Scoring treatment response in patients with relapsing multiple sclerosis

Prediction of on-treatment disability worsening in RRMS with the MAGNIMS score

Background:

The magnetic resonance imaging in multiple sclerosis (MAGNIMS) score combines relapses and magnetic resonance imaging (MRI) lesions to predict disability outcomes in relapsing–remitting multiple sclerosis (RRMS) treated with interferon-β.

Objective:

To validate the MAGNIMS score and extend to other disease-modifying therapies (DMTs). To examine the prognostic value of gadolinium contrast-enhancing (Gd+) lesions.

Methods:

This RRMS MSBase cohort study ( n = 2293) used a Cox model to examine the prognostic value of relapses, MRI activity and the MAGNIMS score for disability worsening during treatment with interferon-β and three other DMTs.

Results:

Three new T2 lesions (hazard ratio (HR) = 1.60, p = 0.028) or two relapses (HR = 2.24, p = 0.002) on interferon-β (for 12 months) were predictive of disability worsening over 4 years. MAGNIMS score = 2 (1 relapse and ⩾3 T2 lesions or ⩾2 relapses) was associated with a greater risk of disability worsening on interferon-β (HR = 2.0, p = 0.001). In pooled cohort of four DMTs, similar associations were seen (MAGNIMS score = 2: HR = 1.72, p = 0.001). Secondary analyses demonstrated that the addition of Gd+ to the MAGNIMS did not materially improve its prediction of disability worsening.

Conclusion:

We have validated the MAGNIMS score in RRMS and extended its application to three other DMTs: 1 relapse and ⩾3 T2 lesions or ⩾2 relapses predicted worsening of disability. Contrast-enhancing lesions did not substantially improve the prognostic score.

Clinical Outcomes of Escalation vs Early Intensive Disease-Modifying Therapy in Patients With Multiple Sclerosis

Importance

Uncertainty remains about how aggressively to treat early multiple sclerosis. High-efficacy disease-modifying therapies (DMTs) are often reserved for individuals expressing poor prognostic features at baseline.

Objective

To analyze long-term outcomes in a population-based cohort according to initial treatment strategy.

Design, Setting and Participants

In this cohort study, data were derived from January 1998 to December 2016, and analysis was performed in January 2017. From a total of 720 patients prescribed a DMT, 592 (82%) were included in analysis. Reasons for exclusion were first treated elsewhere or privately (n = 39), clinical trial participant (n = 25), and insufficient clinical data (n = 45).

Exposures

Patients were classified according to first-line treatment strategy: high-efficacy (early intensive treatment [EIT]) or moderate-efficacy DMT (escalation [ESC]).

Main Outcomes and Measures

Primary outcome was 5-year change in Expanded Disability Status Scale score. Secondary outcome was time to sustained accumulation of disability (SAD). Models were adjusted for sex, age at treatment, year of starting DMT, and escalation to high-efficacy treatment in the ESC group.

Results

Mean (SD) age of 592 patients at symptom onset was 27.0 (9.4) years. Mean (SD) 5-year change in Expanded Disability Status Scale score was lower in the EIT group than the ESC group (0.3 [1.5] vs 1.2 [1.5]); this remained significant after adjustment for relevant covariates (β = -0.85; 95% CI, -1.38 to -0.32; P = .002). Median (95% CI) time to SAD was 6.0 (3.17-9.16) years for EIT and 3.14 (2.77-4.00) years for ESC (P = .05). For those within the ESC group who escalated to high-efficacy DMT as second-line treatment, median (95% CI) time to SAD was 3.3 years (1.8-5.6; compared with EIT group log-rank test P = .08). After adjustment for relevant covariates, there was no difference in hazard of SAD between the groups. However, 60% of those who escalated to high-efficacy DMTs were observed to develop SAD while still receiving initial moderate-efficacy treatment before escalation.

Conclusions and Relevance

In a real-life setting, long-term outcomes were more favorable following early intensive therapy vs first-line moderate-efficacy DMT. Contemporary surveillance strategies and escalation protocols may be insufficiently responsive. This finding is particularly relevant as patients in real-world practice are typically selected for an EIT approach to therapy on the basis of clinical and radiological features predictive of a poor outcome. These data support the need for a prospective randomized clinical trial.

Reaching an evidence-based prognosis for personalized treatment of multiple sclerosis

Personalized treatment is ideal for multiple sclerosis (MS) owing to the heterogeneity of clinical features, but current knowledge gaps, including validation of biomarkers and treatment algorithms, limit practical implementation. The contemporary approach to personalized MS therapy depends on evidence-based prognostication, an initial treatment choice and evaluation of early treatment responses to identify the need to switch therapy. Prognostication is directed by baseline clinical, environmental and demographic factors, MRI measures and biomarkers that correlate with long-term disability measures. The initial treatment choice should be a shared decision between the patient and physician. In addition to prognosis, this choice must account for patient-related factors, including comorbidities, pregnancy planning, preferences of the patients and their comfort with risk, and drug-related factors, including safety, cost and implications for treatment sequencing. Treatment response has traditionally been assessed on the basis of relapse rate, MRI lesions and disability progression. Larger longitudinal data sets have enabled development of composite outcome measures and more stringent standards for disease control. Biomarkers, including neurofilament light chain, have potential as early surrogate markers of prognosis and treatment response but require further validation. Overall, attainment of personalized treatment for MS is complex but will be refined as new data become available.

A fully convolutional neural network for new T2-w lesion detection in multiple sclerosis

•

A deep learning model for new T2-w lesions detection in multiple sclerosis is presented.

•

Combining a learning-based registration network with a segmentation one increases the performance.

•

The proposed model decreases false-positives while increasing true-positives.

•

Better performance compared to other supervised and unsupervised state-of-the-art approaches.

Introduction: Longitudinal magnetic resonance imaging (MRI) has an important role in multiple sclerosis (MS) diagnosis and follow-up. Specifically, the presence of new T2-w lesions on brain MR scans is considered a predictive biomarker for the disease. In this study, we propose a fully convolutional neural network (FCNN) to detect new T2-w lesions in longitudinal brain MR images.

Methods: One year apart, multichannel brain MR scans (T1-w, T2-w, PD-w, and FLAIR) were obtained for 60 patients, 36 of them with new T2-w lesions. Modalities from both temporal points were preprocessed and linearly coregistered. Afterwards, an FCNN, whose inputs were from the baseline and follow-up images, was trained to detect new MS lesions. The first part of the network consisted of U-Net blocks that learned the deformation fields (DFs) and nonlinearly registered the baseline image to the follow-up image for each input modality. The learned DFs together with the baseline and follow-up images were then fed to the second part, another U-Net that performed the final detection and segmentation of new T2-w lesions. The model was trained end-to-end, simultaneously learning both the DFs and the new T2-w lesions, using a combined loss function. We evaluated the performance of the model following a leave-one-out cross-validation scheme.

Results: In terms of the detection of new lesions, we obtained a mean Dice similarity coefficient of 0.83 with a true positive rate of 83.09% and a false positive detection rate of 9.36%. In terms of segmentation, we obtained a mean Dice similarity coefficient of 0.55. The performance of our model was significantly better compared to the state-of-the-art methods (p < 0.05).

