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Chisari CG, Amato MP, Di Sapio A, Foschi M, Iaffaldano P, Inglese M, Fermo SL, Lugaresi A, Lus G, Mascoli N, Montepietra S, Pesci I, Quatrale R, Salemi G, Torri Clerici V, Totaro R, Valentino P, Filippi M, Patti F. Active and non-active secondary progressive multiple sclerosis patients exhibit similar disability progression: results of an Italian MS registry study (ASPERA). J Neurol 2024; 271:6801-6810. [PMID: 39190108 PMCID: PMC11446943 DOI: 10.1007/s00415-024-12621-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/29/2024] [Accepted: 08/01/2024] [Indexed: 08/28/2024]
Abstract
'Active' and 'non-active' secondary progressive MS (SPMS) have distinct pathophysiological mechanisms and clinical characteristics, but there is still no consensus regarding the frequency of these MS forms in the real-world setting. We aimed to evaluate the frequency of 'active' and 'non-active' SPMS in a large cohort of Italian MS patients and the differences in terms of clinical and MRI characteristics and disease progression. This multicenter study collected data about MS patients who have transitioned to the SP form in the period between 1st January 2014 and 31st December 2019 and followed by the MS centers contributing to the Italian MS Registry. Patients were divided into 'active SPMS' and 'non-active SPMS', based on both reported MRI data and relapse activity in the year before conversion to SPMS. Out of 68,621, 8,316 (12.1%) patients were diagnosed with SPMS. Out of them, 872 (10.5%) were classified into patients with either 'active' or 'non-active' SPMS. A total of 237 were classified into patients with 'active SPMS' (27.2%) and 635 as 'non-active SPMS' (72.8%). 'Non-active SPMS' patients were older, with a longer disease duration compared to those with 'active SPMS'. The percentages of patients showing progression independent of relapse activity (PIRA) at 24 months were similar between 'active' and 'non-active' SPMS patients (67 [27.4%] vs 188 [29.6%]; p = 0.60). In the 'active' group, 36 (15.2%) patients showed relapse-associated worsening (RAW). Comparison of the survival curves to EDSS 6 and 7 according to disease activity did not show significant differences (p = 0.68 and p = 0.71). 'Active' and 'non-active' SPMS patients had a similar risk of achieving disability milestones, suggesting that progression is primarily attributed to PIRA and only to a small extent to disease activity.
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Affiliation(s)
- Clara Grazia Chisari
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Multiple Sclerosis Center, University of Catania, Catania, Italy
- Multiple Sclerosis Unit; Neurology Clinic, Policlinico "G. Rodolico- San Marco", Catania, Italy
| | - Maria Pia Amato
- Department of NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy
| | - Alessia Di Sapio
- Department of Neurology, Regional Referral Multiple Sclerosis Center, University Hospital San Luigi Gonzaga, Orbassano, Turin, Italy
| | - Matteo Foschi
- Department of Neuroscience, Multiple Sclerosis Center, S. Maria delle Croci Hospital of Ravenna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L'Aquila, L'Aquila, Italy
| | - Pietro Iaffaldano
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Salvatore Lo Fermo
- Multiple Sclerosis Unit; Neurology Clinic, Policlinico "G. Rodolico- San Marco", Catania, Italy
| | - Alessandra Lugaresi
- UOSI Riabilitazione Sclerosi Multipla, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giacomo Lus
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Science, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Nerina Mascoli
- Neurology Unit, Department of Medicine, S. Anna Hospital, Como, Italy
| | - Sara Montepietra
- MS Centre, SMN Hospital, AUSL Reggio Emilia, Reggio Emilia, Italy
| | - Ilaria Pesci
- Centro Sclerosi Multipla Unità Operativa Neurologia, Azienda Unità Sanitaria Locale, Ospedale Di Vaio, Fidenza, Parma, Italy
| | - Rocco Quatrale
- Dipartimento Di Scienze Neurologiche, UOC Di Neurologia, Ospedale Dell'Angelo AULSS 3 Serenissima, Venice Mestre, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Valentina Torri Clerici
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Rocco Totaro
- Demyelinating Disease Center, San Salvatore Hospital, L'Aquila, Italy
| | - Paola Valentino
- Institute of Neurology, University Magna Graecia, Catanzaro, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Multiple Sclerosis Center, University of Catania, Catania, Italy.
- Multiple Sclerosis Unit; Neurology Clinic, Policlinico "G. Rodolico- San Marco", Catania, Italy.
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Bsteh G, Aicher ML, Walde JF, Krajnc N, Haider L, Traxler G, Gradl C, Salmen A, Riedl K, Poskaite P, Leyendecker P, Altmann P, Auer M, Berek K, Di Pauli F, Kornek B, Leutmezer F, Rommer PS, Zulehner G, Zrzavy T, Deisenhammer F, Chan A, Berger T, Hoepner R, Hammer H, Hegen H. Association of Disease-Modifying Treatment With Outcome in Patients With Relapsing Multiple Sclerosis and Isolated MRI Activity. Neurology 2024; 103:e209752. [PMID: 39197111 DOI: 10.1212/wnl.0000000000209752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Isolated value of MRI metrics in relapsing multiple sclerosis (RMS) as a surrogate marker of response to disease-modifying treatment (DMT) and, thus, as decision criteria for DMT escalation in the absence of clinical signs of disease activity is still a matter of debate. The aim of this study was to investigate whether DMT escalation based on isolated MRI activity affects clinical outcome. METHODS Combining data from 5 MS centers in Austria and Switzerland, we included patients with RMS aged at least 18 years who (1) had initiated first-line, low-to-moderate-efficacy DMT (interferon β, glatiramer acetate, teriflunomide, or dimethyl fumarate) continued for ≥12 months, (2) were clinically stable (no relapses or disability progression) on DMT for 12 months, (3) had MRI at baseline and after 12 months on DMT, and (4) had available clinical follow-up for ≥2 years after the second MRI. The primary endpoint was occurrence of relapse during follow-up. The number of new T2 lesions (T2L) and DMT strategy (continuing low-/moderate-efficacy DMT vs escalating DMT) were used as covariates in regression analyses. RESULTS A total of 131 patients with RMS, median age of 36 (25th-75th percentiles: 29-43) years, 73% women, were included and observed over a median period of 6 (5-9) years after second MRI. Sixty-two (47%) patients had relapse. Patients who continued first-line DMT had a 3-fold increased risk of relapse given 2 new T2L (hazard ratio [HR] 3.2, lower limit [LL] of 95% CI: 1.5) and a 4-fold increased risk given ≥3 new T2L (HR 4.0, LL-CI: 2.1). Escalation of DMT lowered the risk of relapse in patients with 2 new T2L by approximately 80% (HR 0.2, upper limit [UL] of 95% CI: 1.3) and with ≥3 new T2L by 70% (HR 0.3, UL-CI: 0.8). In case of only 1 new T2L, the increased risk of relapse and the treatment effect did not reach statistical significance of 5%. DISCUSSION In our real-world cohort of patients clinically stable under low-to-moderate-efficacy DMT, escalation of DMT based on isolated MRI activity decreased risk of further relapse when at least 2 new T2L had occurred. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that clinically stable patients with MS on low-/moderate-efficacy DMT with ≥3 new T2L on MRI who escalate DMT have a reduced risk of relapse and Expanded Disability Status Scale progression.
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Affiliation(s)
- Gabriel Bsteh
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Marie L Aicher
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Janette F Walde
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Nik Krajnc
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Lukas Haider
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Gerhard Traxler
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Christiane Gradl
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Anke Salmen
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Katharina Riedl
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Paulina Poskaite
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Philipp Leyendecker
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Patrick Altmann
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Michael Auer
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Klaus Berek
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Franziska Di Pauli
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Barbara Kornek
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Fritz Leutmezer
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Paulus S Rommer
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Gudrun Zulehner
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Tobias Zrzavy
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Florian Deisenhammer
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Andrew Chan
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Thomas Berger
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Robert Hoepner
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Helly Hammer
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
| | - Harald Hegen
- From the Department of Neurology (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), and Comprehensive Center for Clinical Neurosciences & Mental Health (G.B., N.K., K.R., P.A., B.K., F.L., P.S.R., G.Z., T.Z., T.B.), Medical University of Vienna, Austria; Department of Neurology (M.L.A., A.S., A.C., R.H., H. Hammer), Inselspital, Bern University Hospital and University of Bern, Switzerland; Department of Statistics (J.F.W.), Faculty of Economics and Statistics, University of Innsbruck; Department of Biomedical Imaging and Image Guided Therapy (L.H.), Clinical Department of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; Department of Neurology 2 (G.T.), Med Campus III, Kepler University Hospital GmbH, Linz; Department of Neurology (C.G.), Medical University of St. Pölten; and Departments of Neuroradiology (P.P.) and Neurology (P.L., M.A., K.B., F.D.P., F.D., H. Hegen), Medical University of Innsbruck, Austria
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3
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Lepore V, Paletta P, Bosetti C, Santucci C, Ponzio M, Pupillo E, Leone MA, Bergamaschi R, Mosconi P. Temporal and spatial patterns in the prescriptions of disease-modifying therapies for multiple sclerosis. Results from the Italian Multiple Sclerosis and Related Disorders Register. Mult Scler Relat Disord 2024; 87:105638. [PMID: 38713966 DOI: 10.1016/j.msard.2024.105638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/02/2024] [Accepted: 04/18/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND The therapeutic scenario in multiple sclerosis (MS) has evolved over recent years with the progressive introduction of new drugs focused to better balance efficacy, safety and management requirements. The objective of this study was to examine the prescribing patterns of disease-modifying therapies (DMT) over time and across different geographic areas, and the latency between disease onset, first Register center visit, disease diagnosis, and the start of treatment in a large cohort of persons with MS from the Italian Multiple Sclerosis and Related Disorders Register. METHODS Up to 2022, the Register collected data from 124 centers on more than 78,000 persons, of whom 56,872 received at least one DMT prescription. Beside baseline demographic and clinical characteristics, we focused on DMT according to their efficacy distinguishing between moderate-efficacy (ME), or high-efficacy (HE). RESULTS There was a higher probability of prescribing HE-DMT for increasing calendar years (multivariable odds ratio, OR=11.51 in 2021 or thereafter vs before 2000), in males (OR=1.08 vs females), patients with primary progressive with or without relapse (OR=3.00 vs clinically isolated syndrome), those with a higher Expanded Disability Status Scale score (OR=3.85 for >4 versus 0-1), and those from larger referral centers (OR=1.89 vs smaller ones). Conversely, higher age at onset was associated to a lower probability of prescribing HE-DMT (OR=0.74 at 40 or more vs <20 years). A trend to shorter times was observed in subsequent calendar years for disease onset, first center visit, diagnosis and first DMT prescription. No trend was detected based on the location of the geographic referral centers. The times between disease onset, first center visit, and diagnosis and the first DMT prescription showed significant decreases according to the year, while differences were less evident for the geographic areas. CONCLUSION This study highlights some factors influencing the choice of HE-DMT, including aspects of both healthcare and clinical phenotype. The absence of a geographic pattern may indicate some homogeneity in DMT prescriptions across different Italian MS centers.
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Affiliation(s)
- Vito Lepore
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Pasquale Paletta
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Cristina Bosetti
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Claudia Santucci
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy; Department of Clinical Sciences and Community Health, University of Milan, Via Giovanni Celoria 22, 20133 Milano, Italy
| | - Michela Ponzio
- Scientific Research Area, Italian Multiple Sclerosis Foundation, Via Operai 40, 16149 Genova, Italy
| | - Elisabetta Pupillo
- Dipartimento di Neuroscienze, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Maurizio A Leone
- Dipartimento di Neuroscienze, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Roberto Bergamaschi
- Centro Sclerosi Multipla, IRCCS Fondazione Mondino, Via Mondino 2, 27100 Pavia, Italy
| | - Paola Mosconi
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy.
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Singer BA, Feng J, Chiong-Rivero H. Early use of high-efficacy therapies in multiple sclerosis in the United States: benefits, barriers, and strategies for encouraging adoption. J Neurol 2024; 271:3116-3130. [PMID: 38615277 PMCID: PMC11136864 DOI: 10.1007/s00415-024-12305-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Multiple sclerosis (MS) is characterized by progressive neuroinflammation and neurodegeneration from disease onset that, if left untreated, can result in the accumulation of irreversible neurological disability. Early intervention with high-efficacy therapies (HETs) is increasingly recognized as the best strategy to delay or mitigate disease progression from the earliest stages of the disease and to prevent long-term neurodegeneration. Although there is growing clinical and real-world evidence supporting early HET intervention, foregoing this strategy in favor of a traditional escalation approach prioritizing lower-efficacy disease-modifying therapies remains a common approach in clinical practice. This review explores potential health care professional- and patient-related barriers to the early use of HETs in patients with MS in the United States. Barriers can include regulatory and reimbursement restrictions; knowledge gaps and long-term safety concerns among health care professionals; and various individual, cultural, and societal factors affecting patients. Potential strategies for overcoming these barriers and encouraging early HET use are proposed.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA.
| | - Jenny Feng
- Ochsner Medical Center, New Orleans, LA, USA
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5
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Ontaneda D, Chitnis T, Rammohan K, Obeidat AZ. Identification and management of subclinical disease activity in early multiple sclerosis: a review. J Neurol 2024; 271:1497-1514. [PMID: 37864717 PMCID: PMC10972995 DOI: 10.1007/s00415-023-12021-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/22/2023] [Accepted: 09/24/2023] [Indexed: 10/23/2023]
Abstract
IMPORTANCE Early treatment initiation in multiple sclerosis (MS) is crucial in preventing irreversible neurological damage and disability progression. The current assessment of disease activity relies on relapse rates and magnetic resonance imaging (MRI) lesion activity, but inclusion of other early, often "hidden," indicators of disease activity may describe a more comprehensive picture of MS. OBSERVATIONS Early indicators of MS disease activity other than relapses and MRI activity, such as cognitive impairment, brain atrophy, and fatigue, are not typically captured by routine disease monitoring. Furthermore, silent progression (neurological decline not clearly captured by standard methods) may occur undetected by relapse and MRI lesion activity monitoring. Consequently, patients considered to have no disease activity actually may have worsening disease, suggesting a need to revise MS management strategies with respect to timely initiation and escalation of disease-modifying therapy (DMT). Traditionally, first-line MS treatment starts with low- or moderate-efficacy therapies, before escalating to high-efficacy therapies (HETs) after evidence of breakthrough disease activity. However, multiple observational studies have shown that early initiation of HETs can prevent or reduce disability progression. Ongoing randomized clinical trials are comparing escalation and early HET approaches. CONCLUSIONS AND RELEVANCE There is an urgent need to reassess how MS disease activity and worsening are measured. A greater awareness of "hidden" indicators, potentially combined with biomarkers to reveal silent disease activity and neurodegeneration underlying MS, would provide a more complete picture of MS and allow for timely therapeutic intervention with HET or switching DMTs to address suboptimal treatment responses.
