Neuropsychologic status in multiple sclerosis after treatment with glatiramer

Relevance of cognitive deterioration in early relapsing-remitting MS: a 3-year follow-up study

OBJECTIVE

To assess longitudinally cognitive functioning in relapsing-remitting multiple sclerosis (RRMS) patients and its relationship with clinical and MRI variables.

METHODS

Early RRMS patients and matched healthy controls were assessed in parallel in three testing sessions over 3 years, using the Rao's Brief Repeatable Battery of Neuropsychological Tests. Patients also underwent an MRI analysis of T2-weighted lesion volume (T2LV), number of gadolinium-enhanced lesions and whole brain atrophy. Forty-nine RRMS patients (mean age 36.9 ± 8.9 years; mean disease duration 2.9 ± 1.7 years, mean Expanded Disability Status Scale, 1.7 ± 0.7) and 56 healthy controls were recruited.

RESULTS

At baseline, cognitive impairment was detected in 15 patients (30.6%). After 3 years, cognitive functioning worsened in the 29.3% of patients, whereas Expanded Disability Status Scale progression was observed in only three patients. The most sensitive test to detect cognitive deterioration over time was the Symbol Digit Modalities Test (SDMT). Only the presence of moderate cognitive impairment at baseline predicted further cognitive deterioration (p = 0.03). Among MRI variables, T2LV showed a weak to moderate relationship with some cognitive tasks.

CONCLUSIONS

Over a 3-year period cognitive deterioration can be expected in approximately one-third of MS patients with relatively short disease duration. The SDMT is particularly suitable for longitudinal assessment of MS-related cognitive changes.

Cognitive dysfunction in multiple sclerosis: the effect of pharmacological interventions

Research has recently focused on cognitive dysfunction in multiple sclerosis (MS). Cognitive deficits are frequently encountered in patients and account for important impairment in quality of life, therefore posing a major therapeutic challenge for the disease. We presently review studies on cognitive effects of pharmacological treatments in MS. There is evidence for a possible beneficial effect of immunomodulatory treatments, particularly of interferons, and also of acetylcholinesterase inhibitors on cognition in MS, which, however, requires evaluation in larger, multi-centre, longitudinal studies. Methodological issues and future prospects regarding the investigation of this issue are also discussed.

Quality of life in multiple sclerosis: effects of current treatment options

Multiple sclerosis is the most common non-traumatic neurodegenerative disease in adults. Most of the patients present with both physical and mental deficits which reflect the dissemination of the lesions in the central nervous system, produced by the inflammatory process. The incomplete recovery after relapses, the accumulation of new deficits and the progressive nature of the condition interfere with daily activities of individuals and have a negative impact on their well-being. Indeed, studies show that quality of life measurements are constantly lower in patients with multiple sclerosis. Estimation of health-related quality of life is being increasingly recognized as necessary when analysing the effectiveness of treatment modalities and for the follow up of patients with chronic diseases such as multiple sclerosis. Current immunomodulatory interventions that are shown to reduce the frequency of relapses and delay disease progression might also have a positive effect on quality of life measurements. Additive pharmacological agents that target cognitive impairments and common symptoms such as depression, fatigue and pain, along with life-style modifications and rehabilitation programmes are also important for the appropriate management that aims to improve quality of life.

Assessment and rehabilitation of cognitive impairment in multiple sclerosis

Patients with multiple sclerosis (MS) have a substantial risk of cognitive dysfunction, even in the earliest stages of the disease, where there is minimum physical disability. Despite the high prevalence rates and the significant impact of cognitive dysfunction on quality of life in this population, cognitive functions are not routinely assessed due to the high cost and time consumption. This article provides an overview of the current state of knowledge related to cognition in MS and on the optimal approach to neuropsychological assessment of this population. It then focuses on the pharmacological and other treatment options available for MS patients with, or at risk for developing, cognitive impairment. The available immune-modulating agents may reduce the development of new lesions and therefore prevent or minimize the progression of cognitive decline. However, there is currently insufficient evidence concerning the efficiency of symptomatic treatment in MS. There is also currently no optimal non-pharmacological treatment strategy for cognitive decline in MS, as the studies published to date report heterogeneous results. Nevertheless, non-pharmacological treatments such as cognitive rehabilitation may benefit some MS patients. As cognition is increasingly recognized as a major feature of MS, its assessment and rehabilitation will become a greater priority.

Glatiramer acetate for multiple sclerosis

BACKGROUND

This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2004 , Issue 1 . Art. No.: CD004678. DOI: 10.1002/14651858.CD004678)Previous studies have shown that glatiramer acetate (Copaxone (R)), a synthetic amino acid polymer is effective in experimental allergic encephalomyelitis (EAE), and improve the outcome of patients with multiple sclerosis (MS).

OBJECTIVES

To verify the clinical efficacy of glatiramer acetate in the treatment of MS patients with relapsing remitting (RR) and progressive (P) course.

SEARCH STRATEGY

We searched the Cochrane MS Group Trials Register (26 March 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2009), MEDLINE (PubMed) (January 1966 to 26 March 2009), EMBASE (January 1988 to 26 March 2009) and hand searching of symposia reports (1990-2009).

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing glatiramer acetate and placebo in patients with definite MS, whatever the administration schedule and disease course, were eligible for this review.

DATA COLLECTION AND ANALYSIS

Both patients with RR and P MS were analysed. Study protocols were comparable across trials. No major flaws were found in methodological quality. However, efficacy of blinding should be balanced against side effects, including injection-site reactions.

MAIN RESULTS

Among 409 retrieved references, we identified 16 RCTs; six of them, published between 1987 and 2007, met the selection criteria and were included in this review. Five hundred and forty RR patients and 1049 PMS contributed to the analysis. In RR MS, a decrease in the mean EDSS score (-0.33 and -0.45), was found respectively at 2 years and 35 months without any significant effect on sustained disease progression. The reduction of mean number of relapse was evident at 1 year (-0.35 ) 2 years (-0.51 ) and 35 months (-0.64), but significant studies ' heterogeneity was found. The number of hospitalisations and steroid courses were significantly reduced. No benefit was shown in P MS patients. No major toxicity was found. The most common systemic adverse event was a transient and self-limiting patterned reaction of flushing, chest tightness, sweating, palpitations, anxiety. Local injection-site reactions were observed in up to a half of patients treated with glatiramer acetate, thus making a blind assessment of outcomes questionable.

