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Kallmann BA, Tiel-Wilck K, Kullmann JS, Engelmann U, Chan A. Real-life outcomes of teriflunomide treatment in patients with relapsing multiple sclerosis: TAURUS-MS observational study. Ther Adv Neurol Disord 2019; 12:1756286419835077. [PMID: 30944584 PMCID: PMC6437319 DOI: 10.1177/1756286419835077] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/08/2019] [Indexed: 01/06/2023] Open
Abstract
Background Teriflunomide is a once-daily oral immunomodulatory agent approved for the treatment of relapsing-remitting multiple sclerosis (MS). We aimed to obtain data on the effectiveness, tolerability, and subject satisfaction with teriflunomide (Aubagio®) under clinical practice conditions in unselected MS patients. Methods This work was a non-interventional, prospective, longitudinal, observational study in 307 sites in Germany. Results A total of 1128 patients were eligible for the efficacy analysis [67.5% female; mean age (± standard deviation) 44.9 ± 9.7 years, range 20-73 years]. Time since first MS symptoms was 10.6 ± 8.2 years, and time since MS diagnosis was 8.9 ± 7.6 years. Expanded Disability Status Scale (EDSS) score at inclusion was 2.3 ± 1.5 (70.4% with score < 3.5). The mean observation period was 16.3 ± 9.1 months. A total of 75.2% had received previous disease-modifying therapies (DMTs) at any time. Of these patients, 504 (44.7%) received no DMT within 6 months of study entry, 593 patients (52.6%) had DMT discontinued prior to study entry [glatiramer acetate in 10.6%, subcutaneous interferon-beta 1a (IFNβ-1a) in 9.3%, intramuscular IFNβ-1a or IFNβ-1b in 6.6% each, azathioprine oral in 0.4%, other in 7.3%, last medication not known in 12.0%]. The mean annualized relapse rate decreased from 0.87 in the 24 months prior to study entry to 0.35 in the 24 months after study entry (n = 468; p ⩽ 0.001). EDSS and Fatigue Severity Scale remained stable. In patients who received previous MS treatments, Treatment Satisfaction Questionnaire (TSQM-9) values (maximum = 100), for the observation at 24 months improved by 8.1 points for effectiveness, 17.0 points for convenience, and 15.3 points for global satisfaction (p ⩽ 0.001 each, compared with study entry). In the safety cohort (n = 1139), the proportion of patients with adverse events (AEs) of any severity was 35.8%, and with serious events 13.0%. The most frequently reported AEs were diarrhea (n = 55), followed by MS relapse (n = 48), hair thinning (n = 38), and viral upper respiratory tract infection (n = 31). Conclusions Relapse rate was halved during the observation period in comparison with the same time period before study entry. Patient satisfaction with teriflunomide was high in this real-world observation of patients, the majority of whom switched from other DMTs. The safety and tolerability profile of teriflunomide was similar to that reported in previous clinical trials.
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Affiliation(s)
| | - Klaus Tiel-Wilck
- Neurologisches Facharztzentrum Berlin, Berlin, Germany, for the NeuroTransData Study Group
| | - Jennifer S Kullmann
- Medical Management MS, Medical Affairs, Sanofi-Aventis Deutschland GmbH, Siemensstraße 5b, 63263 Neu-Isenburg, Germany
| | - Ulrich Engelmann
- Medical Affairs, Sanofi-Aventis Deutschland GmbH, Neu-Isenburg, Germany
| | - Andrew Chan
- Department of Neurology, Bern University Hospital, University of Bern, Switzerland
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Marques VD, Passos GRD, Mendes MF, Callegaro D, Lana-Peixoto MA, Comini-Frota ER, Vasconcelos CCF, Sato DK, Ferreira MLB, Parolin MKF, Damasceno A, Grzesiuk AK, Muniz A, Matta APDC, Oliveira BESD, Tauil CB, Maciel DRK, Diniz DS, Corrêa EC, Coronetti F, Jorge FMH, Sato HK, Gonçalves MVM, Sousa NADC, Nascimento OJM, Gama PDD, Domingues R, Simm RF, Thomaz RB, Morales RDR, Dias RM, Apóstolos-Pereira SD, Machado SCN, Junqueira TDF, Becker J. Brazilian Consensus for the Treatment of Multiple Sclerosis: Brazilian Academy of Neurology and Brazilian Committee on Treatment and Research in Multiple Sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 76:539-554. [PMID: 30231128 DOI: 10.1590/0004-282x20180078] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 05/16/2018] [Indexed: 12/21/2022]
Abstract
The expanding therapeutic arsenal in multiple sclerosis (MS) has allowed for more effective and personalized treatment, but the choice and management of disease-modifying therapies (DMTs) is becoming increasingly complex. In this context, experts from the Brazilian Committee on Treatment and Research in Multiple Sclerosis and the Neuroimmunology Scientific Department of the Brazilian Academy of Neurology have convened to establish this Brazilian Consensus for the Treatment of MS, based on their understanding that neurologists should be able to prescribe MS DMTs according to what is better for each patient, based on up-to-date evidence and practice. We herein propose practical recommendations for the treatment of MS, with the main focus on the choice and management of DMTs, as well as present a review of the scientific rationale supporting therapeutic strategies in MS.
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Affiliation(s)
- Vanessa Daccach Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas de Ribeirão Preto, Ribeirão Preto SP, Brasil
| | | | - Maria Fernanda Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | - Dagoberto Callegaro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | - Marco Aurélio Lana-Peixoto
- Universidade Federal de Minas Gerais, Centro de Investigação em Esclerose Múltipla de Minas Gerais, Belo Horizonte MG, Brasil
| | | | | | | | | | | | | | | | | | | | | | - Carlos Bernardo Tauil
- Universidade de Brasília, Brasília DF, Brasil.,Universidade Católica de Brasília, Brasília DF, Brasil
| | | | | | | | | | - Frederico M H Jorge
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | | | | | | | | | | | - Renan Domingues
- Senne Líquor Diagnóstico, São Paulo SP, Brasil.,Hospital Cruz Azul, São Paulo SP, Brasil.,Faculdade São Leopoldo Mandic, Campinas SP, Brasil
| | - Renata Faria Simm
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | | | | | | | | | | | | | - Jefferson Becker
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre RS, Brasil.,Universidade Federal Fluminense, Niterói RJ, Brasil
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103
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Buron MD, Chalmer TA, Sellebjerg F, Frederiksen J, Góra MK, Illes Z, Kant M, Mezei Z, Petersen T, Rasmussen PV, Roshanisefat H, Hassanpour-Kalam-Roudy H, Sejbæk T, Tsakiri A, Weglewski A, Sorensen PS, Magyari M. Comparative effectiveness of teriflunomide and dimethyl fumarate: A nationwide cohort study. Neurology 2019; 92:e1811-e1820. [PMID: 30877188 DOI: 10.1212/wnl.0000000000007314] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 12/20/2018] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To compare on-treatment efficacy and discontinuation outcomes in teriflunomide (TFL) and dimethyl fumarate (DMF) in the treatment of relapsing-remitting multiple sclerosis (RRMS) in a real-world setting. METHODS We identified all patients starting TFL or DMF from the Danish Multiple Sclerosis Registry and compared on-treatment efficacy outcomes between DMF using TFL, adjusted for clinical baseline variables and propensity score-based methods. RESULTS We included 2,236 patients in the study: 1,469 patients on TFL and 767 on DMF. Annualized relapse rates (ARRs) in TFL and DMF were 0.16 (95% confidence interval [CI] 0.13-0.20) and 0.09 (95% CI 0.07-0.12), respectively. Relapse rate ratio for DMF/TFL was 0.58 (95% CI 0.46-0.73, p < 0.001). DMF had a higher relapse-free survival proportion at 48 months of follow-up (p < 0.05). We observed no difference in Expanded Disability Status Scale score worsening. Discontinuations due to disease breakthrough were 10.2% (95% CI 7.6%-12.8%) and 22.1% (95% CI 19.2%-25.0%) for DMF and TFL, respectively. A subgroup analysis of ARRs in 708 patients with available baseline MRI T2 lesion amount reported similar results after adjustment. CONCLUSION We found lower ARR, higher relapse-free survival, and lower incidence of discontinuation due to disease breakthrough on treatment with DMF compared with TFL. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with RRMS, DMF is more effective in preventing relapses and has lower discontinuation due to disease breakthrough compared with TFL.
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Affiliation(s)
- Mathias Due Buron
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark.
| | - Thor Ameri Chalmer
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Finn Sellebjerg
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Jette Frederiksen
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Monika Katarzyna Góra
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Zsolt Illes
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Matthias Kant
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Zsolt Mezei
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Thor Petersen
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Peter Vestergaard Rasmussen
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Homayoun Roshanisefat
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Houry Hassanpour-Kalam-Roudy
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Tobias Sejbæk
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Anna Tsakiri
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Arkadiusz Weglewski
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Per Soelberg Sorensen
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
| | - Melinda Magyari
- From the Danish Multiple Sclerosis Center (M.D.B., T.A.C., F.S., P.S.S., M.M.), Rigshospitalet; Copenhagen University Hospital Rigshospitalet (J.F., H.H.-K.-R.), Glostrup; Slagelse Hospital (M.K.G.); Odense University Hospital (Z.I., T.S.), University of Southern Denmark; Hospital of Southern Jutland (M.K.), Sønderborg; Aalborg University Hospital (Z.M.); Aarhus University Hospital (T.P., P.V.R.); Greater Copenhagen Hospitals-NOH (H.R.), Hillerød; University Hospital of Sjaelland (A.T.), Roskilde; and Department of Neurology, Copenhagen University Hospital Herlev (A.W.), Denmark
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Zivadinov R, Bergsland N, Carl E, Ramasamy DP, Hagemeier J, Dwyer MG, Lizarraga AA, Kolb C, Hojnacki D, Weinstock-Guttman B. Effect of Teriflunomide and Dimethyl Fumarate on Cortical Atrophy and Leptomeningeal Inflammation in Multiple Sclerosis: A Retrospective, Observational, Case-Control Pilot Study. J Clin Med 2019; 8:jcm8030344. [PMID: 30870983 PMCID: PMC6463015 DOI: 10.3390/jcm8030344] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/28/2019] [Accepted: 03/07/2019] [Indexed: 02/08/2023] Open
Abstract
Background: Pathologic changes in cortical gray matter (GM) and leptomeninges contribute to disability worsening in patients with multiple sclerosis (MS), but there is little evidence whether disease-modifying treatments can slow down cortical pathology in MS. Objectives: To investigate the effect of teriflunomide (TFM) and dimethyl fumarate (DMF) in reducing cortical pathology, as determined by percentage cortical volume change (PCVC) and leptomeningeal contrast enhancement (LMCE) on MRI. Methods: This was a retrospective, single-center, observational study that selected 60 TFM- and 60 DMF-treated MS patients over 24 months. Results: TFM had a lower rate of PCVC compared to DMF over 24 months (−0.2% vs. −2.94%, p = 0.004). Similar results were observed for percentage GM volume change over 0–12 (p = 0.044) and 0–24 (−0.44% vs. −3.12%, p = 0.015) months. No significant differences were found between the TFM and DMF groups in the frequency and number of LMCE foci over the follow-up. TFM showed a numerically lower rate of whole brain atrophy over 24 months (p = 0.077), compared to DMF. No significant clinical or MRI lesion differences between TFM and DMF were detected over follow-up. Conclusions: These findings suggest that TFM has a superior effect on the preservation of cortical GM volume, compared to DMF.
