Interferons in relapsing remitting multiple sclerosis: a systematic review

A multicenter, prospective, quasi-experimental evaluation study of a patient education program to foster multiple sclerosis self-management competencies

OBJECTIVE

To determine the impact of the self-management training program "S.MS" for new multiple sclerosis (MS) patients.

METHOD

Multicenter, prospective, quasi-experimental study with 31 MS patients in the intervention group (training program) and 33 participants in the control group (CG) (brochures). Data were collected before, after and 6 months after the interventions. Analysis of change was done by ANCOVA with repeated measurements.

RESULTS

At baseline, participants in CG were younger at the time of diagnosis, suffered more frequently from relapsing-remitting MS and took more MS-medication on a permanent basis. The intervention had a stable significant effect on each dimension of self-management ability, on total self-management ability (ES=0.194, p<0.001), on anxiety (ES=0.193, p=0.001), and on disease-specific quality of life (ES=0.120, p=0.007). Regarding depression, a significant interaction effect of time and intervention could be observed (ES=0.106, p=0.011). No effect was found on disease-specific knowledge. High participant acceptance was reported.

CONCLUSION

"S.MS" participation was associated with a significant and sustained improvement of self-management abilities, anxiety and disease-specific quality of life in a quasi-experimental study design. Using RCT or CRT-designs would be desirable to further improve the evidence of treatment effectiveness.

PRACTICE IMPLICATIONS

This study provides substantial evidence that "S.MS" fosters patients' self-management ability.

Azathioprine versus beta interferons for relapsing-remitting multiple sclerosis: a multicentre randomized non-inferiority trial

For almost three decades in many countries azathioprine has been used to treat relapsing-remitting multiple sclerosis. However its efficacy was usually considered marginal and following approval of β interferons for this indication it was no longer recommended as first line treatment, even if presently no conclusive direct β interferon-azathioprine comparison exists. To compare azathioprine efficacy versus the currently available β interferons in relapsing-remitting multiple sclerosis, a multicenter, randomized, controlled, single-blinded, non-inferiority trial was conducted in 30 Italian multiple sclerosis centers. Eligible patients (relapsing-remitting course; ≥ 2 relapses in the last 2 years) were randomly assigned to azathioprine or β interferons. The primary outcome was annualized relapse rate ratio (RR) over 2 years. Key secondary outcome was number of new brain MRI lesions. Patients (n = 150) were randomized in 2 groups (77 azathioprine, 73 β interferons). At 2 years, clinical evaluation was completed in 127 patients (62 azathioprine, 65 β interferons). Annualized relapse rate was 0.26 (95% Confidence Interval, CI, 0.19-0.37) in the azathioprine and 0.39 (95% CI 0.30-0.51) in the interferon group. Non-inferiority analysis showed that azathioprine was at least as effective as β interferons (relapse RRAZA/IFN 0.67, one-sided 95% CI 0.96; p<0.01). MRI outcomes were analyzed in 97 patients (50 azathioprine and 47 β interferons). Annualized new T2 lesion rate was 0.76 (95% CI 0.61-0.95) in the azathioprine and 0.69 (95% CI 0.54-0.88) in the interferon group. Treatment discontinuations due to adverse events were higher (20.3% vs. 7.8%, p = 0.03) in the azathioprine than in the interferon group, and concentrated within the first months of treatment, whereas in the interferon group discontinuations occurred mainly during the second year. The results of this study indicate that efficacy of azathioprine is not inferior to that of β interferons for patients with relapsing-remitting multiple sclerosis. Considering also the convenience of the oral administration, and the low cost for health service providers, azathioprine may represent an alternative to interferon treatment, while the different side effect profiles of both medications have to be taken into account.

TRIAL REGISTRATION

EudraCT 2006-004937-13.

Activity of liver enzymes in multiple sclerosis patients with Hot-nature diet and co-supplemented hemp seed, evening primrose oils intervention

BACKGROUND

It is unknown whether diets with a high dietary total antioxidant capacity (TAC) can modify oxidative stress, low-grade inflammation, or liver dysfunction, all of which are risk factors for multiple sclerosis disease. This study assesses alanine amino-transferase (ALT), aspartate-aminotransferase (AST) and gamma-glutamyl transferase (GGT) activities in MS patients treated with co-supplemented hemp seed and evening primrose oils as well as Hot-nature diet and the therapeutic potential this intervention.

METHODS AND MATERIALS

In this double blind, randomized trial, 100 MS patients with EDSS<6 were allocated into 3 groups: "group A", who received co-supplemented hemp seed and evening primrose oils with advised Hot-nature diet; "group B",who received olive oil; and "group C", who received the co-supplemented oils. Clinically, EDSS as well as serum level of liver enzymes (GGT, AST, and ALT) were assessed at baseline and after 6 months.

RESULTS

Mean follow-up was 180±2.9 SD days (N=65, 23 M and 42 F aged 34.25±8.07 years with disease duration of 6.80±4.33 years). There was no significant difference in the study parameters at baseline. Serum levels of liver enzymes (GGT, AST, and ALT) were serially monitored. Intervention was associated with liver function alteration in three groups. Significance decreased in EDSS score and the levels of liver enzymes were found in groups A and C, whereas elevated serum liver enzymes and EDSS score were observed in group B after the intervention.

CONCLUSION

Selecting foods according to their Total antioxidant capacity such as co-supplemented hemp seed and evening primrose oils with Hot-nature diet affects antioxidant intake and can have beneficial effects on improving EDSS score and activity of liver enzymes in RRMS patients.

Hughes syndrome and Multiple sclerosis

Multiple sclerosis (MS) and antiphospholipid syndrome (APS) share common clinical, laboratory and radiological features. We reviewed all the English papers on MS and APS published in the literature from 1965 to 2014 using PubMed and Google Scholar. We found that APS can mimic antiphospholipid antibodies (aPL)-positive MS in many ways in its clinical presentation. Nevertheless, APS diagnosis, clinical manifestations and management differ from those of MS. aPL were found in MS patients with titers ranging from 2% to 88%. The distribution and volume of lesions on magnetic resonance imaging (MRI) may help to differentiate MS from primary APS. In addition, atypical MS presentation can guide physicians toward an alternative diagnosis, especially when features of thrombosis and/or history of connective tissue disease are present. In that case, an anticoagulation trial could be worthwhile.