Conclusions: Our proposal shows the benefits of combining a learning-based registration network with a segmentation network. Compared to other methods, the proposed model decreases the number of false positives. During testing, the proposed model operates faster than the other two state-of-the-art methods based on the DF obtained by Demons.

Monitoring, Switching, and Stopping Multiple Sclerosis Disease-Modifying Therapies

PURPOSE OF REVIEW

This article reviews appropriate monitoring of the various multiple sclerosis (MS) disease-modifying therapies, summarizes the reasons patients switch or stop treatment, and provides a framework for making these management decisions.

RECENT FINDINGS

With the increasing number of highly effective immunotherapies available for MS, the possibility of better control of the disease has increased, but with it, the potential for side effects has rendered treatment decisions more complicated. Starting treatment early with more effective and better-tolerated disease-modifying therapies reduces the likelihood of switching because of breakthrough disease or lack of compliance. Clinical and radiographic surveillance, and often blood and other paraclinical tests, should be performed periodically, depending on the disease-modifying therapy. Helping patients navigate the uncertainty around switching or stopping treatment, either temporarily or permanently, is one of the most important things we do as providers of MS care.

SUMMARY

Ongoing monitoring of drug therapy is a crucial component of long-term MS care. Switching treatments may be necessary for a variety of reasons. Permanent discontinuation of treatment may be appropriate for some patients with MS, although more study is needed in this area.

Factors associated with therapeutic inertia among pharmacists caring for people with multiple sclerosis

INTRODUCTION

Pharmacists play a critical role on therapeutic decisions in multiple sclerosis (MS) care. Therapeutic inertia (TI) is defined as the lack of treatment initiation or escalation when there was evidence of clinical and radiological disease activity. The aim of this study was to assess factors associated with TI among pharmacists involved in MS care.

METHODS

A multicenter, non-interventional, cross-sectional study involving hospital pharmacists in Spain was conducted. Participants answered questions regarding their standard practice, risk preferences, and management of nine simulated MS case-scenarios. We created a score defined as the number of case-scenarios that fit the TI criteria over the total number of presented cases (score range from 0-6). Similarly, an optimal treatment score (OTS) was created to determine the degree of appropriate pharmacological decisions (ranging from 0-lowest to 9-highest). Candidate predictors of TI included demographic data, practice setting, years of practice, MS expertise, number of MS patients managed at hospital/year, participation in MS clinical trials, and participants' risk preferences.

RESULTS

Overall, 65 pharmacists initiated and completed the study (response rate: 45.5%). The mean age was 43.5 ± 7.8 years and 67.1% were female. Forty-two (64.6%) participants had specialization in MS management. Overall, the mean TI score was 3.4 ± 1.1. Of 390 individual responses, 224 (57.4%) met the TI criteria. All participants failed to recommend treatment escalation in at least one of the six case-scenarios. The mean OTS was 4.1 ± 1.4. Of 585 individual responses, 264 (45.1%) met the optimal choice criteria. Only 40% of participants (23/65) made five or more optimal treatment choices. Lower experience in dispensing MS drugs and lack of specialization in MS were the most common factors associated with TI and optimal management. The multivariable analysis revealed that more years of experience (p = 0.03), being a co-author of a peer-reviewed publication (p = 0.03), and specialization in MS (p = 0.017) were associated with lower TI scores (adjusted R² = 0.23).

CONCLUSION

Therapeutic inertia was observed in all pharmacist participants, affecting over fifty percent of MS treatment choices. Continuing education and specialization in MS may facilitate therapeutic decisions in MS care.

Consensus recommendations for the diagnosis and treatment of multiple sclerosis: 2019 revisions to the MENACTRIMS guidelines

With evolving diagnostic criteria and the advent of new oral and parenteral therapies for MS, most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and in time, and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of multiple sclerosis (MS) therapies is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, and progressive MS. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.

Retrospectively acquired cohort study to evaluate the long-term impact of two different treatment strategies on disability outcomes in patients with relapsing multiple sclerosis (RE.LO.DI.MS): data from the Italian MS Register

BACKGROUND

The increase in disease-modifying drugs (DMDs) allows individualization of treatment in relapsing multiple sclerosis (RMS); however, the long-term impact of different treatment sequences is not well established. This is particularly relevant for MS patients who may need to postpone more aggressive DMD strategies.

OBJECTIVE

To evaluate different therapeutic strategies and their long-term outcomes, measured as relapses and confirmed disability progression (CDP), in MS 'real-world' settings.

METHODS

Multicentre, observational, retrospectively acquired cohort study evaluating the long-term impact of different treatment strategies on disability outcomes in patients with RMS in the Italian MS Register.

RESULTS

We evaluated 1152 RMS-naïve patients after propensity-score adjustment. Patients included were receiving: interferon beta-1a (IFN-β1a) 44 µg switching to fingolimod (FTY; IFN-switchers; n = 97); FTY only (FTY-stayers; n = 157); IFN-β1a only (IFN-stayers; n = 849). CDP and relapses did not differ between FTY-stayers and IFN-switchers [HR (95% CI) 0.99 (0.48-2.04), p = 0.98 and 0.81 (0.42-1.58), p = 0.55, respectively]. However, IFN-stayers showed increased risk of relapses compared with FTY-stayers [HR (95% CI) 1.46 (1.00-2.12), p = 0.05].

CONCLUSION

The ideal treatment option for MS is becoming increasingly complex, with the need to balance benefit and risks. Our results suggest that starting with FTY affects the long-term disease outcome similarly to escalating from IFN-β1a to FTY.

Comparison of The Expression of miR-326 between Interferon beta Responders and Non-Responders in Relapsing-Remitting Multiple Sclerosis

Objective

Multiple sclerosis (MS) is an inflammatory disease resulting in demyelination of the central nervous system (CNS). T helper 17 (Th17) subset protects the human body against pathogens and induces neuroinflammation, which leads to neurodegeneration. MicroRNAs (miRNAs) are a specific class of small (~22 nt) non-coding RNAs that act as post-transcriptional regulators. The expression of the miR-326 is highly associated with the pathogenesis of MS disease in patients through the promotion of Th17 development. Recently, studies showed that disease-modifying therapies (DMTs) could balance the dysregulation of miRNAs in the immune cells of patients with relapsing-remitting MS (RRMS). Interferon-beta (IFN-β) has emerged as one of the most common drugs for the treatment of RR-MS patients. The purpose of this study was to evaluate the expression of the miR-326 in RRMS patients who were responders and non- responders to IFN-β treatment.

Materials and Methods

In this cross-sectional study, a total of 70 patients (35 responders and 35 non-responders) were enrolled. We analyzed the expression of the miR-326 in peripheral blood mononuclear cells (PBMCs) of RRMS patients at least one year after the initiation of IFN-β therapy. Real-time polymerase chain reaction (RT-PCR) was applied to measure the expression of the miR-326.

Results

The results showed no substantial change in the expression of the miR-326 between responders and non- responders concerning the treatment with IFN-β. Although the expression of the miR-326 was slightly reduced in IFN-β-responders compared with IFN-β-non-responders; however, the reduction of the miR-326 was not statistically significant.

