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Abstract
PURPOSE OF REVIEW This article discusses acute exacerbations (relapses) of multiple sclerosis (MS). Relapses are a hallmark of MS and are often associated with significant functional impairment and decreased quality of life. This review discusses the proposed pathophysiology of MS relapses, triggering factors, associated markers, variants of clinical presentation, and diagnostic recommendations. RECENT FINDINGS Most MS exacerbations are followed by a period of repair leading to clinical remission; however, residual deficits may persist after MS relapse and contribute to the stepwise progression of disability. Treatment of MS relapses is important as it helps to shorten the duration of disability associated with their course. Successful treatment of relapse helps patients with MS obtain a vital sense of being able to gain control over the disease. Patients with relapsing MS who receive treatment report better outcomes than those who are simply observed. This article discusses treatment options for MS relapse, including systemic corticosteroids, adrenocorticotropic hormone, and plasma exchange. Recent findings related to the mechanisms of action of steroids and adrenocorticotropic hormone are also reviewed, and other potential therapies are assessed. A proposed algorithm for MS relapse management is presented, including strategies for steroid-resistant MS exacerbations. SUMMARY MS relapses need to be recognized in a timely manner and treated using recommended therapeutic methods.
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Abstract
Multiple sclerosis (MS) commonly affects the cerebellum causing acute and chronic symptoms. Cerebellar signs contribute significantly to clinical disability, and symptoms such as tremor, ataxia, and dysarthria are particularly difficult to treat. Increasing knowledge concerning the pathophysiology of cerebellar disease in MS from human postmortem studies, experimental models, and clinical trials has raised the hope that cerebellar symptoms will be better treated in the future.
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Affiliation(s)
- Alastair Wilkins
- MS and Stem Cell Group, University of Bristol, Learning and Research, Southmead Hospital, Bristol, United Kingdom
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Abdelhak A, Weber MS, Tumani H. Primary Progressive Multiple Sclerosis: Putting Together the Puzzle. Front Neurol 2017; 8:234. [PMID: 28620346 PMCID: PMC5449443 DOI: 10.3389/fneur.2017.00234] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 05/12/2017] [Indexed: 12/23/2022] Open
Abstract
The focus of multiple sclerosis research has recently turned to the relatively rare and clearly more challenging condition of primary progressive multiple sclerosis (PPMS). Many risk factors such as genetic susceptibility, age, and Epstein–Barr virus (EBV) infection may interdepend on various levels, causing a complex pathophysiological cascade. Variable pathological mechanisms drive disease progression, including inflammation-associated axonal loss, continuous activation of central nervous system resident cells, such as astrocytes and microglia as well as mitochondrial dysfunction and iron accumulation. Histological studies revealed diffuse infiltration of the gray and white matter as well as of the meninges with inflammatory cells such as B-, T-, natural killer, and plasma cells. While numerous anti-inflammatory agents effective in relapsing remitting multiple sclerosis basically failed in treatment of PPMS, the B-cell-depleting monoclonal antibody ocrelizumab recently broke the dogma that PPMS cannot be treated by an anti-inflammatory approach by demonstrating efficacy in a phase 3 PPMS trial. Other treatments aiming at enhancing remyelination (MD1003) as well as EBV-directed treatment strategies may be promising agents on the horizon. In this article, we aim to summarize new advances in the understanding of risk factors, pathophysiology, and treatment of PPMS. Moreover, we introduce a novel concept to understand the nature of the disease and possible treatment strategies in the near future.
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Affiliation(s)
| | - Martin S Weber
- Department of Neuropathology, University Medical Center, Georg August University, Göttingen, Germany.,Department of Neurology, University Medical Center, Georg August University, Göttingen, Germany
| | - Hayrettin Tumani
- Department of Neurology, Ulm University, Ulm, Germany.,Specialty Clinic of Neurology Dietenbronn, Schwendi, Germany
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Mills EA, Mirza A, Mao-Draayer Y. Emerging Approaches for Validating and Managing Multiple Sclerosis Relapse. Front Neurol 2017; 8:116. [PMID: 28424654 PMCID: PMC5372802 DOI: 10.3389/fneur.2017.00116] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 03/14/2017] [Indexed: 12/17/2022] Open
Abstract
The autoimmune disease multiple sclerosis (MS) is characterized by relapses in the majority of patients. A definitive clinical diagnosis of relapse in MS can be complicated by the presence of an infection or comorbid disorder. In this mini-review, we describe efforts to develop enhanced imaging techniques and biomarker detection as future tools for relapse validation. There is emerging evidence of roles for meningeal inflammation, sex hormones, comorbid metabolic or mood disorders, and a dysregulated immune profile in the manifestation and severity of relapse. Specific subsets of immune cells likely drive the pathophysiology of relapse, and identification of a patient's unique immunological signature of relapse may help guide future diagnosis and treatment. Finally, these studies highlight the diversity in terms of relapse presentation, immunological signature, and response in patients with MS, indicating that going forward the best approach to assessment and treatment of relapse will be multifactorial and highly personalized.