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Affiliation(s)
- Daniel Ontaneda
- Mellen Center for Multiple Sclerosis, Department of Neurology, Cleveland Clinic, Cleveland, OH, USA.
| | - Tanuja Chitnis
- Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kottil Rammohan
- Division of Multiple Sclerosis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ahmed Z Obeidat
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
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Rhodes JS, Aumon A, Morin S, Girard M, Larochelle C, Brunet-Ratnasingham E, Pagliuzza A, Marchitto L, Zhang W, Cutler A, Grand'Maison F, Zhou A, Finzi A, Chomont N, Kaufmann DE, Zandee S, Prat A, Wolf G, Moon KR. Gaining Biological Insights through Supervised Data Visualization. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.11.22.568384. [PMID: 38293135 PMCID: PMC10827133 DOI: 10.1101/2023.11.22.568384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Dimensionality reduction-based data visualization is pivotal in comprehending complex biological data. The most common methods, such as PHATE, t-SNE, and UMAP, are unsupervised and therefore reflect the dominant structure in the data, which may be independent of expert-provided labels. Here we introduce a supervised data visualization method called RF-PHATE, which integrates expert knowledge for further exploration of the data. RF-PHATE leverages random forests to capture intricate featurelabel relationships. Extracting information from the forest, RF-PHATE generates low-dimensional visualizations that highlight relevant data relationships while disregarding extraneous features. This approach scales to large datasets and applies to classification and regression. We illustrate RF-PHATE's prowess through three case studies. In a multiple sclerosis study using longitudinal clinical and imaging data, RF-PHATE unveils a sub-group of patients with non-benign relapsingremitting Multiple Sclerosis, demonstrating its aptitude for time-series data. In the context of Raman spectral data, RF-PHATE effectively showcases the impact of antioxidants on diesel exhaust-exposed lung cells, highlighting its proficiency in noisy environments. Furthermore, RF-PHATE aligns established geometric structures with COVID-19 patient outcomes, enriching interpretability in a hierarchical manner. RF-PHATE bridges expert insights and visualizations, promising knowledge generation. Its adaptability, scalability, and noise tolerance underscore its potential for widespread adoption.
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Selmaj K, Cree BAC, Barnett M, Thompson A, Hartung HP. Multiple sclerosis: time for early treatment with high-efficacy drugs. J Neurol 2024; 271:105-115. [PMID: 37851189 PMCID: PMC10769939 DOI: 10.1007/s00415-023-11969-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/19/2023]
Abstract
This review addresses current changes in the approach to treating patients with multiple sclerosis (MS). The widely practiced approach of utilizing agents with lower treatment efficacy (LETA) at onset with subsequent escalation has been challenged by new data suggesting that MS patients derive greater benefit when therapy is initiated with high-efficacy treatment agents (HETA). Several recent studies compared treatment efficacy and safety of early administration of HETA versus LETA. The results of randomized, double blind, phase III studies with LETA as a control arm and population-based larger and longer studies using propensity scoring, marginal structural modeling and weighted cumulative exposure analysis support the benefit of early treatment with HETA. Patients initiating their treatment with HETA, regardless of prognostic factors and MRI burden at baseline, showed significantly lower annualized relapse rate (ARR) and reduced disability progression in follow-up periods of up to 10-15 years. Moreover, the safety profile of recently approved HETA ameliorates concerns about off-target effects associated with a number of earlier high-efficacy drugs. Patient perception has also changed with an increasing preference for medication profiles that both improve symptoms and prevent disease progression. Accumulating data from randomized studies and the results of large population-based studies demonstrating short-term and longer-term patient benefits support the view that HETA should be more widely used. The adoption of early treatment with HETA capitalizes on a window of opportunity for anti-inflammatory drugs to maximally impact disease pathology and heralds a sea change in clinical practice toward pro-active management and away from a philosophy routed in generating clinical benefit as a consequence of treatment failure.
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Affiliation(s)
- Krzysztof Selmaj
- Department of Neurology, University of Warmia and Mazury, 30 Warszawska Ave, 10-082, Olsztyn, Poland.
- Center of Neurology, Lodz, Poland.
| | - Bruce A C Cree
- Department of Neurology, Weill Neurosciences Institute, UCSF, San Francisco, USA
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney, Sydney, Australia
| | - Alan Thompson
- Faculty of Brain Sciences, University College, London, London, UK
| | - Hans-Peter Hartung
- Brain and Mind Centre, University of Sydney, Sydney, Australia
- Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Palacky University, Olomouc, Olomouc, Czech Republic
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8
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Spelman T, Magyari M, Butzkueven H, Van Der Walt A, Vukusic S, Trojano M, Iaffaldano P, Horáková D, Drahota J, Pellegrini F, Hyde R, Duquette P, Lechner-Scott J, Sajedi SA, Lalive P, Shaygannejad V, Ozakbas S, Eichau S, Alroughani R, Terzi M, Girard M, Kalincik T, Grand'Maison F, Skibina O, Khoury SJ, Yamout B, Sa MJ, Gerlach O, Blanco Y, Karabudak R, Oreja-Guevara C, Altintas A, Hughes S, McCombe P, Ampapa R, de Gans K, McGuigan C, Soysal A, Prevost J, John N, Inshasi J, Stawiarz L, Manouchehrinia A, Forsberg L, Sellebjerg F, Glaser A, Pontieri L, Joensen H, Rasmussen PV, Sejbaek T, Poulsen MB, Christensen JR, Kant M, Stilund M, Mathiesen H, Hillert J. Predictors of treatment switching in the Big Multiple Sclerosis Data Network. Front Neurol 2023; 14:1274194. [PMID: 38187157 PMCID: PMC10771327 DOI: 10.3389/fneur.2023.1274194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Abstract
Background Treatment switching is a common challenge and opportunity in real-world clinical practice. Increasing diversity in disease-modifying treatments (DMTs) has generated interest in the identification of reliable and robust predictors of treatment switching across different countries, DMTs, and time periods. Objective The objective of this retrospective, observational study was to identify independent predictors of treatment switching in a population of relapsing-remitting MS (RRMS) patients in the Big Multiple Sclerosis Data Network of national clinical registries, including the Italian MS registry, the OFSEP of France, the Danish MS registry, the Swedish national MS registry, and the international MSBase Registry. Methods In this cohort study, we merged information on 269,822 treatment episodes in 110,326 patients from 1997 to 2018 from five clinical registries. Patients were included in the final pooled analysis set if they had initiated at least one DMT during the relapsing-remitting MS (RRMS) stage. Patients not diagnosed with RRMS or RRMS patients not initiating DMT therapy during the RRMS phase were excluded from the analysis. The primary study outcome was treatment switching. A multilevel mixed-effects shared frailty time-to-event model was used to identify independent predictors of treatment switching. The contributing MS registry was included in the pooled analysis as a random effect. Results Every one-point increase in the Expanded Disability Status Scale (EDSS) score at treatment start was associated with 1.08 times the rate of subsequent switching, adjusting for age, sex, and calendar year (adjusted hazard ratio [aHR] 1.08; 95% CI 1.07-1.08). Women were associated with 1.11 times the rate of switching relative to men (95% CI 1.08-1.14), whilst older age was also associated with an increased rate of treatment switching. DMTs started between 2007 and 2012 were associated with 2.48 times the rate of switching relative to DMTs that began between 1996 and 2006 (aHR 2.48; 95% CI 2.48-2.56). DMTs started from 2013 onwards were more likely to switch relative to the earlier treatment epoch (aHR 8.09; 95% CI 7.79-8.41; reference = 1996-2006). Conclusion Switching between DMTs is associated with female sex, age, and disability at baseline and has increased in frequency considerably in recent years as more treatment options have become available. Consideration of a patient's individual risk and tolerance profile needs to be taken into account when selecting the most appropriate switch therapy from an expanding array of treatment choices.
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Affiliation(s)
- Tim Spelman
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- MSBase Foundation, Melbourne, VIC, Australia
| | - Melinda Magyari
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Helmut Butzkueven
- MSBase Foundation, Melbourne, VIC, Australia
- MS and Neuroimmunology Research, Central Clinical School, Alfred and Box Hill Hospitals, Monash University, Melbourne, VIC, Australia
| | - Anneke Van Der Walt
- MSBase Foundation, Melbourne, VIC, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Sandra Vukusic
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- Centre des Neurosciences de Lyon, L'Institut national de la santé et de la recherche médicale 1028 et Centre national de la recherche scientifique joint research units5292, Lyon, France
- Faculté de Médicine Lyon-Est, Université Claude Bernard Lyon 1, Villeurbanne, Auvergne-Rhône-Alpes, France
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Pietro Iaffaldano
- Department of Translational Biomedicine and Neuroscience, DiBraiN, University of Bari Aldo Moro, Bari, Italy
| | - Dana Horáková
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Jirí Drahota
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Fabio Pellegrini
- Biogen International GmbH, Zug, Switzerland
- Biogen Digital Health, Biogen Spain, Madrid, Spain
| | | | - Pierre Duquette
- University of Montreal Hospital Research Centre and Universite de Montreal, Montreal, QC, Canada
| | - Jeannette Lechner-Scott
- University Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, Hunter New England Health, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Seyed Aidin Sajedi
- Department of Neurology, Neuroscience Research Center, Golestan University of Medical Sciences, Gogan, Iran
| | - Patrice Lalive
- Faculty of Medicine, Division of Neurology, Geneva University Hospital, Geneva, Switzerland
| | | | | | - Sara Eichau
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Murat Terzi
- Medical Faculty, 19 Mayis University, Samsun, Türkiye
| | - Marc Girard
- University of Montreal Hospital Research Centre and Universite de Montreal, Montreal, QC, Canada
| | - Tomas Kalincik
- Clinical Outcomes Research Unit, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | | | - Olga Skibina
- MS and Neuroimmunology Research, Central Clinical School, Alfred and Box Hill Hospitals, Monash University, Melbourne, VIC, Australia
| | - Samia J. Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bassem Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maria Jose Sa
- Department of Neurology, Faculty of Health Sciences, University Fernando Pessoa, Porto, Portugal
| | - Oliver Gerlach
- Academic MS Center Zuyderland, Department of Neurology, Zuyderland Medical Center, Sittard-Geleen, Netherlands
| | - Yolanda Blanco
- Center of Neuroimmunology, Service of Neurology, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | | | - Ayse Altintas
- Department of Neurology, School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Türkiye
| | | | | | | | | | | | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Türkiye
| | | | - Nevin John
- Monash Health, Melbourne, VIC, Australia
| | | | - Leszek Stawiarz
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Ali Manouchehrinia
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Lars Forsberg
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Anna Glaser
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Luigi Pontieri
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Hanna Joensen
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | | | - Tobias Sejbaek
- Department of Neurology, Southwest Jutland Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Mai Bang Poulsen
- Department of Neurology, Nordsjællands Hospital, Hillerød, Denmark
| | - Jeppe Romme Christensen
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Matthias Kant
- Department of Neurology, Hospital of Southern Jutland, University of Southern Denmark, Aabenraa, Denmark
| | - Morten Stilund
- Department of Neurology, Physiotherapy and Occupational Therapy, Gødstrup Hospital, Herning, Denmark
- NIDO | Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Henrik Mathiesen
- Department of Neurology, Copenhagen University Hospital Herlev and Gentofte, København, Denmark
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Szepanowski F, Steubing RD, Güngör C, Zipfel J, Mausberg AK, Kleinschnitz C, Stettner M. High-dose biotin neither fosters remyelination nor stimulates malonyl coenzyme A synthesis in the regenerating nerve. Neural Regen Res 2023; 18:1623-1624. [PMID: 36571371 PMCID: PMC10075130 DOI: 10.4103/1673-5374.361542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Fabian Szepanowski
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Rebecca D Steubing
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Cansu Güngör
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Jaqueline Zipfel
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Anne K Mausberg
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Mark Stettner
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University Duisburg-Essen, Essen, Germany
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10
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Bsteh G, Hegen H, Altmann P, Auer M, Berek K, Di Pauli F, Haider L, Kornek B, Krajnc N, Leutmezer F, Macher S, Rommer P, Walchhofer LM, Zebenholzer K, Zulehner G, Deisenhammer F, Pemp B, Berger T. Retinal layer thickness predicts disability accumulation in early relapsing multiple sclerosis. Eur J Neurol 2023; 30:1025-1034. [PMID: 36719184 DOI: 10.1111/ene.15718] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE This study was undertaken to investigate baseline peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell and inner plexiform layer (GCIPL) thickness for prediction of disability accumulation in early relapsing multiple sclerosis (RMS). METHODS From a prospective observational study, we included patients with newly diagnosed RMS and obtained spectral-domain optical coherence tomography scan within 90 days after RMS diagnosis. Impact of pRNFL and GCIPL thickness for prediction of disability accumulation (confirmed Expanded Disability Status Scale [EDSS] score ≥ 3.0) was tested by multivariate (adjusted hazard ratio [HR] with 95% confidence interval [CI]) Cox regression models. RESULTS We analyzed 231 MS patients (mean age = 30.3 years, SD = 8.1, 74% female) during a median observation period of 61 months (range = 12-93). Mean pRNFL thickness was 92.6 μm (SD = 12.1), and mean GCIPL thickness was 81.4 μm (SD = 11.8). EDSS ≥ 3 was reached by 28 patients (12.1%) after a median 49 months (range = 9-92). EDSS ≥ 3 was predicted with GCIPL < 77 μm (HR = 2.7, 95% CI = 1.6-4.2, p < 0.001) and pRNFL thickness ≤ 88 μm (HR = 2.0, 95% CI = 1.4-3.3, p < 0.001). Higher age (HR = 1.4 per 10 years, p < 0.001), incomplete remission of first clinical attack (HR = 2.2, p < 0.001), ≥10 magnetic resonance imaging (MRI) lesions (HR = 2.0, p < 0.001), and infratentorial MRI lesions (HR = 1.9, p < 0.001) were associated with increased risk of disability accumulation, whereas highly effective disease-modifying treatment was protective (HR = 0.6, p < 0.001). Type of first clinical attack and presence of oligoclonal bands were not significantly associated. CONCLUSIONS Retinal layer thickness (GCIPL more than pRNFL) is a useful predictor of future disability accumulation in RMS, independently adding to established markers.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Haider
- Department of Neuroradiology, Medical University of Vienna, Vienna, Austria
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Karin Zebenholzer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gudrun Zulehner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Berthold Pemp
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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11
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Menendez L, Osherov M, Nitsan Z, Alkrenawi M, Gelfand A, Hovel N, Appel S, Milo R. The consequences of switching Gilenya to generics for Fingolimod. Mult Scler Relat Disord 2023; 74:104692. [PMID: 37099833 DOI: 10.1016/j.msard.2023.104692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/22/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND On May 2017, two generic drugs for fingolimod were introduced into the market in Israel, and most MS patients treated with Gilenya® (Novartis) were switched to fingolimod (Teva), or to Finolim (Rafa). In this study we analyzed the consequences of switching to generic fingolimod in a single MS center. METHODS Study population included relapsing MS patients who were treated with Gilenya® for at least two year before May 2017, switched to generic fingolimod and remained on treatment for at least 2 years thereafter. Data before and after the switch were compared. RESULTS Twenty-seven patients fulfilled the inclusion criteria (F = 20, RRMS=20, SPMS=7, average age 49±11.4 years, average disease duration=16.6 ± 7.6 years). Seventeen patients had to be switched back to the original Gilenya® due to intolerable new or worsening clinical adverse events (n = 9), clinical relapse (n = 1), clinical relapse with adverse events (n = 3), elevation of liver enzymes > X3 ULN (n = 3) and elevation of amylase (n = 1). Expanded Disability Status Scale (EDSS) score increased in 4 patients during the year before the switch, and in 12 patients during the year of treatment with generic fingolimod (p = 0.036). CONCLUSION The tolerability, retention rate and probably efficacy of generic fingolimod seems to be lower than the original Gilenya®.