Long-term influence of combined oral contraceptive use on the clinical course of relapsing-remitting multiple sclerosis

OBJECTIVE

To assess the long-term effects of combined oral contraceptives (COCs) on the clinical course of relapsing-remitting multiple sclerosis (RRMS), focusing on disability progression and evolution to secondary-progressive multiple sclerosis (SPMS).

DESIGN

Retrospective and exploratory study.

SETTING

Academic medical center.

PATIENT(S)

A total of 174 women with clinically confirmed MS; of these, 33 had evolved to SPMS at the time of enrollment in the study, whereas 141 still had a relapsing-remitting form of disease.

INTERVENTION(S)

Women were interviewed to obtain gynecologic and obstetric history.

MAIN OUTCOME MEASURE(S)

Expanded Disability Status Scale (EDSS); Multiple Sclerosis Severity Score (MSSS); annualized relapse rate; evolution to SPMS.

RESULT(S)

Mean±SD duration of disease was 14.3±9.8 years. Compared with non-users of COCs, COC users had lower EDSS scores and MSSS only in the subset of the population with prior or current immunomodulatory treatment. Nonuse of COCs was a predictor of disease evolution in SPMS, whether treated or not with immunomodulatory drugs. The annualized relapse rate was not influenced by COC use. No differences in EDSS scores and evolution to SPMS depending on COC formulation were detected.

CONCLUSION(S)

Our results suggest that COC use is associated with a less severe disease and less severe evolution. Whether different doses or types of progestin may have different effects remains to be defined.

Information provision for people with multiple sclerosis

BACKGROUND

People with multiple sclerosis (MS) are confronted with a number of important uncertainties concerning many aspects of the disease. Among others, these include diagnosis, prognosis, disease course, disease-modifying therapies, symptomatic therapies and non-pharmacological interventions. It has been shown that people with MS demand adequate information to be able to actively participate in medical decision making and to self-manage their disease. On the other hand, it has been found that patients' disease-related knowledge is poor. Therefore, guidelines have recommended clear and concise high-quality information at all stages of the disease. Several studies have outlined communication and information deficits in the care of people with MS and, accordingly, a number of information and decision support programmes have been published.

OBJECTIVES

To evaluate the effectiveness of information provision interventions for people with MS that aim to promote informed choice and improve patient-relevant outcomes.

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register which contains trials from CENTRAL (The Cochrane Library 2013, Issue 6), MEDLINE, EMBASE, CINAHL, LILACS, PEDro and clinical trials registries (12 June 2013) as well as other sources. In addition, we searched PsycINFO, trial registries, and reference lists of identified articles. We also contacted trialists.

SELECTION CRITERIA

Randomised controlled trials, cluster randomised controlled trials and quasi-randomised trials comparing information provision for people with MS or suspected MS (intervention groups) with usual care or other types of information provision (control groups) were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the retrieved articles for relevance and methodological quality, and extracted data. Critical appraisal of studies addressed the risk of selection bias, performance bias, attrition bias and detection bias. We contacted authors of relevant studies for additional information.

MAIN RESULTS

Ten randomised controlled trials involving a total of 1314 participants met the inclusion criteria and were analysed. The interventions addressed a variety of topics using different approaches for information provision in different settings. Topics included disease-modifying therapy, relapse management, self-care strategies, fatigue management, family planning and general health promotion. The interventions contained decision aids, educational programmes, self-care interventions and personal interviews with physicians. All interventions were complex interventions using more than one active component, but the number and extent of the intervention components differed markedly between studies. The studies had a variable risk of bias. We did not perform meta-analyses due to marked clinical heterogeneity. All four studies assessing MS-related knowledge (524 participants; moderate-quality evidence) detected significant differences between groups as a result of the interventions indicating that information provision may successfully increase participants' knowledge. There were mixed results from four studies reporting effects on decision making (836 participants; low-quality evidence) and from five studies assessing quality of life (605 participants; low-quality evidence). There were no adverse events in the six studies reporting on adverse events.

AUTHORS' CONCLUSIONS

Information provision for people with MS seems to increase disease-related knowledge, with less clear results on decision making and quality of life. There seem to be no negative side effects from informing patients about their disease. Interpretation of study results remains challenging due to the marked heterogeneity of the interventions and outcome measures.

Evidence-based patient information programme in early multiple sclerosis: a randomised controlled trial

OBJECTIVE

To evaluate the efficacy of an evidence-based patient information programme aiming to increase informed choice in patients with early multiple sclerosis (MS).

BACKGROUND

Patients with early MS face a number of uncertainties concerning diagnosis, prognosis and effectiveness of immunotherapy. Prior studies suggest that evidence-based patient information combined with group education can promote informed choice in MS patients.

METHODS

A 12-month, six-centre, double-blind randomised controlled clinical trial with 192 patients with a diagnosis of confirmed relapsing-remitting MS or clinical isolated syndrome in Germany. A 4-h interactive evidence-based educational programme was compared with a 4-h MS-specific stress management programme. The primary endpoint was informed choice after 6 months comprising risk knowledge and congruency between attitude towards immunotherapy and actual immunotherapy uptake. Secondary endpoints included autonomy preference, decision autonomy, decisional conflict and satisfaction, anxiety and depression, and number of immunotherapies.

RESULTS

For the primary endpoint, a significant difference was shown with 50 of 85 (59%) participants in the intervention group achieving informed choice after 6 months compared with 18 of 89 (20%) in the control group (OR 0.2 (95% CI 0.1 to 0.4), p<0.001). Four weeks after the intervention, more participants in the intervention group showed good risk knowledge (difference between groups 39% (95% CI 26% to 53%), p<0.001). There were no significant differences between groups for attitude towards immunotherapy and for immunotherapy uptake. There were trends towards increased autonomy preference after the intervention and increased adherence to immunotherapies in the intervention group.

CONCLUSIONS

The intervention significantly increased informed choice and relevant risk knowledge without negative side effects.