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Affiliation(s)
- Elizabeth A Mills
- Molecular and Behavioral Neuroscience Institute, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ali Mirza
- Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Yang Mao-Draayer
- Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
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55
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Giovannoni G, Cutter G, Sormani MP, Belachew S, Hyde R, Koendgen H, Knappertz V, Tomic D, Leppert D, Herndon R, Wheeler-Kingshott CAM, Ciccarelli O, Selwood D, di Cantogno EV, Ben-Amor AF, Matthews P, Carassiti D, Baker D, Schmierer K. Is multiple sclerosis a length-dependent central axonopathy? The case for therapeutic lag and the asynchronous progressive MS hypotheses. Mult Scler Relat Disord 2017; 12:70-78. [PMID: 28283111 DOI: 10.1016/j.msard.2017.01.007] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 01/06/2017] [Accepted: 01/12/2017] [Indexed: 10/20/2022]
Abstract
Trials of anti-inflammatory therapies in non-relapsing progressive multiple sclerosis (MS) have been stubbornly negative except recently for an anti-CD20 therapy in primary progressive MS and a S1P modulator siponimod in secondary progressive MS. We argue that this might be because trials have been too short and have focused on assessing neuronal pathways, with insufficient reserve capacity, as the core component of the primary outcome. Delayed neuroaxonal degeneration primed by prior inflammation is not expected to respond to disease-modifying therapies targeting MS-specific mechanisms. However, anti-inflammatory therapies may modify these damaged pathways, but with a therapeutic lag that may take years to manifest. Based on these observations we propose that clinically apparent neurodegenerative components of progressive MS may occur in a length-dependent manner and asynchronously. If this hypothesis is confirmed it may have major implications for the future design of progressive MS trials.
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Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK.
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA.
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
| | | | | | | | | | | | | | - Robert Herndon
- University of Mississippi Medical Center, Jackson, MS, USA.
| | - Claudia A M Wheeler-Kingshott
- NMR Research Unit, Queen Square MS Centre, Department of Neuroinflammation, UCL Institute of Neurology, Queen Square, London, UK.
| | - Olga Ciccarelli
- NMR Research Unit, Queen Square MS Centre, Department of Neuroinflammation, UCL Institute of Neurology, Queen Square, London, UK; NIHR University College Hospitals Biomedical Research Centre (BRC), UK.
| | - David Selwood
- Wolfson Institute for Biomedical Research, UCL, London, UK.
| | | | | | - Paul Matthews
- Department of Medicine, Imperial College, London, UK.
| | - Daniele Carassiti
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK.
| | - David Baker
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK.
| | - Klaus Schmierer
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK.
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Dahdaleh M, Alroughani R, Aljumah M, AlTahan A, Alsharoqi I, Bohlega SA, Daif A, Deleu D, Inshasi J, Karabudak R, Sahraian MA, Taha K, Yammout BI, Zakaria M. Intervening to reduce the risk of future disability from multiple sclerosis: are we there yet? Int J Neurosci 2017; 127:944-951. [PMID: 28029270 DOI: 10.1080/00207454.2016.1277424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Disease-modifying therapies (DMTs) delay or may prevent the progression of patients with high-risk clinically isolated syndrome (CIS) to clinically definite multiple sclerosis (MS), and from relapsing-remitting MS to secondary progressive MS. Current evidence on the effects of DMT on disability in MS is supported by the use of the Expanded Disability Status Scale (EDSS), which is dominated by ambulation, and usually used as a secondary outcome measure. Less is known about the long-term effects of DMTs on other aspects of functional status, particularly cognition, which is a key determinant of ability to work. The time scale for measurements of disability is at most a few years, with scant data from more than 10 years of observation. Longer prospective follow-up of large numbers of patients with CIS is needed to determine whether early intervention with a DMT influences long-term disease progression. Finally, the emergence of the radiologically isolated syndrome (RIS) as a clinical entity has shifted the debate about when to intervene to an even earlier time frame. Balancing the significant side-effects associated with DMT in general and the expected outcome of pharmacologic intervention is increasingly problematic for managing patients with uncertain prognosis, as many patients may have low-risk CIS, benign MS or patients with RIS only. Preventing long-term disability in MS should be recognised more clearly as an important outcome in its own right, with disability measured more consistently with more sensitive instruments beyond the use of the EDSS.