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12
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Drake SS, Zaman A, Simas T, Fournier AE. Comparing RNA-sequencing datasets from astrocytes, oligodendrocytes, and microglia in multiple sclerosis identifies novel dysregulated genes relevant to inflammation and myelination. WIREs Mech Dis 2023; 15:e1594. [PMID: 36600404 DOI: 10.1002/wsbm.1594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/25/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023]
Abstract
Central nervous system (CNS) inflammation is a key factor in multiple sclerosis (MS). Invasion of peripheral immune cells into the CNS resulting from an unknown signal or combination of signals results in activation of resident immune cells and the hallmark feature of the disease: demyelinating lesions. These lesion sites are an amalgam of reactive peripheral and central immune cells, astrocytes, damaged and dying oligodendrocytes, and injured neurons and axons. Sustained inflammation affects cells directly located within the lesion site and further abnormalities are apparent diffusely throughout normal-appearing white matter and grey matter. It is only relatively recently, using animal models, new tissue sampling techniques, and next-generation sequencing, that molecular changes occurring in CNS resident cells have been broadly captured. Advances in cell isolation through Fluorescence Activated Cell Sorting (FACS) and laser-capture microdissection together with the emergence of single-cell sequencing have enabled researchers to investigate changes in gene expression in astrocytes, microglia, and oligodendrocytes derived from animal models of MS as well as from primary patient tissue. The contribution of some dysregulated pathways has been followed up in individual studies; however, corroborating results often go unreported between sequencing studies. To this end, we have consolidated results from numerous RNA-sequencing studies to identify and review novel patterns of differentially regulated genes and pathways occurring within CNS glial cells in MS. This article is categorized under: Neurological Diseases > Molecular and Cellular Physiology.
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Affiliation(s)
- Sienna S Drake
- McGill University, Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Aliyah Zaman
- McGill University, Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Tristan Simas
- McGill University, Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Alyson E Fournier
- McGill University, Montreal Neurological Institute, Montreal, Quebec, Canada
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13
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Lager B, Liseno J, Božin I, England SM, Shankar SL, Mendoza JP, Lewin JB. Real-World Analysis Affirms the High Persistence and Adherence Observed with Diroximel Fumarate in Patients with Multiple Sclerosis. Neurol Ther 2023; 12:145-159. [PMID: 36334241 PMCID: PMC9837354 DOI: 10.1007/s40120-022-00413-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Adherence to disease-modifying therapies is key for achieving optimal outcomes in multiple sclerosis (MS). Diroximel fumarate (DRF) is an oral fumarate approved for treatment of relapsing forms of MS. It has the same pharmacologically active metabolite as dimethyl fumarate (DMF) and similar efficacy and safety profiles, but with demonstrated fewer gastrointestinal (GI) related adverse events (AEs). There are limited data characterizing persistence and adherence to DRF in the real world. METHODS This retrospective analysis of the AcariaHealth Specialty Pharmacy Program included patients with MS initiating DRF from 1 December 2019 to 30 January 2021. This analysis evaluated persistence, measured as proportion of patients remaining on therapy; discontinuation rate due to GI AEs; and adherence measured by proportion of days covered (PDC). RESULTS Overall, 1143 patients were included; 433 (37.9%) patients had been treated with prior DMF and switched to DRF. Persistence was high in both groups: the estimated proportion of patients remaining on DRF at 16 months was 82.3% [95% confidence internal (CI) 77.2-86.3%], and 90.1% (95% CI 82.2-94.6%) in the DMF to DRF group. Fifty-two (4.5%) patients overall and 15 (3.5%) in the DMF switch subgroup discontinued DRF due to GI AEs. Mean PDC was 90.8% (95% CI 89.2-92.5%), and 85.4% (95% CI 83.3-87.4%) of patients achieved PDC ≥ 80% in the overall population. In the DMF to DRF group, mean PDC was 90.7% (95% CI 88.0-93.5%), and 84.8% (95% CI 81.4-88.1%) of patients achieved PDC ≥ 80%. CONCLUSION In this analysis of > 1000 patients treated with DRF in real-world clinical practice, overall persistence at 16 months was high, treatment discontinuation due to GI AEs was low, and patients were highly adherent to therapy. Of 433 patients who switched from DMF to DRF, most (> 90%) were able to tolerate and persist on DRF after switching. Graphical abstract available for this article.
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14
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Collorone S, Kodali S, Toosy AT. The protective role of breastfeeding in multiple sclerosis: Latest evidence and practical considerations. Front Neurol 2023; 13:1090133. [PMID: 36761920 PMCID: PMC9902945 DOI: 10.3389/fneur.2022.1090133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/23/2022] [Indexed: 01/25/2023] Open
Abstract
The immunoprotective role of pregnancy in multiple sclerosis (MS) has been known for decades. Conversely, there has been rich debate on the topic of breastfeeding and disease activity in MS. In clinical practice, women are often offered to restart their disease-modifying drug (DMD) soon after delivery to maintain their relapse risk protection. Limited available information about peri-partum DMD safety can discourage women to choose breastfeeding, despite the World Health Organization's recommendation to breastfeed children for the first 6 months of life exclusively. New evidence is emerging about the protective role of exclusive breastfeeding on relapse rate. Research studies shed light on the hormonal and immunological mechanisms driving the risk of relapses during pregnancy and postpartum. Finally, case reports, real-world data, and clinical trials are increasing our knowledge of the safety of DMDs for the fetus and infant. While some DMDs must be avoided, others may be considered in highly active pregnant or lactating women with MS. This mini-review conveys recent evidence regarding the protective role of exclusive breastfeeding in MS and offers clinicians practical considerations for a patient-tailored approach.
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Affiliation(s)
- Sara Collorone
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Srikirti Kodali
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Ahmed T Toosy
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
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15
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Pozzilli C, Pugliatti M, Vermersch P, Grigoriadis N, Alkhawajah M, Airas L, Oreja-Guevara C. Diagnosis and treatment of progressive multiple sclerosis: A position paper. Eur J Neurol 2023; 30:9-21. [PMID: 36209464 PMCID: PMC10092602 DOI: 10.1111/ene.15593] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/05/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Multiple sclerosis (MS) is an unpredictable disease characterised by a highly variable disease onset and clinical course. Three main clinical phenotypes have been described. However, distinguishing between the two progressive forms of MS can be challenging for clinicians. This article examines how the diagnostic definitions of progressive MS impact clinical research, the design of clinical trials and, ultimately, treatment decisions. METHODS We carried out an extensive review of the literature highlighting differences in the definition of progressive forms of MS, and the importance of assessing the extent of the ongoing inflammatory component in MS when making treatment decisions. RESULTS Inconsistent results in phase III clinical studies of treatments for progressive MS, may be attributable to differences in patient characteristics (e.g., age, clinical and radiological activity at baseline) and endpoint definitions. In both primary and secondary progressive MS, patients who are younger and have more active disease will derive the greatest benefit from the available treatments. CONCLUSIONS We recommend making treatment decisions based on the individual patient's pattern of disease progression, as well as functional, clinical and imaging parameters, rather than on their clinical phenotype. Because the definition of progressive MS differs across clinical studies, careful selection of eligibility criteria and study endpoints is needed for future studies in patients with progressive MS.
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Affiliation(s)
- Carlo Pozzilli
- Multiple Sclerosis Center, Sant'Andrea Hospital, Rome, Italy.,Department of Human Neuroscience, University Sapienza, Rome, Italy
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy.,Interdepartmental Center of Research for Multiple Sclerosis and Neuro-inflammatory and Degenerative Diseases, University of Ferrara, Ferrara, Italy
| | - Patrick Vermersch
- Inserm U1172 LilNCog, CHU Lille, FHU Precise, University of Lille, Lille, France
| | - Nikolaos Grigoriadis
- Laboratory of Experimental Neurology and Neuroimmunology, Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mona Alkhawajah
- Section of Neurology, Neurosciences Center, King Faisal Specialist Hospital and Research Center, College of Medicine, Al Faisal University, Riyadh, Kingdom of Saudi Arabia
| | - Laura Airas
- Division of Clinical Neurosciences, University of Turku, Turku, Finland.,Neurocenter of Turku University Hospital, Turku, Finland
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clinico San Carlos, IdISSC, Madrid, Spain.,Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain
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Ahmed T. Neural stem cell engineering for the treatment of multiple sclerosis. BIOMEDICAL ENGINEERING ADVANCES 2022. [DOI: 10.1016/j.bea.2022.100053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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17
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Sgarlata E, Chisari CG, Toscano S, Finocchiaro C, Lo Fermo S, Millefiorini E, Patti F. Changes in John Cunningham Virus Index in Multiple Sclerosis Patients Treated with Different Disease-Modifying Therapies. Curr Neuropharmacol 2022; 20:1978-1987. [PMID: 34766895 PMCID: PMC9886813 DOI: 10.2174/1570159x19666211111123202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Progressive Multifocal Leukoencephalopathy (PML) is an opportunistic infection caused by John Cunningham virus (JCV) reactivation, potentially associated with natalizumab (NTZ) treatment for Multiple Sclerosis (MS). The anti-JCV antibodies titre (JCV index) increases during NTZ treatment; however, the effects of other disease-modifying therapies (DMTs) on the JCV index have not been fully explored. OBJECTIVE The aim of the study was to evaluate changes in the JCV index during treatment with several DMTs. METHODS This longitudinal study evaluated the JCV index before starting DMT (T0) and during treatment with DMT (T1). RESULTS A total of 260 participants (65.4 % females, mean age 43 ± 11.3 ) were enrolled: 68 (26.2 %) treated with fingolimod (FTY), 65 (25 %) rituximab or ocrelizumab (RTX/OCR), 37 (14.2 %) dimethyl-fumarate (DMF), 29 (11.2 %) cladribine (CLD), 23 (8.8 %) teriflunomide (TFM), 20 (7.7 %) interferon or glatiramer acetate (IFN/GA), and 18 (6.9 %) alemtuzumab (ALM). At T1, the percentage of patients with JCV index <0.90 was found to be significantly increased in the ALM group (16.7 % versus 66.7 %, p = 0.05), while the percentage of patients with JCV index >1.51 was found to be significantly reduced in the RTX/OCR group (51.6 % versus 37.5 %, p = 0.04). In the FTY group, a significant reduction in the percentage of patients with JCV index <0.90 was also found (23.5 % versus 1.4 %, p = 0.0006). The mean JCV index was reduced in the RTX/OCR and ALM groups, while a significant increase was observed in the FTY group. CONCLUSION DMTs with a T and/or B depleting mechanism of action induced a significant reduction in the JCV index. These results may suggest new possible sequencing strategies potentially maximizing disease control while reducing the PML risk.
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Affiliation(s)
| | | | | | | | | | | | - Francesco Patti
- Address correspondence to this author at the Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy; Tel: 0953782783; E-mail:
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18
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Porwal MH, Salter A, Patel D, Obeidat AZ. Alopecia in Multiple Sclerosis Patients Treated with Disease Modifying Therapies. J Cent Nerv Syst Dis 2022; 14:11795735221109674. [PMID: 35769950 PMCID: PMC9234852 DOI: 10.1177/11795735221109674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There is currently limited literature addressing the reporting of alopecia in
multiple sclerosis (MS) patients treated with disease-modifying therapies
(DMTs). Anecdotal reports of hair thinning from patients on various DMTs
prompted further investigation of a large database. OBJECTIVE To analyze total reports, source of reporting, age distribution, and sex
distribution of alopecia associated with DMTs. METHODS FDA Adverse Event Reporting System (FAERS) public dashboard and OpenFDA
database were analyzed for alopecia reports between January 1, 2009, and
June 30, 2020, attributed to usage in MS of FDA approved DMTs. The main
outcomes included total reports for each drug, age, sex distribution, and
reporting source. OpenFDA data was used for statistical analyses including
reporting odds ratios (ROR) and information components. RESULTS 8759 alopecia reports were identified among 44 114 adverse events in skin and
subcutaneous tissue disorders (19.9%). 3701 (42.3%) with teriflunomide, 1675
(19.1%) with dimethyl fumarate, 985 (11.2%) with natalizumab, 926 (10.6%)
with fingolimod, 659 (7.5%) with interferon beta-1a, 257 (2.9%) with
glatiramer acetate, 243 (2.8%) with ocrelizumab, 124 (1.4%) with interferon
beta-1b, 117 (1.3%) with alemtuzumab, 36 (.4%) with siponimod, 24 (.3%) with
cladribine, and 12 (.1%) with rituximab. Reports were mostly made by
patients (78.3%) and highest in fifth and sixth decades of life. OpenFDA
analyses showed increased ROR (ROR 95% confidence interval) of alopecia in
females with teriflunomide (18.00, 17.12-18.93), alemtuzumab (1.43,
1.16-1.76), dimethyl fumarate (1.26, 1.18-1.34), and ocrelizumab (1.28,
1.11-1.49). Increased ROR in males was associated with teriflunomide (24.65,
20.72-29.31). CONCLUSION We identified many reports of alopecia for DMTs in addition to teriflunomide.
Within the limitations of the database, increased RORs of alopecia were
observed for females treated with alemtuzumab, dimethyl fumarate, and
ocrelizumab. The source of reporting was largely driven by female patients.
Possible alopecia, even if transient, should be considered during patient
education when starting DMTs.