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Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
- Center for Biomedical Imaging at the Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
| | - Ellen Carl
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
| | - Deepa P Ramasamy
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
| | - Jesper Hagemeier
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
| | - Michael G Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
- Center for Biomedical Imaging at the Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
| | - Alexis A Lizarraga
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
| | - Channa Kolb
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
| | - David Hojnacki
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
| | - Bianca Weinstock-Guttman
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA.
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105
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Gregson A, Thompson K, Tsirka SE, Selwood DL. Emerging small-molecule treatments for multiple sclerosis: focus on B cells. F1000Res 2019; 8:F1000 Faculty Rev-245. [PMID: 30863536 PMCID: PMC6402079 DOI: 10.12688/f1000research.16495.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2019] [Indexed: 12/27/2022] Open
Abstract
Multiple sclerosis (MS) is a major cause of disability in young adults. Following an unknown trigger (or triggers), the immune system attacks the myelin sheath surrounding axons, leading to progressive nerve cell death. Antibodies and small-molecule drugs directed against B cells have demonstrated good efficacy in slowing progression of the disease. This review focusses on small-molecule drugs that can affect B-cell biology and may have utility in disease management. The risk genes for MS are examined from the drug target perspective. Existing small-molecule therapies for MS with B-cell actions together with new drugs in development are described. The potential for experimental molecules with B-cell effects is also considered. Small molecules can have diverse actions on B cells and be cytotoxic, anti-inflammatory and anti-viral. The current B cell-directed therapies often kill B-cell subsets, which can be effective but lead to side effects and toxicity. A deeper understanding of B-cell biology and the effect on MS disease should lead to new drugs with better selectivity, efficacy, and an improved safety profile. Small-molecule drugs, once the patent term has expired, provide a uniquely sustainable form of healthcare.
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Affiliation(s)
- Aaron Gregson
- The Wolfson Institute for Biomedical Research, University College London, Gower Street, London, WC1E 6BT, UK
| | - Kaitlyn Thompson
- Department of Pharmacological Sciences, Stony Brook University, Stony Brook, New York, 11794, USA
| | - Stella E Tsirka
- Department of Pharmacological Sciences, Stony Brook University, Stony Brook, New York, 11794, USA
| | - David L Selwood
- The Wolfson Institute for Biomedical Research, University College London, Gower Street, London, WC1E 6BT, UK
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106
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Zivadinov R, Kresa-Reahl K, Weinstock-Guttman B, Edwards K, Burudpakdee C, Bergsland N, Dwyer MG, Khatri B, Thangavelu K, Chavin J, Mandel M, Cohan S. Comparative effectiveness of teriflunomide and dimethyl fumarate in patients with relapsing forms of MS in the retrospective real-world Teri-RADAR study. J Comp Eff Res 2019; 8:305-316. [PMID: 30754997 DOI: 10.2217/cer-2018-0135] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
AIM Head-to-head clinical trials of teriflunomide (TFM) versus dimethyl fumarate (DMF) have not been conducted. OBJECTIVES To compare the real-world effectiveness of TFM versus DMF. METHODS Anonymized data were collected from patients with relapsing multiple sclerosis (MS) initiating treatment with teriflunomide (N = 50) or DMF (N = 50). RESULTS On follow-up magnetic resonance imaging (MRI) compared with baseline, with TFM versus DMF treatment, the proportion of patients with new/enlarging T2 or gadolinium-enhancing lesions was 30.0 versus 40.0% (p = 0.2752). However, median annualized percent whole brain volume change was -0.1 versus -0.5 (p = 0.0212). There were no significant treatment differences on additional MRI and clinical end points and no unexpected safety signals. CONCLUSION The effectiveness of teriflunomide was superior to DMF on whole brain atrophy and similar to DMF on other MRI/clinical end points.
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Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, University at Buffalo, Buffalo, NY, USA.,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, Buffalo, NY, USA
| | - Kiren Kresa-Reahl
- Providence Multiple Sclerosis Center, Providence St Joseph Health, Portland, OR, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Center for Treatment & Research, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Keith Edwards
- Multiple Sclerosis Center of Northeastern New York, NY, USA
| | | | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, University at Buffalo, Buffalo, NY, USA
| | - Michael G Dwyer
- Buffalo Neuroimaging Analysis Center, University at Buffalo, Buffalo, NY, USA.,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, Buffalo, NY, USA
| | - Bhupendra Khatri
- Wheaton Franciscan Healthcare, Center for Neurological Disorders, Milwaukee, WI, USA
| | | | | | | | - Stanley Cohan
- Providence Multiple Sclerosis Center, Providence St Joseph Health, Portland, OR, USA
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107
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Deleu D, Mesraoua B, Canibaño B, Melikyan G, Al Hail H, El-Sheikh L, Ali M, Al Hussein H, Ibrahim F, Hanssens Y. Oral disease-modifying therapies for multiple sclerosis in the Middle Eastern and North African (MENA) region: an overview. Curr Med Res Opin 2019; 35:249-260. [PMID: 29764226 DOI: 10.1080/03007995.2018.1476334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND The introduction of new disease-modifying therapies (DMTs) for remitting-relapsing multiple sclerosis (RRMS) has considerably transformed the landscape of therapeutic opportunities for this chronic disabling disease. Unlike injectable drugs, oral DMTs promote patient satisfaction and increase therapeutic adherence. REVIEW This article reviews the salient features about the mode of action, efficacy, safety, and tolerability profile of approved oral DMTs in RRMS, and reviews their place in clinical algorithms in the Middle East and North Africa (MENA) region. A systematic review was conducted using a comprehensive search of MEDLINE, PubMed, Cochrane Database of Systematic Reviews (period January 1, 1995-January 31, 2018). Additional searches of the American Academy of Neurology and European Committee for Treatment and Research in Multiple Sclerosis abstracts from 2012-2017 were performed, in addition to searches of the Food and Drug Administration and European Medicines Agency websites, to obtain relevant safety information on these DMTs. CONCLUSIONS Four oral DMTs: fingolimod, teriflunomide, dimethyl fumarate, and cladribine have been approved by the regulatory agencies. Based on the number needed to treat (NNT), the potential role of these DMTs in the management of active and highly active or rapidly evolving RRMS is assessed. Finally, the place of the oral DMTs in clinical algorithms in the MENA region is reviewed.
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Affiliation(s)
- Dirk Deleu
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Boulenouar Mesraoua
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Beatriz Canibaño
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Gayane Melikyan
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Hassan Al Hail
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Lubna El-Sheikh
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Musab Ali
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Hassan Al Hussein
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Faiza Ibrahim
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Yolande Hanssens
- b Department of Clinical Services Unit , Corporate Pharmacy, Hamad Medical Corporation , Doha , State of Qatar
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108
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Hartung HP, Graf J, Kremer D. Long-term follow-up of multiple sclerosis studies and outcomes from early treatment of clinically isolated syndrome in the BENEFIT 11 study. J Neurol 2019; 267:308-316. [PMID: 30610426 DOI: 10.1007/s00415-018-09169-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/21/2018] [Accepted: 12/21/2018] [Indexed: 01/03/2023]
Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) with a diverse disease course involving inflammation and degeneration of neurons and axons. Multiple sclerosis results from a complex interaction of genetic and environmental factors and clinically several disease subtypes with marked variation in symptoms can be discerned. Disease-modifying therapies (DMTs) impact disease activity and outcome. Long-term follow-up studies of DMTs in MS have generally shown that the short-term effects in clinical trials are maintained for up to 21 years, e.g. in the case of interferon beta-1b. However, attainment can be a problem in these studies. On the one hand, so-called real-world studies can augment clinical trials by providing data on the long-term effectiveness and safety of DMTs but lack, on the other hand, randomization and may, in addition, also yield biased findings as a result of compliance issues. Long-term data from clinical trials in clinically isolated syndrome (CIS) patients have been limited but in the case of interferon beta-1b this aspect has been addressed over 11 years in the BENEFIT 11 trial. The results suggest that early treatment results in persistent long-term benefits including conversion to clinically definite MS (CDMS) as well as time to and risk of a first relapse. Here we primarily review the findings of the BENEFIT 11 trial in the context of long-term studies.
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Affiliation(s)
- Hans-Peter Hartung
- Department of Neurology, UKD, Center for Neurology and Neuropsychiatry, LVR Klinikum Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Jonas Graf
- Department of Neurology, UKD, Center for Neurology and Neuropsychiatry, LVR Klinikum Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - David Kremer
- Department of Neurology, UKD, Center for Neurology and Neuropsychiatry, LVR Klinikum Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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Abstract
Multiple sclerosis treatment faces tremendous changes owing to the approval of new medications, some of which are available as oral formulations. Until now, the four orally available medications, fingolimod, dimethylfumarate (BG-12), teriflunomide, and cladribine have received market authorization, whereas laquinimod is still under development. Fingolimod is a sphingosine-1-phosphate inhibitor, which is typically used as escalation therapy and leads to up to 60% reduction of the annualized relapse rate, but might also have neuroprotective properties. In addition, there are three more specific S1P agonists in late stages of development: siponimod, ponesimod, and ozanimod. Dimethylfumarate has immunomodulatory and cytoprotective functions and is used as baseline therapy. Teriflunomide, the active metabolite of the rheumatoid arthritis medication leflunomide, targets the dihydroorotate dehydrogenase, thus inhibiting the proliferation of lymphocytes by depletion of pyrimidines. Here we will review the mechanisms of action, clinical trial data, as well as data about safety and tolerability of the compounds.
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Affiliation(s)
- Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
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110
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Beckmann Y, Türe S. Headache characteristics in multiple sclerosis. Mult Scler Relat Disord 2019; 27:112-116. [DOI: 10.1016/j.msard.2018.09.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 09/18/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
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111
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Rocca MA, Preziosa P, Filippi M. Application of advanced MRI techniques to monitor pharmacologic and rehabilitative treatment in multiple sclerosis: current status and future perspectives. Expert Rev Neurother 2018; 19:835-866. [PMID: 30500303 DOI: 10.1080/14737175.2019.1555038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Advances in magnetic resonance imaging (MRI) technology and analyses are improving our understanding of the pathophysiology of multiple sclerosis (MS). Due to their ability to grade the presence of irreversible tissue loss, microstructural tissue abnormalities, metabolic changes and functional plasticity, the application of these techniques is also expanding our knowledge on the efficacy and mechanisms of action of different pharmacological and rehabilitative treatments. Areas covered: This review discusses recent findings derived from the application of advanced MRI techniques to evaluate the structural and functional substrates underlying the effects of pharmacologic and rehabilitative treatments in patients with MS. Current applications as outcome in clinical trials and observational studies, their interpretation and possible pitfalls in their use are discussed. Finally, how these techniques could evolve in the future to improve monitoring of disease progression and treatment response is examined. Expert commentary: The number of treatments currently available for MS is increasing. The application of advanced MRI techniques is providing reliable and specific measures to better understand the targets of different treatments, including neuroprotection, tissue repair, and brain plasticity. This is a fundamental progress to move toward personalized medicine and individual treatment selection.