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Affiliation(s)
- Maurice Dahdaleh
- a Department of Internal Medicine, Neurology Section , Arab Medical Center and Khalidi Hospital , Amman , Jordan
| | - Raed Alroughani
- b Division of Neurology, Amiri Hospital, Kuwait and Division of Neurology , Dasman Diabetes Institute , Kuwait City , Kuwait
| | - Mohammed Aljumah
- c King Abdullah International Medical Research Center , King Saud Ben Abdulaziz University for Health Sciences, NGHA , Riyadh , Saudi Arabia.,d KFMC, Ministry of Health , Riyadh , Saudi Arabia
| | - Abdulrahman AlTahan
- e Neurology Section , King Khalid University Hospital, King Saud University and Dallah Hospital , Riyadh , Saudi Arabia
| | - Issa Alsharoqi
- f Clinical Neurosciences Department , Salmaniya Medical Complex , Manama , Bahrain
| | - Saeed A Bohlega
- g Department of Neurosciences , King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia
| | - Abdulkader Daif
- h Neurology Division, King Khalid University Hospital , King Saud University , Riyadh , Saudi Arabia
| | - Dirk Deleu
- i Department of Neurology (Medicine) , Hamad Medical Corporation , Doha , Qatar
| | - Jihad Inshasi
- j Neurology Department, Rashid Hospital and Dubai Medical College , Dubai Health Authority , Dubai , United Arab Emirates
| | - Rana Karabudak
- k Department of Neurology, Neuroimmunology Unit , Hacettepe University Hospitals , Ankara , Turkey
| | - Mohammed A Sahraian
- l MS Research Center , Neuroscience Institute, Tehran University of Medical Sciences , Tehran , Iran
| | - Karim Taha
- m Merck Serono Intercontinental Region , Dubai , United Arab Emirates
| | - Bassem I Yammout
- n Multiple Sclerosis Center , American University of Beirut Medical Center , Beirut , Lebanon
| | - Magd Zakaria
- o Neuropsychiatric Department, Faculty of Medicine , Ain Shams University , Egypt
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Borisow N, Kleiter I, Gahlen A, Fischer K, Wernecke KD, Pache F, Ruprecht K, Havla J, Krumbholz M, Kümpfel T, Aktas O, Ringelstein M, Geis C, Kleinschnitz C, Berthele A, Hemmer B, Angstwurm K, Weissert R, Stellmann JP, Schuster S, Stangel M, Lauda F, Tumani H, Mayer C, Zeltner L, Ziemann U, Linker RA, Schwab M, Marziniak M, Then Bergh F, Hofstadt-van Oy U, Neuhaus O, Winkelmann A, Marouf W, Rückriem L, Faiss J, Wildemann B, Paul F, Jarius S, Trebst C, Hellwig K. Influence of female sex and fertile age on neuromyelitis optica spectrum disorders. Mult Scler 2016; 23:1092-1103. [PMID: 27758954 DOI: 10.1177/1352458516671203] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gender and age at onset are important epidemiological factors influencing prevalence, clinical presentation, and treatment response in autoimmune diseases. OBJECTIVE To evaluate the impact of female sex and fertile age on aquaporin-4-antibody (AQP4-ab) status, attack localization, and response to attack treatment in patients with neuromyelitis optica (NMO) and its spectrum disorders (neuromyelitis optica spectrum disorder (NMOSD)). METHODS Female-to-male ratios, diagnosis at last visit (NMO vs NMOSD), attack localization, attack treatment, and outcome were compared according to sex and age at disease or attack onset. RESULTS A total of 186 NMO/SD patients (82% female) were included. In AQP4-ab-positive patients, female predominance was most pronounced during fertile age (female-to-male ratio 23:1). Female patients were more likely to be positive for AQP4-abs (92% vs 55%; p < 0.001). Interval between onset and diagnosis of NMO/SD was longer in women than in men (mean 54 vs 27 months; p = 0.023). In women, attacks occurring ⩽40 years of age were more likely to show complete remission ( p = 0.003) and better response to high-dose intravenous steroids ( p = 0.005) compared to woman at >40 years. CONCLUSION Our data suggest an influence of sex and age on susceptibility to AQP4-ab-positive NMO/SD. Genetic and hormonal factors might contribute to pathophysiology of NMO/SD.