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Affiliation(s)
- Mokshal H Porwal
- Department of neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amber Salter
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dhruvkumar Patel
- Midwestern University Arizona College of Osteopathic Medicine, Glendale, AZ, USA
| | - Ahmed Z Obeidat
- Department of neurology, Medical College of Wisconsin, Milwaukee, WI, USA
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Neurodegeneration in Multiple Sclerosis: The Role of Nrf2-Dependent Pathways. Antioxidants (Basel) 2022; 11:antiox11061146. [PMID: 35740042 PMCID: PMC9219619 DOI: 10.3390/antiox11061146] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 12/10/2022] Open
Abstract
Multiple sclerosis (MS) encompasses a chronic, irreversible, and predominantly immune-mediated disease of the central nervous system that leads to axonal degeneration, neuronal death, and several neurological symptoms. Although various immune therapies have reduced relapse rates and the severity of symptoms in relapsing-remitting MS, there is still no cure for this devastating disease. In this brief review, we discuss the role of mitochondria dysfunction in the progression of MS, focused on the possible role of Nrf2 signaling in orchestrating the impairment of critical cellular and molecular aspects such as reactive oxygen species (ROS) management, under neuroinflammation and neurodegeneration in MS. In this scenario, we propose a new potential downstream signaling of Nrf2 pathway, namely the opening of hemichannels and pannexons. These large-pore channels are known to modulate glial/neuronal function and ROS production as they are permeable to extracellular Ca2+ and release potentially harmful transmitters to the synaptic cleft. In this way, the Nrf2 dysfunction impairs not only the bioenergetics and metabolic properties of glial cells but also the proper antioxidant defense and energy supply that they provide to neurons.
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Berek K, Hegen H, Hocher J, Auer M, Di Pauli F, Krajnc N, Angermann R, Barket R, Zinganell A, Riedl K, Deisenhammer F, Berger T, Bsteh G. Retinal layer thinning as a biomarker of long-term disability progression in multiple sclerosis. Mult Scler 2022; 28:1871-1880. [PMID: 35652366 DOI: 10.1177/13524585221097566] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Peripapillary retinal nerve fibre layer and macular ganglion cell plus inner plexiform layer thinning are markers of neuroaxonal degeneration in multiple sclerosis. OBJECTIVE We aimed to investigate the value of peripapillary retinal nerve fibre layer and ganglion cell plus inner plexiform layer thinning for prediction of long-term disability. METHODS This is a 6-year prospective longitudinal study on 93 multiple sclerosis patients. Optical coherence tomography scans were performed at baseline, after 1, 2 and 6 years. Primary endpoint was disability progression after 6 years, defined as expanded disability status scale worsening and/or cognitive deterioration. Univariate and multivariate analysis was used to investigate the value of peripapillary retinal nerve fibre layer and ganglion cell plus inner plexiform layer to predict the primary endpoint. RESULTS A total of 57 (61.3%) patients had disability worsening, 40 (43.0%) expanded disability status scale worsening and 34 (36.6%) cognitive deterioration. Mean peripapillary retinal nerve fibre layer and ganglion cell plus inner plexiform layer baseline thickness were 93.0 and 75.2 µm, and mean annualised peripapillary retinal nerve fibre layer and ganglion cell plus inner plexiform layer thinning rates over 6 years were 1.3 and 1.6 µm, respectively. Univariate and multivariate analysis revealed lower peripapillary retinal nerve fibre layer and ganglion cell plus inner plexiform layer baseline thickness and higher annualised thinning rates in patients with disability progression after 6 years. Effects were more pronounced for ganglion cell plus inner plexiform layer and expanded disability status scale worsening than for peripapillary retinal nerve fibre layer models and cognitive deterioration. CONCLUSION Ganglion cell plus inner plexiform layer and peripapillary retinal nerve fibre layer measurements depict neurodegeneration and predict disability progression in multiple sclerosis.
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Affiliation(s)
- Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Hocher
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Reinhard Angermann
- Department of Ophthalmology and Optometry, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert Barket
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Katharina Riedl
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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21
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The current standing of autologous haematopoietic stem cell transplantation for the treatment of multiple sclerosis. J Neurol 2022; 269:3937-3958. [PMID: 35399125 PMCID: PMC8995166 DOI: 10.1007/s00415-022-11063-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/01/2022]
Abstract
AbstractAutologous haematopoietic stem cell transplantation (aHSCT) is gaining traction as a valuable treatment option for patients affected by severe multiple sclerosis (MS), particularly the relapsing–remitting form. We describe the current literature in terms of clinical trials, observational and retrospective studies, as well as immune reconstitution following transplantation, with a focus on the conditioning regimens used for transplantation. The evidence base predominantly consists of non-randomised, uncontrolled clinical trials or data from retrospective or observational cohorts, i.e. very few randomised or controlled trials. Most often, intermediate-intensity conditioning regimens are used, with promising results from both myeloablative and lymphoablative strategies, as well as from regimens that are low and high intensity. Efficacy of transplantation, which is likely secondary to immune reconstitution and restored immune tolerance, is, therefore, not clearly dependent on the intensity of the conditioning regimen. However, the conditioning regimen may well influence the immune response to transplantation. Heterogeneity of conditioning regimens among studies hinders synthesis of the articles assessing post-aHSCT immune system changes. Factors associated with better outcomes were lower Kurtzke Expanded Disability Status Scale, relapsing–remitting MS, younger age, and shorter disease duration at baseline, which supports the guidance for patient selection proposed by the European Society for Blood and Marrow Transplantation. Interestingly, promising outcomes were described for patients with secondary progressive MS by some studies, which may be worth taking into account when considering treatment options for patients with active, progressive disease. Of note, a significant proportion of patients develop autoimmune disease following transplantation, with alemtuzumab-containing regimens associated with the highest incidence.
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22
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Bsteh G, Hegen H, Berek K, Altmann P, Auer M, Di Pauli F, Haider L, Leutmezer F, Rommer P, Walchhofer LM, Wurth S, Zinganell A, Deisenhammer F, Berger T. Olfactory threshold predicts treatment response in relapsing multiple sclerosis. Mult Scler 2022; 28:1541-1552. [PMID: 35282741 DOI: 10.1177/13524585221079744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Olfactory threshold (OT) is associated with short-term inflammatory activity in relapsing multiple sclerosis (RMS). Objective: We aimed to investigate OT for prediction of treatment response in RMS. Methods: In this 5-year prospective study on 123 RMS patients, OT was measured at disease-modifying treatment (DMT) initiation (M0), after 3 months (M3), and 12 months (M12) by Sniffin’ Sticks test. Primary endpoint was defined as an absence of relapse during the observation period, with Expanded Disability Status Scale (EDSS) progression and magnetic resonance imaging (MRI) activity being the secondary endpoints. Optimal cutoff values were determined by receiver operating characteristic analyses and their predictive value assessed by multivariable Cox regression models. Results: Higher OT scores at M0, M3, and M12 were independently associated with decreased relapse probability with the strongest risk reduction at M3 (hazard ratio (HR) = 0.44, p < 0.001). Improvement of OT scores from M0 to M3 (ΔOTM3) was also associated with reduced relapse risk (HR = 0.12, p < 0.001). OT score > 6.5 at M3 was the strongest predictor of relapse freedom (HR = 0.10, p < 0.001) with high diagnostic accuracy (positive predictive value (PPV) = 87%), closely followed by ΔOTM3 ⩾ 0.5 (HR = 0.12, p < 0.001, PPV = 86%). Conclusions: OT is an independent predictor of freedom of disease activity upon DMT initiation within 5 years and may be a useful biomarker of treatment response.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Haider
- Department of Neuroradiology, Medical University of Vienna, Vienna, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Sebastian Wurth
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Insights into Human-Induced Pluripotent Stem Cell-Derived Astrocytes in Neurodegenerative Disorders. Biomolecules 2022; 12:biom12030344. [PMID: 35327542 PMCID: PMC8945600 DOI: 10.3390/biom12030344] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 02/06/2023] Open
Abstract
Most neurodegenerative disorders have complex and still unresolved pathology characterized by progressive neuronal damage and death. Astrocytes, the most-abundant non-neuronal cell population in the central nervous system, play a vital role in these processes. They are involved in various functions in the brain, such as the regulation of synapse formation, neuroinflammation, and lactate and glutamate levels. The development of human-induced pluripotent stem cells (iPSCs) reformed the research in neurodegenerative disorders allowing for the generation of disease-relevant neuronal and non-neuronal cell types that can help in disease modeling, drug screening, and, possibly, cell transplantation strategies. In the last 14 years, the differentiation of human iPSCs into astrocytes allowed for the opportunity to explore the contribution of astrocytes to neurodegenerative diseases. This review discusses the development protocols and applications of human iPSC-derived astrocytes in the most common neurodegenerative conditions.
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Berek K, Paganini C, Hegen H, Bsteh G, Grams A, Auer M, Berger T, Deisenhammer F, Di Pauli F. Natalizumab treatment during pregnancy in multiple sclerosis-clinical and bioethical aspects of an ongoing debate. Wien Med Wochenschr 2022; 172:373-378. [PMID: 35142953 DOI: 10.1007/s10354-022-00913-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Natalizumab is an approved treatment for relapsing remitting multiple sclerosis; however, its safety during pregnancy is not formally proven. CASE PRESENTATION We report a woman with multiple sclerosis being treated with natalizumab before pregnancy. After withdrawal of natalizumab, she suffered a severe, disabling rebound. In agreement with the patient, natalizumab was restarted during pregnancy. Our patient improved substantially and gave birth to a healthy boy. CONCLUSION Use of natalizumab during pregnancy may be an option in highly active multiple sclerosis.
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Affiliation(s)
- Klaus Berek
- Departmentof Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Paganini
- Department of Christian Philosophy, University of Innsbruck, Innsbruck, Austria
| | - Harald Hegen
- Departmentof Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Departmentof Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Franziska Di Pauli
- Departmentof Neurology, Medical University of Innsbruck, Innsbruck, Austria.
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25
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Saposnik G, Andhavarapu S, Fernández Ó, Kim HJ, Wiendl H, Foss M, Zuo F, Havrdová EK, Celius E, Caceres F, Magyari M, Bermel R, Costa A, Terzaghi M, Kalincik T, Popescu V, Amato MP, Montalban X, Oh J. Factors associated with treatment escalation among MS specialists and general neurologists: Results from an International cojoint study. Mult Scler Relat Disord 2022; 58:103404. [PMID: 35216786 DOI: 10.1016/j.msard.2021.103404] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/19/2021] [Accepted: 11/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies in multiple sclerosis (MS) showed that therapeutic inertia (TI) affects 60-90% of neurologists and up to 25% of daily treatment decisions. The objective of this study was to determine the most common factors and attribute levels associated with decisions to treatment escalation in an international study in MS care. METHODS 300 neurologists with MS expertise from 20 countries were invited to participate. Participants were presented with 12 pairs of simulated MS patient profiles described by 13 clinically relevant factors. We used disaggregated discrete choice experiments to estimate the weight of factors and attributes affecting physicians' decisions when considering treatment selection. Participants were asked to select the ideal candidate for treatment escalation from modest to higher-efficacy therapies. RESULTS Overall, 229 neurologists completed the study (completion rate: 76.3%). The top 3 weighted factors associated with treatment escalation were: previous relapses (20%), baseline expanded disability status scale [EDSS] (18%), and MRI activity (13%). Patient demographics and desire for pregnancy had a modest influence (≤ 3%). We observed differences in the weight of factors associated with treatment escalation between MS specialists and non-MS specialists. CONCLUSIONS Our results provide critical information on factors influencing neurologists' treatment decisions and should be applied to continuing medical education strategies.
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Affiliation(s)
- G Saposnik
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, 55 Queen St E, Toronto, Ontario M5C 1R6, Canada; Director and Founder, NeuroEconSolutions© (www.neuroeconsolutions.com), Toronto, Canada; Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada.
| | - S Andhavarapu
- Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ó Fernández
- Department of Pharmacology, Faculty of Medicine, University of Malaga, Institute of Biomedical Research of Malaga, Regional University Hospital of Malaga, Spain
| | - H J Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Republic of Korea
| | - H Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Germany
| | - M Foss
- Bootstrap Analytics, Calgary, Canada
| | - F Zuo
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
| | - E K Havrdová
- Department of Neurology, First Medical Faculty, Center for Clinical Neuroscience, Charles University, Prague, Czech Republic
| | - E Celius
- Department of Neurology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - F Caceres
- Institute of Restorative Neurosciences, Buenos Aires, Argentina
| | - M Magyari
- Danish Multiple Sclerosis Center, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - R Bermel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, United States
| | - A Costa
- Neurology Department, Faculty of Medicine University of Porto, Centro Hospitalar Universitário São João, Portugal
| | - M Terzaghi
- Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
| | - T Kalincik
- Department of Medicine, MS Centre, Royal Melbourne Hospital Core Unit, University of Melbourne, Melborne, Australia
| | - V Popescu
- University MS Centre, Noorderhart Hospital, Pelt, Belgium; Hasselt University, Hasselt, Belgium
| | - M P Amato
- Department of Neurofarba, IRCCS Fondazione Don Carlo Gnocchi, University of Florence, Florence, Italy
| | - X Montalban
- Department of Neurology, Hospital Vall d´Hebron, Centre d'Esclerosi Mútiple de Catalunya, Universitat Autonoma de Barcelona, Spain
| | - J Oh
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, 55 Queen St E, Toronto, Ontario M5C 1R6, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
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Health-Related Quality of Life with Diroximel Fumarate in Patients with Relapsing Forms of Multiple Sclerosis: Findings from Qualitative Research Using Patient Interviews. Adv Ther 2022; 39:3199-3213. [PMID: 35556227 PMCID: PMC9098785 DOI: 10.1007/s12325-022-02164-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/17/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Diroximel fumarate (DRF) is an oral fumarate for relapsing multiple sclerosis (MS). Clinical and real-world studies of DRF have demonstrated improved gastrointestinal (GI) tolerability and low (< 1%) GI-related treatment discontinuation versus dimethyl fumarate (DMF) and high rates of treatment adherence. Our aim was to conduct a concept elicitation study to identify treatment-related concepts most meaningful to patients and to evaluate how these concepts shape the patient perspective of DRF. METHODS In-depth qualitative interviews were conducted with patients from October to December 2020. US adults who had been prescribed DRF through routine clinical care and had taken DRF for ≥ 3 weeks in the past 6 months were eligible to participate. Semi-structured interviews explored patient perceptions on treatment selection and impact. RESULTS Seventeen patients participated in the study. Mean (SD) age was 49.3 (12.0) years. Sixteen patients reported prior disease-modifying therapy, while 10 (58.8%) had prior DMF. DRF treatment duration ranged from ~ 6 weeks to 10 months. Four key concepts emerged: (1) overall wellness and quality of life, (2) ease of administration, (3) minimal and manageable side effects, and (4) patient optimism due to MS treatments. Mode of administration (82.4%), no/mild side effects (70.6%), convenience over injectable/infusion medications (58.8%), and effectiveness (64.7%) were cited as positive aspects of DRF treatment. Frequent dosing (52.9%) and food requirements (41.2%) were cited as negative attributes; however, 94.1% had no dietary changes since starting treatment. CONCLUSION The patient perspective is a key aspect when considering a disease-modifying therapy for MS, given the multitude of options currently available. Overall wellness, ease of administration, and minimal and manageable side effects were DRF-related concepts most meaningful to patients on therapy. Acknowledging these patient perceptions in shared decision-making may lead to greater patient adherence and optimal treatment outcomes.