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Affiliation(s)
- Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy
| | - Paolo Preziosa
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy
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112
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Should Spinal MRI Be Routinely Performed in Patients With Clinically Isolated Optic Neuritis? J Neuroophthalmol 2018; 38:502-510. [DOI: 10.1097/wno.0000000000000685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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113
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Romeo MAL, Martinelli V, Dalla Costa G, Colombo B, De Feo D, Esposito F, Ferrè L, Guaschino C, Guerrieri S, Liberatore G, Martinelli Boneschi F, Merlini A, Messina M, Messina R, Nuara A, Preziosa P, Radaelli M, Rocca MA, Rodegher M, Sangalli F, Strambo D, Moiola L, Comi G. Assessing the role of innovative therapeutic paradigm on multiple sclerosis treatment response. Acta Neurol Scand 2018; 138:447-453. [PMID: 30033621 DOI: 10.1111/ane.12999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/17/2018] [Accepted: 06/26/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Within the last decade, many changes have been made to the management of patients with multiple sclerosis (MS). The aim of our study was to investigate the global impact of all these changes on the disease's course. MATERIALS AND METHODS This single-centre study was carried out on patients with multiple sclerosis (pwMS) who started treatment with first-line disease-modifying therapies. We have compared three large cohorts of patients with MS diagnosis, for three consecutive periods within July 2001, August 2001-December 2005, and January 2006-September 2011. RESULTS A total of 1068 relapsing-remitting pwMS cases were included. Patients in the last cohort began treatment earlier (P < 0.0001), started more frequent treatment with high-dose interferon beta or glatiramer acetate (P < 0.0001), and had experienced a more frequent treatment escalation strategy (P = 0.004) than patients in other cohorts. The multivariate analysis adjusted for baseline characteristics showed that pwMS of the last cohort had a high probability of showing no evidence of disease activity (NEDA3) at 4 years (OR 3.22, 95% CIs 1.89-5.47; P < 0.0001). These results were confirmed in a propensity score analysis. CONCLUSIONS Our study showed an improvement over the last 15 years in the treatment response; this observation can be associated to a paradigm shift in MS treatment strategies.
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Affiliation(s)
- Marzia A. L. Romeo
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
- Vita-Salute San Raffaele University; Milan Italy
| | - Vittorio Martinelli
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Gloria Dalla Costa
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Bruno Colombo
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Donatella De Feo
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Federica Esposito
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
- Laboratory of Genetics of Neurological Complex Disorders; San Raffaele Scientific Institute; Milan Italy
| | - Laura Ferrè
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
- Laboratory of Genetics of Neurological Complex Disorders; San Raffaele Scientific Institute; Milan Italy
| | - Clara Guaschino
- Department of Neurology; Sant'Antonio Abate Hospital; Gallarate Italy
| | - Simone Guerrieri
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Giuseppe Liberatore
- Milan University; IRCCS Humanitas Clinical and Research Center; Rozzano Italy
| | | | - Arianna Merlini
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Mariajosè Messina
- Department of Neurology; I.R.C.C.S. Policlinico San Donato; San Donato Italy
| | - Roberta Messina
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Arturo Nuara
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Paolo Preziosa
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
- Neuroimaging Research Unit; San Raffaele Scientific Institute; Vita-Salute San Raffaele University; Milan Italy
| | - Marta Radaelli
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Maria A. Rocca
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
- Neuroimaging Research Unit; San Raffaele Scientific Institute; Vita-Salute San Raffaele University; Milan Italy
| | - Mariaemma Rodegher
- Department of Neurology; I.R.C.C.S. Policlinico San Donato; San Donato Italy
| | - Francesca Sangalli
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Davide Strambo
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Lucia Moiola
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
| | - Giancarlo Comi
- Department of Neurology; Institute of Experimental Neurology; San Raffaele Scientific Institute; Milan Italy
- Vita-Salute San Raffaele University; Milan Italy
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114
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Patient-reported outcomes in patients with relapsing forms of MS switching to teriflunomide from other disease-modifying therapies: Results from the global Phase 4 Teri-PRO study in routine clinical practice. Mult Scler Relat Disord 2018; 26:211-218. [DOI: 10.1016/j.msard.2018.09.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/31/2018] [Accepted: 09/14/2018] [Indexed: 01/12/2023]
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115
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Pol S, Sveinsson M, Sudyn M, Babek N, Siebert D, Bertolino N, Modica CM, Preda M, Schweser F, Zivadinov R. Teriflunomide's Effect on Glia in Experimental Demyelinating Disease: A Neuroimaging and Histologic Study. J Neuroimaging 2018; 29:52-61. [PMID: 30232810 DOI: 10.1111/jon.12561] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/31/2018] [Accepted: 09/04/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Teriflunomide reduces disability progression and brain atrophy in multiple sclerosis patients. The exact mechanism of action by which teriflunomide exerts these effects is currently unknown. We assessed the effect of teriflunomide on brain glial cells in the Theiler's murine encephalomyelitis virus (TMEV) by using a histological approach in combination with neuroimaging. METHODS Forty-eight SJL female mice received an intracerebral injection of TMEV at 6-8 weeks of age and were then treated with teriflunomide (n = 24) or placebo (n = 24) for 9 months. They were examined with MRI and behavioral testing at 2, 6, and 9 months postinduction (mPI). Of those, 18 teriflunomide-treated and 17 controls mice were analyzed histologically at 9 mPI to sample from different brain regions for myelination status, microglial density, and oligodendroglial lineage. The histological and MRI outcomes were correlated. RESULTS Corpus callosum microglial density was numerically lower in the teriflunomide-treated mice compared to the control group (141.1 ± 21.7 SEM vs. 214.74 ± 34.79 SEM, Iba1+ cells/mm2 , P = .087). Basal ganglia (BG) microglial density in the teriflunomide group exhibited a negative correlation with fractional anisotropy (P = .021) and a positive correlation with mean diffusivity (P = .034), indicating less inflammation and axonal damage. Oligodendroglial lineage cell and myelin density were not significantly different between treatment groups. However, a significant positive correlation between BG oligodendrocytes and BG volume (P = .027), and with N-acetyl aspartate concentration (P = .008), was found in the teriflunomide group, indicating less axonal loss. CONCLUSION Teriflunomide altered microglia density and oligodendrocytes differentiation, which was associated with less evident microstructural damage on MRI.
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Affiliation(s)
- Suyog Pol
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Michele Sveinsson
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Michelle Sudyn
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Natan Babek
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Danielle Siebert
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Nicola Bertolino
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Claire M Modica
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Marilena Preda
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY.,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY
| | - Ferdinand Schweser
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY.,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY.,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY
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Adverse psychiatric effects of disease-modifying therapies in multiple Sclerosis: A systematic review. Mult Scler Relat Disord 2018; 26:124-156. [PMID: 30248593 DOI: 10.1016/j.msard.2018.09.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/16/2018] [Accepted: 09/10/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Psychiatric comorbidity is prevalent in persons with multiple sclerosis (MS). Few studies have assessed whether second-generation disease-modifying therapies (DMT) are associated with adverse psychiatric effects. OBJECTIVE We aimed to systematically review the literature regarding the APEs associated with natalizumab, fingolimod, dimethyl fumarate, teriflunomide and alemtuzumab in MS. As a secondary objective, we evaluated changes in anxiety or depression scores following treatment with the aforementioned DMTs. METHODS We searched MEDLINE, EMBASE, International Pharmaceutical Abstracts, PsychINFO, Central Register of Controlled Trials & Cochrane database of systematic reviews for published studies, and clinicaltrials.gov and regulatory documents from the US and Canada for unpublished studies. Data sources were searched from inception to September 2017. Studies reporting adverse psychiatric effects involving any DMT of interest were included. We report the incidence proportions of the adverse psychiatric effects and, where applicable, risk differences between DMT-exposed and unexposed individuals along with the corresponding 95% confidence intervals. We calculated the standardized mean differences (SMD) of changes in anxiety and depression scores if reported as study outcomes, and pooled the data using random effects meta-analysis. RESULTS Of 4389 abstracts screened, 78 met the inclusion criteria, including 48 clinical trials, 28 observational studies and 2 case reports. Depression was the most commonly reported adverse psychiatric effect. Incidence proportions for all adverse psychiatric effects ranged from 0 to 24.7%. None of the DMT studied were associated with a statistically significant increased risk of any adverse psychiatric effect (range of risk difference: -7.69% [95%CI: -16.06%, 5.56%] to 6.67 [-8.56, 15.59]). Eighteen studies examined changes in depression or anxiety following fingolimod, natalizumab or dimethyl fumarate treatment; depression symptoms improved in fingolimod-treated groups (SMD [95%CI]: 1.18 [0.17, 2.19]). We did not identify studies examining changes in these outcomes following treatment with any of the other DMTs. CONCLUSION The DMTs reviewed were not associated with an increased risk of adverse psychiatric effect in MS, and some may reduce the incidence of depressive symptoms. This may reflect either a positive direct effect (e.g. immune modulation) or an indirect effect arising due to a positive impact on disease activity or course.
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Gholamzad M, Ebtekar M, Ardestani MS, Azimi M, Mahmodi Z, Mousavi MJ, Aslani S. A comprehensive review on the treatment approaches of multiple sclerosis: currently and in the future. Inflamm Res 2018; 68:25-38. [DOI: 10.1007/s00011-018-1185-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/13/2018] [Accepted: 08/23/2018] [Indexed: 12/13/2022] Open
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118
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Grand'Maison F, Yeung M, Morrow SA, Lee L, Emond F, Ward BJ, Laneuville P, Schecter R. Sequencing of disease-modifying therapies for relapsing-remitting multiple sclerosis: a theoretical approach to optimizing treatment. Curr Med Res Opin 2018; 34:1419-1430. [PMID: 29583054 DOI: 10.1080/03007995.2018.1458023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Multiple sclerosis (MS) is a chronic disease which usually begins in young adulthood and is a lifelong condition. Individuals with MS experience physical and cognitive disability resulting from inflammation and demyelination in the central nervous system. Over the past decade, several disease-modifying therapies (DMTs) have been approved for the management of relapsing-remitting MS (RRMS), which is the most prevalent phenotype. The chronic nature of the disease and the multiple treatment options make benefit-risk-based sequencing of therapy essential to ensure optimal care. The efficacy and short- and long-term risks of treatment differ for each DMT due to their different mechanism of action on the immune system. While transitioning between DMTs, in addition to immune system effects, factors such as age, disease duration and severity, disability status, monitoring requirements, preference for the route of administration, and family planning play an important role. Determining a treatment strategy is therefore challenging as it requires careful consideration of the differences in efficacy, safety and tolerability, while at the same time minimizing risks of immune modulation. In this review, we discuss a sequencing approach for treating RRMS, with importance given to the long-term risks and individual preference when devising a treatment plan. Evidence-based strategies to counter breakthrough disease are also addressed.
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Affiliation(s)
| | - Michael Yeung
- b Clinical Neurosciences, Foothills Medical Centre , Calgary , Alberta , Canada
| | - Sarah A Morrow
- c London Health Sciences Center (LHSC), Western University , London , Ontario , Canada
| | - Liesly Lee
- d Department of Neurology , Sunnybrook Health Sciences Centre , Toronto , Ontario , Canada
| | - Francois Emond
- e CHU de Québec - hôpital de l'Enfant-Jésus , Quebec City , Quebec , Canada
| | - Brian J Ward
- f Department of Microbiology & Immunology , McGill University , Montreal , Quebec , Canada
| | - Pierre Laneuville
- g Department of Medicine , McGill University , Montreal , Quebec , Canada
| | - Robyn Schecter
- h Novartis Pharmaceuticals Canada Inc. , Dorval , Quebec , Canada
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Thouvenot E. Should we treat patients with radiologically isolated syndrome (RIS)? Yes. Rev Neurol (Paris) 2018; 174:689-692. [PMID: 30041882 DOI: 10.1016/j.neurol.2018.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 05/28/2018] [Indexed: 10/28/2022]
Affiliation(s)
- E Thouvenot
- Service de neurologie, hôpital Caremeau, CHU de Nîmes, 9, place du Prof.-R.-Debré, 30029 Nîmes cedex 9, France; Institut de génomique fonctionnelle, UMR5203, INSERM 1191, université de Montpellier, Montpellier, France.