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Affiliation(s)
- Nadja Borisow
- NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Anna Gahlen
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Katrin Fischer
- Department of Neurology, Asklepios Fachklinikum Teupitz, Teupitz, Germany
| | | | - Florence Pache
- NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology and Clinical and Experimental Multiple Sclerosis Research Center, Charité University Medicine Berlin, Berlin, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Medical Campus Grosshadern, Ludwig Maximilians University of Munich, Munich, Germany
| | - Markus Krumbholz
- Institute of Clinical Neuroimmunology, Medical Campus Grosshadern, Ludwig Maximilians University of Munich, Munich, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, Medical Campus Grosshadern, Ludwig Maximilians University of Munich, Munich, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian Geis
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany/Hans-Berger Department of Neurology and Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | | | - Achim Berthele
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany/Munich Cluster for Systems Neurology (SyNergy), Technische Universität München, Munich, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Robert Weissert
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Jan-Patrick Stellmann
- Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany/Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon Schuster
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Stangel
- Department of Clinical Neuroimmunology and Neurochemistry and Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Florian Lauda
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Hayrettin Tumani
- Department of Neurology at RKU and Specialty Clinic of Neurology Dietenbronn, University of Ulm, Ulm, Germany
| | - Christoph Mayer
- Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | - Lena Zeltner
- Department of Neurology and Stroke and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology and Stroke and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ralf A Linker
- Department of Neurology, Friedrich-Alexander University Erlangen-Nüremberg, Erlangen, Germany
| | - Matthias Schwab
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Martin Marziniak
- Department of Neurology, University of Münster, Münster, Germany/Department of Neurology and Neurological Intensive Care, Isar-Amper-Clinic, Munich-East, Haar, Germany
| | | | - Ulrich Hofstadt-van Oy
- Department of Neurology, Klinikum Bayreuth, Bayreuth, Germany/Department of Neurology, Klinikum Westfalen, Dortmund, Germany
| | - Oliver Neuhaus
- Department of Neurology, SRH Krankenhaus Sigmaringen, Sigmaringen, Germany
| | | | - Wael Marouf
- Department of Neurology, HELIOS Hanseklinikum Stralsund, Stralsund, Germany
| | - Lioba Rückriem
- Department of Neurology, MediClin Hedon Klinik, Lingen, Germany
| | - Jürgen Faiss
- Department of Neurology, Asklepios Fachklinikum Teupitz, Teupitz, Germany
| | | | - Friedemann Paul
- NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité University Medicine Berlin, Berlin, Germany/Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité University Medicine Berlin, Berlin, Germany
| | - Sven Jarius
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Scalfari A, Lederer C, Daumer M, Nicholas R, Ebers GC, Muraro PA. The relationship of age with the clinical phenotype in multiple sclerosis. Mult Scler 2016; 22:1750-1758. [DOI: 10.1177/1352458516630396] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 01/07/2016] [Indexed: 11/17/2022]
Abstract
Background: The multiple sclerosis (MS) clinical course and relapses frequency before progression vary widely. Objective: To investigate the influence of age on the MS phenotype. Methods: Among 751 primary progressive (PP = 217) and secondary progressive (SP = 534) MS patients from the London Ontario database, we assessed the relationship of age on the relapse frequency and on the progressive phase evolution, and the impact of relapses on the age at onset of progression. Results: Age at onset did not influence the early attacks frequency, but patients younger at onset had larger number of total attacks before progression (age = 27.4, 31.0 and 32.8 mean years; ⩾4, 2–3 and 1 relapses, respectively) and longer latency to SP. Although frequent early relapses predicted younger age at SP onset, patients with no attacks (primary progressive multiple sclerosis (PPMS)), or 1, 2–3 and ⩾4 relapses during the relapsing-remitting phase started progressing at similar age (38.6, 41.3, 41.4 and 39.2 mean years, respectively). The age at onset of progressive phase did not affect its evolution. Conclusions: Age strongly influences the phenotype before progression. Relapsing-remitting patients younger at onset are more likely to display a predominantly inflammatory course, yet relapses number does not affect the age at onset of progression.