Disease-modifying drugs for the early treatment of multiple sclerosis

The introduction of new immunomodulatory therapies such as, interferon-beta, glatiramer acetate (Copaxone, Teva Pharmaceutical Industries) and mitoxantrone (Ralenova, Wyeth Pharma; Novantrone, Immunex Corp.) has considerably improved the therapeutic options for patients with multiple sclerosis. These agents have been shown to reduce relapse rate, slow down progression of disability and prevent the accumulation of magnetic resonance imaging lesion load in clinically definite multiple sclerosis. Moreover, two formulations of interferon-beta delayed conversion into clinically definite multiple sclerosis in patients with clinically isolated syndromes suggestive of multiple sclerosis. Since axonal damage leading to irreversible neurological disability is already present early at the onset of the disease, immunomodulatory therapy should start as soon as possible. This article reviews the arguments for the early initiation of therapy and provides an overview of clinical studies dealing with the early treatment of multiple sclerosis.

Investigation of heterogeneity in the association between interferon beta and disability progression in multiple sclerosis: an observational study

BACKGROUND AND PURPOSE

It was recently reported that there was no significant overall association between interferon beta exposure and disability progression in relapsing-remitting multiple sclerosis (RRMS) patients in an observational study from Canada. In the current study, the potential for heterogeneity in the association between exposure to interferon beta and disability progression across patients' baseline characteristics was investigated.

METHODS

RRMS patients treated with interferon beta (n = 868) and two cohorts of untreated patients (829 contemporary and 959 historical controls) were included. The main outcome was time from interferon beta treatment eligibility (baseline) to a confirmed and sustained Expanded Disability Status Scale (EDSS) score 6 using a multivariable Cox model, with treatment as a time-varying predictor, testing interaction effects for five pre-specified baseline characteristics: sex, age, disease duration, EDSS and annualized relapse rate (ARR) based on the previous 2 years.

RESULTS

Significant heterogeneity was found in the association of interferon beta exposure and disability progression only across ARR, and only when treated patients were compared with historical controls (P = 0.005 at a Bonferroni-adjusted alpha of 0.01). For patients with ARR>1, treatment-exposed time was associated with a hazard ratio of 0.38 (95%CI 0.20-0.75) for disability progression compared with the unexposed time.

CONCLUSIONS

RRMS patients with more frequent relapses at baseline may be more likely to benefit from interferon beta treatment with respect to long-term disability progression.

Fluctuations in appraisal over time in the context of stable versus non-stable health

PURPOSE

This study seeks to estimate clinically significant change in quality of life (QOL) appraisal by comparing changes in appraisal over 6 months of follow-up in people with multiple sclerosis who experienced no change in symptoms versus those with worsening symptoms. This estimation is important for enabling valid interpretation of longitudinal change, both in terms of ensuring the comparison of scores and for response shift estimation.

METHODS

This is a secondary analysis of longitudinal data (N = 859) of participants in the North American Research Committee on Multiple Sclerosis registry. Patient groupings were characterized on the basis of self-reported symptom change over 1 year of follow-up and compared in terms of their responses to the QOL Appraisal Profile. Bonferroni adjustments reduced the type I error rate, and interpretation was restricted to those comparisons with small or larger effect sizes using Cohen's criteria.

RESULTS

The Symptoms Unchanged group evidenced more change in Frame of Reference goal delineation themes and Combinatory Algorithm, whereas the Symptoms Worse group evidenced more change in Sampling of Experience and Standards of Comparison items. The group differences were, however, not large or statistically significant in most cases, likely due to being under-powered to detect interaction effects.

CONCLUSIONS

Many aspects of appraisal are relatively constant in the context of unchanging and changing symptom experience, but symptom changes led patients to make substantial shifts in what experiences they sample when thinking about their health-related QOL. These underlying cognitive processes may help people to maintain homeostasis in their perceived QOL.

Effects of exercise training on fatigue in multiple sclerosis: a meta-analysis

OBJECTIVE

To provide a quantitative synthesis of randomized controlled trials examining the effect of exercise training on symptomatic fatigue in persons with multiple sclerosis (MS).

METHODS

Electronic databases (Web of Science, PubMed, PsycInfo, and Google Scholar) were searched for articles published between 1960 and October 2012 by using the key words "fatigue," OR "tiredness," OR "energy," OR "mood," OR "lassitude," AND "exercise," OR "physical activity," OR "rehabilitation," OR "fitness" WITH "multiple sclerosis." The initial search resulted in 311 articles, of which 74 were reviewed in detail and 17 met the inclusion criteria and provided enough data to compute effect sizes (ESs; Cohen d). The meta-analysis was conducted using a meta-analysis software program, and a random-effects model was used to calculate the overall ES, expressed as Hedge g.

RESULTS

The weighted mean ES from 17 randomized controlled trials with 568 participants with MS was 0.45 (standard error = 0.12, 95% confidence interval = 0.22-0.68, z = 3.88, p ≤ .001). The weighted mean ES was slightly heterogeneous (Q = 29.9, df = 16, p = .019).

CONCLUSIONS

The cumulative evidence supports that exercise training is associated with a significant small reduction in fatigue among persons with MS.

Mitoxantrone for multiple sclerosis

BACKGROUND

This is an updated Cochrane review of the previous published version.Mitoxantrone (MX) has been shown to be moderately effective in reducing the clinical outcome measures of disease activity in multiple sclerosis (MS) patients.

OBJECTIVES

The main objective was to assess the efficacy and safety of MX compared to a control group in relapsing-remitting (RRMS), progressive relapsing (PRMS) and secondary progressive (SPMS) MS participants.

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register (June 2012) and reference lists of articles. We also undertook handsearching and contacted trialists and pharmaceutical companies.

SELECTION CRITERIA

Randomised, double-blinded, controlled trials (RCTs) comparing the administration of MX versus placebo or MX plus steroids treatment versus placebo plus steroids treatment were included.

DATA COLLECTION AND ANALYSIS

The review authors independently selected articles for inclusion. They independently extracted clinical, safety and magnetic resonance imaging (MRI) data, resolving disagreements by discussion. Risk of bias was evaluated to assess the quality of the studies. Treatment effect was measured using odds ratios (OR) with 95% confidence intervals (CI) for the binary outcomes and mean differences (MD) with 95% CI for the continuous outcomes. If heterogeneity was absent, a fixed-effect model was used.