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Epstein DJ, Dunn J, Deresinski S. Infectious Complications of Multiple Sclerosis Therapies: Implications for Screening, Prophylaxis, and Management. Open Forum Infect Dis 2018; 5:ofy174. [PMID: 30094293 PMCID: PMC6080056 DOI: 10.1093/ofid/ofy174] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/12/2018] [Indexed: 12/12/2022] Open
Abstract
Multiple sclerosis therapies include interferons, glatiramer, and multiple immunosuppressive drugs. Discerning infectious risks of immunosuppressive drugs requires understanding their mechanisms of action and analyzing interventional studies and postmarketing observational data. Though identical immunosuppressive therapies are sometimes used in non-neurologic conditions, infectious risks may differ in this population. Screening for and treatment of latent tuberculosis (TB) infection should be prioritized for patients receiving alemtuzumab; ocrelizumab is likely not associated with an increased risk of TB. Hepatitis B virus (HBV) reactivation can be devastating for patients treated with ocrelizumab and alemtuzumab, whereas the small molecule oral agents do not likely pose substantial risk of HBV. Progressive multifocal leukoencephalopathy is a particular concern with natalizumab. Alemtuzumab, and possibly natalizumab and fingolimod, risks herpes virus reactivation and may warrant prophylaxis. Unusual opportunistic infections have been described. Vaccination is an important tool in preventing infections, though vaccine timing and contraindications can be complex.
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Affiliation(s)
- David J Epstein
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Jeffrey Dunn
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Stan Deresinski
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California
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121
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Meltzer E, Prasad S. Updates and Controversies in the Management of Acute Optic Neuritis. Asia Pac J Ophthalmol (Phila) 2018; 7:251-256. [PMID: 29667789 DOI: 10.22608/apo.2018108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Optic neuritis remains a common diagnosis with controversial management. Although typical optic neuritis is often associated with "good" recovery of visual acuity, patients are often left with persistent impairments of contrast sensitivity, color vision, and visual field. These permanent visual deficits correlate with structural injury to the anterior visual pathway and are closely linked to visual quality of life. High dose corticosteroids are commonly used for patients with acute optic neuritis. However, even several decades after the initial clinical trials, there remains significant controversy regarding the efficacy and utility of this treatment. There is a need for more effective treatments, and many new immunomodulatory and neuroprotective agents have been investigated recently. Atypical optic neuritis, such as that seen with neuromyelitis optica spectrum disorder, often requires more aggressive initial treatment. Thus, it is important for clinicians to have a framework for rapid diagnosis and triage of patients who present with typical or atypical optic neuritis. Lastly, optic neuritis is associated with an elevated long-term risk of developing multiple sclerosis. Some patients may benefit from initiation of medications targeting multiple sclerosis at the time of initial presentation of optic neuritis. Appropriate identification and treatment of patients at highest risk of developing multiple sclerosis may help impact their disease course, while limiting exposure to potential adverse effects in patients who are at lower risk and do not require disease-modifying treatment.
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Affiliation(s)
- Ethan Meltzer
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sashank Prasad
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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122
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Wilbur C, Yeh EA. Radiologically isolated syndrome in children: Current knowledge and future directions. Mult Scler Relat Disord 2018; 24:79-84. [PMID: 29966829 DOI: 10.1016/j.msard.2018.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 06/16/2018] [Indexed: 10/28/2022]
Abstract
As the use of magnetic resonance imaging (MRI) grows in clinical practice, clinicians are increasingly faced with the difficult task of interpreting the significance of incidental findings on brain MRI. Among individuals found to have incidental brain MRI findings, a small number have white matter abnormalities on MRI that resemble the demyelinating lesions of multiple sclerosis (MS) in the absence of a history of relevant clinical symptoms. This has been termed radiologically isolated syndrome (RIS). Recent years have seen growing interest in RIS, with observational studies that have specifically focused on answering questions regarding the subsequent risk of future clinical events and diagnosis of MS in adults and children with these findings. Given the high rate of subsequent clinical events seen in adult studies, knowledge related to RIS in children is paramount, particularly given the higher disease activity and burden in children with MS. This review examines this question, providing an overview of RIS with a focus on its significance in children including current definitions, its association with MS, and knowledge related to therapeutic interventions for RIS. We conclude with suggestions for an approach to assessment of and subsequent surveillance in children fulfilling criteria for RIS and directions for future study.
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Affiliation(s)
- Colin Wilbur
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Department of Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada.
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123
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Hosseini Z, Matusinec J, Rudko DA, Liu J, Kwan BYM, Salehi F, Sharma M, Kremenchutzky M, Menon RS, Drangova M. Morphology-Specific Discrimination between MS White Matter Lesions and Benign White Matter Hyperintensities Using Ultra-High-Field MRI. AJNR Am J Neuroradiol 2018; 39:1473-1479. [PMID: 29930096 DOI: 10.3174/ajnr.a5705] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/05/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Recently published North American Imaging in Multiple Sclerosis guidelines call for derivation of a specific radiologic definition of MS WM lesions and mimics. The purpose of this study was to use SWI and magnetization-prepared FLAIR images for sensitive differentiation of MS from benign WM lesions using the morphologic characteristics of WM lesions. MATERIALS AND METHODS Seventeen patients with relapsing-remitting MS and 18 healthy control subjects were enrolled retrospectively. For each subject, FLAIR and multiecho gradient-echo images were acquired using 7T MR imaging. Optimized postprocessing was used to generate single-slice SWI of cerebral veins. SWI/FLAIR images were registered, and 3 trained readers performed lesion assessment. Morphology, location of lesions, and the time required for assessment were recorded. Analyses were performed on 3 different pools: 1) lesions of >3 mm, 2) nonconfluent lesions of >3 mm, and 3) nonconfluent lesions of >3 mm with no or a single central vein. RESULTS The SWI/FLAIR acquisition and processing protocol enabled effective assessment of central veins and hypointense rims in WM lesions. Assessment of nonconfluent lesions with ≥1 central vein enabled the most specific and sensitive differentiation of patients with MS from controls. A threshold of 67% perivenous WM lesions separated patients with MS from controls with a sensitivity of 94% and specificity of 100%. Lesion assessment took an average of 12 minutes 10 seconds and 4 minutes 33 seconds for patients with MS and control subjects, respectively. CONCLUSIONS Nonconfluent lesions of >3 mm with ≥1 central vein were the most sensitive and specific differentiators between patients with MS and control subjects.
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Affiliation(s)
- Z Hosseini
- From the Biomedical Engineering Graduate Program (Z.H., R.S.M., M.D.).,Imaging Research Laboratories (Z.H., J.L., R.S.M., M.D.), Robarts Research Institute
| | | | - D A Rudko
- Department of Neurology and Neurosurgery (D.A.R.), McConnell Brain Imaging Centre, Montreal Neurological Institute.,Department of Biomedical Engineering (D.A.R.), McGill University, Montreal, Quebec, Canada
| | - J Liu
- Imaging Research Laboratories (Z.H., J.L., R.S.M., M.D.), Robarts Research Institute
| | | | - F Salehi
- Medical Imaging (B.Y.M.K., F.S., M.S.)
| | - M Sharma
- Medical Imaging (B.Y.M.K., F.S., M.S.).,Department of Clinical Neurological Sciences (M.S., M.K.), Western University and London Health Sciences Centre, London, Ontario, Canada
| | - M Kremenchutzky
- Department of Clinical Neurological Sciences (M.S., M.K.), Western University and London Health Sciences Centre, London, Ontario, Canada
| | - R S Menon
- From the Biomedical Engineering Graduate Program (Z.H., R.S.M., M.D.).,Imaging Research Laboratories (Z.H., J.L., R.S.M., M.D.), Robarts Research Institute.,Medical Biophysics (R.S.M., M.D.), Schulich School of Medicine and Dentistry; Western University, London, Ontario, Canada
| | - M Drangova
- From the Biomedical Engineering Graduate Program (Z.H., R.S.M., M.D.) .,Imaging Research Laboratories (Z.H., J.L., R.S.M., M.D.), Robarts Research Institute.,Medical Biophysics (R.S.M., M.D.), Schulich School of Medicine and Dentistry; Western University, London, Ontario, Canada
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124
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First-line therapy in relapsing remitting multiple sclerosis. Rev Neurol (Paris) 2018; 174:419-428. [DOI: 10.1016/j.neurol.2018.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/11/2018] [Accepted: 03/12/2018] [Indexed: 11/21/2022]
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125
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The Shifting Landscape of Disease-Modifying Therapies for Relapsing Multiple Sclerosis. J Neuroophthalmol 2018; 38:210-216. [PMID: 29750735 DOI: 10.1097/wno.0000000000000659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is the most common nontraumatic neurological disorder of young adults, and roughly 85% of patients present with the relapsing form of the disease. Over the past 2 decades, the treatment arsenal for relapsing MS has expanded and evolved from mildly effective and relatively benign injectable agents to potent cell-depleting monoclonal agents. The latter have the potential to achieve disease remission coupled with risk of moderate to severe adverse events with which all MS care providers will need to acquaint themselves. METHODS This review is based on a detailed assessment of MS pivotal trials, extension studies, and expert reviews of the agents discussed. RESULTS/CONCLUSIONS The following review should aid those practitioners directly and indirectly involved in the care of MS patients in understanding the benefits and risks associated with the medications they prescribe.
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126
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Zivadinov R, Bergsland N, Hagemeier J, Carl E, Kolb H, Hojnacki D, Weinstock-Guttman B. Effect of teriflunomide on gray and white matter brain pathology in multiple sclerosis using volumetric and diffusion-tensor imaging MRI measures. J Neurol Sci 2018; 388:175-181. [DOI: 10.1016/j.jns.2018.03.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/28/2018] [Accepted: 03/15/2018] [Indexed: 01/15/2023]
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127
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Gerardi C, Bertele' V, Rossi S, Garattini S, Banzi R. Preapproval and postapproval evidence on drugs for multiple sclerosis. Neurology 2018; 90:964-973. [PMID: 29695598 DOI: 10.1212/wnl.0000000000005561] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/26/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review the evidence supporting the European Union marketing authorization of drugs for multiple sclerosis (MS) and assess how far postmarketing research addresses information gaps at the time of approval. METHODS Through its database, we identified drugs approved by the European Medicines Agency and gathered data on pivotal trials from the European Public Assessment Reports and corresponding publications. We searched Medline, Embase, Cochrane Library, and trial registries for postmarketing randomized controlled trials testing the drugs identified in any form of the disease. RESULTS Since approval of interferon and glatiramer up to 2017, the Agency has examined 10 drugs for the treatment of MS, and 8 were included in this study: alemtuzumab, daclizumab, dimethyl fumarate, fampridine, fingolimod, peginterferon-β-1a, natalizumab, and teriflunomide. We analyzed 16 pivotal trials enrolling almost 16,000 participants. Eleven compared new drugs to placebo, 5 to interferon-β-1a. Annualized relapse rate was the primary outcome in two-thirds and coprimary with disability progression in the 2 studies of alemtuzumab. Of the 52 postmarketing trials, 24 reported final results and 28 were ongoing, terminated, or completed but no results were available. None directly compared the approved drugs, thus leaving their respective therapeutic values unknown. Data on the prevention of disease progression were scarce: none of the disease-modifying drugs showed any effect on disability progression. CONCLUSION The lack of comparative evidence and data on clinical effectiveness hamper the assessment of therapeutic value and place in therapy of drugs approved for MS.