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Affiliation(s)
- A Scalfari
- Centre for Neuroscience, Division of Brain Sciences, Department of Medicine, Wolfson Neuroscience Laboratories, Imperial College London, London, UK
| | - C Lederer
- Sylvia Lawry Centre for Multiple Sclerosis Research, Munich, Germany
| | - M Daumer
- Sylvia Lawry Centre for Multiple Sclerosis Research, Munich, Germany
| | - R Nicholas
- Centre for Neuroscience, Division of Brain Sciences, Department of Medicine, Wolfson Neuroscience Laboratories, Imperial College London, London, UK/Department of Neurosciences, Imperial College Healthcare NHS Trust, London, UK
| | - GC Ebers
- Department of Clinical Neurology, Oxford University, Oxford, UK
| | - PA Muraro
- Centre for Neuroscience, Division of Brain Sciences, Department of Medicine, Wolfson Neuroscience Laboratories, Imperial College London, London, UK
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Stewart T, Spelman T, Havrdova E, Horakova D, Trojano M, Izquierdo G, Duquette P, Girard M, Prat A, Lugaresi A, Grand'Maison F, Grammond P, Sola P, Shaygannejad V, Hupperts R, Alroughani R, Oreja-Guevara C, Pucci E, Boz C, Lechner-Scott J, Bergamaschi R, Van Pesch V, Iuliano G, Ramo C, Taylor B, Slee M, Spitaleri D, Granella F, Verheul F, McCombe P, Hodgkinson S, Amato MP, Vucic S, Gray O, Cristiano E, Barnett M, Sanchez Menoyo JL, van Munster E, Saladino ML, Olascoaga J, Prevost J, Deri N, Shaw C, Singhal B, Moore F, Rozsa C, Shuey N, Skibina O, Kister I, Petkovska-Boskova T, Ampapa R, Kermode A, Butzkueven H, Jokubaitis V, Kalincik T. Contribution of different relapse phenotypes to disability in multiple sclerosis. Mult Scler 2016; 23:266-276. [PMID: 27055805 DOI: 10.1177/1352458516643392] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study evaluated the effect of relapse phenotype on disability accumulation in multiple sclerosis. METHODS Analysis of prospectively collected data was conducted in 19,504 patients with relapse-onset multiple sclerosis and minimum 1-year prospective follow-up from the MSBase cohort study. Multivariable linear regression models assessed associations between relapse incidence, phenotype and changes in disability (quantified with Expanded Disability Status Scale and its Functional System scores). Sensitivity analyses were conducted. RESULTS In 34,858 relapses recorded during 136,462 patient-years (median follow-up 5.9 years), higher relapse incidence was associated with greater disability accumulation (β = 0.16, p < 0.001). Relapses of all phenotypes promoted disability accumulation, with the most pronounced increase associated with pyramidal (β = 0.27 (0.25-0.29)), cerebellar (β = 0.35 (0.30-0.39)) and bowel/bladder (β = 0.42 (0.35-0.49)) phenotypes (mean (95% confidence interval)). Higher incidence of each relapse phenotype was associated with an increase in disability in the corresponding neurological domain, as well as anatomically related domains. CONCLUSION Relapses are associated with accumulation of neurological disability. Relapses in pyramidal, cerebellar and bowel/bladder systems have the greatest association with disability change. Therefore, prevention of these relapses is an important objective of disease-modifying therapy. The differential impact of relapse phenotypes on disability outcomes could influence management of treatment failure in multiple sclerosis.
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Affiliation(s)
- Tamasine Stewart
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Tim Spelman
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, General University Hospital and Charles University in Prague, Prague, Czech Republic
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, General University Hospital and Charles University in Prague, Prague, Czech Republic
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | | | - Pierre Duquette
- Hôpital Notre Dame, CHUM and Université de Montréal, Montreal, QC, Canada
| | - Marc Girard
- Hôpital Notre Dame, CHUM and Université de Montréal, Montreal, QC, Canada
| | - Alexandre Prat
- Hôpital Notre Dame, CHUM and Université de Montréal, Montreal, QC, Canada
| | - Alessandra Lugaresi
- MS Centre, Department of Neuroscience, Imaging and Clinical Sciences, 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy
| | | | | | - Patrizia Sola
- Neurology Unit, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, Modena, Italy
| | - Vahid Shaygannejad
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Raed Alroughani
- Department of Neurology, Amiri Hospital, Kuwait City, Kuwait
| | - Celia Oreja-Guevara
- University Hospital San Carlos, El Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | - Cavit Boz
- Karadeniz Technical University, Trabzon, Turkey
| | - Jeannette Lechner-Scott
- Hunter Medical Research Institute, The University of Newcastle Australia, Callaghan, NSW, Australia
| | | | | | | | | | - Bruce Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Mark Slee
- Flinders University and Medical Centre, Adelaide, SA, Australia
| | | | | | | | - Pamela McCombe
- Centre for Clinical Research, The University of Queensland Australia, Brisbane, QLD, Australia
| | - Suzanne Hodgkinson
- Departments of Nephrology and Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Maria Pia Amato
- Section of Neurosciences, NEUROFARBA, University of Florence, Florence, Italy