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Mi Y, Han J, Zhu J, Jin T. Role of the PD-1/PD-L1 Signaling in Multiple Sclerosis and Experimental Autoimmune Encephalomyelitis: Recent Insights and Future Directions. Mol Neurobiol 2021; 58:6249-6271. [PMID: 34480337 PMCID: PMC8639577 DOI: 10.1007/s12035-021-02495-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/12/2021] [Indexed: 12/19/2022]
Abstract
Multiple sclerosis (MS) is an autoimmunity-related chronic demyelination disease of the central nervous system (CNS), causing young disability. Currently, highly specific immunotherapies for MS are still lacking. Programmed cell death 1 (PD-1) is an immunosuppressive co-stimulatory molecule, which is expressed on activated T lymphocytes, B lymphocytes, natural killer cells, and other immune cells. PD-L1, the ligand of PD-1, is expressed on T lymphocytes, B lymphocytes, dendritic cells, and macrophages. PD-1/PD-L1 delivers negative regulatory signals to immune cells, maintaining immune tolerance and inhibiting autoimmunity. This review comprehensively summarizes current insights into the role of PD-1/PD-L1 signaling in MS and its animal model experimental autoimmune encephalomyelitis (EAE). The potentiality of PD-1/PD-L1 as biomarkers or therapeutic targets for MS will also be discussed.
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Affiliation(s)
- Yan Mi
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Xinmin Street 71#, Changchun, 130021 China
| | - Jinming Han
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Xinmin Street 71#, Changchun, 130021 China
- Present Address: Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Zhu
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Xinmin Street 71#, Changchun, 130021 China
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Tao Jin
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Xinmin Street 71#, Changchun, 130021 China
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Long-Term Safety and Efficacy of Subcutaneous Cladribine Used in Increased Dosage in Patients with Relapsing Multiple Sclerosis: 20-Year Observational Study. J Clin Med 2021; 10:jcm10215207. [PMID: 34768726 PMCID: PMC8584572 DOI: 10.3390/jcm10215207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/17/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Abstract
Cladribine is currently registered as a 10-milligram tablet formulation with a fixed cumulative dosage of 3.5 mg/kg over 2 years. It is important to investigate if an increased dosage may lead to further clinical stability with preserved safety. This study used an off-label subcutaneous (s.c.) formulation of cladribine and compared outcomes (Expanded Disability Status Scale (EDSS) scores and disease progression) between 52 relapsing multiple sclerosis (RMS) patients receiving different s.c. dosing regimens with up to 20 years of follow-up. The study group received induction therapy with s.c. cladribine (1.8 mg/kg cumulative dose; consistent with 3.5 mg/kg of cladribine tablets). Patients were subsequently offered maintenance therapy (repeated courses of 0.3 mg/kg s.c. cladribine during 5–20-year follow-up). Forty-one patients received an increased cumulative dose (higher than the induction dose of 1.8 mg/kg); 11 received the standard induction dose. Risk of progression on the EDSS correlated with lower cumulative dose (p < 0.05) and more advanced disability at treatment initiation (p < 0.05) as assessed by EDSS change between year 1 and years 5 and 10 as the last follow-up. Maintenance treatment was safe and well-tolerated, based on limited source data. Subcutaneous cladribine with increased cumulative maintenance dosage was associated with disease stability and favorable safety over a prolonged period of follow-up (up to 20 years) in RMS patients.
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Vermersch P, Oreja-Guevara C, Siva A, Van Wijmeersch B, Wiendl H, Wuerfel J, Buffels R, Kadner K, Kuenzel T, Comi G. Efficacy and safety of ocrelizumab in patients with relapsing-remitting multiple sclerosis with suboptimal response to prior disease-modifying therapies: A primary analysis from the phase 3b CASTING single-arm, open-label trial. Eur J Neurol 2021; 29:790-801. [PMID: 34748672 PMCID: PMC9299209 DOI: 10.1111/ene.15171] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/21/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Using the treatment goal of "no evidence of disease activity" (NEDA) incorporating magnetic resonance imaging (MRI) re-baselining, we aimed to assess the efficacy of ocrelizumab in patients with relapsing-remitting multiple sclerosis with a prior suboptimal response, defined by MRI or relapse criteria, to one or two disease-modifying therapies (DMTs). METHODS CASTING was a prospective, international, multicenter, single-arm, open-label phase 3 trial (NCT02861014). Patients (Expanded Disability Status Scale [EDSS] score ≤ 4.0, with discontinued prior DMT of ≥6 months duration due to suboptimal disease control) received intravenous ocrelizumab 600 mg every 24 weeks for 96 weeks. The primary endpoint was NEDA (defined as absence of relapses, disability progression, and inflammatory MRI measures, with prespecified MRI re-baselining at Week 8) over 96 weeks. RESULTS A total of 680 patients were enrolled, 167 (24.6%) based on MRI activity only. At Week 96, 74.8% (95% confidence interval [CI] 71.3-78.0, n/N = 492/658) of patients had NEDA. NEDA was highest among patients enrolled due to MRI activity alone (80.6% [95% CI 68.6-89.6], n/N = 50/62) versus those enrolled for relapse (75.1% [95% CI 69.0-80.6], n/N = 172/229) or for relapse with MRI (70.5% [95% CI 60.0-79.0], n/N = 74/105). NEDA across subgroups was highest in patients with a baseline EDSS score <2.5 (77.2% [95% CI 72.8-81.2], n/N = 315/408). NEDA was higher in patients receiving one prior DMT (77.6% [95% CI 73.2-81.6], n/N = 312/402) versus two prior DMTs (70.3% [95% CI 64.3-75.8], n/N = 180/256). CONCLUSIONS In patients switching therapy due to suboptimal disease control, treatment with ocrelizumab led to an overall high NEDA rate across a wide range of disease-related and demographic subgroups, regardless of prior treatment background, with no new safety signals detected.
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Affiliation(s)
- Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | | | - Aksel Siva
- Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
| | | | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Jens Wuerfel
- Medical Image Analysis Center (MIAC AG), Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | | | | | | | - Giancarlo Comi
- Vita-Salute San Raffaele University, Milan Casa di Cura del Policlinico, Milan, Italy
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Dahlke F, Arnold DL, Aarden P, Ganjgahi H, Häring DA, Čuklina J, Nichols TE, Gardiner S, Bermel R, Wiendl H. Characterisation of MS phenotypes across the age span using a novel data set integrating 34 clinical trials (NO.MS cohort): Age is a key contributor to presentation. Mult Scler 2021; 27:2062-2076. [PMID: 33507835 PMCID: PMC8564259 DOI: 10.1177/1352458520988637] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Oxford Big Data Institute, multiple sclerosis (MS) physicians and Novartis aim to address unresolved questions in MS with a novel comprehensive clinical trial data set. OBJECTIVE The objective of this study is to describe the Novartis-Oxford MS (NO.MS) data set and to explore the relationships between age, disease activity and disease worsening across MS phenotypes. METHODS We report key characteristics of NO.MS. We modelled MS lesion formation, relapse frequency, brain volume change and disability worsening cross-sectionally, as a function of patients' baseline age, using phase III study data (≈8000 patients). RESULTS NO.MS contains data of ≈35,000 patients (>200,000 brain images from ≈10,000 patients), with >10 years follow-up. (1) Focal disease activity is highest in paediatric patients and decreases with age, (2) brain volume loss is similar across age and phenotypes and (3) the youngest patients have the lowest likelihood (<25%) of disability worsening over 2 years while risk is higher (25%-75%) in older, disabled or progressive MS patients. Young patients benefit most from treatment. CONCLUSION NO.MS will illuminate questions related to MS characterisation, progression and prognosis. Age modulates relapse frequency and, thus, the phenotypic presentation of MS. Disease worsening across all phenotypes is mediated by age and appears to some extent be independent from new focal inflammatory activity.
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Affiliation(s)
| | - Douglas L Arnold
- Brain Imaging Centre, Montreal Neurological
Institute and Hospital, McGill University, Montréal, QC, Canada
| | | | - Habib Ganjgahi
- Oxford Big Data Institute, Li Ka Shing Centre
for Health Information and Discovery, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
| | | | | | - Thomas E Nichols
- Oxford Big Data Institute, Li Ka Shing Centre
for Health Information and Discovery, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
| | | | - Robert Bermel
- Department of Neurology, Mellen MS Center,
Cleveland Clinic, Cleveland, OH, USA
| | - Heinz Wiendl
- Department of Neurology, University Hospital
Münster, Münster, Germany
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31
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Vogelsang A, Eichler S, Huntemann N, Masanneck L, Böhnlein H, Schüngel L, Willison A, Loser K, Nieswandt B, Kehrel BE, Zarbock A, Göbel K, Meuth SG. Platelet Inhibition by Low-Dose Acetylsalicylic Acid Reduces Neuroinflammation in an Animal Model of Multiple Sclerosis. Int J Mol Sci 2021; 22:9915. [PMID: 34576080 PMCID: PMC8465626 DOI: 10.3390/ijms22189915] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 01/10/2023] Open
Abstract
Aside from the established immune-mediated etiology of multiple sclerosis (MS), compelling evidence implicates platelets as important players in disease pathogenesis. Specifically, numerous studies have highlighted that activated platelets promote the central nervous system (CNS)-directed adaptive immune response early in the disease course. Platelets, therefore, present a novel opportunity for modulating the neuroinflammatory process that characterizes MS. We hypothesized that the well-known antiplatelet agent acetylsalicylic acid (ASA) could inhibit neuroinflammation by affecting platelets if applied at low-dose and investigated its effect during experimental autoimmune encephalomyelitis (EAE) as a model to study MS. We found that oral administration of low-dose ASA alleviates symptoms of EAE accompanied by reduced inflammatory infiltrates and less extensive demyelination. Remarkably, the percentage of CNS-infiltrated CD4+ T cells, the major drivers of neuroinflammation, was decreased to 40.98 ± 3.28% in ASA-treated mice compared to 56.11 ± 1.46% in control animals at the disease maximum as revealed by flow cytometry. More interestingly, plasma levels of thromboxane A2 were decreased, while concentrations of platelet factor 4 and glycoprotein VI were not affected by low-dose ASA treatment. Overall, we demonstrate that low-dose ASA could ameliorate the platelet-dependent neuroinflammatory response in vivo, thus indicating a potential treatment approach for MS.
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Affiliation(s)
- Anna Vogelsang
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany; (S.E.); (N.H.); (L.M.); (H.B.); (K.G.)
| | - Susann Eichler
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany; (S.E.); (N.H.); (L.M.); (H.B.); (K.G.)
| | - Niklas Huntemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany; (S.E.); (N.H.); (L.M.); (H.B.); (K.G.)
- Department of Neurology, University Hospital Düsseldorf, 40225 Düsseldorf, Germany;
| | - Lars Masanneck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany; (S.E.); (N.H.); (L.M.); (H.B.); (K.G.)
- Department of Neurology, University Hospital Düsseldorf, 40225 Düsseldorf, Germany;
| | - Hannes Böhnlein
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany; (S.E.); (N.H.); (L.M.); (H.B.); (K.G.)
| | - Lisa Schüngel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, 48149 Münster, Germany; (L.S.); (B.E.K.); (A.Z.)
| | - Alice Willison
- The Northern Foundation School, Newcastle-upon-Tyne University Hospitals, Newcastle-upon-Tyne NE15 8NY, UK;
| | - Karin Loser
- Department of Human Medicine, Institute of Immunology, Carl von Ossietzky University Oldenburg, 26129 Oldenburg, Germany;
| | - Bernhard Nieswandt
- Rudolf Virchow Center, Research Center for Experimental Biomedicine, University of Würzburg, 97080 Würzburg, Germany;
| | - Beate E. Kehrel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, 48149 Münster, Germany; (L.S.); (B.E.K.); (A.Z.)
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, 48149 Münster, Germany; (L.S.); (B.E.K.); (A.Z.)
| | - Kerstin Göbel
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany; (S.E.); (N.H.); (L.M.); (H.B.); (K.G.)
| | - Sven G. Meuth
- Department of Neurology, University Hospital Düsseldorf, 40225 Düsseldorf, Germany;
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32
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Spelman T, Magyari M, Piehl F, Svenningsson A, Rasmussen PV, Kant M, Sellebjerg F, Joensen H, Hillert J, Lycke J. Treatment Escalation vs Immediate Initiation of Highly Effective Treatment for Patients With Relapsing-Remitting Multiple Sclerosis: Data From 2 Different National Strategies. JAMA Neurol 2021; 78:1197-1204. [PMID: 34398221 DOI: 10.1001/jamaneurol.2021.2738] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Treatment strategies for relapsing-remitting multiple sclerosis (RRMS) vary markedly between Denmark and Sweden. The difference in the association of these national strategies with clinical outcomes is unknown. Objective To investigate the association of national differences in disease-modifying treatment (DMT) strategies for RRMS with disability outcomes. Design, Setting, and Participants This cohort study used data on 4861 patients from the Danish and Swedish national multiple sclerosis (MS) registries from the date of index DMT initiation (between January 1, 2013, and December 31, 2016) until the last recorded visit at time of data extraction (October 2, 2019). Exposures All MS-specific DMTs initiated during the observation period were included in the analysis. Main Outcomes and Measures The primary study outcome was time to 24-week confirmed disability worsening. Secondary outcomes were 24-week confirmed disability improvement, milestone Expanded Disability Status Scale scores of 3 and 4, annualized relapse rate, time to first relapse, and treatment switching. Data were analyzed using inverse probability of treatment weighting-based models using a propensity score to weight and correct the comparison for the imbalance of confounders observed at baseline between the 2 countries. Results A total of 2700 patients from the Swedish MS registry (1867 women [69.2%]; mean [SD] age, 36.1 [9.5] years) and 2161 patients from the Danish MS registry (1472 women [68.1%]; mean [SD] age, 37.3 [9.4 years]) started a first DMT between 2013 and 2016, were included in the analysis, and were observed for a mean (SD) of 4.1 (1.5) years. A total of 1994 Danish patients (92.3%) initiated a low to moderately effective DMT (teriflunomide, 907 [42.0%]) and 165 (7.6%) initiated a highly effective DMT, whereas a total of 1769 Swedish patients (65.5%) initiated a low to moderately effective DMT (teriflunomide, 64 [2.4%]) and 931 (34.5%) initiated a highly effective DMT. The Swedish treatment strategy was associated with a 29% reduction in the rate of postbaseline 24-week confirmed disability worsening relative to the Danish treatment strategy (hazard ratio, 0.71; 95% CI, 0.57-0.90; P = .004). The Swedish treatment strategy was also associated with a 24% reduction in the rate of reaching an expanded disability status scale score of 3 (hazard ratio, 0.76; 95% CI, 0.60-0.97; P = .03) and a 25% reduction in the rate of reaching an expanded disability status scale score of 4 (hazard ratio, 0.75; 95% CI, 0.61-0.96; P = .01) relative to Danish patients. Conclusions and Relevance The findings of this study suggest that there is an association between differences in treatment strategies for RRMS and disability outcomes at a national level. Escalation of treatment efficacy was inferior to using more efficacious DMT as initial treatment.