Conclusion

Overall, since IFN-β doesn’t normalize abnormal expression of miR-326, this might suggest that IFN-β affects Th17 development through epigenetic mechanisms other than miR-326 regulation.

Management of seizures in patients with multiple sclerosis; an Iranian consensus

PURPOSE

Cooccurrence of a seizure in a patient with multiple sclerosis (MS) may complicate the management process. Questions, which may complicate the management process of a patient with MS and seizure, include "how should we approach to the patient", "how should we treat the patient", "how should we modify the patient's MS treatment strategy", etc. METHODS: We searched the electronic database PubMed on March 30, 2018 for articles in English that included the following search terms: "epilepsy" AND "multiple sclerosis" or "seizure" AND "multiple sclerosis" since 2013, to obtain the best recent relevant scientific evidence on the topic. A working group of 6 epilepsy and 5 MS experts took part in two consensus workshops in Tehran, Iran, in 2018. The final consensus manuscript was prepared and approved by all participants.

RESULTS

The search with words "seizure" and "multiple sclerosis" yielded 121 entries; 10 were relevant to the topic. The search with words "epilepsy" and "multiple sclerosis" yielded 400 entries; 7 were relevant to the topic. We reviewed these 17 articles and also some other references, derived from these articles or relevant to the topic, for the purpose of our review.

CONCLUSION

Cooccurrence of a seizure in a patient with MS may complicate the management process. In this review, we tried to provide answers to the frequently asked questions, considering the best available scientific evidence and expert opinion.

Traffic Lights Intervention Reduces Therapeutic Inertia: A Randomized Controlled Trial in Multiple Sclerosis Care

Background: Therapeutic inertia (TI) is a common phenomenon among physicians who care for patients with chronic conditions. We evaluated the efficacy of the traffic light system (TLS) educational intervention to reduce TI among neurologists with MS expertise. Methods: In this randomised, controlled trial, 90 neurologists who provide care to MS patients were randomly assigned to the TLS intervention (n = 45) or to the control group (n = 45). The educational intervention employed the TLS, a behavioral strategy that facilitates therapeutic choices by facilitating reflective decisions. The TLS consisted in a short, structured, single session intervention of 5-7 min duration. Participants made therapeutic choices of 10 simulated case-scenarios. The primary outcome was a reduction in TI based on a published TI score (case-scenarios in which a participant showed TI divided by the total number of scenarios where TI was possible ranging from 0 to 8). Results: All participants completed the study and were included in the primary analysis. TI was lower in the TLS group (1.47, 95% CI 1.32-1.61) compared to controls (1.93; 95% CI 1.79-2.08). The TLS group had a lower prevalence of TI compared to controls (0.67, 95% CI 0.62-0.71 vs. 0.82, 95% CI 0.78-0.86; p = 0.001). The multivariate analysis, adjusted for age, specialty, years of practice, and risk preference showed a 70% reduction in TI for the TLS intervention compared to controls (OR 0.30; 95% CI 0.10-0.89). Conclusions: In this randomized trial, the TLS strategy decreases the incidence of TI in MS care irrespective of age, expertise, years for training, and risk preference of participants, which would lead to better patient outcomes.

Highly Aggressive Multiple Sclerosis

PURPOSE OF REVIEW

Newly introduced disease-modifying therapies offer greater efficacy than previous therapies but also have serious side effects. This article reviews factors useful in identifying those at risk of developing aggressive relapsing multiple sclerosis (MS) and therapies available for treatment.

RECENT FINDINGS

Several factors predict aggressive MS, including demographic factors, relapses, symptom characteristics, MRI activity, and other biomarkers. These can be used to select patients for more aggressive therapies, including natalizumab, alemtuzumab, fingolimod, and ocrelizumab. Additional off-label treatments are available for patients with severe disease. The benefits and side effects of these treatments must be considered when making therapeutic decisions.

SUMMARY

Selecting patients who are most appropriate for aggressive therapy involves considering risk factors for poor outcomes, early recognition of treatment failure, balancing treatment efficacy and side effects, and sharing the decision with patients to assist them in making optimal treatment choices. Vigilance for signs of treatment failure and early switching to more aggressive therapy are important components in optimal care.

Emotional expressions associated with therapeutic inertia in multiple sclerosis care

BACKGROUND

Emotions play a critical role in our daily decisions. However, it remains unclear how and what sort of emotional expressions are associated with therapeutic decisions in multiple sclerosis (MS) care. Our goal was to evaluate the relationship between emotions and affective states (as captured by muscle facial activity and emotional expressions) and TI amongst neurologists caring for MS patients when making therapeutic decisions.

METHODS

38 neurologists with expertise in MS were invited to participate in a face-to-face study across Canada. Participants answered questions regarding their clinical practice, aversion to ambiguity, and the management of 10 simulated case-scenarios. TI was defined as lack of treatment initiation or escalation when there was clear evidence of clinical and radiological disease activity. We recorded facial muscle activations and their associated emotional expressions during the study, while participants made therapeutic choices. We used a validated machine learning algorithm of the AFFDEX software to code for facial muscle activations and a predefined mapping to emotional expressions (disgust, fear, surprise, etc.). Mixed effects models and mediation analyses were used to evaluate the relationship between ambiguity aversion, facial muscle activity/emotional expressions and TI measured as a binary variable and a continuous score.

RESULTS

34 (89.4%) neurologists completed the study. The mean age [standard deviation (SD)] was 44.6 (11.5) years; 38.3% were female and 58.8% self-identified as MS specialists. Overall, 17 (50%) participants showed TI in at least one case-scenario and the mean (SD) TI score was 0.74 (0.90). Nineteen (55.9%) participants had aversion to ambiguity in the financial domain. The multivariate analysis adjusted for age, sex and MS expertise showed that aversion to ambiguity in the financial domain (OR 1.56, 95%CI 1.32-1.86) was associated with TI. Most common muscle activations included mouth open (23.4%), brow furrow (20.9%), brow raise (17.6%), and eye widening (13.1%). Most common emotional expressions included fear (5.1%), disgust (3.2%), sadness (2.9%), and surprise (2.8%). After adjustment for age, sex, and physicians' expertise, the multivariate analysis revealed that brow furrow (OR 1.04; 95%CI 1.003-1.09) and lip suck (OR 1.06; 95%CI 1.01-1.11) were associated with an increase in TI prevalence, whereas upper lip raise (OR 0.30; 95%CI 0.15-0.59), and chin raise (OR 0.90; 95%CI 0.83-0.98) were associated with lower likelihood of TI. Disgust and surprise were associated with a lower TI score (disgust: p < 0.001; surprise: p = 0.008) and lower prevalence of TI (OR_disgust: 0.14, 95%CI 0.03-0.65; OR_surprise: 0.66, 94%CI 0.47-0.92) after adjusting for covariates. The mediation analysis showed that brow furrow was a partial mediator explaining 21.2% (95%CI 14.9%-38.9%) of the association between aversion to ambiguity and TI score, followed by nose wrinkle 12.8% (95%CI 8.9%-23.4%). Similarly, disgust was the single emotional expression (partial mediator) that attenuated (-13.2%, 95%CI -9.2% to -24.3%) the effect of aversion to ambiguity on TI.