AUTHORS' CONCLUSIONS

Glatiramer acetate did show a partial efficacy in RR MS in term of relapse -related clinical outcomes, without any significant effect on clinical progression of disease measured as sustained disability. The drug is not effective in progressive MS patients.

Visual memory in patients after anterior right temporal lobectomy and adult normative data for the Brown Location Test

Several large meta-analytic studies have failed to support a consistent relationship between visual or "nonverbal" memory deficits and right mesial temporal lobe changes. The Brown Location Test (BLT), a recently developed dot location learning and memory test, uses a nonsymmetrical array and provides control over many of the confounding variables (e.g., verbal influence and drawing requirements) inherent in other measures of visual memory. In the present investigation, we evaluated the clinical utility of the BLT in patients who had undergone left or right anterior mesial temporal lobectomy. We also provide normative data of 298 healthy adults for standardized scores. Results revealed significantly worse performance on the BLT in the right as compared to the left lobectomy group and the healthy adult normative sample. The present findings support a role for the right anterior mesial temporal lobe in dot location learning and memory.

Disease biomarkers in multiple sclerosis: potential for use in therapeutic decision making

Multiple sclerosis (MS) is an autoimmune disorder of the brain and spinal cord that predominantly affects white matter. MS has a variable clinical presentation and has no 'diagnostic' laboratory test; this often results in delays to definite diagnosis. In confronting the disease, early diagnosis and appropriate, timely therapeutic intervention are critical factors in ensuring favorable long-term outcomes. The availability of reliable biomarkers could radically alter our management of MS at critical phases of the disease spectrum. Identification of markers that could predict the development of MS in high-risk populations would allow for intervention strategies that may prevent evolution to definite disease. Work with anti-myelin antibodies and the ongoing analysis of microarray gene expression have thus far not yielded biomarkers that predict future disease development. Similarly, extensive studies with serum and cerebrospinal fluid (CSF) have not yielded a disease-specific and sensitive diagnostic biomarker for MS. Establishment of disease diagnosis always leads to questions about long-term prognosis because in an individual patient the natural history of the disease is clinically unpredictable. Biomarkers that correlate with myelin loss, spinal cord disease, grey matter and subcortical demyelination need to be developed in order to accurately predict the disease course. The bulk of effort in biomarker development in MS has been concentrated in the area of monitoring disease activity. At present, a disease 'activation' panel of CSF biomarkers would include the following: interleukin-6 or its soluble receptor, nitric oxide and nitric oxide synthase, osteopontin, and fetuin-A. Although disease activity in MS is predominantly inflammatory, disease progression is likely to be the result of neurodegeneration. Therefore, the roles of proteins indicative of neuronal, axonal, and glial loss such as neurofilaments, tau, 14-3-3 proteins, and N-acetylaspartate are all under investigation, as are proteins affecting remyelination and regeneration, such as Nogo-A. With the increasing awareness of cognition dysfunction in MS, molecules such as apolipoprotein and proteins in the amyloid precursor protein pathway implicated in dementia are also being examined. Serum biomarkers that help monitor therapeutic efficacy such as the titer of antibody to beta-interferon, a first-line medication in MS, are established in clinical practice. Ongoing work with biomarkers that reflect drug bioavailability and factors that distinguish between medication responders and nonresponders are also under investigation. The discovery of new biomarkers relies on applying advances in proteomics along with microarray gene and antigen analysis and will hopefully result in the establishment of specific biomarkers for MS.

Effects of immunomodulatory treatment with subcutaneous interferon beta-1a oncognitive decline in mildly disabled patients with relapsing—remitting multiple sclerosis

The objective of this study was to assess the effects of subcutaneous (sc) interferon beta-1a (IFNβ-1a) on cognition in mildly disabled patients with relapsing—remitting multiple sclerosis (RRMS). Patients aged 18—50 years with RRMS (McDonald criteria; Expanded Disability Status Scale score ≤4.0) were assigned IFNβ therapy at the physician’s discretion and underwent standardized magnetic resonance imaging, neurological examination and neuropsychological testing at the baseline and regular intervals for up to three years.

This analysis included 459 patients who received sc IFNβ-1a (44 mcg: n = 236; 22 mcg: n = 223; three-year follow up was available for 318 patients). The hazard ratio for cognitive impairment over three years (44 mcg versus 22 mcg) was 0.68 (95% confidence interval [CI]: 0.480—0.972), suggesting a 32% lower risk with the higher dose treatment. At year 3, the proportion of patients who were cognitively impaired increased slightly from 23.5% at the baseline to 24.8% in the IFNβ-1a 22 mcg treatment group, but remained stable at 15.2% in the IFNβ-1a 44 mcg treatment group. The proportion of patients with cognitive impairment at year 3 was significantly higher in the 22 mcg group than in the 44 mcg group (P = 0.03), although a trend was also seen at the baseline (P = 0.058). Multivariate logistic regression (corrected for baseline cognitive deficits) indicated that treatment with the higher dose of IFNβ-1a was predictive of lower cognitive impairment at three years (odds ratio: 0.51, 95% CI: 0.26—0.99) compared with the lower dose of IFNβ-1a.

These findings suggest that sc IFNβ-1a may have dose-dependent cognitive benefits in mildly disabled patients with RRMS, and may support early initiation of high-dose IFNβ-1a treatment.

Cognitive impairment in multiple sclerosis

Multiple sclerosis (MS) is a progressive disease of the CNS that is characterised by widespread lesions in the brain and spinal cord. MS results in motor, cognitive, and neuropsychiatric symptoms, all of which can occur independently of one another. The common cognitive symptoms include deficits in complex attention, efficiency of information processing, executive functioning, processing speed, and long-term memory. These deficits detrimentally affect many aspects of daily life, such as the ability to run a household, participate fully in society, and maintain employment--factors that can all affect the overall quality of life of the patient. The increased use of neuroimaging techniques in patients with MS has advanced our understanding of structural and functional changes in the brain that are characteristic of this disease, although much remains to be learned. Moreover, examination of efforts to treat the cognitive deficits in MS is still in the early stages.

Cognitive impairment in multiple sclerosis

BACKGROUND

Cognitive impairment is increasingly being recognized as a common and disabling symptom of multiple sclerosis (MS) that contributes to poor quality of life in affected patients. Despite the high prevalence of cognitive impairment in MS, cognitive function is not assessed routinely in clinical practice or in clinical trials. The perception that cognitive assessments are costly, time-consuming, complicated, and difficult to administer and interpret has contributed, at least in part, to the failure to incorporate cognitive testing into standard clinical evaluation of patients with MS. Detailed studies of cognitive impairment in MS are rare and guidelines for the assessment of cognitive function in MS are lacking.