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Affiliation(s)
- Tim Spelman
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Melinda Magyari
- The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | | | - Matthias Kant
- Multiple Sclerosis Clinic Southern Denmark, Department of Brain and Nerve Diseases, University of Southern Denmark, Odense, Denmark.,Department of Brain & Nerve Diseases, Hospital of Southern Jutland, Odense, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanna Joensen
- The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
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33
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Tobias Z, Esther D, Niklas S, Dennis W, Alexander W, Helmut R, Michael H, Fahmy AD, Stefanie M, Fritz L, Thomas B, Gabriel B, Klaus ZU, Paulus R. Rituximab versus mitoxantrone: comparing effectiveness and safety in advanced relapsing multiple sclerosis. Ther Adv Chronic Dis 2021; 12:20406223211024366. [PMID: 34377385 PMCID: PMC8323410 DOI: 10.1177/20406223211024366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/12/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Rituximab (RTX), a CD20 depleting agent, is a frequently used off-label treatment for multiple sclerosis (MS), while mitoxantrone (MTX) is approved, albeit rarely used for active relapsing MS (RMS). However, observational data comparing RTX and MTX effectiveness and safety are scarce. Objective: We aimed to compare effectiveness and safety of MTX and RTX in patients with active RMS. Methods: From combined retrospective clinical data of three MS centers, we selected patients who had received at least one infusion of RTX or MTX and had at least a 6-month clinical follow-up available. Treatment groups were compared by propensity score (PS)-adjusted regression and inverse PS-weighted generalized estimated equation models regarding disability progression, relapse activity, and adverse events (AEs). Results: We included 292 RMS patients (mean age 41.8 years, 71.6% female) who received RTX (119 patients, mean age 36.8 years, 74.8% female) or MTX (173 patients mean age 45.3 years, 69.4% female). Using both PS methods, we did not find a significant effect favoring RTX or MTX treatment regarding the probability of disability worsening or relapse occurrence. However, RTX treatment was associated with a significantly lower probability of severe AEs and AEs. Conclusions: RTX shows comparable effectiveness but a favorable safety profile compared with MTX in active RMS.
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Affiliation(s)
- Zrzavy Tobias
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Daniels Esther
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Stuka Niklas
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Weber Dennis
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Rauschka Helmut
- Department of Neurology, Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders and Diseases, Klinik Donaustadt, Vienna, Austria
| | - Hecker Michael
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Aboulenein-Djamshidian Fahmy
- Department of Neurology, Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders and Diseases, Klinik Donaustadt, Vienna, Austria
| | - Meister Stefanie
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Leutmezer Fritz
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Berger Thomas
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Bsteh Gabriel
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Zettl Uwe Klaus
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Rommer Paulus
- Department of Neurology, Medical University of Vienna, Vienna, Austria Department of Neurology, Rostock University Medical Center, Rostock, Germany
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34
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Espiritu AI, Remalante-Rayco PPM. High-dose biotin for multiple sclerosis: A systematic review and meta-analyses of randomized controlled trials. Mult Scler Relat Disord 2021; 55:103159. [PMID: 34332461 DOI: 10.1016/j.msard.2021.103159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Biotin may activate the acetyl-CoA-, 3-methylcrotonyl-CoA-, propionyl-CoA-, and pyruvate carboxylases to increase myelin repair and/or synthesis, and may enhance the production of adenosine triphosphate (ATP), which may be essential to prevent neurodegeneration. The purpose of this review was to determine the effectiveness and safety of high-dose biotin (HDB) in multiple sclerosis via a systematic review of randomized controlled trials. METHODS We searched the following electronic databases for relevant articles: MEDLINE, CENTRAL, EMBASE, Scopus, and ClinicalTrials.gov website until April 2021. We considered randomized clinical trials (RCTs) that involved adult patients diagnosed with any phenotype of multiple sclerosis that conforms with the McDonald 2010/2017 criteria or the Lublin 2014 criteria. We included studies employing high-dose biotin or "MD1003" administered orally for at least 300 mg/day and given for at least three months. The methodological quality assessment of the included studies was done using the Cochrane Risk of Bias (RoB) tool. The GRADE approach was used to assess the certainty of evidence [COE]. RESULTS Out of 366 records identified, three RCTs involving 889 individuals diagnosed with MS (830 participants had progressive MS (PMS); 59 had RRMS) were pooled for analyses. The overall female:male ratio was 1.16:1. All included trials used HDB as an adjunctive treatment. The risks of bias in the three studies were low across the domains. At 12 to 15 months, there is insufficient evidence that the HDB and placebo arms differed in terms of composite improvement of MS-related disability (relative risk (RR) 2.87; 95% CI 0.29-28.40; 2 trials; 796 participants; I2 = 66%) [low COE], improvement in expanded disability status scale (IEDSS) (RR 2.27; 95% CI 0.25-20.98; 2 trials; 796 participants; I2 = 63%) [low COE], and both IEDSS and improvement in 25-foot walk time (ITW25) (IEDSS-ITW25) (RR 0.58; 95% CI 0.17-2.00; 2 trials; 796 participants; I2 = 13%) [moderate COE] among patients with PMS. Pooled data for ITW25 at 12 to 15 months yielded statistical significance (RR 2.06; 95% CI 1.04-4.09; 2 trials; 796 participants; I2 = 0%) [moderate COE] favoring HDB among patients with PMS. At 12 to 15 months, no significant differences were found in terms of mean change in EDSS (MD -0.06; 95% CI -0.14-0.02; 2 studies; 796 participants; 889 participants; I2 = 68%) among patients with PMS. Synthesized data on incidence of any AEs (RR 0.98; 95% CI 0.92-1.04; 3 trials; I2 = 0%) [high COE] and any serious AEs (RR 0.98; 95% CI 0.77-1.24; 3 trials; 889 participants; I2 = 0%) [moderate COE] were not significantly different between HDB and placebo groups. Out of 662 pooled patients in the HDB group, 31 patients (4.7%) were found to have laboratory test interference compared to zero event in the pooled placebo group [high COE]. CONCLUSIONS A moderate certainty of evidence suggests a potential benefit in favor of HDB administered for 12 to 15 months in terms of ITW25 in patients with PMS. However, an important trade-off of this benefit is the high certainty of evidence suggesting an increased incidence of laboratory test interference when HDB is taken.
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Affiliation(s)
- Adrian I Espiritu
- Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines; Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, ON M5B 1W8, Canada.
| | - Patricia Pauline M Remalante-Rayco
- Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines; Division of Rheumatology, Department of Medicine, University of Toronto and University Health Network Toronto Western Hospital, Toronto, ON M5T 2S8, Canada
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35
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Freeman L, Kee A, Tian M, Mehta R. Retrospective Claims Analysis of Treatment Patterns, Relapse, Utilization, and Cost Among Patients with Multiple Sclerosis Initiating Second-Line Disease-Modifying Therapy. Drugs Real World Outcomes 2021; 8:497-508. [PMID: 34136997 PMCID: PMC8605953 DOI: 10.1007/s40801-021-00251-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 11/28/2022] Open
Abstract
Background Real-world studies of disease-modifying therapies (DMTs) in multiple sclerosis (MS) have reported suboptimal adherence. Objective We aimed to describe treatment patterns, relapses, healthcare resource utilization, and costs in MS patients experiencing their first observed DMT switch. Methods In this retrospective, claims database study, adult patients were selected if they had an MS diagnosis and DMT claim during the study period (1 January 2009–31 March 2019). Patients who switched to a new DMT between 1 January 2010 and 31 March 2018 were included. Adherence, persistence, relapses, and all-cause and MS-related healthcare utilization and costs were reported pre- and post-index. Results In total, 1554 MS patients were identified; the mean age was 46 years and most (74%) were female. The majority of patients switched from an injectable DMT (n = 1116; 71.8%), and patients generally switched to an oral DMT (n = 878; 57%). Among patients who switched DMTs, 46.0% (n = 715) were nonadherent, 42% (n = 645) were nonpersistent, and 21.5% (n = 334) relapsed in the 12 months post-switch. An increase in all-cause and MS-related healthcare costs was observed pre- to post-index for all patients. Cost drivers included outpatient visit costs and pharmacy prescriptions. Compared with patients who switched to an injectable DMT, those who switched to an oral DMT had significantly higher persistence and adherence. No significant difference was observed in post-index relapse or all-cause and MS-related total cost of care. Conclusion Low adherence and poor persistence remain following an initial DMT switch; however, patients who switched to oral DMTs had higher persistence and adherence. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-021-00251-w. Multiple sclerosis (MS) is a disabling disease that is treated with disease-modifying therapies (DMTs). Little is known about how patients with MS take their medication, how disease progression may change with treatment, or what the impact of switching to a new DMT is on the cost of care. In an analysis of commercially insured individuals, patients with MS were examined before and after switching to a new DMT. Results showed that the patients most often switched from an injectable medication to an oral DMT; however, a large proportion of patients did not take the prescription as directed by their physician. Additionally, a large proportion of patients did not stay on their new therapy. Nearly one-third of patients experienced an MS relapse after they switched to a new treatment, and healthcare costs increased following the treatment switch. A higher proportion of patients switching to an oral DMT took their medication as prescribed by their physicians, stayed on therapy, and incurred smaller increases in cost compared with patients switching to injectable medications. Despite such improvements, additional treatments are needed for patients with MS.
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Affiliation(s)
- Leorah Freeman
- Health Discovery Building, Dell Medical School, The University of Texas at Austin, 1601 Trinity St, Austin, TX, 78701, USA.
| | | | - Marc Tian
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Rina Mehta
- Bristol Myers Squibb, Princeton, NJ, USA
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36
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Cree BAC, Arnold DL, Chataway J, Chitnis T, Fox RJ, Pozo Ramajo A, Murphy N, Lassmann H. Secondary Progressive Multiple Sclerosis: New Insights. Neurology 2021; 97:378-388. [PMID: 34088878 PMCID: PMC8397587 DOI: 10.1212/wnl.0000000000012323] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 05/13/2021] [Indexed: 01/01/2023] Open
Abstract
In most cases, multiple sclerosis (MS) begins with a relapsing-remitting course followed by insidious disability worsening that is independent from clinically apparent relapses and is termed secondary progressive MS (SMPS). Major differences exist between relapsing-remitting MS (RRMS) and SPMS, especially regarding therapeutic response to treatment. This review provides an overview of the pathology, differentiation, and challenges in the diagnosis and treatment of SPMS. We emphasize the criticality of conversion from a relapsing-remitting to a secondary progressive disease course not only because such conversion is evidence of disability progression, but also because, until recently, treatments that effectively reduced disability progression in relapsing MS were not proven to be effective in SPMS. Clear clinical, imaging, immunologic, or pathologic criteria marking the transition from RRMS to SPMS have not yet been established. Early identification of SPMS will require tools that, together with the use of appropriate treatments, may result in better long-term outcomes for the population of patients with SPMS.
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Affiliation(s)
- Bruce A C Cree
- From the UCSF Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), University of California San Francisco; NeuroRx Research (D.L.A.), Montreal; Brain Imaging Centre (D.L.A.), Montreal Neurological Institute, McGill University, Canada; Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation (J.C.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; National Institute for Health Research (J.C.), University College London Hospitals, Biomedical Research Centre, UK; Brigham Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA; Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (R.J.F.), Cleveland Clinic, OH; Oxford PharmaGenesis (A.P.R.), UK; Novartis Pharma AG (N.M.), Basel, Switzerland; and Center for Brain Research (H.L.), Medical University of Vienna, Austria.