CONCLUSIONS

TI was observed in half of participants in at least one case-scenario. Our data suggest that facial metrics (e.g. brow furrow, nose wrinkle) and emotional expressions (e.g. disgust) are associated with physicians' choices and partially mediate the effect of aversion to ambiguity on TI.

Rituximab vs placebo induction prior to glatiramer acetate monotherapy in multiple sclerosis

OBJECTIVE

To examine whether rituximab induction followed by glatiramer acetate (GA) monotherapy is more effective than GA alone for the treatment of relapsing multiple sclerosis with active disease.

METHODS

This was a single-center, double-blind, placebo-controlled study. Fifty-five participants were randomly assigned (1:1 ratio) to either rituximab (R-GA) or placebo (P-GA) induction, followed by GA therapy initiated in all participants. Participants were followed up to 3 years. The primary endpoint was the number of participants with no evidence of disease activity (NEDA): those without relapse, new MRI lesions, and sustained change in disability.

RESULTS

Twenty-eight and 27 participants received rituximab and placebo induction, respectively, with one participant in each arm withdrawing before 6-month MRI. There were no significant differences in baseline characteristics. At end of study, 44.44% of R-GA participants demonstrated NEDA vs 19.23% of P-GA participants (p = 0.049). Treatment failed for a smaller proportion of R-GA participants (37.04% R-GA vs 69.23% P-GA, p = 0.019), and time to treatment failure was longer (23.32 months R-GA vs 11.29 months P-GA, p = 0.027). Fewer participants in the R-GA arm had new lesions (25.93% R-GA vs 61.54% P-GA, p = 0.009), and there were fewer new T2 lesions (0.48 R-GA vs 1.96 P-GA, p = 0.027). Probability of demonstrating NEDA in the R-GA arm returned to baseline within the study period. There were no differences in adverse events.

CONCLUSIONS

Induction therapy with rituximab followed by GA may provide superior efficacy in the short term than GA alone in relapsing multiple sclerosis, but this benefit appears to wane within the study period. Larger studies are needed to assess sustainability of results.

CLINICALTRIALSGOV IDENTIFIER

NCT01569451.

[Real-world evidence : Benefits and limitations in multiple sclerosis research]

BACKGROUND

Real-world evidence (RWE) expands the data obtained in randomized clinical trials (RCTs), which are based on both homogeneous selected patient groups and limited study durations, to long-term experiences in clinical routine. In particular, chronic diseases such as multiple sclerosis (MS) with both heterogeneous pathologies and a growing number of therapeutic options require a careful RWE-based assessment of long-term efficacy and safety parameters.

OBJECTIVE

This review presents RWE data sources applied in MS research and discusses potential quality standards.

MATERIAL AND METHODS

This article is based on the results of an expert meeting of the authors held in October 2015 and a selective literature search.

RESULTS

The RWE data sources include the reporting system of drug safety monitoring, non-interventional studies, MS-specific registries, administrative health databases, and electronic medical records. These data sources have different objectives and are subject to specific limitations with respect to the disease and therapy-relevant analytical options. The combination of different sources into an integrative approach might improve the validity of RWE in MS research; however, this objective requires the standardization of data collection and processing as well as the definition of uniform and transnational quality standards.

CONCLUSION

There is still a need for high-quality, comprehensive, and valid RWE data as these data cover additional aspects of patient care and expand the data available by complementary information. Further development of an integrative RWE approach requires cooperation at various levels with the aim of the best possible standardization and harmonization of clinical MS data.

Unraveling treatment response in multiple sclerosis: A clinical and MRI challenge

Over the last few decades, the improved diagnostic criteria, the wide use of MRI, and the growing availability of effective pharmacologic treatments have led to substantial advances in the management of multiple sclerosis (MS). The importance of early diagnosis and treatment is now well-established, but there is still no consensus on how to define and monitor response to MS treatments. In particular, the clinical relevance of the detection of minimal MRI activity is controversial and recommendations on how to define and monitor treatment response are warranted. An expert panel of the Magnetic Resonance Imaging in MS Study Group analyzed and discussed published studies on treatment response in MS. The evolving concept of no evidence of disease activity and its effect on predicting long-term prognosis was examined, including the option of defining a more realistic target for daily clinical practice: minimal evidence of disease activity. Advantages and disadvantages associated with the use of MRI activity alone and quantitative scoring systems combining on-treatment clinical relapses and MRI active lesions to detect treatment response in the real-world setting were also discussed. While most published studies on this topic involved patients treated with interferon-β, special attention was given to more recent studies providing evidence based on treatment with other and more efficacious oral and injectable drugs. Finally, the panel identified future directions to pursue in this research field.

The Role of Prescribing Generic (Non-proprietary) Drugs in the Prevalence of Therapeutic Inertia in Multiple Sclerosis Care

Importance: The prescription of generic (non-proprietary) compared to brand-name drugs is increasing worldwide. In many developing and emerging countries, generics companies market products at similar costs as brand-name competitors benefiting from more flexible compliance rules and regulations for marketing their products in the health system. Together, this phenomenon may influence prescriber's behavior (e.g., maintaining the same treatment despite guideline's recommendations or despite evidence of disease progression).

Objectives: To compare the prevalence of therapeutic inertia (TI) between primary prescription of brand-name vs. generic drugs in the management of MS in Argentina.

Design: We conducted a population-based online study comprising 117 neurologists with expertise in MS. Participants answered questions regarding their clinical practice, most commonly prescribed disease modifying agents, and therapeutic choices of 10 simulated case-scenarios that assessed TI. Inertia was defined as the lack of treatment initiation or escalation despite evidence of clinical and radiological activity (8 case-scenarios, 720 individual responses). We created the generic-brand name score (GBS) according to the 5 most frequently prescribed generic (n = 16) vs. brand-name (n = 9) drugs for MS, where scores higher than 1 indicated higher prescription of generic drugs and scores lower than 1 indicated higher prescription of brand-name agents. Candidate predictors of prescribing generic drugs included demographic data, MS specialist vs. general neurologist, practice setting, years of practice, volume of MS patients, risk preferences, costs of annual treatment.

Participants and setting: population-based prospective study using including neurologists who care for patients with multiple sclerosis across Argentina.

Exposure: prescription of generic vs. brand-name MS drugs

Main outcome of interest: Therapeutic inertia (TI), defined as lack of treatment escalation when goals are unmet. Secondary outcomes included factors associated with generic drug prescription and costs of MS treatment.

Results: Ninety participants completed the study (completion rate 76.9%). TI was observed in 153 (21.3%) of participants' responses. The evaluation of aggregate responses revealed a mean GBS score (SD) of 3.44 (2.1), with 46 (51.1%) participants having a GBS equal to or higher than 1. Older age (OR 1.19; 95% CI 1.00–1.42), being a general neurologist (OR 3.91; 95% CI 1.19–12.8), and being more willing to take risks in multiple domains (SOEP score OR 1.06, 95% CI 1.01–1.12) were associated with higher prescription of generic drugs in MS care. Costs of treatment were not associated with prescribing generic drugs. There was no difference in the annual costs of MS treatment for primary prescribers of brand-name vs. generic drugs (67,500 US$ vs. 67,496 US$; p = 0.99).