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Affiliation(s)
- Chiara Gerardi
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Vittorio Bertele'
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvia Rossi
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvio Garattini
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Rita Banzi
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
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Armoiry X, Kan A, Melendez-Torres GJ, Court R, Sutcliffe P, Auguste P, Madan J, Counsell C, Clarke A. Short- and long-term clinical outcomes of use of beta-interferon or glatiramer acetate for people with clinically isolated syndrome: a systematic review of randomised controlled trials and network meta-analysis. J Neurol 2018; 265:999-1009. [PMID: 29356977 PMCID: PMC5937891 DOI: 10.1007/s00415-018-8752-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 12/20/2022]
Abstract
Background Beta-interferon (IFN-β) and glatiramer acetate (GA) have been evaluated in people with clinically isolated syndrome (CIS) with the aim to delay a second clinical attack and a diagnosis of clinically definite multiple sclerosis (CDMS). We systematically reviewed trials evaluating the short- and long-term clinical effectiveness of these drugs in CIS. Methods We searched multiple electronic databases. We selected randomised controlled studies (RCTs) conducted in CIS patients and where the interventions were IFN-β and GA. Main outcomes were time to CDMS, and discontinuation due to adverse events (AE). We compared interventions using random-effect network meta-analyses (NMA). We also reported outcomes from long-term open-label extension (OLE) studies. Results We identified five primary studies. Four had open-label extensions following double-blind periods comparing outcomes between early vs delayed DMT. Short-term clinical results (double-blind period) showed that all drugs delayed CDMS compared to placebo. Indirect comparisons did not suggest superiority of any one active drug over another. We could not undertake a NMA for discontinuation due to AE. Long-term clinical results (OLE studies) showed that the risk of developing CDMS was consistently reduced across studies after early DMT treatment compared to delayed DMT (HR = 0.64, 95% CI 0.55, 0.74). No data supported the benefit of DMTs in reducing the time to, and magnitude of, disability progression. Conclusions Meta-analyses confirmed that IFN-β and GA delay time to CDMS compared to placebo. In the absence of evidence that early DMTs can reduce disability progression, future research is needed to better identify patients most likely to benefit from long-term DMTs. Electronic supplementary material The online version of this article (10.1007/s00415-018-8752-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- X Armoiry
- Warwick Medical School, Division of Health Sciences, University of Warwick, Gibbet Hill Road, CV4 7AL, Coventry, England, UK.
| | - A Kan
- Warwick Medical School, Division of Health Sciences, University of Warwick, Gibbet Hill Road, CV4 7AL, Coventry, England, UK
| | - G J Melendez-Torres
- Warwick Medical School, Division of Health Sciences, University of Warwick, Gibbet Hill Road, CV4 7AL, Coventry, England, UK
| | - R Court
- Warwick Medical School, Division of Health Sciences, University of Warwick, Gibbet Hill Road, CV4 7AL, Coventry, England, UK
| | - P Sutcliffe
- Warwick Medical School, Division of Health Sciences, University of Warwick, Gibbet Hill Road, CV4 7AL, Coventry, England, UK
| | - P Auguste
- Warwick Medical School, Division of Health Sciences, University of Warwick, Gibbet Hill Road, CV4 7AL, Coventry, England, UK
| | - J Madan
- Warwick Medical School, Division of Health Sciences, University of Warwick, Gibbet Hill Road, CV4 7AL, Coventry, England, UK
| | - C Counsell
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
| | - A Clarke
- Warwick Medical School, Division of Health Sciences, University of Warwick, Gibbet Hill Road, CV4 7AL, Coventry, England, UK
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129
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Montalban X, Gold R, Thompson AJ, Otero-Romero S, Amato MP, Chandraratna D, Clanet M, Comi G, Derfuss T, Fazekas F, Hartung HP, Havrdova E, Hemmer B, Kappos L, Liblau R, Lubetzki C, Marcus E, Miller DH, Olsson T, Pilling S, Selmaj K, Siva A, Sorensen PS, Sormani MP, Thalheim C, Wiendl H, Zipp F. ECTRIMS/EAN Guideline on the pharmacological treatment of people with multiple sclerosis. Mult Scler 2018; 24:96-120. [PMID: 29353550 DOI: 10.1177/1352458517751049] [Citation(s) in RCA: 404] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Xavier Montalban
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ralf Gold
- Department of Neurology, Ruhr University, St. Josef-Hospital, Bochum, Germany
| | - Alan J Thompson
- Department of Brain Repair & Rehabilitation and Faculty of Brain Sciences, University College London Institute of Neurology, London, UK
| | - Susana Otero-Romero
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron University Hospital, Barcelona, Spain/Preventive Medicine and Epidemiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maria Pia Amato
- Department of Neurosciences, Psychology, Drugs and Child Health Area (NEUROFARBA), Section Neurosciences, University of Florence, Florence, Italy
| | | | - Michel Clanet
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Giancarlo Comi
- Neurological Department, Institute of Experimental Neurology (INSPE), Scientific Institute Hospital San Raffaele, Universita' Vita-Salute San Raffaele, Milan, Italy
| | - Tobias Derfuss
- Departments of Neurology and Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Hans Peter Hartung
- Multiple Sclerosis Center, Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Bernhard Hemmer
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität München and Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | | | - Roland Liblau
- INSERM UMR U1043 - CNRS U5282, Université de Toulouse, UPS, Centre de Physiopathologie de Toulouse Purpan, Toulouse, France
| | - Catherine Lubetzki
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1127, ICM-GHU Pitié-Salpêtrière, Paris, France
| | - Elena Marcus
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - David H Miller
- NMR Research Unit and Queen Square Multiple Sclerosis Centre, University College London Institute of Neurology, London, UK
| | - Tomas Olsson
- Neuroimmunology Unit, Center for Molecular Medicine, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Steve Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Krysztof Selmaj
- Department of Neurology, Medical University of Lodz, Lodz, Poland
| | - Axel Siva
- Clinical Neuroimmunology Unit and MS Clinic, Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey
| | - Per Soelberg Sorensen
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | | | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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130
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Montalban X, Gold R, Thompson AJ, Otero‐Romero S, Amato MP, Chandraratna D, Clanet M, Comi G, Derfuss T, Fazekas F, Hartung HP, Havrdova E, Hemmer B, Kappos L, Liblau R, Lubetzki C, Marcus E, Miller DH, Olsson T, Pilling S, Selmaj K, Siva A, Sorensen PS, Sormani MP, Thalheim C, Wiendl H, Zipp F. ECTRIMS
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EAN
guideline on the pharmacological treatment of people with multiple sclerosis. Eur J Neurol 2018; 25:215-237. [DOI: 10.1111/ene.13536] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/27/2017] [Indexed: 01/21/2023]
Affiliation(s)
- X. Montalban
- Multiple Sclerosis Centre of Catalonia (Cemcat) Department of Neurology‐Neuroimmunology Vall d'Hebron University Hospital Barcelona Spain
| | - R. Gold
- Department of Neurology Ruhr University, St Josef‐Hospital Bochum Germany
| | - A. J. Thompson
- Department of Brain Repair and Rehabilitation Faculty of Brain Sciences University College London Institute of Neurology London UK
| | - S. Otero‐Romero
- Multiple Sclerosis Centre of Catalonia (Cemcat) Department of Neurology‐Neuroimmunology Vall d'Hebron University Hospital Barcelona Spain
- Preventive Medicine and Epidemiology Department Vall d'Hebron University Hospital Barcelona Spain
| | - M. P. Amato
- Department NEUROFARBA Section Neurosciences University of Florence Florence Italy
| | | | - M. Clanet
- Department of Neurology Toulouse University Hospital Toulouse France
| | - G. Comi
- Neurological Department Institute of Experimental Neurology (INSPE) Scientific Institute Hospital San Raffaele University Vita‐Salute San Raffaele Milan Italy
| | - T. Derfuss
- Departments of Neurology and Biomedicine University Hospital Basel Basel Switzerland
| | - F. Fazekas
- Department of Neurology Medical University of Graz Graz Austria
| | - H. P. Hartung
- Department of Neurology Medical Faculty, Multiple Sclerosis Heinrich‐Heine‐University Düsseldorf Germany
| | - E. Havrdova
- Department of Neurology and Centre of Clinical Neuroscience First Faculty of Medicine and General University Hospital Charles University Prague Czech Republic
| | - B. Hemmer
- Department of Neurology Klinikum Rechts der Isar Technische Universität München MunichGermany
- Munich Cluster for Systems Neurology (SyNergy) Munich Germany
| | - L. Kappos
- University Hospital Basel Basel Switzerland
| | - R. Liblau
- INSERM UMR U1043 – CNRS U5282 Centre de Physiopathologie de Toulouse Purpan Université de Toulouse, UPS ToulouseFrance
| | - C. Lubetzki
- ICM‐GHU Pitié‐Salpêtrière Sorbonne Universités UPMC Univ Paris 06, UMR_S 1127 Paris France
| | - E. Marcus
- Centre for Outcomes Research and Effectiveness (CORE) Research Department of Clinical, Educational and Health Psychology University College London LondonUK
| | - D. H. Miller
- NMR Research Unit Queen Square Multiple Sclerosis Centre University College London (UCL) Institute of Neurology London UK
| | - T. Olsson
- Neuroimmunology Unit Centre for Molecular Medicine, L8:04 Karolinska University Hospital (Solna) Stockholm Sweden
| | - S. Pilling
- Centre for Outcomes Research and Effectiveness (CORE) Research Department of Clinical, Educational and Health Psychology University College London LondonUK
| | - K. Selmaj
- Department of Neurology Medical University of Lodz Lodz Poland
| | - A. Siva
- Clinical Neuroimmunology Unit and MS Clinic Department of Neurology Cerrahpasa School of Medicine Istanbul University Istanbul Turkey
| | - P. S. Sorensen
- Danish Multiple Sclerosis Centre Department of Neurology Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | | | - C. Thalheim
- European Multiple Sclerosis Platform (EMSP) Schaerbeek/Brussels Belgium
| | - H. Wiendl
- Department of Neurology University of Münster MünsterGermany
| | - F. Zipp
- Department of Neurology Focus Program Translational Neuroscience (FTN) and Immunology (FZI) Rhine‐Main Neuroscience Network (rmn2) University Medical Centre of the Johannes Gutenberg University Mainz Mainz Germany
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131
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Miller AE. Switching or Discontinuing Disease-Modifying Therapies for Multiple Sclerosis. Continuum (Minneap Minn) 2018; 22:851-63. [PMID: 27261686 DOI: 10.1212/con.0000000000000327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews the reasons for discontinuation or switching of multiple sclerosis disease-modifying therapy as well as procedures that might mitigate risk to the patient under such circumstances. RECENT FINDINGS Recent review of the literature, as well as the author's extensive clinical experience, indicate that the discontinuation of multiple sclerosis disease-modifying therapies occurs for many reasons. Often one medication is stopped at the recommendation of the physician in order to switch to another medication. However, often the decision to discontinue medication is made by the patient. Unfortunately, in still other situations, treatment is stopped because of circumstances beyond the control of either patient or physician (eg, a loss of insurance coverage). Currently available data do not permit a conclusion about whether it is ever safe to discontinue disease-modifying therapy in a stable patient without the expectation of return of disease activity. SUMMARY Clinicians must help patients avoid unnecessary and undesirable cessation of disease-modifying therapy. While switches of therapy are often necessary, steps to minimize both adverse events and the risk of recurrent disease should be undertaken. Whether disease-modifying therapy can ever be purposely discontinued without incurring a significant risk of disease recurrence remains to be determined.