| | - Douglas L Arnold
- From the UCSF Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), University of California San Francisco; NeuroRx Research (D.L.A.), Montreal; Brain Imaging Centre (D.L.A.), Montreal Neurological Institute, McGill University, Canada; Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation (J.C.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; National Institute for Health Research (J.C.), University College London Hospitals, Biomedical Research Centre, UK; Brigham Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA; Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (R.J.F.), Cleveland Clinic, OH; Oxford PharmaGenesis (A.P.R.), UK; Novartis Pharma AG (N.M.), Basel, Switzerland; and Center for Brain Research (H.L.), Medical University of Vienna, Austria
| | - Jeremy Chataway
- From the UCSF Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), University of California San Francisco; NeuroRx Research (D.L.A.), Montreal; Brain Imaging Centre (D.L.A.), Montreal Neurological Institute, McGill University, Canada; Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation (J.C.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; National Institute for Health Research (J.C.), University College London Hospitals, Biomedical Research Centre, UK; Brigham Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA; Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (R.J.F.), Cleveland Clinic, OH; Oxford PharmaGenesis (A.P.R.), UK; Novartis Pharma AG (N.M.), Basel, Switzerland; and Center for Brain Research (H.L.), Medical University of Vienna, Austria
| | - Tanuja Chitnis
- From the UCSF Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), University of California San Francisco; NeuroRx Research (D.L.A.), Montreal; Brain Imaging Centre (D.L.A.), Montreal Neurological Institute, McGill University, Canada; Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation (J.C.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; National Institute for Health Research (J.C.), University College London Hospitals, Biomedical Research Centre, UK; Brigham Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA; Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (R.J.F.), Cleveland Clinic, OH; Oxford PharmaGenesis (A.P.R.), UK; Novartis Pharma AG (N.M.), Basel, Switzerland; and Center for Brain Research (H.L.), Medical University of Vienna, Austria
| | - Robert J Fox
- From the UCSF Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), University of California San Francisco; NeuroRx Research (D.L.A.), Montreal; Brain Imaging Centre (D.L.A.), Montreal Neurological Institute, McGill University, Canada; Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation (J.C.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; National Institute for Health Research (J.C.), University College London Hospitals, Biomedical Research Centre, UK; Brigham Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA; Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (R.J.F.), Cleveland Clinic, OH; Oxford PharmaGenesis (A.P.R.), UK; Novartis Pharma AG (N.M.), Basel, Switzerland; and Center for Brain Research (H.L.), Medical University of Vienna, Austria
| | - Angela Pozo Ramajo
- From the UCSF Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), University of California San Francisco; NeuroRx Research (D.L.A.), Montreal; Brain Imaging Centre (D.L.A.), Montreal Neurological Institute, McGill University, Canada; Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation (J.C.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; National Institute for Health Research (J.C.), University College London Hospitals, Biomedical Research Centre, UK; Brigham Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA; Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (R.J.F.), Cleveland Clinic, OH; Oxford PharmaGenesis (A.P.R.), UK; Novartis Pharma AG (N.M.), Basel, Switzerland; and Center for Brain Research (H.L.), Medical University of Vienna, Austria
| | - Niamh Murphy
- From the UCSF Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), University of California San Francisco; NeuroRx Research (D.L.A.), Montreal; Brain Imaging Centre (D.L.A.), Montreal Neurological Institute, McGill University, Canada; Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation (J.C.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; National Institute for Health Research (J.C.), University College London Hospitals, Biomedical Research Centre, UK; Brigham Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA; Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (R.J.F.), Cleveland Clinic, OH; Oxford PharmaGenesis (A.P.R.), UK; Novartis Pharma AG (N.M.), Basel, Switzerland; and Center for Brain Research (H.L.), Medical University of Vienna, Austria
| | - Hans Lassmann
- From the UCSF Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), University of California San Francisco; NeuroRx Research (D.L.A.), Montreal; Brain Imaging Centre (D.L.A.), Montreal Neurological Institute, McGill University, Canada; Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation (J.C.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; National Institute for Health Research (J.C.), University College London Hospitals, Biomedical Research Centre, UK; Brigham Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA; Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (R.J.F.), Cleveland Clinic, OH; Oxford PharmaGenesis (A.P.R.), UK; Novartis Pharma AG (N.M.), Basel, Switzerland; and Center for Brain Research (H.L.), Medical University of Vienna, Austria
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Mockus TE, Munie A, Atkinson JR, Segal BM. Encephalitogenic and Regulatory CD8 T Cells in Multiple Sclerosis and Its Animal Models. THE JOURNAL OF IMMUNOLOGY 2021; 206:3-10. [PMID: 33443060 DOI: 10.4049/jimmunol.2000797] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/14/2020] [Indexed: 02/06/2023]
Abstract
Multiple sclerosis (MS), a neuroinflammatory disease that affects millions worldwide, is widely thought to be autoimmune in etiology. Historically, research into MS pathogenesis has focused on autoreactive CD4 T cells because of their critical role in the animal model, experimental autoimmune encephalomyelitis, and the association between MS susceptibility and single-nucleotide polymorphisms in the MHC class II region. However, recent studies have revealed prominent clonal expansions of CD8 T cells within the CNS during MS. In this paper, we review the literature on CD8 T cells in MS, with an emphasis on their potential effector and regulatory properties. We discuss the impact of disease modifying therapies, currently prescribed to reduce MS relapse rates, on CD8 T cell frequency and function. A deeper understanding of the role of CD8 T cells in MS may lead to the development of more effective and selective immunomodulatory drugs for particular subsets of patients.
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Affiliation(s)
- Taryn E Mockus
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210
| | - Ashley Munie
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210.,Graduate Program in Immunology, University of Michigan Medical School, Ann Arbor, MI 48109; and
| | - Jeffrey R Atkinson
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210
| | - Benjamin M Segal
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210; .,Neuroscience Research Institute, The Ohio State University, Columbus, OH 43210
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Fronza M, Lorefice L, Frau J, Cocco E. An Overview of the Efficacy and Safety of Ozanimod for the Treatment of Relapsing Multiple Sclerosis. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:1993-2004. [PMID: 34007159 PMCID: PMC8123972 DOI: 10.2147/dddt.s240861] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/14/2021] [Indexed: 12/20/2022]
Abstract
Multiple sclerosis (MS) is a complex disease of the central nervous system that can cause permanent disability in young adults. A large armamentarium is available for its management and is increasing over time. Ozanimod is an oral drug belonging to the sphingosine-1-phosphate receptor (S1PR) modulator family recently approved in different countries for MS with active disease. It selectively modulates S1PR1 and S1PR5 to prevent autoreactive lymphocytes from entering the central nervous system (CNS), where they can determine inflammation and neurodegeneration. Ozanimod was tested in one Phase II and two Phase III pivotal trials and was shown to be effective and well tolerated. Moreover, further investigations, including comparative trials with other S1P modulators and MS disease-modifying drugs, are needed to better define placement in MS treatment. Furthermore, ozanimod is currently under evaluation for inflammatory bowel diseases, such as ulcerative colitis and Crohn’s disease, in international phase III studies. This article retraces the itinerary leading to the approval of ozanimod for MS treatment and its peculiarities and potentiality inside the S1PR modulator family.
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Affiliation(s)
- Marzia Fronza
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Lorena Lorefice
- Multiple Sclerosis Center, Binaghi Hospital, ATS Sardegna, ASSL Cagliari, Cagliari, Italy
| | - Jessica Frau
- Multiple Sclerosis Center, Binaghi Hospital, ATS Sardegna, ASSL Cagliari, Cagliari, Italy
| | - Eleonora Cocco
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.,Multiple Sclerosis Center, Binaghi Hospital, ATS Sardegna, ASSL Cagliari, Cagliari, Italy
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Tommasin S, Cocozza S, Taloni A, Giannì C, Petsas N, Pontillo G, Petracca M, Ruggieri S, De Giglio L, Pozzilli C, Brunetti A, Pantano P. Machine learning classifier to identify clinical and radiological features relevant to disability progression in multiple sclerosis. J Neurol 2021; 268:4834-4845. [PMID: 33970338 PMCID: PMC8563671 DOI: 10.1007/s00415-021-10605-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 01/22/2023]
Abstract
Objectives To evaluate the accuracy of a data-driven approach, such as machine learning classification, in predicting disability progression in MS. Methods We analyzed structural brain images of 163 subjects diagnosed with MS acquired at two different sites. Participants were followed up for 2–6 years, with disability progression defined according to the expanded disability status scale (EDSS) increment at follow-up. T2-weighted lesion load (T2LL), thalamic and cerebellar gray matter (GM) volumes, fractional anisotropy of the normal appearing white matter were calculated at baseline and included in supervised machine learning classifiers. Age, sex, phenotype, EDSS at baseline, therapy and time to follow-up period were also included. Classes were labeled as stable or progressed disability. Participants were randomly chosen from both sites to build a sample including 50% patients showing disability progression and 50% patients being stable. One-thousand machine learning classifiers were applied to the resulting sample, and after testing for overfitting, classifier confusion matrix, relative metrics and feature importance were evaluated. Results At follow-up, 36% of participants showed disability progression. The classifier with the highest resulting metrics had accuracy of 0.79, area under the true positive versus false positive rates curve of 0.81, sensitivity of 0.90 and specificity of 0.71. T2LL, thalamic volume, disability at baseline and administered therapy were identified as important features in predicting disability progression. Classifiers built on radiological features had higher accuracy than those built on clinical features. Conclusions Disability progression in MS may be predicted via machine learning classifiers, mostly evaluating neuroradiological features. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10605-7.
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Affiliation(s)
- Silvia Tommasin
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell'Università, 30, 00185, Rome, Italy.
| | - Sirio Cocozza
- Dipartimento di Scienze Biomediche Avanzate, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Alessandro Taloni
- Institute for Complex Systems, Italian National Research Council, Rome, Italy
| | - Costanza Giannì
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell'Università, 30, 00185, Rome, Italy
| | | | - Giuseppe Pontillo
- Dipartimento di Scienze Biomediche Avanzate, Università degli Studi di Napoli Federico II, Naples, Italy.,Dipartimento di Ingegneria Elettrica e delle Tecnologie dell'Informazione, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Maria Petracca
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell'Università, 30, 00185, Rome, Italy.,Dipartimento di Neuroscienze, Scienze Riproduttive e Odontostomatologiche, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Serena Ruggieri
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell'Università, 30, 00185, Rome, Italy.,Neuroimmunology Unit, IRCSS Fondazione Santa Lucia, Rome, Italy
| | - Laura De Giglio
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell'Università, 30, 00185, Rome, Italy.,Neurology Unit, Medicine Department, San Filippo Neri Hospital, Rome, Italy
| | - Carlo Pozzilli
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell'Università, 30, 00185, Rome, Italy
| | - Arturo Brunetti
- Dipartimento di Scienze Biomediche Avanzate, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Patrizia Pantano
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell'Università, 30, 00185, Rome, Italy.,Department of Radiology, IRCCS NEUROMED, Pozzilli, Italy
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Moussa M, Abou Chakra M, Papatsoris AG, Dabboucy B, Hsieh M, Dellis A, Fares Y. Perspectives on urological care in multiple sclerosis patients. Intractable Rare Dis Res 2021; 10:62-74. [PMID: 33996350 PMCID: PMC8122310 DOI: 10.5582/irdr.2021.01029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system. Lower urinary tract dysfunction due to MS includes a dysfunction of the storage phase or dysfunction of the voiding phase or a detrusor-sphincter dyssynergia. Baseline evaluation includes a voiding chart, an ultrasound scan of the urinary tract, urine culture, and an urodynamic study. For storage symptoms, antimuscarinics are the first-line treatment, and clean intermittent catheterization (CIC) is indicated if there is concomitant incomplete bladder emptying. Intradetrusor injections with botulinum toxin A (BTX-A), are recommended for refractory cases. Urinary diversion is rarely indicated. For patients with voiding symptoms, CIC and alpha-blockers are usually offered. Sexual dysfunction in patients with MS is multifactorial. Phosphodiesterase type 5 inhibitors are first-line therapies for MS-associated erectile dysfunction in both male and female patients. This review summarizes the epidemiology, pathogenesis, risk factors, genetic, clinical manifestations, diagnostic tests, and management of MS. Lastly, the urologic outcomes and therapies are reviewed.
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Affiliation(s)
- Mohamad Moussa
- Chairman of Urology Department, Lebanese University & Al Zahraa Hospital, University Medical Center, Beirut, Lebanon
| | - Mohamad Abou Chakra
- Urology Department, Lebanese University, Beirut, Lebanon
- Address correspondence to:Mohamad Abou Chakra, Faculty of Medicine, Department of Urology, Lebanese University. Beirut, Lebanon. E-mail:
| | - Athanasios G. Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Baraa Dabboucy
- Department of Neurosurgery, Lebanese University, Beirut, Lebanon
| | - Michael Hsieh
- Division of Urology, Children's National Hospital, Washington, USA
- Department of Urology, The George Washington University, Washington, USA
| | - Athanasios Dellis
- Department of Urology/General Surgery, Areteion Hospital, Athens, Greece
| | - Youssef Fares
- Department of Neurosurgery, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
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Borgini M, Mondal P, Liu R, Wipf P. Chemical modulation of Kv7 potassium channels. RSC Med Chem 2021; 12:483-537. [PMID: 34046626 PMCID: PMC8128042 DOI: 10.1039/d0md00328j] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/01/2020] [Indexed: 01/10/2023] Open
Abstract
The rising interest in Kv7 modulators originates from their ability to evoke fundamental electrophysiological perturbations in a tissue-specific manner. A large number of therapeutic applications are, in part, based on the clinical experience with two broad-spectrum Kv7 agonists, flupirtine and retigabine. Since precise molecular structures of human Kv7 channel subtypes in closed and open states have only very recently started to emerge, computational studies have traditionally been used to analyze binding modes and direct the development of more potent and selective Kv7 modulators with improved safety profiles. Herein, the synthetic and medicinal chemistry of small molecule modulators and the representative biological properties are summarized. Furthermore, new therapeutic applications supported by in vitro and in vivo assay data are suggested.