The evaluation of individual responses revealed that participants with higher prescription of generics—reflected by a higher GBS—had higher incident risk of TI (mean GBS 3.61 for TI vs. 2.96 for no TI; p < 0.001). Multivariate analysis revealed that a prescription of generic agents was associated with an increased incident risk of TI (OR 1.56; 95%CI 1.07–2.29). There was no difference in the annual costs of MS treatment for participants that exhibited TI vs. those without TI (67,426 US$ vs. 67,704 US$; p = 0.66).

Conclusions: General neurologist, older age, and willingness to take risks were associated with increased prescription of generic drugs despite similar costs compared to brand-name agents. In our study, the prescription of generic-MS drugs was associated with a higher incident risk of therapeutic inertia.

Therapeutic Inertia in Multiple Sclerosis Care: A Study of Canadian Neurologists

Introduction: According to previous studies, therapeutic inertia (TI) may affect 7 out of 10 physicians who care for MS patients, particularly in countries where clinical guidelines are not widely used. Limited information is available on the prevalence of TI and its associated factors across Canada.

Objectives: (i) To evaluate factors associated with TI amongst neurologists caring for MS patients across Canada; (ii) to compare the prevalence of TI observed in Canadian neurologists to the prevalence of TI observed in Argentinean, Chilean, and Spanish neurologists (historical controls from prior studies).

Design: One hundred and eight neurologists with expertise in MS were invited to participate in an online study in Canada. Participants answered questions regarding their clinical practice, risk preferences, management of 10 simulated case-scenarios. The design of that study was similar to that of the prior studies completed in Argentina and Chile (n = 115). TI was defined as lack of treatment initiation or escalation when there was clear evidence of clinical and radiological disease activity (8 case-scenarios, 440 individual responses). A TI score was created & defined as the number of case-scenarios that fit the TI criteria over the total number of presented cases (score range from 0 to 8), with a higher score corresponding to a higher TI. TI scores observed in the Canadian study were compared with those observed in Argentina and Chile, as both studies followed the same design, case-scenarios and methodologies. Predictors of TI included demographic data, MS specialist vs. general neurologist, practice setting, years of practice, volume of MS patients and risk preferences.

Results: Fifty-five Canadian neurologists completed the study (completion rate: 50.9%). The mean age (±SD) was 38.3 (±15) years; 47.3% of the participants were female and 56.4% self-identified as MS specialists. Overall, 54 of 440 (12.3%) individual responses were classified as TI. 60% of participants displayed TI in at least one case-scenario. The mean TI score across Canada [0.98 (SD = 1.15)] was significantly lower than the TI score observed in the Argentinean-Chilean [1.82 (SD = 1.47); p < 0.001] study. The multivariable analysis revealed that older age (p = 0.018), years of experience (p = 0.04) and willingness to risk further disease progression by avoiding treatment initiation or treatment change (p = 0.043) were independent predictors of TI.

Conclusions: TI in Canada was observed in 6 out of 10 neurologists, affecting on average 1 in 8 therapeutic decisions in MS care. TI in Canada is significantly lower than in the other studied countries. Factors associated with TI include older age, lower years of experience, and willingness to risk disease progression by avoiding treatment initiation or treatment change. Differences in clinical practice patterns and adherence/access to accepted MS guidelines may explain how TI in Canada differs significantly from TI in Argentina-Chile.

Silent lesions on MRI imaging - Shifting goal posts for treatment decisions in multiple sclerosis

BACKGROUND

The current best practice suggests yearly magnetic resonance imaging (MRI) to monitor treatment response in multiple sclerosis (MS) patients.

OBJECTIVE

To evaluate the current practice of clinicians changing MS treatment based on subclinical new MRI lesions alone.

METHODS

Using MSBase, an international MS patient registry with MRI data, we analysed the probability of treatment change among patients with clinically silent new MRI lesions.

RESULTS

A total of 8311 MRI brain scans of 4232 patients were identified. Around 26.9% (336/1247) MRIs with one new T2 lesion were followed by disease-modifying therapy (DMT) change, increasing to 50.2% (129/257) with six new T2 lesions. DMT change was twice as likely with new T1 contrast enhancing compared to new T2 lesions odds ratio (OR): 2.43, 95% confidence interval (CI): 2.00-2.96 vs OR: 1.26 (95% CI: 1.22-1.29). DMT change with new MRI lesions occurred most frequently with 'injectable' DMTs. The probability of switching therapy was greater only after high-efficacy therapies became available in 2007 (after, OR: 1.43, 95% CI: 1.28-1.59 vs before, OR: 0.98, 95% CI: 0.520-1.88).

CONCLUSION

MS clinicians rely increasingly on MRI alone in their treatment decisions, utilizing low thresholds (1 new T2 lesion) for optimizing MS therapy. This signals a shift towards no evidence of disease activity (NEDA)-3 since high-efficacy therapies became available.

Effect of interferon beta-1a subcutaneously three times weekly on clinical and radiological measures and no evidence of disease activity status in patients with relapsing-remitting multiple sclerosis at year 1

Background

In the PRISMS study, interferon beta-1a subcutaneously (IFN β-1a SC) reduced clinical and radiological disease burden at 2 years in patients with relapsing–remitting multiple sclerosis. The study aimed to characterize efficacy of IFN β-1a SC 44 μg and 22 μg three times weekly (tiw) at Year 1.

Methods

Exploratory endpoints included annualized relapse rate (ARR), 3-month confirmed disability progression (1-point Expanded Disability Status Scale increase if baseline was < 6.0 [0.5-point if baseline was ≥6.0]), active T2 lesions, and no evidence of disease activity (NEDA; defined as no relapses [subanalyzed by relapse severity], 3-month confirmed progression, or active T2 lesions). Effect of IFN β-1a SC in prespecified patient subgroups was also assessed.

Results

Patients were randomized to IFN β-1a 22 μg (n = 189), 44 μg (n = 184), or placebo (n = 187). At 1 year, IFN β-1a SC tiw reduced ARR (p < 0.001), risk of disability progression (p ≤ 0.029), and mean number of active T2 lesions per patients per scan (p < 0.001) versus placebo. Clinical and radiological benefits were seen as early as Month 2 and 3. Outcomes in subgroups were consistent with those in the overall population. More patients treated with IFN β-1a SC tiw achieved NEDA status, versus placebo, regardless of relapse severity (p ≤ 0.006).

Conclusion

Clinical, radiological, and NEDA outcomes at Year 1 were consistent with Year 2 results. Treatment efficacy was consistent in pre-specified patient subgroups.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1145-x) contains supplementary material, which is available to authorized users.