TREATMENT

How to manage cognitive decline in MS also requires further study. Licensed disease-modifying drug (DMD) treatments for MS reduce brain lesion development, and associations between brain lesions and cognitive performance have been reported, providing a rationale for DMD treatment of MS-associated cognitive impairment. There is some evidence for cognitive benefits of DMDs, but as few pivotal DMD trials included cognitive assessments, the effects of these agents on cognition are not fully understood and more studies are needed.

CONCLUSIONS

It is only through further studies that it will be possible to identify patients with, or at risk of, cognitive impairment and to provide appropriate therapy to limit the effects of this potentially devastating symptom.

Treatment of cognitive impairment in multiple sclerosis: is the use of acetylcholinesterase inhibitors a viable option?

Approximately half of all patients with multiple sclerosis (MS) experience cognitive impairment, most commonly with regard to new learning and memory. Cognitive dysfunction is a leading cause of disability in MS and it can have profound social and economic consequences for patients and their families. Research on treatment for cognitive impairment in MS is still in the early stages, as it is for most neurological conditions. The available disease-modifying therapies in MS may provide some modest benefit to cognition, but patients with MS clearly need better treatment for cognitive dysfunction. A number of studies have assessed symptomatic treatments of cognition in MS, and the results of these small, underpowered studies have been mixed. Regardless, acetylcholinesterase inhibitors (AChEIs) have been the most promising class of medications tested in MS to date. Seven of eight studies on AChEIs have shown positive results, although it is difficult to assess their adequacy since only three of the studies have been published in peer reviewed journals, with the rest appearing only as abstracts. The earliest AChEI studies in MS examined physostigmine, but the short half-life and prominent adverse effects of this medication may have limited its use compared with other AChEIs. All of the more recent AChEI studies have used donepezil, which, from the limited data available to date, appears to have been relatively well tolerated among MS patients. The largest randomized controlled trial of donepezil included 69 subjects and found that donepezil improved verbal learning and memory compared with placebo during neuropsychological testing. That study also found that patients receiving donepezil were more likely to report memory improvement than those receiving placebo, and the study clinician also noted a cognitive benefit among those on donepezil as opposed to placebo. There are still many unanswered questions regarding the use of AChEIs in MS, including the effects of their long-term use in a chronic disease such as MS. On the whole, to date the research on AChEIs in MS must be considered preliminary, and it is premature to recommend the clinical use of this class of medications at the present time.

Cognitive dysfunction in MS: bridging the gap between neurocognitive deficits, neuropsychological batteries and MRI

Multiple sclerosis (MS) is an inflammatory and neurodegenerative disease of the CNS. Its sequelae include both physical and cognitive disability. Advances in neuropsychological testing and screening have led to increased recognition of cognitive impairment in MS; more than half of MS patients have been found to have some degree of cognitive impairment. Strong correlations have been found between neuropsychological testing, brain atrophy and other brain imaging techniques. These tools can aid in the comprehensive evaluation of MS patients. Genetic markers, such as ApoE and brain-derived neurotrophic factor polymorphisms, may also correlate with cognitive impairment in MS. This review details advances in recognizing and predicting cognitive dysfunction in MS. Increased understanding and better evaluation and monitoring of cognitive status in MS may improve the sensitivity of studies designed to test new disease-modifying therapies and interventions for cognitive impairment.

Cognitive impairment in multiple sclerosis

Cognitive dysfunctions are frequent symptoms of multiple sclerosis (MS) and occur in up to 65% of patients. Especially memory, attention, executive and visual constructive functions are impaired. These problems strongly affect patients' ability to work, social relationships, and quality of life. Symptoms of physical disabilities can arise independently. Cognitive dysfunctions are clear indicators of MS progression, because they represent highly complex functions that depend on the integrity of the neuronal networks. Once manifested after a relapse, they remain stable . Given a differentiating diagnosis, it is possible to treat these dysfunctions by cognitive training and with pharmaceutical drugs, for example by immunomodulating drugs. However, treatment options are limited at present. This report provides a detailed description of cognitive functions and performance in MS patients, their comorbidities such as fatigue and depression and therapeutic options.

A new measure of visual location learning and memory: development and psychometric properties for the Brown Location Test (BLT)

There are a variety of well-established neuropsychological tests that are helpful in identifying global and specific verbal memory deficits. In contrast, tests of visual memory have produced less consistent results likely due in part to confounding variables such as verbal encodability, administration difficulties, and insufficient differentiation of among types of visual memory. The Brown Location Test (BLT) was designed to specifically measure visual memory for location of identical objects (dots) and address limitations found in commonly employed visual memory tests. This paper describes the empirical basis for the BLT and reports the psychometric properties of the test. Results indicate good internal and alternate form reliabilities. Factor analysis of a brief test battery confirmed that BLT performance is generally independent of verbal memory and global intellectual abilities. BLT performance declined with age, but there was no association between performance and gender, education, or intellectual functioning. In view of the favorable psychometric properties observed during preliminary studies, additional normative and validation studies in healthy and patient populations are warranted.

Prise en charge thérapeutique des troubles cognitifs dans la sclérose en plaques : données et perspectives

Taking in charge cognitive disorders is a new concept in the global care of MS patients. Cognitive disorders are observed in the all forms of the disease, sometimes early on in the evolution. These disorders can be evaluated in details even detected despite any complain in the patient. Because of the lack of clear demonstration that disease-modifying treatments could act on cognition, new specific therapeutic issues have emerged during last years. This article first discusses relationships between disease-modifying treatments and cognition for the different forms of the disease, then analyse the effects of symptomatic drug therapy especially the use of anticholinesterasics. In the last part of the article new issues about antagonists of excitatory amino-acids and individual or group cognitive training are discussed. Recent functional imaging data concerning cerebral adaptation and their modifications by drug or non-drug procedures in MS patients suggest interesting therapeutic development in a next future.

Cognitive function in relapsing multiple sclerosis: Minimal changes in a 10-year clinical trial

BACKGROUND

Although cognitive impairment is common in patients with multiple sclerosis (MS), its value as a clinical trial endpoint remains uncertain. For example, in the randomized, blinded, pivotal trial of glatiramer acetate (GA) in patients with relapsing MS, improvements occurred in neuropsychological test scores during 2 years of treatment regardless of whether patients received GA or placebo, likely due to practice effects.