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Abstract
PURPOSE OF REVIEW This article provides an evidence-based approach to the management of patients with early relapsing multiple sclerosis (MS). RECENT FINDINGS Numerous clinical trials have shown the role of disease-modifying therapies in reducing relapses and new MRI lesions in patients with relapsing MS. Many of these trials also show the ability of these agents to delay disability progression, and a few suggest that disease-modifying therapies may slow brain atrophy in relapsing MS; however, very few suggest that disease-modifying therapies can improve symptoms or disability. The therapeutic armamentarium of disease-modifying therapies includes five interferon formulations, two versions of glatiramer acetate, mitoxantrone, natalizumab, fingolimod, teriflunomide, dimethyl fumarate, and alemtuzumab. SUMMARY Although multiple disease-modifying therapies exist, the risks of these vary markedly, head-to-head comparator trials are limited, and no prospective biomarkers for treatment efficacy exist; therefore, choosing a disease-modifying therapy for an individual patient with MS is a difficult decision. This difficulty is compounded by limitations in predicting a patient's disease course, and the risk tolerance of the patient and opinions of the care partner need to be factored into the decision analysis as well. After a disease-modifying therapy is chosen, vigilance for clinical or radiographic breakthrough disease is very important, as this may suggest a suboptimal response to the chosen therapy. Furthermore, the role of symptom management and wellness should always remain part of the approach to the patient with MS.
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Tur C, Moccia M, Barkhof F, Chataway J, Sastre-Garriga J, Thompson AJ, Ciccarelli O. Assessing treatment outcomes in multiple sclerosis trials and in the clinical setting. Nat Rev Neurol 2018; 14:75-93. [PMID: 29326424 DOI: 10.1038/nrneurol.2017.171] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Increasing numbers of drugs are being developed for the treatment of multiple sclerosis (MS). Measurement of relevant outcomes is key for assessing the efficacy of new drugs in clinical trials and for monitoring responses to disease-modifying drugs in individual patients. Most outcomes used in trial and clinical settings reflect either clinical or neuroimaging aspects of MS (such as relapse and accrual of disability or the presence of visible inflammation and brain tissue loss, respectively). However, most measures employed in clinical trials to assess treatment effects are not used in routine practice. In clinical trials, the appropriate choice of outcome measures is crucial because the results determine whether a drug is considered effective and therefore worthy of further development; in the clinic, outcome measures can guide treatment decisions, such as choosing a first-line disease-modifying drug or escalating to second-line treatment. This Review discusses clinical, neuroimaging and composite outcome measures for MS, including patient-reported outcome measures, used in both trials and the clinical setting. Its aim is to help clinicians and researchers navigate through the multiple options encountered when choosing an outcome measure. Barriers and limitations that need to be overcome to translate trial outcome measures into the clinical setting are also discussed.
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Affiliation(s)
- Carmen Tur
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK
| | - Marcello Moccia
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Federico II University, Via Sergio Pansini 5, Naples 80131, Italy
| | - Frederik Barkhof
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,Institute of Healthcare Engineering, University College London, Engineering Front Building, Room 2.01, 2nd Floor, Torrington Place, WC1E 7JE London, UK.,Vrije Universiteit (VU) University Medical Centre - Radiology and Nuclear Medicine, Van der Boechorststraat 7 F/A-114, 1081 BT Amsterdam, Netherlands.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK
| | - Jaume Sastre-Garriga
- Multiple Sclerosis Centre of Catalonia, Department of Neurology and Neuroimmunology, Vall d'Hebron University Hospital, 119-129, 08035 Barcelona, Spain
| | - Alan J Thompson
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK.,University College London Faculty of Brain Sciences, Institute of Neurology, Department of Brain Repair and Rehabilitation, Queen Square, London WC1N 3BG, UK
| | - Olga Ciccarelli
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK
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Feucht N, Maier M, Lepennetier G, Pettenkofer M, Wetzlmair C, Daltrozzo T, Scherm P, Zimmer C, Hoshi MM, Hemmer B, Korn T, Knier B. Optical coherence tomography angiography indicates associations of the retinal vascular network and disease activity in multiple sclerosis. Mult Scler 2018; 25:224-234. [PMID: 29303033 DOI: 10.1177/1352458517750009] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Patients with multiple sclerosis (MS) and clinically isolated syndrome (CIS) may show alterations of retinal layer architecture as measured by optical coherence tomography. Little is known about changes in the retinal vascular network during MS. OBJECTIVE To characterize retinal vessel structures in patients with MS and CIS and to test for associations with MS disease activity. METHOD In all, 42 patients with MS or CIS and 50 healthy controls underwent retinal optical coherence tomography angiography (OCT-A) with analysis of the superficial and deep vascular plexuses and the choriocapillaries. We tested OCT-A parameters for associations with retinal layer volumes, history of optic neuritis (ON), and the retrospective disease activity. RESULTS Inner retinal layer volumes correlated positively with the density of both the superficial and deep vascular plexuses. Eyes of MS/CIS patients with a history of ON revealed reduced vessel densities of the superficial and deep vascular plexuses as compared to healthy controls. Higher choriocapillary vessel densities were associated with ongoing inflammatory disease activity during 24 months prior to OCT-A examination in MS and CIS patients. CONCLUSION Optic neuritis is associated with rarefaction of the superficial and deep retinal vessels. Alterations of the choriocapillaries might be linked to disease activity in MS.
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Affiliation(s)
- Nikolaus Feucht
- Department of Ophthalmology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Mathias Maier
- Department of Ophthalmology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Gildas Lepennetier
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany/ Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Moritz Pettenkofer
- Department of Ophthalmology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Carmen Wetzlmair
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Tanja Daltrozzo
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Pauline Scherm
- Department of Ophthalmology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Muna-Miriam Hoshi
- 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), Munich, Germany
| | - Thomas Korn
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany/ Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany/ Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Benjamin Knier
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany/ Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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TaŞKapilioĞLu ÖZ. Recent Advances in the Treatment for Multiple Sclerosis; Current New Drugs Specific for Multiple Sclerosis. Noro Psikiyatr Ars 2018; 55:S15-S20. [PMID: 30692849 PMCID: PMC6278629 DOI: 10.29399/npa.23402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/23/2018] [Indexed: 01/16/2023] Open
Abstract
Since the first approved parenteral drug for the treatment of multiple sclerosis (MS) in 1993 (interferon [IFN] beta, and later glatiramer acetate [GA]), today there are both parenteral and oral treatment options for MS. After IFN beta preparations, glatiramer acetate was developed; and, until the approval of natalizumab in 2006, those dominated the treatment of MS. Later on, among oral drug options, cladribine made a promising entry; however, due to safety concerns, it was withdrawn soon. Afterwards, with the understanding of the role of sphingosine-1 phosphate (S1P) receptors in the pathogenesis of MS, fingolimod was approved in 2010, which was followed by other oral agents such as teriflunomide and dimethyl fumarate. Recently newer IV treatment options such as alemtuzumab, rituximab and ocrelizumab have widened the treatment arena. Recently, after submitting new efficacy and safety data, cladribine was approved for MS by EMA, in 2017. Moreover, seven years after its rejection due to safety reasons, in August 2018 FDA accepted to re-evaluate the data of cladribine as a treatment option for relapsing remitting MS (RRMS). Another oral treatment option, Laquinimod, was not approved because it could not be shown to slow disability progression despite favourable effect in relapsing MS. Newer generation S1P receptor modulators are being investigated currently, and they are expected to come into the treatment arena soon. In this article, mechanisms of actions, clinical trial results, and side effects of the newer drugs used for MS, are reviewed. IFN beta and glatiramer acetate were not included since they have clinical experience nearing 30 years.
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Affiliation(s)
- ÖZlem TaŞKapilioĞLu
- Department of Neurology, Mehmet Ali Aydınlar Acıbadem University School of Medicine, İstanbul, Turkey
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136
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Huh SY. The early diagnosis and treatments in multiple sclerosis. KOSIN MEDICAL JOURNAL 2017. [DOI: 10.7180/kmj.2017.32.2.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system that leads to neurological disability. The diagnosis of MS relies on the MRI criteria, which can demonstrate dissemination in space and time. Exclusion of other demyelinating mimics is essential because there are no specific biomarker for MS and MRI criteria are still have imperfect. There is incremental improvements in MS treatment option that have contributed to the delay of disease progression. The early initiation of DMT may ameliorate the neurological disability. In this review, we discusses the new diagnostic MS criteria and summarize the evidences supporting the early treatment in the course of MS.
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137
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Miller AE. Oral teriflunomide in the treatment of relapsing forms of multiple sclerosis: clinical evidence and long-term experience. Ther Adv Neurol Disord 2017; 10:381-396. [PMID: 29204190 PMCID: PMC5703103 DOI: 10.1177/1756285617722500] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 07/01/2017] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Aaron E. Miller
- Icahn School of Medicine at Mount Sinai, The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, 5 East 98th Street, Box 1138, New York, NY 10029, USA
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138
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Elkjaer ML, Molnar T, Illes Z. Teriflunomide for multiple sclerosis in real-world setting. Acta Neurol Scand 2017; 136:447-453. [PMID: 28321835 DOI: 10.1111/ane.12755] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Teriflunomide 14 mg is a once-daily oral disease-modifying treatment for relapsing-remitting multiple sclerosis. We examined adverse event (AE) profile and efficacy in real life. MATERIALS AND METHODS In this observational cohort study, we retrospectively examined 1521 blood samples and data of 102 patients followed for up to 28 months. RESULTS The number of female patients starting teriflunomide peaked in the fifth decade, 10 years later compared to male patients (P<.001), reflecting pregnancy concerns. Seventy-six percentages of patients shifted to teriflunomide from treatment with interferon-beta. Expanded disability status scale improved in 11% of patients (18.2±3.6 months follow-up) and remained constant in 67.5% (15±5.3 months follow-up). Of ten relapses, three occurred within 6 months after starting treatment. Seventeen patients (16.5%) discontinued teriflunomide: 53% because of AEs and 29% because of relapse. Levels of alanine aminotransferase (ALT) remained normal in 95.3% of the blood samples and remained below 1.5 times the upper limit of normal in 91% of the 4.7% abnormal samples. One-third of the patients had abnormal ALT values at least once. Haematological abnormalities were found in <4% of the blood samples, but at least one abnormal value was observed in up to 21% of the patients. CONCLUSIONS Efficacy and safety of teriflunomide in real-life setting support data obtained by the pivotal trials. Laboratory abnormalities are rare among the large number of samples, but patients may commonly have a single mild, abnormal value if frequently tested.
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Affiliation(s)
- M. L. Elkjaer
- Department of Neurology; Odense University Hospital; Odense Denmark
| | - T. Molnar
- Department of Anesthesiology and Intensive Care; University of Pecs; Pecs Hungary
| | - Z. Illes
- Department of Neurology; Odense University Hospital; Odense Denmark
- Department of Clinical Research; University of Southern Denmark; Odense Denmark
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Auricchio F, Scavone C, Cimmaruta D, Di Mauro G, Capuano A, Sportiello L, Rafaniello C. Drugs approved for the treatment of multiple sclerosis: review of their safety profile. Expert Opin Drug Saf 2017; 16:1359-1371. [PMID: 28976217 DOI: 10.1080/14740338.2017.1388371] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic immune-mediated inflammatory disorder of the brain and spinal cord characterized by inflammation, demyelination, and axonal degeneration. Area covered: Even though the pharmacological armamentarium for MS treatment is considerably improved in the last 20 years, safety data especially for the second-line and innovative treatments are lacking. In order to analyze the safety profile of drugs used for the treatment of MS, a literature review of pre-marketing, post-marketing studies and case reports was performed. Expert opinion: Nowadays, the numerous drugs approved in the last years for the treatment of MS allow a better control of the disease and a better patient compliance. The main advantages of the new disease-modifying agents for MS (DMTs), in fact, derive from the new oral administration and the prolonged half-life with consequent improvement in compliance compared to first-line therapy which required subcutaneous administrations. However, DMTs can cause serious, sometimes life-threatening or fatal, drug adverse reactions. Due to the lack of safety data and given the recent marketing approval of the last DMTs for MS, observational studies and post-marketing surveillance activities will be necessary in order to improve the knowledge about the safety profile of these drugs and the improvement of their use in clinical practice.