Immune-cell BDNF expression in treatment-naïve relapsing-remitting multiple sclerosis patients and following one year of immunomodulation therapy

Although neurons are the main source of neurotrophins in the healthy brain, neurotrophins can also be expressed in the immune system. We have previously shown that in relapsing-remitting multiple sclerosis (RRMS) lower immune-cell neurotrophin levels are associated with brain atrophy and cognitive impairment. The aim of the present study was to assess if immune-cell neurotrophin expression is impaired in MS as compared with the healthy controls, and to describe if these levels change in treatment-naïve RRMS patients, following one year of immunomodulation. Fifty treatment-naïve RRMS patients were assessed at baseline and after one year of immunomodulation (beta-interferons/glatiramer acetate). The control group included 39 healthy subjects matched according to age and gender. Peripheral blood mononuclear cells (PBMCs) were isolated from heparinized blood using Ficoll-Histopaque gradient. The levels of brain-derived-neurotrophic-factor (BDNF), beta-nerve-growth-factor (beta-NGF), neurotrophin-3 (NT-3) and neurotrophin-4/5 (NT-4/5) were measured in PBMC lysates with ELISA. BDNF levels were significantly lower in MS than in the healthy controls (median 613 vs. 1657pg/mg protein, p<0.001). After one year of immunomodulation, BDNF expression did not change significantly (p=0.06) on the group level. In 70% of patients there was no increase in BDNF level, and in 30% it increased. We observed no differences between treatment groups. Other neurotrophins were detected in a minority of MS samples (as opposed to the controls). To conclude, we have shown that immune-cell production of neurotrophins is impaired in MS patients. In our MS cohort standard immunomodulation failed to restore normal BDNF levels in PBMCs within one year of therapy.

Weekly enhanced T1-weighted MRI with Gadobutrol injections in MS patients: Is there a signal intensity increase in the dentate nucleus and the globus pallidus?

BACKGROUND AND PURPOSE

Gadolinium-based contrast agents (GBCAs) administration have drastically improved the accuracy of Multiple Sclerosis (MS) diagnosis by highlighting any damage to the brain blood barrier, thereby differentiating between active and non-active lesions. Following multiple administrations of GBCAs, several MS studies have reported a signal intensity (SI) increase on unenhanced T1-weighted images in certain brain regions such as the dentate nucleus (DN) and the globus pallidus (GP). Our aim was therefore to determine the accumulation of macrocyclic GBCAs on enhanced T1-weighted images SI in the DN and the GP of MS patients injected eight times.

MATERIALS AND METHODS

Five MS patients underwent eight weekly consecutive MRI scans. Enhanced 3D T1-weighted images with Gadobutrol as a macrocyclic GBCA, were acquired. A ROI-based approach was applied for the evaluation of SI in the DN to middle cerebellar peduncle (DN-MCP) and GP to semi-oval white matter (GP-SOWM) ratios. An analysis of variance on repeated measures was used for the statistical analysis of each ratio.

RESULTS

No DN-MCP and GP-SOWM SI ratio differences were observed over the eight-weeks period using the macrocyclic GBCA.

CONCLUSION

Iterative and weekly injections of macrocyclic GBCAs are not associated with T1 signal increase in the DN and GP of MS patients. These results would suggest a no gadolinium accumulation in the brain using macrocyclic GBCA even after several close injections and promote the use of a macrocylcic GBCA rather than linear agents for MS patients.

Improved Detection of New MS Lesions during Follow-Up Using an Automated MR Coregistration-Fusion Method

BACKGROUND AND PURPOSE

MR imaging is the key examination in the follow-up of patients with MS, by identification of new high-signal T2 brain lesions. However, identifying new lesions when scrolling through 2 follow-up MR images can be difficult and time-consuming. Our aim was to compare an automated coregistration-fusion reading approach with the standard approach by identifying new high-signal T2 brain lesions in patients with multiple sclerosis during follow-up MR imaging.

MATERIALS AND METHODS

This prospective monocenter study included 94 patients (mean age, 38.9 years) treated for MS with dimethyl fumarate from January 2014 to August 2016. One senior neuroradiologist and 1 junior radiologist checked for new high-signal T2 brain lesions, independently analyzing blinded image datasets with automated coregistration-fusion or the standard scroll-through approach with a 3-week delay between the 2 readings. A consensus reading with a second senior neuroradiologist served as a criterion standard for analyses. A Poisson regression and logistic and γ regressions were used to compare the 2 methods. Intra- and interobserver agreement was assessed by the κ coefficient.

RESULTS

There were significantly more new high-signal T2 lesions per patient detected with the coregistration-fusion method (7 versus 4, P < .001). The coregistration-fusion method detected significantly more patients with at least 1 new high-signal T2 lesion (59% versus 46%, P = .02) and was associated with significantly faster overall reading time (86 seconds faster, P < .001) and higher reader confidence (91% versus 40%, P < 1 × 10^-4). Inter- and intraobserver agreement was excellent for counting new high-signal T2 lesions.

CONCLUSIONS

Our study showed that an automated coregistration-fusion method was more sensitive for detecting new high-signal T2 lesions in patients with MS and reducing reading time. This method could help to improve follow-up care.

'No evidence of disease activity' - is it an appropriate surrogate in multiple sclerosis?

The increasing number of disease‐modifying treatments available for multiple sclerosis has broadened treatment options for patients, but also challenges clinicians to select the best therapy for each individual at the appropriate stage of the disease. Early prediction of treatment response still remains one of the main difficulties in the management of multiple sclerosis patients. The concept of ‘no evidence of disease activity’ (NEDA) has been proposed as a surrogate for treatment response based on the absence of relapses, disability progression and radiological activity. Although there are several apparently logical arguments for the NEDA approach, there are also some major concerns that have to be considered and that are not sufficiently addressed yet. Amongst others, each parameter's limitations are not eliminated solely by its use within a composite score, and the contribution of each parameter to NEDA is not well balanced, as the detection of, for example, a single new magnetic resonance imaging lesion is considered as significant as the occurrence of a severely disabling relapse. NEDA in its current form also neglects underlying pathophysiology of the disease, has not been shown to fulfil formal criteria of a surrogate marker and its prognostic value has not been sufficiently evidenced yet. From a clinical point of view, ‘evidence of disease activity’ seems the more relevant surrogate; however, its implications are even less clear than those of NEDA. Here, existing literature on NEDA is critically reviewed and improvements are discussed that value its potential use in clinical trials and, even more importantly, treatment decision making in daily routine.

Predictive value of early magnetic resonance imaging measures is differentially affected by the dose of interferon beta-1a given subcutaneously three times a week: an exploratory analysis of the PRISMS study

BACKGROUND

On-treatment magnetic resonance imaging lesions may predict long-term clinical outcomes in patients receiving interferon β-1a. This study aimed to assess the effect of active T2 and T1 gadolinium-enhancing (Gd+) lesions on relapses and 3-month confirmed Expanded Disability Status Scale (EDSS) progression in the PRISMS clinical trial.

METHODS

Exploratory analyses assessed whether active T2 and T1 Gd + lesions at Month 6, or active T2 lesions at Month 12, predicted clinical outcomes over 4 years in PRISMS.