OBJECTIVES

To assess long-term changes in neuropsychological status following 10 years of prospective evaluation in a typical immunotherapy trial cohort.

METHODS

Participants in the ongoing open-label GA extension study repeated the Brief Repeatable Battery of Neuropsychological Tests an average of 10.6+/-0.4 years after their initial baseline evaluation.

RESULTS

Mean scores on tests of memory and semantic retrieval were not significantly changed over 10 years of follow-up, but tests of attention showed declines for the group as a whole. Using a threshold of a 0.5 SD decline to define significant worsening, individual tests showed declines in 27-49% of participants and a composite score showed worsening in 19%. Controlling for age, gender, and education level, cognitive tests tended to worsen more in participants with better baseline cognitive test scores and higher EDSS scores. Changes in cognitive test scores during the first 2 years of observation were predictive of 10-year changes.

CONCLUSIONS

Most patients with relapsing MS had stable cognitive performance during 10 years of prospective evaluation, some of which may be related to a therapeutic effect of GA. Because cognitive changes occur slowly on average, they may not be responsive enough to serve as useful endpoints in studies of course-modifying therapies in relapsing MS.

Treatment of neuropsychiatric conditions associated with multiple sclerosis

This article reviews the treatment of behavioral disturbances associated with multiple sclerosis. Pharmacological and psychotherapeutic treatment data, when available, are presented for five discrete conditions: major depression, bipolar affective disorder, anxiety, psychosis, pseudobulbar affect and cognitive dysfunction. Despite the paucity of empirical treatment data that characterizes all of these conditions, with the exception of pseudobulbar affect, the message from open-label trials and anecdotal experience is that therapy is often successful, leading to improvements in quality of life for patients. Thus, all health professionals involved in the care of multiple sclerosis patients should have a good working knowledge of the neurotherapeutics of multiple sclerosis-related behavioral disorders.

Symptomatic treatment of multiple sclerosis. Multiple Sclerosis Therapy Consensus Group (MSTCG) of the German Multiple Sclerosis Society

Besides immunomodulation and immunosuppression, the specific treatment of symptoms is an essential component of the overall management of multiple sclerosis (MS). Symptomatic treatment is aimed at the elimination or reduction of symptoms impairing the functional abilities and quality of life of the affected patients. Moreover, with symptomatic treatment the development of a secondary physical impairment due to an existing one may be avoided. Many therapeutic techniques as well as different drugs are used for the treatment of MS symptoms, but only a few of them have been investigated, especially in MS patients, and are approved by the national health authorities. Despite an overwhelming number of publications, only a few evidence-based studies exist and consensus reports are very rare, too. Therefore, it seemed necessary to develop a consensus statement on symptomatic treatment of MS comprising existing evidence-based literature as well as therapeutic experience of neurologists who have dealt with these problems over a long time. This consensus paper contains proposals for the treatment of the most common MS symptoms: disorders of motor function and coordination, of cranial nerve function, of autonomic, cognitive, and psychological functions as well as MS-related pain syndromes and epileptic seizures.

Managing the symptoms of multiple sclerosis: a multimodal approach

BACKGROUND

Patients with multiple sclerosis (MS) may experience numerous symptoms, including spasticity, fatigue, cognitive dysfunction, depression, bladder dysfunction, bowel dysfunction, sexual dysfunction, and pain.

OBJECTIVE

This article reviews the pharmacologic and nonpharmacologic interventions used to manage the symptoms of MS and discusses how interventions for a particular MS symptom may have an impact on other symptoms.

METHODS

The English-language literature was reviewed through November 2005 using MEDLINE and the Cochrane Database of Systematic Reviews, with no restriction on year. The search terms included multiple sclerosis, disease-modifying therapies, adverse events, and combinations of multiple sclerosis with terms such as spasticity, fatigue, depression, mood disorders, pain, bladder dysfunction, bowel dysfunction, sexual dysfunction, cognitive dysfunction, and quality of life.

RESULTS

The numerous options for the treatment of MS symptoms have shown varying degrees of efficacy and tolerability. Certain symptoms, if left untreated, may precipitate exacerbation of others. For example, spasticity may lead to pain and bladder and bowel dysfunction, whereas fatigue can compromise cognitive function. Similarly, the adverse effects of treatments for certain symptoms may further compromise other aspects of function. For example, the use of antidepressants may lead to sexual dysfunction, and treatments for spasticity and pain may cause sedation, which can worsen fatigue, cognitive dysfunction, and depressed mood.

CONCLUSIONS

MS is associated with numerous symptoms that can be adversely affected by each other and by therapeutic interventions. Careful clinical monitoring and individualization of pharmacologic and non-pharmacologic therapies are recommended to manage the symptoms of MS, with the goals of improving or maintaining function and preserving the patient's quality of life.

Are there protective treatments for cognitive decline in MS?

Despite its frequency and high functional impact, very little is known about effective strategies for managing cognitive impairment in multiple sclerosis (MS). Disease-modifying drugs, such as beta-interferons and glatiramer acetate, may prevent or reduce the progression of cognitive dysfunction by containing the development of new cerebral lesions. To date, clinical trials have provided inconsistent results, with neuropsychological effects documented only in one trial. Moreover, pilot studies have tested symptomatic therapies for fatigue, a frequent symptom in MS, which may share a common physiopathological substrate with cognitive dysfunction. Small trials with amantadine, pemoline, 4-aminopyridine and 3-4 aminopyridine have provided mainly negative results. Acetylcholinesterase inhibitors (AChEI) used to treat Alzheimer's disease (AD)-such as donepezil, rivastigmine, and galantamine-have recently been tested in other cognitive disorders, including MS. The majority of pilot trials with AchEI in MS have provided promising results, and the donepezil study recently published by Krupp et al. represents a major development in this field. As for non-pharmacological interventions based on cognitive rehabilitation, few studies have used an experimental approach and, in general, results have been disappointingly negative. Further research is clearly needed in this area.

Retraining attention in MS

Cognitive decline is frequently observed in multiple sclerosis (MS) and has a major impact on quality of life. Therefore it would be important to offer therapeutic strategies to the patients. In the past, several studies were conducted on pharmacological or cognitive treatment. However, there is currently no specific treatment for cognitive decline and the studies published so far report heterogeneous results. The present paper focuses on the cognitive treatment strategies by reviewing and discussing the few studies that have been carried out in this area. In addition, results of a recently completed fMRI study on the visualization of cognitive training effects will be reported. This review clearly points out that further research in this area is needed to clarify the effects of cognitive intervention. Larger sample sizes and standardized neuropsychological outcome measures as well as standardized training tools are required to allow for comparisons between different studies and to improve our understanding of cognitive decline and the processes of cognitive recovery in MS.