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Affiliation(s)
- Fabiana Auricchio
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Cristina Scavone
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Daniela Cimmaruta
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Gabriella Di Mauro
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Annalisa Capuano
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Liberata Sportiello
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Concetta Rafaniello
- a Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", School of Medicine , University of Campania "Luigi Vanvitelli" , Naples , Italy
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Coyle PK, Khatri B, Edwards KR, Meca-Lallana JE, Cavalier S, Rufi P, Benamor M, Brette S, Robinson M, Gold R. Patient-reported outcomes in relapsing forms of MS: Real-world, global treatment experience with teriflunomide from the Teri-PRO study. Mult Scler Relat Disord 2017; 17:107-115. [DOI: 10.1016/j.msard.2017.07.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/23/2017] [Accepted: 07/05/2017] [Indexed: 11/29/2022]
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141
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Landais A, Alhendi R, Gouverneur A, Teron-Aboud B. A case of lymphoma in a patient on teriflunomide treatment for relapsing multiple sclerosis. Mult Scler Relat Disord 2017; 17:92-94. [DOI: 10.1016/j.msard.2017.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 06/25/2017] [Accepted: 07/01/2017] [Indexed: 11/30/2022]
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Modica CM, Schweser F, Sudyn ML, Bertolino N, Preda M, Polak P, Siebert DM, Krawiecki JC, Sveinsson M, Hagemeier J, Dwyer MG, Pol S, Zivadinov R. Effect of teriflunomide on cortex-basal ganglia-thalamus (CxBGTh) circuit glutamatergic dysregulation in the Theiler's Murine Encephalomyelitis Virus mouse model of multiple sclerosis. PLoS One 2017; 12:e0182729. [PMID: 28796815 PMCID: PMC5552032 DOI: 10.1371/journal.pone.0182729] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 07/24/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pathology of gray matter is associated with development of physical and cognitive disability in patients with multiple sclerosis. In particular, glutamatergic dysregulation in the cortex-basal ganglia-thalamus (CxBGTh) circuit could be associated with decline in these behaviors. OBJECTIVES To investigate the effect of an immunomodulatory therapy (teriflunomide, Aubagio®) on changes of the CxBGTh loop in the Theiler's Murine Encephalomyelitis Virus, (TMEV) mouse model of MS. METHODS Forty-eight (48) mice were infected with TMEV, treated with teriflunomide (24) or control vehicle (24) and followed for 39 weeks. Mice were examined with MRS and volumetric MRI scans (0, 8, 26, and 39 weeks) in the cortex, basal ganglia and thalamus, using a 9.4T scanner, and with behavioral tests (0, 4, 8, 12, 17, 26, and 39 weeks). Within conditions, MRI measures were compared between two time points by paired samples t-test and across multiple time points by repeated measures ANOVA (rmANOVA), and between conditions by independent samples t-test and rmANOVA, respectively. Data were considered as significant at the p<0.01 level and as a trend at p<0.05 level. RESULTS In the thalamus, the teriflunomide arm exhibited trends toward decreased glutamate levels at 8 and 26 weeks compared to the control arm (p = 0.039 and p = 0.026), while the control arm exhibited a trend toward increased glutamate between 0 to 8 weeks (p = 0.045). In the basal ganglia, the teriflunomide arm exhibited a trend toward decreased glutamate earlier than the control arm, from 0 to 8 weeks (p = 0.011), resulting in decreased glutamate compared to the control arm at 8 weeks (p = 0.016). CONCLUSIONS Teriflunomide may reduce possible excitotoxicity in the thalamus and basal ganglia by lowering glutamate levels.
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Affiliation(s)
- Claire M Modica
- Neuroscience Program, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America.,Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America
| | - Ferdinand Schweser
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America.,Translational Imaging Center, Clinical and Translational Science Institute, University at Buffalo, Buffalo, New York, United States of America
| | - Michelle L Sudyn
- Neuroscience Program, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America.,Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America
| | - Nicola Bertolino
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America
| | - Marilena Preda
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America.,Translational Imaging Center, Clinical and Translational Science Institute, University at Buffalo, Buffalo, New York, United States of America
| | - Paul Polak
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America
| | - Danielle M Siebert
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America.,Exercise Science, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, United States of America
| | - Jacqueline C Krawiecki
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America.,Department of Geology, University at Buffalo, Buffalo, New York, United States of America
| | - Michele Sveinsson
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America
| | - Jesper Hagemeier
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America
| | - Michael G Dwyer
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America
| | - Suyog Pol
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America
| | - Robert Zivadinov
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States of America.,Translational Imaging Center, Clinical and Translational Science Institute, University at Buffalo, Buffalo, New York, United States of America
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Guarnera C, Bramanti P, Mazzon E. Comparison of efficacy and safety of oral agents for the treatment of relapsing-remitting multiple sclerosis. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2193-2207. [PMID: 28814828 PMCID: PMC5546180 DOI: 10.2147/dddt.s137572] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
In the therapeutic scenario of disease-modifying therapies for relapsing-remitting multiple sclerosis, the introduction of oral agents, starting in 2010 with fingolimod, has been a huge step forward in therapeutic options due to the easier administration route. Three oral drugs fingolimod, teriflunomide, and dimethyl fumarate, which are clinically approved for the treatment of relapsing-remitting multiple sclerosis, are reviewed in this work. Results of Phase III clinical trials and their extension studies showed that the three oral agents significantly reduced the annualized relapse rate - a superior efficacy compared to placebo. Fingolimod 0.5 mg consistently reduced clinical relapses and brain volume loss. In all Phase III studies, teriflunomide 14 mg dose showed a reduction in the risk of disability accumulation. Regarding safety profile, fingolimod had more safety issues than the other two agents. For this reason, it should be strictly monitored for risks of infections, cancers, and certain transitory effects such as irregular cardiac function, decreased lymphocyte count, and a higher level of liver enzymes. Adverse effects of teriflunomide are well characterized and can be considered manageable. The main risks marked with dimethyl fumarate were flushing and gastrointestinal events.
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Bsteh G, Ehling R, Walchhofer LM, Hegen H, Auer M, Wurth S, Di Pauli F, Wagner M, Reindl M, Deisenhammer F, Berger T. Paroxysmal and unusual symptoms as first clinical manifestation of multiple sclerosis do not indicate benign prognosis-The PaSiMS II study. PLoS One 2017; 12:e0181458. [PMID: 28749974 PMCID: PMC5547697 DOI: 10.1371/journal.pone.0181458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/01/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Paroxysmal (PS) and unusual symptoms (US) account for approximately 1.6% of initial manifestations of multiple sclerosis (MS) and have comparable conversion rates to clinically definite MS (CDMS) as classical bout onset symptoms (CS). However, long-term prognosis and clinical outcome of patients experiencing PS or US as first clinical manifestation are unclear. METHODS Clinical, MRI and cerebrospinal fluid data were obtained retrospectively and patients presenting with PS or US were compared to patients with CS presentation. RESULTS In a cohort of 532 relapsing onset MS patients followed for a mean period of 11.4 years (SD 3.6), 10 (1.9%) patients initially presented with PS/US. PS/US patients received disease modifying treatment (DMT) in a significantly smaller proportion immediately after the first clinical symptom (30% vs. 61.7%; p = 0.021) and during the observation period (60% vs. 83.5%; p = 0.033). In multivariate models correcting for sex, age at initial symptoms, complete remission of initial symptoms, total number of T2 and contrast-enhancing lesions, presence of oligoclonal bands and DMT exposure, PS/US were not associated with lower annualized relapse rate or lower EDSS over time. CONCLUSION In addition to a similar conversion rate to CDMS, patients presenting with PS/US at disease onset display very similar relapse and disability rates as patients with CS onset. Consequently, initial presentation with PS/US does not indicate benign or atypical MS, but requires DMT initiation based on the same criteria as in CS patients.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rainer Ehling
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Clinic for Rehabilitation Muenster, Muenster, Austria
| | | | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Wurth
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michaela Wagner
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Reindl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Thomas Berger
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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145
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Moss HE. Visual consequences of medications for multiple sclerosis: the good, the bad, the ugly, and the unknown. Eye Brain 2017; 9:13-21. [PMID: 28721111 PMCID: PMC5498528 DOI: 10.2147/eb.s140481] [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] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis (MS) is associated with vision changes both due to MS effects on visual pathways and due to medication effects on the visual pathways. Distinguishing the causes of vision change are critical to appropriate diagnosis and management. The incidence, presentation, and treatment of fingolimod-associated macular edema, alemtuzumab-associated thyroid orbitopathy, and progressive multifocal leukoencephalopathy in MS patients are reviewed. Evidence for beneficial effects of acute, chronic, and symptomatic MS medications on vision is presented.
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Affiliation(s)
- Heather E Moss
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA.,Department of Neurology & Neuroscience, Stanford University, Stanford, CA, USA
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146
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Nandoskar A, Raffel J, Scalfari AS, Friede T, Nicholas RS. Pharmacological Approaches to the Management of Secondary Progressive Multiple Sclerosis. Drugs 2017; 77:885-910. [PMID: 28429241 DOI: 10.1007/s40265-017-0726-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
It is well recognised that the majority of the impact of multiple sclerosis (MS), both personal and societal, arises in the progressive phase where disability accumulates inexorably. As such, progressive MS (PMS) has been the target of pharmacological therapies for many years. However, there are no current licensed treatments for PMS. This stands in marked contrast to relapsing remitting MS (RRMS) where trials have resulted in numerous licensed therapies. PMS has proven to be a more difficult challenge compared to RRMS and this review focuses on secondary progressive MS (SPMS), where relapses occur before the onset of gradual, irreversible disability, and not primary progressive MS where disability accumulation occurs without prior relapses. Although there are similarities between the two forms, in both cases pinpointing when PMS starts is difficult in a condition in which disability can vary from day to day. There is also an overlap between the pathology of relapsing and progressive MS and this has contributed to the lack of well-defined outcomes, both surrogates and clinically relevant outcomes in PMS. In this review, we used the search term 'randomised controlled clinical drug trials in secondary progressive MS' in publications since 1988 together with recently completed trials where results were available. We found 34 trials involving 21 different molecules, of which 38% were successful in reaching their primary outcome. In general, the trials were well designed (e.g. double blind) with sample sizes ranging from 35 to 1949 subjects. The majority were parallel group, but there were also multi-arm and multidose trials as well as the more recent use of adaptive designs. The disability outcome most commonly used was the Expanded Disability Status Scale (EDSS) in all phases, but also magnetic resonance imaging (MRI)-measured brain atrophy has been utilised as a surrogate endpoint in phase II studies. The majority of the treatments tested in SPMS over the years were initially successful in RRMS. This has a number of implications in terms of targeting SPMS, but principally implies that the optimal strategy to target SPMS is to utilise the prodrome of relapses to initiate a therapy that will aim to both prevent progression and slow its accumulation. This approach is in agreement with the early targeting of MS but requires treatments that are both effective and safe if it is to be used before disability is a major problem. Recent successes will hopefully result in the first licensed therapy for PMS and enable us to test this approach.