RESULTS

Mean active T2 lesion number at Month 6 was significantly lower with interferon beta-1a given subcutaneously (IFN β-1a SC) 44 μg and 22 μg 3×/week (tiw) than with placebo (p < 0.0001). The presence of ≥4 versus 0 active T2 lesions predicted disability progression at Years 3-4 in the IFN β-1a SC 22 μg group only (p < 0.05), whereas the presence of ≥2 versus 0-1 active T2 lesions predicted disability progression in the placebo/delayed treatment (DTx) (Years 2-4; p < 0.05) and IFN β-1a SC 22 μg groups (Years 3-4; p < 0.05). Greater active T2 lesion number at 6 months predicted relapses in the placebo/DTx group only (≥4 vs. 0, Years 1-4; ≥2 vs. 0-1, Years 2-4; p < 0.05), and the presence of T1 Gd + lesions at 6 months predicted disability progression in the IFN β-1a SC 44 μg group only (Year 1; p < 0.05). The presence of ≥2 versus 0-1 active T2 lesions at 12 months predicted disability progression over 3 and 4 years in the IFN β-1a SC 44 μg group.

CONCLUSION

Active T2 lesions at 6 months predicted clinical outcomes in patients receiving placebo or IFN β-1a SC 22 μg, but not in those receiving IFN β-1a SC 44 μg. Active T2 lesions at 12 months may predict outcomes in those receiving IFN β-1a SC 44 μg and are possibly more suggestive of poor response to therapy than T2 results at 6 months.

Recent developments in interferon-based therapies for multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a chronic and disabling immune-mediated disease of the central nervous system. Beta-interferons are the first approved and still the most widely used first-line disease-modifying treatment in MS.

AREAS COVERED

Here we focus on recent developments in pharmacology and delivery systems of beta-interferons, and discuss their place within current state of the art therapeutic approaches. We briefly review the clinical trials for classical and PEGylated formulations, emphasizing effectiveness, safety concerns, and tolerability. The mechanisms of action of IFN-β in view of MS pathogenesis are also debated

EXPERT OPINION

Though only modestly efficient in reducing the annualized relapse rate, beta-interferons remain a valid first-line option due to their good long-term safety profile and cost-efficacy. Moreover, they are endogenous class II cytokines essential for mounting an effective antiviral response, and they may interact with putative MS triggering factors such as Epstein-Barr virus infection and human endogenous retroviruses. Recent improvements in formulations, delivery devices and drug regimens tackle the tolerability and adherence issues frequently seen with these drugs, and scientific advances may offer means for a better selection of patients. Although a well-established immunomodulatory treatment, beta-interferons have not said their last word in the management of MS.

Therapeutic Inertia in the New Landscape of Multiple Sclerosis Care

The landscape of multiple sclerosis (MS) treatment is constantly changing. Significant heterogeneity exists in the efficacy and risks associated with these therapies. Therefore, clinicians have the challenge to tailor treatment based on several factors (disease activity level, risk of progression, individual patient preferences and characteristics, personal expertise, etc.), to identify the optimal balance between safety and efficacy. However, most clinicians have limited education in decision-making and formal training in risk management. Together, these factors may lead to therapeutic inertia (TI); defined as the absence of treatment initiation or intensification when therapeutic goals are unmet. TI may lead to suboptimal treatments choices, worse clinical outcomes, and more disability. This article provides a succinct overview on factors influencing TI in MS care.

Improving multiple sclerosis management and collecting safety information in the real world: the MSDS3D software approach

INTRODUCTION

For safety evaluation, randomized controlled trials (RCTs) are not fully able to identify rare adverse events. The richest source of safety data lies in the post-marketing phase. Real-world evidence (RWE) and observational studies are becoming increasingly popular because they reflect usefulness of drugs in real life and have the ability to discover uncommon or rare adverse drug reactions.

AREAS COVERED

Adding the documentation of psychological symptoms and other medical disciplines, the necessity for a complex documentation becomes apparent. The collection of high-quality data sets in clinical practice requires the use of special documentation software as the quality of data in RWE studies can be an issue in contrast to the data obtained from RCTs. The MSDS3D software combines documentation of patient data with patient management of patients with multiple sclerosis. Following a continuous development over several treatment-specific modules, we improved and expanded the realization of safety management in MSDS3D with regard to the characteristics of different treatments and populations.

EXPERT OPINION

eHealth-enhanced post-authorisation safety study may complete the fundamental quest of RWE for individually improved treatment decisions and balanced therapeutic risk assessment. MSDS3D is carefully designed to contribute to every single objective in this process.

Effectiveness and baseline factors associated to fingolimod response in a real-world study on multiple sclerosis patients

BACKGROUND

Treatment choice in multiple sclerosis (MS) is crucial for optimizing risk-benefit profile.

OBJECTIVE

To assess fingolimod (FTY) effectiveness and identify baseline features associated to disease activity in a large Italian cohort of Relapsing-Remitting (RR) MS patients.

METHODS

Three-hundred sixty-seven RRMS patients starting FTY treatment at San Raffaele Hospital (Milan-Italy) underwent clinical and MRI evaluations for 2 years. Treatment response was assessed considering the proportion of patients with no evidence of disease activity (NEDA) and recording the time to first relapse. Primary analyses were performed stratifying for Natalizumab (NTZ) treatment in the year before (NO_NTZ vs NTZ group), to account for post-NTZ reactivation.

RESULTS

Almost half of patients were NEDA after 2 years, 53.4% in the NO_NTZ group and 36.2% in the NTZ group. Despite an opposite trend during the first 6-12 months, at 2-year follow-up the two groups were comparable for relapses and number of new/enlarging T2 and Gd-enhancing lesions. Baseline parameters of higher disease activity (ARR, Gd enhancing lesions and age at onset) were associated with increased likelihood of failing NEDA criteria or with shorter time to relapse (p < 0.05).

CONCLUSIONS

Our data strengthen FTY effectiveness in everyday clinical practice, even in patients switching from NTZ treatment. Baseline parameters of inflammatory activity are the most important prognostic factors for mid-term disease reactivation also during second-line treatment with FTY, providing hints on how to select therapies towards a more personalized management.

ECTRIMS/EAN Guideline on the pharmacological treatment of people with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a complex disease with new drugs becoming available in the past years. There is a need for a reference tool compiling current data to aid professionals in treatment decisions.

OBJECTIVES

To develop an evidence-based clinical practice guideline for the pharmacological treatment of people with MS.

METHODS

This guideline has been developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology and following the updated EAN recommendations. Clinical questions were formulated in Patients-Intervention-Comparator-Outcome (PICO) format and outcomes were prioritized. The quality of evidence was rated into four categories according to the risk of bias. The recommendations with assigned strength (strong and weak) were formulated based on the quality of evidence and the risk-benefit balance. Consensus between the panelists was reached by use of the modified nominal group technique.

RESULTS

A total of 10 questions were agreed, encompassing treatment efficacy, response criteria, strategies to address suboptimal response and safety concerns and treatment strategies in MS and pregnancy. The guideline takes into account all disease-modifying drugs approved by the European Medicine Agency (EMA) at the time of publication. A total of 21 recommendations were agreed by the guideline working group after three rounds of consensus.