MAIN RESULTS

Three trials were selected and 221 participants were included in the analyses. MX reduced the progression of disability at two years follow-up (proportion of participants with six months confirmed progression of disability (OR 0.30, 95% CI 0.09 to 0.99 and MD -0.36, 95% CI- 0.70 to -0.02; P = 0.04)). Significant results were found regarding the reduction in annualised relapse rate (MD -0.85, 95% CI -1.47 to -0.23; P = 0.007), the proportion of patients free from relapses at one year (OR 7.13, 95% CI 2.06 to 24.61; P = 0.002) and two years (OR 2.82, 95% CI 1.54 to 5.19; P = 0.0008), and the number of patients with active MRI lesions at six months or one year only (OR 0.24, 95% CI 0.10 to 0.57; P = 0.001). Side effects reported in the trials (amenorrhoea, nausea and vomiting, alopecia and urinary tract infections) were more frequent in treated patients than in controls, while no major adverse events have been reported. These results should be considered with caution because of the heterogeneous characteristics of included trials in term of drug dosage, inclusion criteria and quality of included trials. Moreover, it was not possible to estimate the long-term efficacy and safety of MX.

AUTHORS' CONCLUSIONS

MX shows a significant but partial efficacy in reducing the risk of MS progression and the frequency of relapses in patients affected by worsening RRMS, PRMS and SPMS in the short-term follow-up (two years). No major neoplastic events or symptomatic cardiotoxicity related to MX have been reported; however studies with longer follow-up (not included in this review) have raised concerns about the risk of systolic disfunction (˜12%) and therapy-related acute leukaemias (0.8%), which are increasingly reported in the literature.MX should be limited to treating patients with worsening RRMS and SPMS and with evidence of persistent inflammatory activity after a careful assessment of the individual patients' risk and benefit profiles. Assessment should also consider the present availability of alternative therapies with less severe adverse events.

An agent-based simulation model for informed shared decision making in multiple sclerosis

Shared decision making (SDM) is concerned with patient involvement into medical decisions and chronic conditions such as Multiple sclerosis (MS), with only partially effective treatments leading to potential severe side effects, conflicting evidence, and uncertain evidence on outcomes, constitute a typical condition for SDM. As treatment options increase and patients participate more intensively in decisions, the need for evidence-based information (EBI) becomes clear. Natural history (NH) studies of MS represent the basic sources for required EBI and are especially useful to contribute to the practical exercise of prognosis formulation and to enable the evaluation of effectiveness in the context of treatment. Several of these identify early clinical factors predictive of the course of MS but there is no consensus method for determining the long term progression of disability and evolution of individual patients on the basis of observations on the early stages of the disease, which constitutes a major challenge for the practicing neurologist. Aiming at delivering more reliable prognosis estimation, this study combines the distribution of patients reaching specific levels of disability within defined time periods as determined in NH studies, with disability curves and severity scores as a function of time, in terms of percentiles and deciles respectively, derived from longitudinal data analysis studies. A computer agent-based simulation model was implemented as a comprehensive and easy to utilize tool able to predict and monitor progression of disability in MS patients, and to support the neurologist discussing prognosis scenarios with the individual patient for effective SDM.

Association of Expanded Disability Status Scale and Cytokines after Intervention with Co-supplemented Hemp Seed, Evening Primrose Oils and Hot-natured Diet in Multiple Sclerosis Patients(♦)

INTRODUCTION

Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS). Because of limited efficacy and adverse side effects, identifying novel therapeutic and protective agents is important. The aim of this study is to examine the correlations between expanded disability status scale (EDSS) and cytokines after intervention with co-supplemented hemp seed and evening primrose oils and hot-natured diet in patients with relapsing-remitting multiple sclerosis (RRMS).

METHODS

We studied a group of 23 patients with clinically definite RRMS, with EDSS<6 who received co-supplemented hemp seed and evening primrose oils with advising hot-natured diet. Clinically EDSS and immunological factors (plasma cytokines of IL-4, IFN-γ and IL-17) were assessed at baseline and after 6 months.

RESULTS

Mean follow-up was 180±2.9 days (N=23, 7 Male and 16 Females aged 25.0±7.5 years with disease duration 6.26±3.9 years). After 6 months, significant improvements in extended disability status score were found in the patients in agreement with decrease cytokines of IFN-γ and IL-17 and increase cytokines of IL-4. Clinical and immunological parameters showed improvement in the patients after the intervention.

CONCLUSION

Our study shows that co-supplemented hemp seed and evening primrose oils with hot-natured diet can have beneficial effects in improving clinical symptoms in relapsing remitting MS patients and significant correlation was found between EDSS and immunological findings.

Efficacy and safety of venous angioplasty of the extracranial veins for multiple sclerosis. Brave dreams study (brain venous drainage exploited against multiple sclerosis): study protocol for a randomized controlled trial

Background

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system with a disabling progressive course. Chronic cerebrospinal venous insufficiency (CCSVI) has recently been described as a vascular condition characterized by restricted venous outflow from the brain, mainly due to blockages of the internal jugular and azygos veins. Despite a wide variability among studies, it has been found to be associated with MS. Data from a few small case series suggest possible improvement of the clinical course and quality of life by performing percutaneous balloon angioplasty (PTA) of the stenotic veins.

Study design and methods

This is a multicenter, randomized, parallel group, blinded, sham-controlled trial to assess the efficacy and safety of PTA. Participants with relapsing remitting MS or secondary progressive MS and a sonographic diagnosis of CCSVI will be enrolled after providing their informed consent. Each participant will be centrally randomized to receive catheter venography and PTA or catheter venography and sham PTA. Two primary end points with respect to efficacy at 12 months are (1) a combined end point obtained through the integration of five functional indicators, walking, balance, manual dexterity, bladder control, and visual acuity, objectively measured by instruments; and (2) number of new brain lesions measured by T2-weighted MRI sequences. Secondary end points include annual relapse rate, change in Expanded Disability Status Scale score, proportion of patients with zero, one or two, or more than two relapses; fatigue; anxiety and depression; general cognitive state; memory/attention/calculus; impact of bladder incontinence; and adverse events. Six hundred seventy-nine patients will be recruited. The follow-up is scheduled at 12 months. Patients, treating neurologists, trained outcome assessors, and the statistician in charge of data analysis will be masked to the assigned treatment.

Discussion

The study will provide an answer regarding the efficacy of PTA on patients’ functional disability in balance, motor, sensory, visual and bladder function, cognitive status, and emotional status, which are meaningful clinical outcomes, beyond investigating the effects on inflammation. In fact, an important part of patients’ expectations, sustained and amplified by anecdotal data, has to do precisely with these functional aspects.