Neuropsychological assessment, quantitative MRI and ApoE gene polymorphisms in a series of MS patients treated with IFN beta-1b

Few trials issued the effect of disease-modifying medications on cognitive functions in multiple sclerosis. We designed an open-label longitudinal study to evaluate, during 2 years, cognitive performance and its relationship with MRI data and ApoE polymorphism findings in a group of relapsing-remitting (RR) multiple sclerosis (MS) Interferon (IFN) beta-1b-treated patients (median age 30 years, median disease duration 3.4 years). Complete neuropsychological battery was grouped into attention, information learning/memory, language and visuo-spatial functions. Fifty-two patients (33 females) were enrolled in the study. Six patients (11.5%) dropped out, mainly due to side effects. At baseline neuropsychological evaluation, we found 54% normal, 42% mildly impaired and 4% moderately impaired patients. At 2 years follow-up, cognitive status was stable in 65%, improved in 33% and worsened in 2% of patients. No significant relations were found between global cognitive outcome vs. EDSS change, clinical disease activity, MRI data or ApoE gene polymorphisms over the 2 years follow-up. EDSS and MRI fractional volumes were found to correlate with the performance at single tests. Twenty-one patients (45.6%) showed active MRI scans throughout the study, without any worsening at the corresponding neuropsychological examination. This ongoing trial suggests a possible beneficial effect of IFN beta-1b treatment on cognitive functions in RRMS patients. Extension of follow-up and further data analyses are needed to confirm and clarify these findings.

Cognitive dysfunction in patients with relapsing-remitting multiple sclerosis

Cognitive dysfunction is considered one of the clinical markers of multiple sclerosis (MS). However, in the literature there are inconsistent reports on the prevalence of cognitive dysfunction, and separate data for the relapsing-remitting (RR) type of the disease are not always presented. In this study, we submitted 461 RRMS patients to a battery of neuropsychological tests to investigate their impairment in various cognitive domains. As a consequence of the exclusion criteria, the sample is not fully representative of the entire population of RRMS patients. In this selected sample, when only the eight scores of a core battery (Mental Deterioration Battery) were considered (with respective cutoffs), it emerged that 31% of the patients were affected by some degree of cognitive deficit. In particular, 15% had mild, 11.2% moderate and 4.8% had severe impairment. Information processing speed was the most frequently impaired area, followed by memory. When two other tests (SDMT and MCST) were added and cognitive domains were considered, it emerged that 39.3% of the patients were impaired in two or more domains. When four subgroups were obtained by means of cluster analysis and then compared, it emerged that information processing speed and memory deficits differentiated the still cognitively unimpaired from the mildly impaired MS patients. Significant associations were found between cognitive and clinical characteristics. However, due to the large sample size, clinically irrelevant relationships may also have emerged. Even with the limitations imposed by the sample selection and the possible underestimation of the prevalence and severity of cognitive dysfunction, these results seem to provide further evidence that information processing speed deficit may be an early and important marker of cognitive impairment in MS patients.

Significance of neutralizing antibodies to interferon beta during treatment of multiple sclerosis: expert opinions based on the Proceedings of an International Consensus Conference

On August 30, 2002, an international panel of neurologists who specialize in the treatment of multiple sclerosis (MS) was convened in Paris (France) to discuss the issue of neutralizing antibodies (NAb) to interferon beta (IFN-beta) therapy in patients with MS. The goals of this meeting were to: (i) review the most recent clinical information on NAb, (ii) come to a consensus on the clinical relevance of NAb in the management of patients with MS receiving IFN-beta therapy, and (iii) establish a framework for the development of patient management guidelines based on scientific consensus. The meeting was chaired by Hans-Peter Hartung (Heinrich-Heine University, Düsseldorf, Germany) and Huub Schellekens (Utrecht University, Utrecht, the Netherlands). This article summarizes the opinions of the expert panel on a number of key issues raised at the meeting.

Kognitive Defizite bei Multipler Sklerose

Cognitive dysfunctions are frequent symptoms of multiple sclerosis (MS) and occur in up to 65% of patients. Especially memory, attention, executive and visual constructive functions are impaired. These problems strongly affect patients' ability to work, social relationships, and quality of life. Symptoms of physical disabilities can arise independently. Cognitive dysfunctions are clear indicators of MS progression, since they represent highly complex functions depending on the integrity of neuronal networks. Once manifested after a relapse, they remain stable. Given a differentiating diagnosis, it is possible to treat these dysfunctions by cognitive training and pharmacologically for example by immunomodulating drugs. However, treatment options are limited at present. This report provides a detailed description of cognitive functions and performance in MS patients, their comorbidities such as fatigue and depression, currently available diagnostic tools, and therapeutic options.

A longitudinal study of cognition in primary progressive multiple sclerosis

There are few longitudinal studies of cognition in patients with multiple sclerosis, and the results of these studies remain inconclusive. No serial neuropsychological data of an exclusively primary progressive series are available. Cross-sectional analyses have revealed significant correlations between cognition and magnetic resonance imaging (MRI) parameters in primary progressive multiple sclerosis (PPMS). This study investigated cognitive and MRI change in 99 PPMS patients from five European centres for 2 years. They were assessed at 12 month intervals using the Brief Repeatable Battery, a reasoning test, and a measure of depression. The MRI parameters of T1 hypointensity load, T2 lesion load, and partial brain volume were also calculated at each time point. There were no significant differences between the mean cognitive scores of the patients at year 0 and year 2. However, one-third of the patients demonstrated absolute cognitive decline on individual test scores. Results indicated that initial cognitive status on entry into the study was a good predictor of cognitive ability at 2 years. There was only a small number of significant correlations between changes in cognition and changes on MRI, notably T1 hypointensity load with the two attentional tasks (r = -0.266, P = 0.017; r = -0.303, P = 0.012). It is probable that multiple factors underlie this weak relation between the cognitive and MRI measures.