| | | | - Orla Gray
- Craigavon Area Hospital, Portadown, UK
| | | | | | | | | | | | - Javier Olascoaga
- Department of Neurology, Donostia University Hospital, San Sebastian, Spain
| | - Julie Prevost
- Centre Intégré de Santé et de Services Sociaux des Laurentides, Saint-Jerome, QC, Canada
| | - Norma Deri
- Hospital Fernandez, Buenos Aires, Argentina
| | | | - Bhim Singhal
- Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | | | - Csilla Rozsa
- Jahn Ferenc Teaching Hospital, Budapest, Hungary
| | - Neil Shuey
- St Vincent's Hospital, Melbourne, Melbourne, VIC, Australia
| | | | - Ilya Kister
- Department of Neurology, NYU School of Medicine, New York, NY, USA
| | | | | | - Allan Kermode
- Western Australian Neuroscience Research Institute, The University of Western Australia, Perth, WA, Australia/Institute of Immunology and Infectious Diseases, Murdoch University, Perth, WA, Australia
| | - Helmut Butzkueven
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, VIC, Australia/Department of Neurology, Box Hill Hospital, Monash University, Melbourne, VIC, Australia
| | - Vilija Jokubaitis
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Tomas Kalincik
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, VIC, Australia
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Spelman T, Mekhael L, Burke T, Butzkueven H, Hodgkinson S, Havrdova E, Horakova D, Duquette P, Izquierdo G, Grand'Maison F, Grammond P, Barnett M, Lechner-Scott J, Alroughani R, Trojano M, Lugaresi A, Granella F, Pucci E, Vucic S. Risk of early relapse following the switch from injectables to oral agents for multiple sclerosis. Eur J Neurol 2016; 23:729-36. [DOI: 10.1111/ene.12929] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 11/04/2015] [Indexed: 02/04/2023]
Affiliation(s)
- T. Spelman
- Department of Neurology; Royal Melbourne Hospital; Parkville Vic. Australia
- Department of Medicine (RMH); University of Melbourne; Parkville Vic. Australia
| | | | - T. Burke
- Westmead Hospital; Sydney NSW Australia
| | - H. Butzkueven
- Department of Neurology; Royal Melbourne Hospital; Parkville Vic. Australia
- Department of Medicine (RMH); University of Melbourne; Parkville Vic. Australia
| | | | | | | | | | - G. Izquierdo
- Hospital Universitario Virgen Macarena; Sevilla Spain
| | | | - P. Grammond
- Center de réadaptation déficience physique Chaudière-Appalache; Levis QC Canada
| | - M. Barnett
- Brain and Mind Research Institute; Sydney NSW Australia
| | | | | | - M. Trojano
- Department of Basic Medical Sciences; Neuroscience and Sense Organs; University of Bari; Bari Italy
| | - A. Lugaresi
- MS Center; Department of Neuroscience, Imaging and Clinical Sciences; University ‘G. d'Annunzio’; Chieti Italy
| | - F. Granella
- Department of Neurosciences; University of Parma; Parma Italy
| | - E. Pucci
- Neurology Unit; ASUR Marche - AV3; Macerata Italy
| | - S. Vucic
- Westmead Hospital; Sydney NSW Australia
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Kallaur AP, Reiche EMV, Oliveira SR, Simão ANC, Pereira WLDCJ, Alfieri DF, Flauzino T, Proença CDM, Lozovoy MAB, Kaimen-Maciel DR, Maes M. Genetic, Immune-Inflammatory, and Oxidative Stress Biomarkers as Predictors for Disability and Disease Progression in Multiple Sclerosis. Mol Neurobiol 2016; 54:31-44. [PMID: 26732588 DOI: 10.1007/s12035-015-9648-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 12/17/2015] [Indexed: 12/17/2022]
Abstract
The aim of this study was to evaluate the TNFβ NcoI polymorphism (rs909253) and immune-inflammatory, oxidative, and nitrosative stress (IO&NS) biomarkers as predictors of disease progression in multiple sclerosis (MS). We included 212 MS patients (150 female, 62 male, mean (±standard deviation (SD)) age = 42.7 ± 13.8 years) and 249 healthy controls (177 female, 72 male, 36.8 ± 11 years). The disability was measured the Expanded Disability Status Scale (EDSS) in 2006 and 2011. We determined the TNFβ NcoI polymorphism and serum levels of interleukin (IL)-6, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, IL-4, IL-10, and IL-17, albumin, ferritin, and plasma levels of lipid hydroperoxides (CL-LOOH), carbonyl protein, advanced oxidation protein products (AOPPs), nitric oxide metabolites (NOx), and total radical-trapping antioxidant parameter (TRAP). The mean EDSS (±SD) in 2006 was 1.62 ± 2.01 and in 2011 3.16 ± 2.29, and disease duration was 7.34 ± 7.0 years. IL-10, TNF-α, IFN-γ, AOPP, and NOx levels were significantly higher and IL-4 lower in MS patients with a higher 2011 EDSS scores (≥3) as compared with those with EDSS < 3. The actual increases in EDSS from 2006 to 2011 were positively associated with TNF-α and IFN-γ. Increased IFN-γ values were associated with higher pyramidal symptoms and increased IL-6 with sensitive symptoms. Increased carbonyl protein and IL-10 but lowered albumin levels predicted cerebellar symptoms. The TNFB1/B2 genotype decreased risk towards progression of pyramidal symptoms. Treatments with IFN-β and glatiramer acetate significantly reduced TNF-α but did not affect the other IO&NS biomarkers or disease progression. Taken together, IO&NS biomarkers and NcoI TNFβ genotypes predict high disability in MS and are associated with different aspects of disease progression. New drugs to treat MS should also target oxidative stress pathways.