Trial registration

Clinicaltrials.gov NCT01371760

Approved Beta interferons in relapsing-remitting multiple sclerosis: is there an odd one out?

Three interferons are marketed for the treatment of relapsing-remitting multiple sclerosis. In its pivotal trial, one of them demonstrated impressive efficacy as a once-weekly regimen, but later head-to-head studies and reviews questioned its superiority. Analysis of this pivotal trial in publications and health authority reviews has shown that its early termination might have caused attrition bias. Censored patients were different from those completing the study on magnetic resonance imaging parameters and benefited from placebo in terms of relapse rate. Early progression of disability and differences in follow-up duration could have favored the benefit observed for the progression of disability outcome. Only the raw data could be of help to confirm or refute doubts about this trial. Raw data should be made available to the scientific community.

Targeting NOX enzymes in the central nervous system: therapeutic opportunities

Among the pathogenic mechanisms underlying central nervous system (CNS) diseases, oxidative stress is almost invariably described. For this reason, numerous attempts have been made to decrease reactive oxygen species (ROS) with the administration of antioxidants as potential therapies for CNS disorders. However, such treatments have always failed in clinical trials. Targeting specific sources of reactive oxygen species in the CNS (e.g. NOX enzymes) represents an alternative promising option. Indeed, NOX enzymes are major generators of ROS, which regulate progression of CNS disorders as diverse as amyotrophic lateral sclerosis, schizophrenia, Alzheimer disease, Parkinson disease, and stroke. On the other hand, in autoimmune demyelinating diseases, ROS generated by NOX enzymes are protective, presumably by dampening the specific immune response. In this review, we discuss the possibility of developing therapeutics targeting NADPH oxidase (NOX) enzymes for the treatment of different CNS pathologies. Specific compounds able to modulate the activation of NOX enzymes, and the consequent production of ROS, could fill the need for disease-modifying drugs for many incurable CNS pathologies.

The role of mitochondria in axonal degeneration and tissue repair in MS

Axonal injury is a key feature of multiple sclerosis (MS) pathology and is currently seen as the main correlate for permanent clinical disability. Although little is known about the pathogenetic mechanisms that drive axonal damage and loss, there is accumulating evidence highlighting the central role of mitochondrial dysfunction in axonal degeneration and associated neurodegeneration. The aim of this topical review is to provide a concise overview on the involvement of mitochondrial dysfunction in axonal damage and destruction in MS. Hereto, we will discuss putative pathological mechanisms leading to mitochondrial dysfunction and recent imaging studies performed in vivo in patients with MS. Moreover, we will focus on molecular mechanisms and novel imaging studies that address the role of mitochondrial metabolism in tissue repair. Finally, we will briefly review therapeutic strategies aimed at improving mitochondrial metabolism and function under neuroinflammatory conditions.

Long-term persistence with the immunomodulatory drugs for multiple sclerosis: a retrospective database study

BACKGROUND

Immunomodulatory drugs (IMDs) for multiple sclerosis (MS) have been available in Canada since 1995 and are currently the most commonly prescribed treatment for MS. However, relatively little is known about the long-term persistence to these drugs.

OBJECTIVE

The purpose of this study was to describe patterns of, and factors associated with, long-term persistence to the first-line IMDs in an MS population in British Columbia, Canada.

METHODS

Study data were collected from the British Columbia MS database. Adults from British Columbia with definite MS who were prescribed a first-line IMD (interferon beta-1b, interferon beta-1a [subcutaneous and intramuscular], and glatiramer acetate) from January 1, 1995, through December 31, 2008, were eligible for the study. Time to discontinuation of use of all first-line IMDs (ie, switching among IMD therapies was allowed) and the initially prescribed IMD was assessed using Kaplan-Meier survival analysis and multivariate Cox regression.

RESULTS

A total of 1896 patients were included. Mean (SD) age was 40.2 (9.5) years, and 75.1% were female. Median time to discontinuation of all first-line IMD therapies was 6.3 years (95% CI, 5.8-6.7 years). Patients with a longer disease duration and higher level of disability were at higher risk for discontinuing use of the IMDs. Age, sex, and the initial IMD were not associated with discontinuation. Persistence appeared to have decreased over time (P = 0.01 for trend). Median time to discontinued use of, or switching from, the initially prescribed IMD was 2.9 years (95% CI, 2.5-3.2 years).

CONCLUSIONS

Approximately half of the MS patients discontinued use of their IMD within 6 years. It is unknown whether this persistence is adequate because uncertainties remain regarding the optimal level of persistence to the IMDs. Further investigation is needed to examine why some individuals are more at risk for discontinuation of IMD therapy and why, in contrast to other chronic diseases, persistence to IMDs in patients with MS has not improved over time.

Interferon beta for secondary progressive multiple sclerosis

BACKGROUND

Therapy with either recombinant beta-1a or beta-1b interferons (IFNs) is worldwide approved for Relapsing Remitting Multiple Sclerosis (RRMS). A major unanswered question is whether this treatment is able to safely reverse or retard the progressive phase of the disease.

OBJECTIVES

The main objective was to verify whether IFNs treatment in Secondary Progressive Multiple Sclerosis (SPMS) is more effective than placebo in reducing the number of patients who experience disability progression.

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis Group's Trials Register (1995 to 15 February 2011), the reference lists of relevant articles and conference proceedings. Regulatory agencies were used as additional sources of information.

SELECTION CRITERIA

We included all randomised, double or single blind, placebo-controlled trials (RCTs) evaluating the efficacy of IFNs versus placebo in SPMS patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all reports retrieved from the search. They independently extracted clinical, safety and MRI data, using a predefined data extraction form, resolving disagreements after discussion with a third reviewer. Risk of bias was evaluated to assess the quality of the studies. Treatment effect was measured using Risk Ratio (RR) with 95% confidence intervals (CI) for the binary outcomes and Standard Mean Difference with 95% CI for the continuous outcomes.