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Affiliation(s)
- Matteo Borgini
- Department of Chemistry, University of Pittsburgh Pittsburgh PA 15260 USA
| | - Pravat Mondal
- Department of Chemistry, University of Pittsburgh Pittsburgh PA 15260 USA
| | - Ruiting Liu
- Department of Chemistry, University of Pittsburgh Pittsburgh PA 15260 USA
| | - Peter Wipf
- Department of Chemistry, University of Pittsburgh Pittsburgh PA 15260 USA
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Liseno J, Lager B, Miller C, Shankar SL, Mendoza JP, Lewin JB. Multiple Sclerosis Patients Treated With Diroximel Fumarate in the Real-World Setting Have High Rates of Persistence and Adherence. Neurol Ther 2021; 10:349-360. [PMID: 33846959 PMCID: PMC8140165 DOI: 10.1007/s40120-021-00242-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/10/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction Persistence to multiple sclerosis (MS) disease-modifying therapy is fundamental for maximal treatment outcomes. Diroximel fumarate (DRF) is approved in the USA for relapsing MS. Following oral administration, DRF is metabolized to monomethyl fumarate, the active metabolite of dimethyl fumarate (DMF). DRF showed clinically significant improvements in gastrointestinal (GI) tolerability versus DMF in a head-to-head clinical trial; however, real-world persistence/adherence has not been assessed. We evaluated persistence/adherence in DRF-treated patients in a real-world clinical practice. Methods This retrospective analysis of the AcariaHealth Specialty Pharmacy Program included patients initiating DRF from 4 December 2019 through 3 April 2020 and followed until data extraction (31 August 2020). Exclusion criteria included undetermined treatment status (e.g., DRF prescription transfer to a different pharmacy). Endpoints included persistence (overall proportion of patients remaining on DRF), discontinuation rate due to GI adverse events (AEs), and adherence (proportion of days covered [PDC]). GI AEs included GI-related AEs occurring at any time, or any unknown AE without details about the nature of the event if the unknown AE occurred ≤ 90 days after DRF initiation. Results Overall, 160 patients with MS were included. Median (range) patient age was 51 (20−79) years, 80.6% (129/160) of patients were female, and 16.3% (26/160) had prior DMF treatment. Median (range) treatment duration was 7.6 (0.1−10.4) months. Estimated proportion of patients remaining persistent on DRF treatment at 8 months was 88.6% (95% confidence interval [CI] 82.5–2.7). Overall, 3.8% (6/160) of patients discontinued due to GI AEs. Mean PDC was 91.4% (95% CI 89.1−93.7). In a DMF-to-DRF switch subgroup, 92.3% (24/26) remained persistent on DRF, and 3.8% (1/26) discontinued DRF due to GI AEs. Conclusion This real-world analysis of DRF-treated patients showed high overall persistence, low discontinuation rate due to GI AEs, and high adherence to therapy, aligning with expectations based on DRF clinical trials. Data were consistent in the DMF-to-DRF subgroup. Infographic ![]()
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Bsteh G, Hegen H, Altmann P, Auer M, Berek K, Di Pauli F, Leutmezer F, Rommer P, Wurth S, Zinganell A, Zrzavy T, Deisenhammer F, Berger T. Retinal layer thinning predicts treatment failure in relapsing multiple sclerosis. Eur J Neurol 2021; 28:2037-2045. [PMID: 33735479 PMCID: PMC8251588 DOI: 10.1111/ene.14829] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
Background and purpose Peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell plus inner plexiform layer (GCIPL) thinning are markers of neuroaxonal degeneration in multiple sclerosis (MS), which is reduced by disease‐modifying treatment (DMT). We aimed to investigate the potential of pRNFL and GCIPL thinning for prediction of DMT failure in relapsing MS (RMS). Methods In this 4‐year prospective observational study on 113 RMS patients, pRNFL and GCIPL were measured at DMT initiation and after 12 months (M12) and 24 months (M24). Treatment failure was defined as 6‐month confirmed Expanded Disability Status Scale (EDSS) progression and/or Symbol Digit Modalities Test (SDMT) worsening. Optimal cutoff values for predicting treatment failure were determined by receiver operating characteristic analyses and hazard ratios (HRs) by multivariable Cox regression adjusting for age, sex, disease duration, EDSS/SDMT, and DMT class. Results Thinning of GCIPL >0.5 μm/year at M24 showed superior value for treatment failure prediction (HR: 4.5, 95% confidence interval [CI]: 1.8–7.6, p < 0.001; specificity 91%, sensitivity 81%), followed by GCIPL >0.5 μm at M12 (odds ratio [OR]: 3.9, 95% CI: 1.4–6.9, p < 0.001; specificity 85%, sensitivity 78%), and pRNFL ≥2 μm/year at M24 (OR: 3.7, 95% CI: 1.1–6.5, p = 0.023; specificity 84%, sensitivity 69%), whereas pRNFL at M12 was not predictive. Conclusions GCIPL, and to a lesser degree pRNFL, thinning predicts disability progression after DMT initiation and may be a useful and accessible biomarker of treatment failure in RMS.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sebastian Wurth
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Zrzavy
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Benarroch EE. What Is the Role of Sphingosine-1-Phosphate Receptors in Pain? Neurology 2021; 96:525-528. [PMID: 33723022 DOI: 10.1212/wnl.0000000000011605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/15/2022] Open
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Wundes A, Wray S, Gold R, Singer BA, Jasinska E, Ziemssen T, de Seze J, Repovic P, Chen H, Hanna J, Messer J, Miller C, Naismith RT. Improved gastrointestinal profile with diroximel fumarate is associated with a positive impact on quality of life compared with dimethyl fumarate: results from the randomized, double-blind, phase III EVOLVE-MS-2 study. Ther Adv Neurol Disord 2021; 14:1756286421993999. [PMID: 33796143 PMCID: PMC7985943 DOI: 10.1177/1756286421993999] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/15/2021] [Indexed: 01/10/2023] Open
Abstract
Background: Diroximel fumarate (DRF) is a novel oral fumarate approved for relapsing forms of multiple sclerosis (MS). DRF demonstrated significantly improved gastrointestinal (GI) tolerability versus dimethyl fumarate (DMF) with fewer days of Individual Gastrointestinal Symptom and Impact Scale (IGISIS) scores ⩾2, GI adverse events (AEs), and treatment discontinuations due to GI AEs. Our aim was to evaluate the impact of GI tolerability events on quality of life (QoL) for patients with relapsing–remitting MS who received DRF or DMF in EVOLVE-MS-2. Methods: A post hoc analysis was conducted in patients who were enrolled in the randomized, blinded, 5-week, EVOLVE-MS-2 [ClinicalTrials.gov identifier: NCT03093324] study of DRF versus DMF. Patients completed daily IGISIS and Global GISIS (GGISIS) eDiary questionnaires to assess GI symptom intensity and interference with daily activities and work. Results: In total, 504 patients (DRF, n = 253; DMF, n = 251) received study drug and 502 (DRF, n = 253; DMF, n = 249) completed at least one post-baseline questionnaire. With DRF, GI symptoms were less likely to interfere ‘quite a bit’ or ‘extremely’ with regular daily activities [IGISIS: DRF, 9.5% (24/253) versus DMF, 28.9% (72/249)] or work productivity [GGISIS: DRF, 6.1% (10/165) versus DMF, 11.3% (18/159)]. DRF-treated patients had fewer days with ⩾1 h of missed work (DRF, 43 days, n = 20 versus DMF, 88 days, n = 26). DMF-treated patients reported highest GI symptom severity and missed work at week 2–3 shortly after completing the titration period, which coincided with the majority of GI-related treatment discontinuations [58.3% (7/12)]. GI tolerability AEs [DRF, 34.8% (88/253); DMF, 48.2% (121/251)], concomitant symptomatic medication use [DRF, 19.3% (17/88) versus DMF, 30.6% (37/121)], and GI-related discontinuations (DRF, 0.8% versus DMF, 4.8%) were lower with DRF versus DMF. Conclusions: The improved GI tolerability with DRF translated into clinically meaningful benefits to QoL, as patients experienced less impact on daily life and work and required less concomitant symptomatic medication use. Trial registration: [ClinicalTrials.gov identifier: NCT03093324]
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Affiliation(s)
- Annette Wundes
- Department of Neurology, University of Washington Medical Center, Seattle, WA, USA
| | - Sibyl Wray
- Hope Neurology MS Center, Knoxville, TN, USA
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St. Louis, MO, USA
| | - Elzbieta Jasinska
- Collegium Medicum UJK and Clinical Center, RESMEDICA, Kielce, Poland
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Jerome de Seze
- Strasbourg University Hospital and Clinical Investigation Center, INSER 1434, Strasbourg, France
| | - Pavle Repovic
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, WA, USA
| | | | | | - Jordan Messer
- Biogen, 225 Binney Street, Cambridge, MA 02142-1031, USA
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Araujo AGS, Lucchetta RC, Tonin FS, Pontarolo R, Borba HHL, Wiens A. Analysis of completeness for spontaneous reporting of disease-modifying therapies in multiple sclerosis. Expert Opin Drug Saf 2021; 20:735-740. [PMID: 33641547 DOI: 10.1080/14740338.2021.1897566] [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: 10/22/2022]
Abstract
Introduction: Considering the need for effective postmarketing surveillance of disease-modifying therapies (DMTs) in multiple sclerosis (MS), we analyzed the potential of the spontaneous reports for safety signal detection, verifying the completeness of the reports in the FDA Adverse Event Reporting System (FAERS).Methods: All reports with DMTs for MS considered the primary suspect cause of ADRs and registered between January 2004 and June 2019 were selected. The vigiGrade completeness score was applied and reports with a score greater than 0.80 were considered well documented. Descriptive statistical analysis and comparisons of well-documented reports by DMTs were performed.Results: A total of 297,926 reports were analyzed. The lowest completeness rates were observed for type of report (13.5%), dose (62.7%), and time from treatment start to the ADR (79.0%). Overall, 80.8% of reports were classified as well documented and those related to natalizumab had the highest proportion (92.4%, p < 0.001), while the lowest was observed for reports sent in 2017 (53.1%, p < 0.001) and for teriflunomide (48.5%, p < 0.001).Conclusions: The high proportion of well-documented reports for DMTs indicates that they can be a valuable source for safety signal detection. A more careful analysis should be performed for data from the groups identified with low completeness to avoid the disclosure of spurious results.
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Affiliation(s)
- Ariane G S Araujo
- Pharmaceutical Sciences Postgraduate Research Program, Health Sciences Sector, Federal University of Paraná, Curitiba, Brazil
| | - Rosa C Lucchetta
- Department of Drugs and Medicines, Faculty of Pharmaceutical Sciences, São Paulo State University (UNESP), São Paulo, Brazil
| | - Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Research Program, Health Sciences Sector, Federal University of Paraná, Curitiba, Brazil
| | - Roberto Pontarolo
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Helena H L Borba
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Astrid Wiens
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
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Cotchett KR, Dittel BN, Obeidat AZ. Comparison of the Efficacy and Safety of Anti-CD20 B Cells Depleting Drugs in Multiple Sclerosis. Mult Scler Relat Disord 2021; 49:102787. [PMID: 33516134 DOI: 10.1016/j.msard.2021.102787] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/12/2021] [Accepted: 01/19/2021] [Indexed: 12/24/2022]
Abstract
Rituximab, ocrelizumab, ofatumumab and ublituximab are disease modifying therapies (DMT) currently used in the treatment of multiple sclerosis (MS) or are in advanced stages of clinical trials. These monoclonal antibodies deplete B cells by targeting the cell surface protein CD20. This review highlights the similarities and major differences between the four agents. We summarize data from various clinical trials of each of these therapeutics and discuss their efficacy and safety. Additional considerations regarding the route of administration and cost are presented. Among the four therapeutics, only ocrelizumab is approved for primary progressive (PP) MS. Infusion/injection related reactions (IRRs) are the most common adverse events associated with all four therapeutics. In phase III trials of ocrelizumab and ofatumumab, the incidence of IRRs was lower with ofatumumab. Ofatumumab is unique among the four therapeutics due to its availability as a subcutaneous injection (SQ). Although SQ administration may be appealing for some patients it may raise concerns regarding medication compliance among physicians. Phase II trials studying ublituximab for the treatment of RMS yielded promising results. Phase III trials are currently comparing the efficacy of ublituximab to teriflunomide.
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Affiliation(s)
- Kelly R Cotchett
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI; Versiti Blood Research Institute, Milwaukee, WI
| | - Bonnie N Dittel
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI; Versiti Blood Research Institute, Milwaukee, WI
| | - Ahmed Z Obeidat
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI.
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Bsteh G, Hegen H, Riedl K, Altmann P, Auer M, Berek K, Di Pauli F, Ehling R, Kornek B, Monschein T, Rinner W, Schmied C, Wurth S, Zebenholzer K, Zinganell A, Zrzavy T, Zulehner G, Deisenhammer F, Rommer P, Leutmezer F, Berger T. Quantifying the risk of disease reactivation after interferon and glatiramer acetate discontinuation in multiple sclerosis: The VIAADISC score. Eur J Neurol 2021; 28:1609-1616. [PMID: 33370478 PMCID: PMC8248019 DOI: 10.1111/ene.14705] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 12/18/2022]
Abstract
Background and purpose There is a lack of evidence guiding discontinuation of disease‐modifying therapy (DMT) in relapsing multiple sclerosis (RMS). Thus, the objective of this study was to generate and validate a risk score for disease reactivation after DMT discontinuation in RMS. Methods We drew a generation and validation dataset from two separate prospectively collected observational databases including RMS patients who received interferon‐β or glatiramer acetate for ≥12 months, then discontinued DMT for ≥6 months and had ≥2 years of follow‐up available. In the generation sample (n = 168), regression analysis was performed to identify clinical or magnetic resonance imaging (MRI) variables independently predicting disease reactivation after DMT discontinuation. A predictive score was calculated using the variables included in the multivariable model and applied to the validation sample (n = 98). Results The variables included in the final model as independent predictors of disease reactivation were age at discontinuation, MRI activity at discontinuation, and duration of clinical stability (all p < 0.001). The resulting score was able to robustly identify patients at high (83%–85%), moderate (36%–38%), and low risk (7%) of disease reactivation within 5 years after DMT discontinuation in both cohorts. Conclusions The composite VIAADISC score is a valuable tool to inform and support patients and neurologists in the process of decision making to discontinue injectable DMTs.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Katharina Riedl
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rainer Ehling
- Department of Neurology, Clinic for Rehabilitation Münster, Münster, Austria
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Tobias Monschein
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Walter Rinner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Sebastian Wurth
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Karin Zebenholzer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Zrzavy
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gudrun Zulehner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Carré A, Richardson SJ, Larger E, Mallone R. Presumption of guilt for T cells in type 1 diabetes: lead culprits or partners in crime depending on age of onset? Diabetologia 2021; 64:15-25. [PMID: 33084970 PMCID: PMC7717061 DOI: 10.1007/s00125-020-05298-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/20/2020] [Indexed: 12/31/2022]
Abstract
Available evidence provides arguments both for and against a primary pathogenic role for T cells in human type 1 diabetes. Genetic susceptibility linked to HLA Class II lends strong support. Histopathology documents HLA Class I hyperexpression and islet infiltrates dominated by CD8+ T cells. While both hallmarks are near absent in autoantibody-positive donors, the variable insulitis and residual beta cells of recent-onset donors suggests the existence of a younger-onset endotype with more aggressive autoimmunity and an older-onset endotype with more vulnerable beta cells. Functional arguments from ex vivo and in vitro human studies and in vivo 'humanised' mouse models are instead neutral or against a T cell role. Clinical support is provided by the appearance of islet autoantibodies before disease onset. The faster C-peptide loss and superior benefits of immunotherapies in individuals with younger-onset type 1 diabetes reinforce the view of age-related endotypes. Clarifying the relative role of T cells will require technical advances in the identification of their target antigens, in their detection and phenotyping in the blood and pancreas, and in the study of the T cell/beta cell crosstalk. Critical steps toward this goal include the understanding of the link with environmental triggers, the description of T cell changes along the natural history of disease, and their relationship with age and the 'benign' islet autoimmunity of healthy individuals. Graphical abstract.
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Affiliation(s)
- Alexia Carré
- Université de Paris, Institut Cochin, CNRS, INSERM, Paris, France
| | - Sarah J Richardson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
| | - Etienne Larger
- Université de Paris, Institut Cochin, CNRS, INSERM, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université de Paris, Cochin Hospital, Service de Diabétologie et Immunologie Clinique, Paris, France
| | - Roberto Mallone
- Université de Paris, Institut Cochin, CNRS, INSERM, Paris, France.
- Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université de Paris, Cochin Hospital, Service de Diabétologie et Immunologie Clinique, Paris, France.
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Preliminary Results of the FASM Study, an On-Going Italian Active Pharmacovigilance Project. Pharmaceuticals (Basel) 2020; 13:ph13120466. [PMID: 33333889 PMCID: PMC7765255 DOI: 10.3390/ph13120466] [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: 10/19/2020] [Revised: 12/09/2020] [Accepted: 12/12/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIM Disease-modifying therapies (DMTs) used in multiple sclerosis (MS) have distinct safety profiles. In this paper, we report preliminary results of an on-going pharmacovigilance project (the FASM study). RESULTS Neurologists working at involved multiple sclerosis centers collected 272 Individual Case Safety Reports (ICSRs). Adverse drug reactions (ADRs) mainly occurred in adult patients and in a higher percentage of women compared to men. No difference was found in ADRs distribution by seriousness. The outcome was reported as favorable in 61% of ICSRs. Out of 272 ICSRs, almost 53% reported dimethyl fumarate, fingolimod and IFN beta 1a as suspected. These medications were commonly associated to the occurrence of ADRs related hematological, gastrointestinal, general, infective or cancer disorders. The median time to event (days) was 177 for dimethyl fumarate, 1058 for fingolimod and 413 for IFN beta 1a. The median time to event for the remaining suspected drugs was 226. CONCLUSION We believe that our results, together with those that will be presented at the end of the study, may bring new knowledge concerning the safety profile of DMTs and their proper use. This will provide the opportunity to draw new recommendations both for neurologists and patients.
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