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Affiliation(s)
- Ana Paula Kallaur
- Health Sciences Postgraduate Program, Health Sciences Center, State University of Londrina, Londrina, Paraná, 86.038-440, Brazil
| | - Edna Maria Vissoci Reiche
- Department of Pathology, Clinical Analysis and Toxicology, Health Sciences Center, State University of Londrina, Av. Robert Koch, 60, Londrina, Paraná, CEP 86.038-440, Brazil.
| | - Sayonara Rangel Oliveira
- Health Sciences Postgraduate Program, Health Sciences Center, State University of Londrina, Londrina, Paraná, 86.038-440, Brazil
| | - Andrea Name Colado Simão
- Department of Pathology, Clinical Analysis and Toxicology, Health Sciences Center, State University of Londrina, Av. Robert Koch, 60, Londrina, Paraná, CEP 86.038-440, Brazil
| | - Wildea Lice de Carvalho Jennings Pereira
- Health Sciences Postgraduate Program, Health Sciences Center, State University of Londrina, Londrina, Paraná, 86.038-440, Brazil.,Outpatient Clinic for Demyelinating Diseases, University Hospital, State University of Londrina, Londrina, Paraná, 86061-335, Brazil
| | - Daniela Frizon Alfieri
- Health Sciences Postgraduate Program, Health Sciences Center, State University of Londrina, Londrina, Paraná, 86.038-440, Brazil
| | - Tamires Flauzino
- Health Sciences Postgraduate Program, Health Sciences Center, State University of Londrina, Londrina, Paraná, 86.038-440, Brazil
| | - Caio de Meleck Proença
- Outpatient Clinic for Demyelinating Diseases, University Hospital, State University of Londrina, Londrina, Paraná, 86061-335, Brazil
| | - Marcell Alysson Batisti Lozovoy
- Department of Pathology, Clinical Analysis and Toxicology, Health Sciences Center, State University of Londrina, Av. Robert Koch, 60, Londrina, Paraná, CEP 86.038-440, Brazil
| | - Damacio Ramón Kaimen-Maciel
- Outpatient Clinic for Demyelinating Diseases, University Hospital, State University of Londrina, Londrina, Paraná, 86061-335, Brazil.,Department of Clinical Medicine, Health Sciences Center, State University of Londrina, Londrina, Paraná, 86.038-440, Brazil
| | - Michael Maes
- Impact Strategic Research Centre, School of Medicine, Deakin University, Geelong, Victoria, Australia.,Department of Psychiatry, King Chulalongkorn Memorial Hospital, Chulalongkorn, Bangkok, Thailand
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Spelman T, Gray O, Lucas R, Butzkueven H. A Method of Trigonometric Modelling of Seasonal Variation Demonstrated with Multiple Sclerosis Relapse Data. J Vis Exp 2015:e53169. [PMID: 26709960 DOI: 10.3791/53169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
This report describes a novel Stata-based application of trigonometric regression modelling to 55 years of multiple sclerosis relapse data from 46 clinical centers across 20 countries located in both hemispheres. Central to the success of this method was the strategic use of plot analysis to guide and corroborate the statistical regression modelling. Initial plot analysis was necessary for establishing realistic hypotheses regarding the presence and structural form of seasonal and latitudinal influences on relapse probability and then testing the performance of the resultant models. Trigonometric regression was then necessary to quantify these relationships, adjust for important confounders and provide a measure of certainty as to how plausible these associations were. Synchronization of graphing techniques with regression modelling permitted a systematic refinement of models until best-fit convergence was achieved, enabling novel inferences to be made regarding the independent influence of both season and latitude in predicting relapse onset timing in MS. These methods have the potential for application across other complex disease and epidemiological phenomena suspected or known to vary systematically with season and/or geographic location.