MAIN RESULTS

Five RCTs met the inclusion criteria, from which 3122 (1829 IFN and 1293 placebo) treated patients contributed to the analysis. Included population was heterogeneous in terms of baseline clinical characteristics of the disease, in particular the percentage of patients affected by secondary progression with superimposed relapse ranging from 72% to 44%. IFN beta 1a and 1b did not decrease the risk of progression sustained at 6 months (RR, 95% CI: 0.98, [0.82-1.16]) after three years of treatment. A significant decrease of the risk of progression sustained at 3 months (RR, 95% CI: 0.88 [0.80, 0.97]) and of the risk of developing new relapses at three years (RR 0.91, [0.84-0.97]) were found. The risk of developing new active brain lesions decreased over time but this data was obtained from single studies on Magnetic Resonance Imaging (MRI), performed in subgroups of patients; in spite of no effect on progression, the radiological data supported an effect on MRI parameters. The safety profile reflects what is commonly reported in MS IFN-treated patients.

AUTHORS' CONCLUSIONS

Well designed RCTs, evaluating a high number of patients were included in the review. Recombinant IFN beta does not prevent the development of permanent physical disability in SPMS. We were unable to verify the effect on cognitive function for the lack of comparable data. This treatment significantly reduces the risk of relapse and of short -term relapse-related disability.Overall, these results show that IFNs' anti-inflammatory effect is unable to retard progression, when established. In the future, no new RCTs for IFNs versus placebo in SPMS will probably be undertaken, because research is now focusing on innovative drugs. We believe that this review gives conclusive evidence on the clinical efficacy of IFNs versus placebo in SPMS.

Systematic review of disease-modifying therapies to assess unmet needs in multiple sclerosis: tolerability and adherence

Reviews of therapeutic drugs usually focus on the highly selected and closely monitored patient populations from randomized controlled trials. The objective of this study was to review systematically the tolerability and adherence of multiple sclerosis disease-modifying therapies, using data from both randomized controlled trials and observational settings. Relevant literature was identified using predefined search terms, and adverse event and study discontinuation data were extracted and categorized according to study type (randomized controlled trial or observational) and study duration. A total of 151 papers were selected for analysis; 33% were classified as randomized controlled trials and 62% as observational studies. Most of the papers concerned interferon preparations and glatiramer acetate; the limited available information on mitoxantrone and natalizumab precluded extensive examination of these. The most common adverse events were flu-like symptoms (interferon therapies only) and injection-site reactions. Mean discontinuation rates ranged from 16% to 27%. There were no marked differences in tolerability or adherence data from randomized controlled trials and observational studies, but the incidence of adverse events remained high in lengthy studies and discontinuations accumulated with time. The present systematic review of randomized clinical trial and observational data highlights the tolerability and adherence issues associated with commonly used first-line multiple sclerosis treatments.

Response shift in patients with multiple sclerosis: an application of three statistical techniques

OBJECTIVE

With the evolution of theory and methods for detecting recalibration, reprioritization, and reconceptualization response shifts, the time has come to evaluate and compare the current statistical detection techniques. This manuscript presents an overview of a cross-method validation done on the same patient sample.

METHODS

Three statistical techniques were used: Structural Equation Modeling, Latent Trajectory Analysis, and Recursive Partitioning and Regression Tree modeling. The study sample (n = 3,008) was drawn from the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry to represent patients soon after diagnosis, classified as having either a self-reported relapsing, progressive, or stable disease trajectory. Patient-reported outcomes included the disease-specific Performance Scales and the Patient-Derived Disease Steps, and the generic SF-12v2 measure.

RESULTS

Small response shift effect sizes were detected by all of the methods. Recalibration response shift was detected by Structural Equation Modeling, Recursive Partitioning Regression Tree demonstrated patterns consistent with all three types of response shift, and Latent Trajectory Analysis, although unable to distinguish types of response shift, did detect response shift in less than 1% of the sample.

CONCLUSION

The methods and their findings were discussed for operationalization, interpretability, assumptions, ability to use all data points from the study sample, limitations, and strengths. Directions for future research are discussed.

Pharmaceutical industry discursives and the marketization of nursing work: a case example

Increasing pharmaceutical industry presence in health care research and practice has evoked critical social, political, economic, and ethical questions and concern among health care providers, ethicists, economists, and the general citizenry. The case example presented of the 'marketization' of nursing practice not only reveals the magnitude of the purview of the pharmaceutical industry, it demonstrates how that industry imparts effect upon the organization of nursing work, an area of health care professional practice where the ethical polemic of pharmaceutical industry involvement and influence has been largely ignored, and the profession of nursing conspicuously silent. Drawing on a Foucauldian dispositive analysis that troubled the complex apparatus responsible for the production of knowledge and action in the neurology subspecialty of multiple sclerosis (MS), the case discloses how the pharmaceutical industry has created compliance and adherence as clinical imperatives in the practice of MS nursing. The case makes explicit the conscious transformative self-action undertaken by MS nurses as a result of their subjectivation (marketization) and demonstrates how MS nurses have become pawns in pharmaceutical industry strategic games of power, truth, identity, and wealth creation by turning their clinical practice settings into heterodiscursive spaces of surveillance and persuasion. MS nurses have become instruments of the pharmaceutical industry, and their clinical practices ordered, organized, limited, constrained, and marketized as a result.

When to initiate disease-modifying drugs for relapsing remitting multiple sclerosis in adults?

For patients with Relapsing Remitting Multiple Scierosis Beta Interfaerons and Glatiramer Acetate were the first to be licensed for treatment. This review deals with one major question: when to initiate therapy? Through exploring the unique characteristics of the disease and treatement we suggest an approach that should be helpful in the process of decision-making.

A meta-analysis of the efficacy and tolerability of interferon-β in multiple sclerosis, overall and by drug and disease type

BACKGROUND

Interferon-β (IFN-β) is an immunomodulatory agent that has been approved in >80 countries worldwide for the treatment of multiple sclerosis (MS) with a relapsing course. Several studies have found IFN-β beneficial in reducing rates of relapse, whereas others have reported no benefit in this regard.

OBJECTIVE

A systematic review and meta-analysis of published placebo-controlled clinical trials of IFN-β was conducted to determine the efficacy and tolerability of IFN-β in the maintenance of remission of MS and to examine variations in effectiveness according to type of IFN-β and subtype of MS.

METHODS

PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (1966-May 2010) were searched for English-language reports of placebo- controlled trials on the efficacy and/or tolerability of IFN-β in MS. Three reviewers independently examined the abstracts of identified publications for relevance and extracted pertinent data from the selected reports. The key efficacy outcomes of interest were the number of patients with at least one relapse and the mean change in Expanded Disability Status Scale (EDSS) scores. The key tolerability outcomes were the number of discontinuations due to adverse events, number of deaths, and number of patients with completed suicides or suicide attempts. In addition, specific adverse events of interest (flulike symptoms, injection-site reactions, injection-site inflammation, myalgia, depression, leukopenia, lymphopenia, and increased alanine aminotransferase) were analyzed individually and compared between IFN-β and placebo.

