5); 36.3% converted to secondary progressive multiple sclerosis at a mean age of 42.6 years (SD 10.6), a mean time of 8.2 years (SD 5.2) and an estimated mean time of 17.2 years (range 17.1-18.1). A multifocal relapse, age older than 34 years at disease onset and treatment failure independently predicted conversion to secondary progressive multiple sclerosis but did not influence the time to reach an Expanded Disability Status Scale of 6.0. CONCLUSIONS The favourable influence of disease-modifying therapies on long-term disability in relapsing-remitting multiple sclerosis is well established. However, the time to progression onset and the subsequent clinical course in treated patients seem similar to those previously reported in natural history studies. More studies are needed to clarify the effect of disease-modifying therapies once the progressive phase has been reached.
Collapse
|