One-year cyclophosphamide treatment combined with methylprednisolone improves cognitive dysfunction in progressive forms of multiple sclerosis

We conducted an evaluation of changes in cognition in progressive multiple sclerosis (MS) patients receiving monthly intravenously pulse of cyclophosphamide (700 mg/m2) with methylprednisolone (1g). Twenty-eight consecutive progressive MS patients (10 primary progressive, 18 secondary progressive MS) were evaluated before and after six and 12 months of treatment. The WAIS-R score, memory and executive functions were evaluated. Under treatment we found a significant improvement in global cognitive efficiency, encoding abilities, planning abilities and inhibition after six and 12 months. However, mechanisms of action of the positive effect of these anti-inflammatory and immunosuppressive treatments on cognition remain unclear.

Neuropsychological Evaluation and Treatment of Multiple Sclerosis: The Importance of a Neuro-rehabilitation Focus

This article describes the components of a neuropsychologic evaluation and some of the primary indications for its use in multiple sclerosis (MS). We also detail the kinds of neurocognitive and neurobehavioral problems that are cited commonly in the relevant literature and seen in the clinical setting. We provide a brief overview of the brain structures that are affected commonly by MS, and their implications for neuropsychologic function. We have included an overview of some of the current medications that are used to target cognitive and emotional symptoms that can be a direct result of the disease. We also present four representative case examples of composite patients, and briefly review the ways in which neuropsychologic evaluation and neuro-rehabilitation treatments can help people who have MS.

A Practical Approach to Immunomodulatory Therapy for Multiple Sclerosis

This article provides a current overview of the definition and pathogenesis of the disease, the different types of MS, a new diagnostic criteria, the rationale for early therapy, a review of the approved MS therapies, the strategies to evaluate ongoing treatment efficacy,the management of suboptimal treatment responders, and the prospects for future therapies. The article focuses on relapsing remitting MS because most of the therapeutic data deal with this type of MS. The role of mitoxantrone as a "rescue therapy" for suboptimal responders to IMTs is discussed.

Interferon-beta1a treatment for multiple sclerosis

Although multiple sclerosis is probably the most common cause of neurologic disability in young adults, the cause is unknown, the prognosis uncertain and available treatments unsatisfactory. Multiple sclerosis is an inflammatory autoimmune disorder of the CNS and the result of both environmental factors and susceptibility genes. The prognosis is difficult or impossible to predict at the time of diagnosis. Treatments that modulate the course of the disease have only recently become available but the long-term aim to prevent disability and promote repair remains distant. Interferon-beta is the most widely used therapy. The efficacy of interferon-beta in the short term is well documented in many large treatment trials, but the treatment effects are only modest and many issues relating to efficacy in the long term are unresolved. These include uncertain benefit on conversion to secondary-progressive multiple sclerosis, the relevance of neutralizing antibodies and the controversial effect on multiple sclerosis-related brain atrophy.

Dementia associated with toxic causes and autoimmune disease

Toxic causes of dementia include exposure to heavy metals such as lead, mercury and aluminum as well as to carbon monoxide and solvents. Autoimmune conditions include such entities as multiple sclerosis, systemic lupus erythematosus, Behçet's disease and Sjögren's syndrome. These conditions share broadly similar cognitive effects giving rise to impairments with subcortical features. Individuals are often affected at a relatively young age. Optimal preventative strategies include avoidance of toxic substances. Comprehensive neuropsychological assessment is valuable not only diagnostically and for monitoring but also to identify the patients' strengths and weaknesses, so that compensatory strategies can be recommended.

Demenz als Erstsymptom bei spät beginnender Multipler Sklerose

Cognitive impairment is meanwhile accepted as a well-known symptomatology affecting up to 60% of the patients even in the early disease course of multiple sclerosis (MS). After a longer duration the development of dementia is not unusual. However, cognitive dysfunction as the primary or only manifestation of MS is thought to be rare. We report on four elderly patients referred to the memory clinic of our psychiatric university hospital because of beginning dementia. All of them were found to have evidence of a chronic inflammatory CNS process compatible with the diagnosis of MS. At the beginning of their symptomatology all patients were older than 60 years . Just in one case, progressive gait disturbances beginning after cognitive decline contributed to restriction in the activities of daily living. Data of 239 cases of the literature were reviewed and revealed motor disturbances as the main initial symptom and often a primary progressive course with unfavourable prognosis in late onset MS. Until now dementia as the primary symptomatology has not been described in patients older than 60 years. Possibly MS as a differential diagnosis in dementia as well as cognitive impairment as an initial symptom of MS is under-recognized.

Normierung der Brief Repeatable Battery of Neuropsychological Tests (BRB-N) f�r den deutschsprachigen Raum

The Brief Repeatable Battery of Neuropsychological Tests (BRB-N) is a neuropsychological screening battery, often applied in multiple sclerosis (MS) patients. It is almost exclusively administered in trials and not in the daily practice routine because of the lack of normative values. Using a stepwise linear regression analysis, the dependence of test results on age, gender, and education of 241 healthy control subjects was investigated. Z-values of -1.68 or less were considered pathological. Based on the normative values, the proportions of cognitively impaired patients with relapsing-remitting MS (RRMS, n=43) and secondary progressive MS patients (SPMS, n=60) were calculated. The regression model explained 2.7-25.0% of the variance of test performances. Cognitive impairment occurred in 38% and in 47% of the RRMS and the SPMS groups, respectively. In both groups attention and concentration impairment was prominent, while in the SPMS group memory was also frequently affected. The proportion of cognitively impaired MS patients reflected the figures that could be found in the literature.

Pediatric multiple sclerosis

The onset of multiple sclerosis (MS) in childhood is being increasingly recognized. Despite this, there currently exist several barriers to the prompt diagnosis of MS in children. Many clinicians view MS as an exclusively adult-onset disease, and thus they may not entertain the diagnosis in a child. Also, the clinical and radiographic criteria for the diagnosis of MS have not been validated in a pediatric MS population. The available literature, as well as experience gained in a dedicated pediatric MS clinic, is used here to describe features of pediatric MS and contrast these with adult MS. The rationale and importance of future studies in pediatric MS is highlighted.

Computer-aided retraining of memory and attention in people with multiple sclerosis: a randomized, double-blind controlled trial

CONTEXT

Cognitive compromise is one of the main contributing factors to activity and participation restrictions in people with multiple sclerosis (MS). Computer-aided programs are used for retraining memory and attention, but data on the efficacy of these interventions are scarce.

OBJECTIVE

To assess the efficacy of computer-aided retraining of memory and attention in people with MS impaired in these abilities.

DESIGN AND SETTING

Randomized, double-blind, controlled trial.

PARTICIPANTS

Outpatients (n=82) with subjective complaints of poor attention or memory, confirmed by a score <80th percentile in at least two tests of the Brief Repeatable Battery of Neuropsychological Tests (BRBNT).