RESULTS

Nine randomized, placebo-controlled clinical trials of IFN-β met the criteria for inclusion in the meta-analysis. These studies included a total of 3980 patients with MS (2639 with secondary progressive MS, 50 with primary progressive MS, 359 with relapsing MS, and 932 with relapsing-remitting MS; 2552 women, 1428 men; mean age, 40.6 years) randomized to receive either IFN-β or placebo. Of those randomized to treatment, 1893 received IFN-β-1a or placebo, 2029 received IFN-β-1b or placebo, and 58 received natural IFN-β or placebo. The summary relative risks (RRs) for at least one relapse compared with placebo were as follows: 0.86 (95% CI, 0.76 to 0.97; P = 0.011) for all types of IFN-β across all subtypes of MS (7 trials); 1.11 (95% CI, 0.79 to 1.55) for all types of IFN-β in secondary progressive MS (SPMS) (3 trials); and 0.77 (95% CI, 0.57 to 1.05) for all types of IFN-β in relapsing-remitting MS (2 trials). The summary RR for at least one relapse across all types of MS was 0.97 (95% CI, 0.57 to 1.67) for IFN-β-1a (3 trials) and 0.92 (95% CI, 0.85 to 1.00; P = 0.042) for IFN-β-1b (3 trials). The summary RR for at least one relapse was 0.93 (95% CI, 0.75 to 1.14) in patients with SPMS receiving IFN-β-1b. The pooled effect sizes for the mean change in EDSS score with the IFN-β doses used in the Prevention of Relapses and Disability by Interferon beta-1a Subcutaneously in Multiple Sclerosis Accepted for publication August 19, 2010. study were -1.71 (95% CI, -4.70 to 1.28) for the 22-μg dose and -1.71 (95% CI, -4.70 to 1.27) for the 44-μg dose (2 trials). For the tolerability outcomes, the summary RRs were 2.76 (95% CI, 1.97 to 3.89; P < 0.001) for discontinuation due to adverse events (9 trials), 1.53 (95% CI, 0.45 to 5.15) for death (3 trials), and 0.86 (95% CI, 0.41 to 1.79) for completed suicides and suicide attempts (5 trials). The summary RRs for all adverse events of interest (with the exception of depression) were statistically significant for all types of IFN-β compared with placebo across all types of MS (P < 0.01).

CONCLUSIONS

In this meta-analysis of 9 randomized clinical trials, IFN-β was associated with prevention of relapse compared with placebo across all subtypes of MS. However, the effectiveness of IFN-β appeared to vary depending on the type of IFN-β used and the subtype of MS treated.

Walking impairment in patients with multiple sclerosis: exercise training as a treatment option

Multiple sclerosis (MS) is a chronic disease of the central nervous system that culminates in the progression of physical and cognitive disability over time. Walking impairment is a ubiquitous feature of MS and a sentinel characteristic of the later or advanced stages of the disease. This paper presents a conceptual rationale along with empirical evidence for exercise training as a rehabilitation approach for managing walking impairment and improving walking function in persons with MS. Conceptually, MS is associated with a decrease in physical activity, which, in turn, can result in deconditioning across multiple domains of physiological functioning. The resulting deconditioning feeds back and further drives physical inactivity until a threshold is reached that likely initiates the progression of walking impairment in MS. Empirically, physical activity and exercise training have been associated with beneficial effects on walking function in persons with MS. This is based on cross-sectional, longitudinal, and experimental research that included diversity in the breadth of measures of walking, persons with MS, and exercise/physical activity characteristics. Of particular importance, future researchers might consider examining the combinatory effects of exercise training plus pharmacological agents on walking mobility in MS. Collectively, exercise training and physical activity might hold significant potential for the management of progressive mobility disability in MS.

Neurological S1P signaling as an emerging mechanism of action of oral FTY720 (fingolimod) in multiple sclerosis

FTY720 (fingolimod, Novartis) is a promising investigational drug for relapsing forms of multiple sclerosis (MS), an autoimmune and neurodegenerative disorder of the central nervous system. It is currently under FDA review in the United States, and could represent the first approved oral treatment for MS. Extensive, ongoing clinical trials in Phase II/III have supported both the efficacy and safety of FTY720. FTY720 itself is not bioactive, but when phosphorylated (FTY720-P) by sphingosine kinase 2, it becomes active through modulation of 4 of the 5 known G protein-coupled sphingosine 1-phosphate (S1P) receptors. The mechanism of action (MOA) is thought to be immunological, where FTY720 alters lymphocyte trafficking via S1P1. However, MOA for FTY720 in MS may also involve a direct, neurological action within the central nervous system in view of documented S1P receptor-mediated signaling influences in the brain, and this review considers observations that support an emerging neurological MOA.

Risk perception in natalizumab-treated multiple sclerosis patients and their neurologists

BACKGROUND

Natalizumab is associated with the potentially life-threatening side-effect progressive multifocal leukoencephalopathy (PML). Little is known about patients' and physicians' risk estimates and attitudes towards natalizumab treatment.

METHODS

Consecutive natalizumab-treated patients (n = 69) and neurologists (n = 66) in two centres and cooperating private practices received an evidence-based three-page information leaflet about natalizumab-associated PML and an evaluation sheet.

RESULTS

After reading the information, patients were significantly more likely than physicians to intend continuation of natalizumab treatment and willing to accept higher risks of PML: 49% of physicians would stop treatment at a PML risk of 2:10,000 or lower, while only 17% of patients would do so (p < 0.001). This difference could not be explained by risk calculation abilities or lack of understanding. Both groups overestimated natalizumab treatment effects.

CONCLUSION

Patients had a significantly worse perception of multiple sclerosis as a malignant disease. We conclude that patients were willing to accept a higher risk of PML than neurologists. Coherent with their perception of risks and benefits, patients were also more willing to continue treatment. Open information about treatment-related risks is appreciated and might support shared decision making.