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Affiliation(s)
- Tim Spelman
- Department of Neurology, Royal Melbourne Hospital; Department of Medicine (RMH), The University of Melbourne;
| | - Orla Gray
- Department of Neurology, Ulster Hospital
| | - Robyn Lucas
- National Centre for Epidemiology and Population Health, Australian National University
| | - Helmut Butzkueven
- Department of Neurology, Royal Melbourne Hospital; Department of Medicine (RMH), The University of Melbourne
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63
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Scalfari A. Multiple sclerosis relapse phenotype is an important, neglected, determinant of disease outcome – NO. Mult Scler 2015; 21:1371-4. [DOI: 10.1177/1352458515599452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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64
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Scott TF. Multiple sclerosis relapse phenotype is an important, neglected, determinant of disease outcome – YES. Mult Scler 2015; 21:1369-1371. [DOI: 10.1177/1352458515608263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Thomas F Scott
- Drexel University College of Medicine, Allegheny General Hospital, USA
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Spelman T, Kalincik T, Zhang A, Pellegrini F, Wiendl H, Kappos L, Tsvetkova L, Belachew S, Hyde R, Verheul F, Grand-Maison F, Izquierdo G, Grammond P, Duquette P, Lugaresi A, Lechner-Scott J, Oreja-Guevara C, Hupperts R, Petersen T, Barnett M, Trojano M, Butzkueven H. Comparative efficacy of switching to natalizumab in active multiple sclerosis. Ann Clin Transl Neurol 2015; 2:373-87. [PMID: 25909083 PMCID: PMC4402083 DOI: 10.1002/acn3.180] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/09/2014] [Accepted: 01/08/2015] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To compare treatment efficacy and persistence in patients who switched to natalizumab versus those who switched between glatiramer acetate (GA) and interferon-beta (IFNβ) after an on-treatment relapse on IFNβ or GA using propensity score matched real-world datasets. METHODS Patients included were registered in MSBase or the TYSABRI Observational Program (TOP), had relapsed on IFNβ or GA within 12 months prior to switching to another therapy, and had initiated natalizumab or IFNβ/GA treatment ≤6 months after discontinuing prior therapy. Covariates were balanced across post switch treatment groups by propensity score matching at treatment initiation. Relapse, persistence, and disability measures were compared between matched treatment arms in the total population (n = 869/group) and in subgroups defined by prior treatment history (IFNβ only [n = 578/group], GA only [n = 165/group], or both IFNβ and GA [n = 176/group]). RESULTS Compared to switching between IFNβ and GA, switching to natalizumab reduced annualized relapse rate in year one by 65-75%, the risk of first relapse by 53-82% (mean follow-up 1.7-2.2 years) and treatment discontinuation events by 48-65% (all P ≤ 0.001). In the total population, switching to natalizumab reduced the risk of confirmed disability progression by 26% (P = 0.036) and decreased the total disability burden by 1.54 EDSS-years (P < 0.0001) over the first 24 months post switch. INTERPRETATION Using large, real-world, propensity-matched datasets we demonstrate that after a relapse on IFNβ or GA, switching to natalizumab (rather than between IFNβ and GA) led to superior outcomes for patients in all measures assessed. Results were consistent regardless of the prior treatment identity.
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Affiliation(s)
- Timothy Spelman
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne Melbourne, Australia
| | - Tomas Kalincik
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne Melbourne, Australia
| | | | - Fabio Pellegrini
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari Bari, Italy
| | - Heinz Wiendl
- Department of Neurology, University of Münster Münster, Germany
| | - Ludwig Kappos
- Department of Neurology, University Hospital Basel Basel, Switzerland
| | | | | | | | | | | | | | - Pierre Grammond
- Center de réadaptation déficience physique Chaudière-Appalache Levis, Canada
| | | | - Alessandra Lugaresi
- MS Center, Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" Chieti, Italy
| | | | | | | | | | | | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari Bari, Italy
| | - Helmut Butzkueven
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne Melbourne, Australia ; Department of Neurology, Eastern Health, Monash University Box Hill, Australia
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Willis MD, Harding KE, Wardle M, Pickersgill TP, Tomassini V, Loveless S, Robertson NP. Site-specific clinical disease onset in multiple sclerosis. Eur J Neurol 2014; 22:732-5. [PMID: 25196326 DOI: 10.1111/ene.12564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 07/25/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Multiple sclerosis is a chronic inflammatory disorder of the central nervous system characterized by acute episodes of neurological dysfunction thought to reflect focal areas of demyelination occurring in clinically eloquent areas. These symptomatic relapses are generally considered to be random clinical events occurring without discernible pattern. The hypothesis that relapses may follow a predetermined sequence and may provide insights into underlying pathological processes was investigated. METHODS Employing prospective clinical database data from 1482 patients who had experienced one or more consecutive relapses were analysed. Using regression analysis, site and symptom of index event were compared with those of first relapse. RESULTS It is demonstrated that following disease ignition subsequent relapses may not be random events but dependent on characteristics of the index event. All anatomical sites were more likely to be affected in the first relapse if that site had been involved in the index event with a similar association observed when comparing by symptoms. CONCLUSION These findings have importance in understanding the evolution of the disease and predicting individual disease progression and may aid with patient counselling and management.
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Affiliation(s)
- M D Willis
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Heath Park, Cardiff, UK
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