INTERVENTIONS

Participants were randomized to two computer-assisted retraining interventions: memory and attention (study arm), and visuo-constructional and visuo-motor coordination (control arm). Both groups received 16 training sessions over 8 weeks.

OUTCOME MEASURES

Improvement of 20% or more in at least two BRBNT test scores at 8 weeks compared to baseline (primary end point). Changes in depression and health-related quality of life.

RESULTS

An improvement occurred in 45% of study patients vs. 43% of control patients (odds ratio 1.07, 95% confidence interval 0.44-2.64). The study treatment was better than the control treatment only on the word list generation test (p=0.016).

CONCLUSIONS

This trial does not support the efficacy of specific memory and attention retraining in MS.

The neuropsychiatry of multiple sclerosis

This review describes the many neuropsychiatric abnormalities associated with multiple sclerosis (MS). These may be broadly divided into 2 categories: disorders of mood, affect, and behaviour and abnormalities affecting cognition. With respect to the former, the epidemiology, phenomenology, and theories of etiology are described for the syndromes of depression, bipolar disorder, euphoria, pathological laughing and crying, and psychosis attributable to MS. The section discussing cognition reviews the prevalence and nature of cognitive dysfunction, with an emphasis on abnormalities affecting multiple domains of memory, speed of information processing, and executive function. The detection, natural history, and cerebral correlates of cognitive dysfunction are also discussed. Finally, treatment pertaining to all these disorders is reviewed, with the observation that translational research has been found wanting when it comes to providing algorithms to guide clinicians. Guidelines derived from general psychiatry still largely apply, although they may not always be most effective in patients with neurologic disorders. The importance of future research addressing this imbalance is emphasized, for neuropsychiatric sequelae add significantly to the morbidity associated with MS.

Therapy with glatiramer acetate for multiple sclerosis

BACKGROUND

Some clinical data have shown that glatiramer acetate (Copaxone), a synthetic amino acid polymer empirically found to suppress experimental allergic encephalomyelitis (EAE), an animal model of MS, might help improve the outcome of patients with multiple sclerosis (MS).

OBJECTIVES

We performed a Cochrane review of all randomised, placebo-controlled trials of glatiramer acetate in MS, whatever the disease course.

SEARCH STRATEGY

We searched the Cochrane MS Group trials register (June 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2003), MEDLINE (PubMed) (January 1966 to June 2003), EMBASE (January 1988 to June 2003) and hand searching of symposia reports (1990-2002) from the neurological Associations and MS Societies in both Europe and America.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing glatiramer acetate and placebo in patients with definite MS, whatever the administration schedule and disease course, were eligible for this review.

DATA COLLECTION AND ANALYSIS

Both patients with relapsing-remitting (RR) and chronic progressive (CP) MS were analysed. Study protocols were comparable across trials as to patient entry criteria and outcome definition. No major flaws were found in methodological quality. However, efficacy of blinding should be balanced against well-known side effects, including injection-site reactions in glatiramer acetate-treated patients.

MAIN RESULTS

A total of 646 patients contributed to this review, as it is summarised in Table 01. Glatiramer acetate did not show any significant effect on disease progression, measured as a sustained worsening in the Expanded Disability Status Scale (EDSS). On the other hand, a slight decrease in the mean EDSS score, driven by a major study, should be considered in the light of the limited validity of this outcome measure. No benefit was shown in CP MS patients (progression at two years: RR=0.69, 95% CI [0.33 to 1.46]). The frequency of reported adverse events does not support any major toxicity associated with glatiramer acetate administration. The most common systemic adverse event was a transient and self-limiting patterned reaction of flushing, chest tightness, sweating, palpitations, anxiety (relative risk = 3.40 (95% CI [2.22 to 5.21], p <0.00001]). Local injection-site reactions were observed in up to a half of patients treated with glatiramer acetate, thus making a blind assessment of outcomes questionable.

REVIEWER'S CONCLUSIONS

Glatiramer acetate did not show any beneficial effect on the main outcome measures in MS, i.e. disease progression, and it does not substantially affect the risk of clinical relapses. Therefore its routine use in clinical practice is not currently supported. More investigations are needed. Further research should also develop more reliable measures of patient disability over time and include quality of life among primary outcomes.

Cognitive dysfunction in multiple sclerosis: natural history, pathophysiology and management

Cognitive dysfunction is a major cause of disability in patients with multiple sclerosis (MS). The prevalence of cognitive dysfunction is estimated at 45 to 65%. Natural history studies suggest that once cognitive dysfunction develops in a patient with MS, it is not likely to remit. Unlike physical disability in MS, cognitive disability correlates weakly with T2 lesion burden on brain magnetic resonance imaging (MRI). More robust correlations exist with magnetisation transfer imaging and MRI measures of brain atrophy. Patients with MS who have cognitive impairment most commonly display deficits in the cognitive domains of memory, learning, attention and information processing. In diagnosing cognitive dysfunction in a patient with MS, it is important first to recognise and treat the common comorbidities of fatigue and depression. The first step in the treatment of cognitive dysfunction is to delay disease progression, and there are currently five such disease-modifying agents approved for the treatment of MS (two preparations of interferon-beta-1a, interferon-beta-1b, glatiramer acetate and mitoxantrone). Nonpharmacological measures, such as cognitive rehabilitation, occupational therapy and psychotherapy, are the mainstays of symptomatic treatment. Pharmacological symptomatic therapy centres on the treatment of comorbid fatigue and depression. There are currently no effective pharmacological agents approved as symptomatic therapy of cognitive dysfunction in MS.

Effect of interferon-beta-1b on cognitive functions in multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is recognised as a central nervous system disease also affecting cognition. The rate of cognitive dysfunction in MS is in the range of 45-65% and adversely affect the quality of life.

OBJECTIVE

To evaluate the effect of 1 year of treatment with interferon-beta-1b (IFNbeta-1b) on cognitive functions in patients suffering from relapsing-remitting MS.

METHODS

A battery of cognitive tests was used to assess verbal learning, delayed recall, visual learning and recall, complex attention, concentration and verbal fluency at baseline and after 1 year of treatment with IFNbeta-1b. A group of 23 relapsing-remitting MS patients matched for neurological disability served as controls.