Therapeutic strategies in childhood multiple sclerosis

Multiple sclerosis (MS) in children and adolescents accounts for 3-10% of the whole MS population, and is characterized by a relapsing course in almost all cases. The frequency of relapses is higher than in adult onset MS, at least in the first years of evolution. The objective of treatment is to speed the recovery after a relapse, to prevent the occurrence of relapses, and to prevent disease progression and neurodegeneration. The use of drugs for MS in children and adolescents has not been studied in clinical trials, so their use is mainly based on results from trials in adults and from observational studies. There is a consensus to treat acute relapses with intravenous high-dose corticosteroids. The possibility of preventing relapses and disease progression is based on the use of immunomodulatory agents. Interferon-beta (IFNB) and glatiramer acetate (GA) have been demonstrated to be safe and well tolerated in pediatric MS patients, and also to reduce relapse rate and disease progression. Cyclophosphamide and natalizumab could be offered as second-line treatment in patients with a poor response to IFNB or GA. New oral and injectable drugs will be available in the near future: if safe and well tolerated in the long-term follow up of adults with MS, they could be tested in the pediatric MS population.

Cost-effectiveness lessons from disease-modifying drugs in the treatment of multiple sclerosis

In this article, an overview of lessons from cost-effectiveness analyses of disease-modifying drugs for the treatment of multiple sclerosis is provided. Special attention is paid to the uncertainty in reaching a conclusion from the economic evaluations. If recent debates over multiple sclerosis drugs are any indication, the public's understanding of why one conducts an economic evaluation may be at least as important as the cost-effectiveness estimate from the analysis.

Mitochondrial dysfunction: a potential link between neuroinflammation and neurodegeneration?

Dysfunctional mitochondria are thought to play a cardinal role in the pathogenesis of various neurological disorders, such as multiple sclerosis, Alzheimer's disease, Parkinson's disease and stroke. In addition, neuroinflammation is a common denominator of these diseases. Both mitochondrial dysfunction and neuroinflammatory processes lead to increased production of reactive oxygen species (ROS) which are detrimental to neurons. Therefore, neuroinflammation is increasingly recognized to contribute to processes underlying neurodegeneration. Here we describe the involvement of mitochondrial (dys)function in various neurological disorders and discuss the putative link between mitochondrial function and neuroinflammation.

Treatment of multiple sclerosis: role of natalizumab

The results on relapse rate and disease progression of available drugs for multiple sclerosis are shown, as well as their most relevant side effects. Results from pivotal and long-term follow-up studies support the efficacy and safety of interferons and glatiramer acetate. The treatment with mitoxantrone is limited by the occurrence of infertility, cardiotoxicy and leukaemia. Efficacy and tolerability of natalizumab are undisputable, compared to other drugs. Risks related to its treatment are PML, opportunistic infections, hepatotoxicity, melanoma, and their occurrence needs to be more exactly assessed by post-marketing surveillance. The principles of induction versus escalating therapy are also discussed. The final therapeutic decision is based on the evaluation of the disease state and prognosis, based on clinical and instrumental measures, and on the safety/efficacy profile of each treatment.

The Clinical Application of Ozonetherapy

The reader may be eager to examine in which diseases ozonetherapy can be proficiently used and she/he will be amazed by the versatility of this complementary approach (Table 9 1). The fact that the medical applications are numerous exposes the ozonetherapist to medical derision because superficial observers or sarcastic sceptics consider ozonetherapy as the modern panacea. This seems so because ozone, like oxygen, is a molecule able to act simultaneously on several blood components with different functions but, as we shall discuss, ozonetherapy is not a panacea. The ozone messengers ROS and LOPs can act either locally or systemically in practically all cells of an organism. In contrast to the dogma that “ozone is always toxic”, three decades of clinical experience, although mostly acquired in private clinics in millions of patients, have shown that ozone can act as a disinfectant, an oxygen donor, an immunomodulator, a paradoxical inducer of antioxidant enzymes, a metabolic enhancer, an inducer of endothelial nitric oxide synthase and possibly an activator of stem cells with consequent neovascularization and tissue reconstruction.

Assessing cost-effectiveness in the management of multiple sclerosis

Multiple sclerosis (MS) is one of the most common causes of neurological disability in young and middle-aged adults, with current prevalence rates estimated to be 30 per 100,000 populations. Women are approximately twice as susceptible as males, but males are more likely to have progressive disease. The onset of the disease normally occurs between 20 and 40 years of age, with a peak incidence during the late twenties and early thirties, resulting in many years of disability for a large proportion of patients, many of whom require wheelchairs and some nursing home or hospital care. The aim of this study is to update a previous review which considered the cost-effectiveness of disease-modifying drugs (DMDs), such as interferons and glatiramer acetate, with more up to date therapies, such as mitaxantrone hydrochloride and natalizumab in the treatment of MS. The development and availability of new agents has been accompanied by an increased optimism that treatment regimens for MS would be more effective; that the number, severity and duration of relapses would diminish; that disease progression would be delayed; and that disability accumulation would be reduced. However, doubts have been expressed about the effectiveness of these treatments, which has only served to compound the problems associated with endeavors to estimate the relative cost-effectiveness of such interventions.

Disease progression among multiple sclerosis patients before and during a disease-modifying drug program: a longitudinal population-based evaluation

Randomized controlled trials have demonstrated the efficacy of disease-modifying drugs (DMDs) in persons with relapsing—remitting multiple sclerosis (MS) and secondary progressive MS with superimposed relapses. However, these brief studies of selected patients have focused mainly on reducing attacks and must be complemented by evaluations in ‘realworld’ clinical settings to establish the effectiveness of DMD programs in slowing disease progression and to inform health policy and program decision-making. We assessed the effectiveness of DMDs as administered in a comprehensive publicly funded drug insurance program that provides DMDs to a geographically defined population of MS patients who meet specific eligibility criteria. Data from 1752 MS patients (10,312 assessments) seen between 1980 and 2004 at a regional MS Clinic serving the entire population of Nova Scotia, Canada were analysed. Using survival methods we observed a statistically significant reduction in disease progression to specific Expanded Disability Status Scale endpoints following the introduction of this program. Subgroup analyses of patients eligible for treatment using hierarchical linear regression methods also suggested that disease progression was slowed in patients treated with the first DMD prescribed. These findings provide evidence supporting DMD program effectiveness that can be used to inform the broader implementation of such programs.