CONCLUSION

The present guideline will enable homogeneity of treatment decisions across Europe.

The evolution of "No Evidence of Disease Activity" in multiple sclerosis

The availability of effective therapies for patients with relapsing-remitting multiple sclerosis (RRMS) has prompted a re-evaluation of the most appropriate way to measure treatment response, both in clinical trials and clinical practice. Traditional parameters of treatment efficacy such as annualized relapse rate, magnetic resonance imaging (MRI) activity, and disability progression have an important place, but their relative merit is uncertain, and the role of other factors such as brain atrophy is still under study. More recently, composite measures such as "no evidence of disease activity" (NEDA) have emerged as new potential treatment targets, but NEDA itself has variable definitions, is not well validated, and may be hard to implement as a treatment goal in a clinical setting. We describe the development of NEDA as an outcome measure in MS, discuss definitions including NEDA-3 and NEDA-4, and review the strengths and limitations of NEDA, indicating where further research is needed.

Oral teriflunomide in the treatment of relapsing forms of multiple sclerosis: clinical evidence and long-term experience

Key objectives in the treatment of multiple sclerosis (MS) include prevention of relapses, a reduction in the accumulation of disability and slowing of the brain volume loss that occurs from the earliest stages of the disease. Teriflunomide, a once-daily, oral immunomodulatory therapy, has demonstrated efficacy across multiple measures of disease activity and worsening in patients with relapsing forms of MS and in those with a first clinical episode suggestive of MS. In this review, the latest evidence relating to the proposed mechanism of action of teriflunomide in MS is explored, including novel insights provided from the recently completed Teri-DYNAMIC study. Key clinical and magnetic resonance imaging data from the completed long-term extensions of the phase II and III (TEMSO, TOWER and TOPIC) studies are highlighted, and the long-term safety profile of teriflunomide, as evidenced by data from these extension studies, is presented. Although randomized clinical trials represent the highest level of evidence to support the use of therapeutic interventions, it is also important to understand the performance of a particular treatment in the real-world setting. In this regard, the results of the recently completed, global, phase IV Teri-PRO study are of particular interest and provide further insights into the benefits of teriflunomide treatment from the patient perspective. Collectively, the data presented in this review demonstrate a favorable benefit-risk profile for teriflunomide, thereby supporting its long-term use for the treatment of patients with relapsing forms of MS.

A supervised framework with intensity subtraction and deformation field features for the detection of new T2-w lesions in multiple sclerosis

Introduction

Longitudinal magnetic resonance imaging (MRI) analysis has an important role in multiple sclerosis diagnosis and follow-up. The presence of new T2-w lesions on brain MRI scans is considered a prognostic and predictive biomarker for the disease. In this study, we propose a supervised approach for detecting new T2-w lesions using features from image intensities, subtraction values, and deformation fields (DF).

Methods

One year apart multi-channel brain MRI scans were obtained for 60 patients, 36 of them with new T2-w lesions. Images from both temporal points were preprocessed and co-registered. Afterwards, they were registered using multi-resolution affine registration, allowing their subtraction. In particular, the DFs between both images were computed with the Demons non-rigid registration algorithm. Afterwards, a logistic regression model was trained with features from image intensities, subtraction values, and DF operators. We evaluated the performance of the model following a leave-one-out cross-validation scheme.

Results

In terms of detection, we obtained a mean Dice similarity coefficient of 0.77 with a true-positive rate of 74.30% and a false-positive detection rate of 11.86%. In terms of segmentation, we obtained a mean Dice similarity coefficient of 0.56. The performance of our model was significantly higher than state-of-the-art methods.

Conclusions

The performance of the proposed method shows the benefits of using DF operators as features to train a supervised learning model. Compared to other methods, the proposed model decreases the number of false-positives while increasing the number of true-positives, which is relevant for clinical settings.

•

A new framework for detecting new T2-w lesions in multiple sclerosis is proposed.

•

We train logistic regression classifier with subtraction and deformation features.

•

We analyze the effect of deformation field operators on detecting new T2-w lesions.

•

We show an increase in the accuracy due to the addition of deformation fields.

•

The proposed model decreases false-positives while increasing true-positives.

NEDA treatment target? No evident disease activity as an actionable outcome in practice

"No evident disease activity" (NEDA) is a proposed measure of disease activity-free status in multiple sclerosis (MS) that is typically defined as absence of relapses, disability progression, and MRI activity over a defined time period. NEDA is increasingly reported in randomized controlled trials of MS disease modifying therapies where it has some perceived advantages over outcomes such as annualized relapse rate. NEDA has also been proposed as a treatment goal in clinical care. At this point, the long-term implications of early NEDA remain largely unknown. We review current NEDA definitions, use in clinical trials, and its prospects for routine use as an actionable treatment target in clinical practice.

MRI and multiple sclerosis-the evolving role of MRI in the diagnosis and management of MS: a clinician's perspective

The diagnosis of multiple sclerosis (MS) is based on a history consistent with demyelination of the central nervous system and corresponding physical signs on examination. However, this diagnosis is supported radiologically using magnetic resonance imaging (MRI). At present, MRI serves as the most reliable and widely available biomarker for the practising clinician to measure disease activity and treatment response in MS. As MRI remains central to both the diagnosis and management of MS, this paper provides proposed guidelines for its use in routine clinical practice.

The efficacy of cladribine tablets in CIS patients retrospectively assigned the diagnosis of MS using modern criteria: Results from the ORACLE-MS study

Background

Multiple sclerosis (MS) diagnostic criteria have changed since the ORACLE-MS study was conducted; 223 of 616 patients (36.2%) would have met the diagnosis of MS vs clinically isolated syndrome (CIS) using the newer criteria.

Objective

The objective of this paper is to assess the effect of cladribine tablets in patients with a first clinical demyelinating attack fulfilling newer criteria (McDonald 2010) for MS vs CIS.

Methods

A post hoc analysis for subgroups of patients retrospectively classified as fulfilling or not fulfilling newer criteria at the first clinical demyelinating attack was conducted.

Results

Cladribine tablets 3.5 mg/kg (n = 68) reduced the risk of next attack or three-month confirmed Expanded Disability Status Scale (EDSS) worsening by 74% vs placebo (n = 72); p = 0.0009 in patients meeting newer criteria for MS at baseline. Cladribine tablets 5.25 mg/kg (n = 83) reduced the risk of next attack or three-month confirmed EDSS worsening by 37%, but nominal significance was not reached (p = 0.14). In patients who were still CIS after applying newer criteria, cladribine tablets 3.5 mg/kg (n = 138) reduced the risk of conversion to clinically definite multiple sclerosis (CDMS) by 63% vs placebo (n = 134); p = 0.0003. Cladribine tablets 5.25 mg/kg (n = 121) reduced the risk of conversion by 75% vs placebo (n = 134); p < 0.0001.

Conclusions

Regardless of the criteria used to define CIS or MS, 3.5 mg/kg cladribine tablets are effective in patients with a first clinical demyelinating attack.

ClinicalTrials.gov registration: The ORACLE-MS study (NCT00725985).