RESULTS

Eighteen of 23 patients treated with IFNbeta-1b (74%) completed the study. In the IFNbeta-1b-treated group, complex attention, concentration as well as visual learning and recall improved significantly (p = 0.024, p = 0.006 and p = 0.005, respectively), while no deterioration was observed in the other dimensions. In the control group, complex attention, verbal fluency, as well as visual learning and recall deteriorated significantly (p = 0.02, p = 0.004 and p = 0.01, respectively), while no deterioration was observed in the other dimensions.

CONCLUSION

Immunomodulating drugs that reduce the relapse rate and slow the disease progression also inhibit cognitive deterioration in patients with MS.

Risk-benefit assessment of glatiramer acetate in multiple sclerosis

Glatiramer acetate, formerly known as copolymer 1, is a mixture of synthetic polypeptides composed of four amino acids. Glatiramer acetate has been shown to be effective in preventing and suppressing experimental autoimmune encephalitis (EAE), the animal model of multiple sclerosis (MS). Therefore it was tested in several clinical studies, where it was found to slow the progression of disability and to reduce the relapse rate and the magnetic resonance imaging (MRI)-defined disease activity and burden in relapsing-remitting MS. As a daily standard dose, 20mg of glatiramer acetate is injected subcutaneously. After injection, glatiramer acetate undergoes rapid degradation to amino acids and shorter peptides; so it is not possible to measure any systemic plasma concentrations or excretion rates. Two major mechanisms have been proposed to explain the effects of glatiramer acetate in EAE and MS: the induction of glatiramer acetate-reactive T helper 2 (Th2)-like regulatory suppressive cells and the interference with T cell activation as an altered peptide ligand. The most common adverse effects were mild injection site reactions (erythema, inflammation and induration). The most remarkable adverse event is the acute and transient immediate postinjection reaction manifested by flushing, chest tightness, palpitations and dyspnoea. Other reported adverse effects are transient chest pain and lymphadenopathy. Antibodies to glatiramer acetate induced during treatment do not interfere with its clinical effects. In several controlled clinical studies, glatiramer acetate has been shown to provide consistent, reproducible clinical benefits in the target population of patients with relapsing-remitting MS. The safety profile and risk-benefit ratio are excellent. Overall, glatiramer acetate is very well tolerated and has an excellent risk-benefit profile in patients with relapsing-remitting MS.

Cognitive impairments in multiple sclerosis: a review

Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS). Cognitive impairment (CI) may develop at any time during the course of the disease in the presence or absence of neurological disability. On the basis of comprehensive neuropsychological studies, there is now a consensus among investigators that 45 percent to 65 percent of MS patients suffer from some degree and form of cognitive difficulty. Features of CI include bradyphrenia; impaired attention, concentration and abstract reasoning; reduced manual speed and dexterity; deficits in memory retrieval; and language deficits in both the relapsing-remitting and progressive forms of MS. Impairments in all cognitive domains may result from the diffuse spread of microscopic pathology, although a preferential lobar distribution of plaques can present with a predominant deficit in the corresponding cognitive function. Nevertheless, the severity of CI best correlates with total microscopic and macroscopic disease burden of the brain as defined by recently developed magnetic resonance imaging (MRI) sequences. A disruption of connecting intercortical and subcortical pathways is likely to be the main cause of metabolic and functional abnormalities in neurons. However a direct toxic effect of soluble inflammatory products may also compromise neuronal function and survival. Early treatment of MS with interferons and copaxone can prevent or delay the onset of both neurological and cognitive disabilities by reducing the inflammatory activity and damage in the CNS. Until more powerful neuroprotective agents become available, simple neuropsychological screening and cognitive rehabilitation for memory and language impairments will remain important components in the care of MS patients.

Palliative care in patients with multiple sclerosis

Multiple Sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) and can be characterized by acute exacerbations or gradual worsening of neurological function and disability. The course of the disease is highly variable and unpredictable, however, there are short and long-term favorable and unfavorable predictive factors, which may provide some information about the future pattern of the disease. Palliative care in MS is directed at symptom management, psychosocial support, and rehabilitation. The goal in palliative care is to achieve a high quality of life. The disease modifying agents, interferon beta, Glatiramer acetate and Mitoxantrone are the mainstay of treatment in MS. Symptomatic relief and counseling of patients with MS have a strong impact on quality of life.

The brief repeatable battery of neuropsychological tests: normative values allow application in multiple sclerosis clinical practice

The Brief Repeatable Battery of Neuropsychological Tests (BRB-N) is a sensitive measure of cognitive impairment in multiple sclerosis (MS) patients. It consists of the Selective Reminding Test, the 10/36 Spatial Recall Test, the Symbol Digit Modalities Test, the Paced Auditory Serial Addition Test and the Word List Generation Test. We administered one of two parallel versions of the test battery to 140 healthy subjects to produce normative values for both versions. As expected, test scores were influenced by certain variables like age, gender and education. Although constructed as two equivalent versions, for some tests the two versions showed significant differences in test scores, which could not be explained by differences in these variables.

Immunomodulatory drugs for multiple sclerosis: a systematic review of clinical and cost effectiveness

Uncertainties about the clinical and cost effectiveness of immunomodulatory drugs for multiple sclerosis (MS), as well as concerns about funding treatment, continue to influence their use. The National Institute for Clinical Excellence (NICE) in England and Wales has been appraising the evidence on the clinical and cost effectiveness of IFN-beta and glatiramer to provide guidance to the NHS. It has proved a difficult task. This paper is an update of our systematic review which assesses the evidence on the clinical and cost effectiveness of a range of immunomodulatory drugs for MS, including azathioprine, IFN-beta, cladribine, cyclophosphamide, glatiramer, intravenous immunoglobulin (IVIg), methotrexate and mitoxantrone. Searches of electronic databases (such as Medline, Embase and the Cochrane Library) and bibliographies of related papers, as well as consultation with experts, for systematic reviews of randomised controlled trials (RCTs) and direct reports of RCTs revealed 26 studies of clinical effectiveness and eight economic evaluations that met the criteria for inclusion. The quality of the evidence was often poor, affected by methodological limitations. Evidence on the clinical effectiveness of immunomodulatory drugs showed some clinical effect, with reductions in relapse rates and/or progression to disability for people with MS. However, benefits from these drugs may be lessened by side effects. Assessment of cost effectiveness was limited to IFN-beta and glatiramer, showing that any benefit from these drugs was achieved at very high cost. The inadequacies in the evidence of clinical and cost effectiveness on some immunomodulatory drugs for the treatment of people with MS necessitate further rigorous RCTs and comparative economic evaluations of different alternatives.