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Affiliation(s)
- A Nandoskar
- Wolfson Neuroscience Laboratories, Faculty of Medicine, Imperial College London, Hammersmith Hospital Campus, 160 Du Cane Road, London, W12 0NN, UK
| | - J Raffel
- Wolfson Neuroscience Laboratories, Faculty of Medicine, Imperial College London, Hammersmith Hospital Campus, 160 Du Cane Road, London, W12 0NN, UK
| | - A S Scalfari
- Wolfson Neuroscience Laboratories, Faculty of Medicine, Imperial College London, Hammersmith Hospital Campus, 160 Du Cane Road, London, W12 0NN, UK
| | - T Friede
- Department of Medical Statistics, University Medical Center Göttingen, Humboltallee 32, 37073, Göttingen, Germany
| | - R S Nicholas
- Wolfson Neuroscience Laboratories, Faculty of Medicine, Imperial College London, Hammersmith Hospital Campus, 160 Du Cane Road, London, W12 0NN, UK.
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147
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Yong H, Chartier G, Quandt J. Modulating inflammation and neuroprotection in multiple sclerosis. J Neurosci Res 2017; 96:927-950. [PMID: 28580582 DOI: 10.1002/jnr.24090] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/17/2017] [Accepted: 05/04/2017] [Indexed: 12/13/2022]
Abstract
Multiple sclerosis (MS) is a neurological disorder of the central nervous system with a presentation and disease course that is largely unpredictable. MS can cause loss of balance, impaired vision or speech, weakness and paralysis, fatigue, depression, and cognitive impairment. Immunomodulation is a major target given the appearance of focal demyelinating lesions in myelin-rich white matter, yet progression and an increasing appreciation for gray matter involvement, even during the earliest phases of the disease, highlights the need to afford neuroprotection and limit neurodegenerative processes that correlate with disability. This review summarizes key aspects of MS pathophysiology and histopathology with a focus on neuroimmune interactions in MS, which may facilitate neurodegeneration through both direct and indirect mechanisms. There is a focus on processes thought to influence disease progression and the role of oxidative stress and mitochondrial dysfunction in MS. The goals and efficacy of current disease-modifying therapies and those in the pipeline are discussed, highlighting recent advances in our understanding of pathways mediating disease progression to identify and translate both immunomodulatory and neuroprotective therapeutics from the bench to the clinic.
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Affiliation(s)
- Heather Yong
- Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gabrielle Chartier
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacqueline Quandt
- Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
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148
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Metz LM, Li DKB, Traboulsee AL, Duquette P, Eliasziw M, Cerchiaro G, Greenfield J, Riddehough A, Yeung M, Kremenchutzky M, Vorobeychik G, Freedman MS, Bhan V, Blevins G, Marriott JJ, Grand'Maison F, Lee L, Thibault M, Hill MD, Yong VW. Trial of Minocycline in a Clinically Isolated Syndrome of Multiple Sclerosis. N Engl J Med 2017; 376:2122-2133. [PMID: 28564557 DOI: 10.1056/nejmoa1608889] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND On the basis of encouraging preliminary results, we conducted a randomized, controlled trial to determine whether minocycline reduces the risk of conversion from a first demyelinating event (also known as a clinically isolated syndrome) to multiple sclerosis. METHODS During the period from January 2009 through July 2013, we randomly assigned participants who had had their first demyelinating symptoms within the previous 180 days to receive either 100 mg of minocycline, administered orally twice daily, or placebo. Administration of minocycline or placebo was continued until a diagnosis of multiple sclerosis was established or until 24 months after randomization, whichever came first. The primary outcome was conversion to multiple sclerosis (diagnosed on the basis of the 2005 McDonald criteria) within 6 months after randomization. Secondary outcomes included conversion to multiple sclerosis within 24 months after randomization and changes on magnetic resonance imaging (MRI) at 6 months and 24 months (change in lesion volume on T2-weighted MRI, cumulative number of new lesions enhanced on T1-weighted MRI ["enhancing lesions"], and cumulative combined number of unique lesions [new enhancing lesions on T1-weighted MRI plus new and newly enlarged lesions on T2-weighted MRI]). RESULTS A total of 142 eligible participants underwent randomization at 12 Canadian multiple sclerosis clinics; 72 participants were assigned to the minocycline group and 70 to the placebo group. The mean age of the participants was 35.8 years, and 68.3% were women. The unadjusted risk of conversion to multiple sclerosis within 6 months after randomization was 61.0% in the placebo group and 33.4% in the minocycline group, a difference of 27.6 percentage points (95% confidence interval [CI], 11.4 to 43.9; P=0.001). After adjustment for the number of enhancing lesions at baseline, the difference in the risk of conversion to multiple sclerosis within 6 months after randomization was 18.5 percentage points (95% CI, 3.7 to 33.3; P=0.01); the unadjusted risk difference was not significant at the 24-month secondary outcome time point (P=0.06). All secondary MRI outcomes favored minocycline over placebo at 6 months but not at 24 months. Trial withdrawals and adverse events of rash, dizziness, and dental discoloration were more frequent among participants who received minocycline than among those who received placebo. CONCLUSIONS The risk of conversion from a clinically isolated syndrome to multiple sclerosis was significantly lower with minocycline than with placebo over 6 months but not over 24 months. (Funded by the Multiple Sclerosis Society of Canada; ClinicalTrials.gov number, NCT00666887 .).
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Affiliation(s)
- Luanne M Metz
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - David K B Li
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Anthony L Traboulsee
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Pierre Duquette
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Misha Eliasziw
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Graziela Cerchiaro
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Jamie Greenfield
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Andrew Riddehough
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Michael Yeung
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Marcelo Kremenchutzky
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Galina Vorobeychik
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Mark S Freedman
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Virender Bhan
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Gregg Blevins
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - James J Marriott
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Francois Grand'Maison
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Liesly Lee
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Manon Thibault
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - Michael D Hill
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
| | - V Wee Yong
- From the Cumming School of Medicine and the Hotchkiss Brain Institute, Calgary, AB (L.M.M., G.C., J.G., M.Y., M.D.H., V.W.Y.), the University of British Columbia, Vancouver (D.K.B.L., A.L.T., A.R.), the University of Montreal, Montreal (P.D.), Western University, London, ON (M.K.), Fraser Health MS Clinic, Burnaby, BC (G.V.), the University of Ottawa and the Ottawa Hospital Research Institute, Ottawa (M.S.F.), Dalhousie University, Halifax, NS (V.B.), the University of Alberta, Edmonton (G.B.), the University of Manitoba, Winnipeg (J.J.M.), Clinique Neuro Rive-Sud, Greenfield Park, QC (F.G.), the University of Toronto, Toronto (L.L.), and CHA-Hôpital Enfant-Jésus, Quebec, QC (M.T.) - all in Canada; and Tufts University, Boston (M.E.)
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Iaffaldano P, Simone M, Lucisano G, Ghezzi A, Coniglio G, Brescia Morra V, Salemi G, Patti F, Lugaresi A, Izquierdo G, Bergamaschi R, Cabrera-Gomez JA, Pozzilli C, Millefiorini E, Alroughani R, Boz C, Pucci E, Zimatore GB, Sola P, Lus G, Maimone D, Avolio C, Cocco E, Sajedi SA, Costantino G, Duquette P, Shaygannejad V, Petersen T, Fernández Bolaños R, Paolicelli D, Tortorella C, Spelman T, Margari L, Amato MP, Comi G, Butzkueven H, Trojano M. Prognostic indicators in pediatric clinically isolated syndrome. Ann Neurol 2017; 81:729-739. [DOI: 10.1002/ana.24938] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Pietro Iaffaldano
- Department of Basic Medical Sciences, Neurosciences, and Sense Organs; University of Bari Aldo Moro; Bari Italy
| | - Marta Simone
- Child Neuropsychiatry Unit, Department of Basic Medical Sciences, Neurosciences, and Sense Organs; University of Bari Aldo Moro; Bari Italy
| | - Giuseppe Lucisano
- Department of Basic Medical Sciences, Neurosciences, and Sense Organs; University of Bari Aldo Moro; Bari Italy
- Center for Outcomes Research and Clinical Epidemiology, CORESEARCH; Pescara Italy
| | - Angelo Ghezzi
- Multiple Sclerosis Center, Sant'Antonio Abate Hospital; Gallarate Italy
| | | | - Vincenzo Brescia Morra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; University of Naples Federico II; Naples Italy
| | - Giuseppe Salemi
- Department of Clinical Neuroscience; University of Palermo; Palermo Italy
| | - Francesco Patti
- Department of Advanced Medical and Surgical Sciences and Technologies, Multiple Sclerosis Center; University of Catania; Catania Italy
| | - Alessandra Lugaresi
- Department of Biomedical and Neuro Motor Sciences; University of Bologna; Bologna Italy
- IRCCS Institute of Neurological Science and Bellaria Hospital; Bologna Italy
| | - Guillermo Izquierdo
- Department of Neurology; Virgin of Hope of Macarena University Hospital; Seville Spain
| | - Roberto Bergamaschi
- Interdepartment Multiple Sclerosis Research Center; C. Mondino National Institute of Neurology Foundation; Pavia Italy
| | | | - Carlo Pozzilli
- Multiple Sclerosis Center, Sant'Andrea Hospital, Department of Neurology and Psychiatry; Sapienza University; Rome Italy
| | - Enrico Millefiorini
- Multiple Sclerosis Center, Umberto I Hospital; Sapienza University; Rome Italy
| | - Raed Alroughani
- Division of Neurology, Department of Medicine; Amiri Hospital; Kuwait City Kuwait
| | - Cavit Boz
- Karadeniz Technical University; Trabzon Turkey
| | - Eugenio Pucci
- Neurology Unit, ASUR Marche Hospital; Macerata Italy
| | | | - Patrizia Sola
- Department of Neurosciences, Neurology Unit; University of Modena and Reggio Emilia, Sant'Agostino-Estense Hospital; Modena Italy
| | - Giacomo Lus
- Multiple Sclerosis Center, II Division of Neurology, Department of Clinical and Experimental Medicine; Second University of Naples; Naples Italy
| | - Davide Maimone
- Multiple Sclerosis Center, Garibaldi-Nesima Hospital; Catania Italy
| | - Carlo Avolio
- Department of Medical and Surgical Sciences; University of Foggia; Foggia Italy
| | - Eleonora Cocco
- Department of Public Health, Clinical and Molecular Medicine; University of Cagliari; Cagliari Italy
| | - Seyed Aidin Sajedi
- Multiple Sclerosis Center, Golestan Hospital; Ahvaz Jundishapur University of Medical Sciences; Ahvaz Iran
| | | | - Pierre Duquette
- Department of Neurology, Notre Dame Hospital; Montreal Quebec Canada
| | - Vahid Shaygannejad
- Neurosciences Research Center and Department of Neurology; Isfahan University of Medical Sciences; Isfahan Iran
| | | | | | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neurosciences, and Sense Organs; University of Bari Aldo Moro; Bari Italy
| | - Carla Tortorella
- Department of Basic Medical Sciences, Neurosciences, and Sense Organs; University of Bari Aldo Moro; Bari Italy
| | - Tim Spelman
- Department of Neurology, Box Hill Hospital; Monash University; Melbourne Victoria Australia
- Department of Medicine at Royal Melbourne Hospital; University of Melbourne; Parkville Victoria Australia
| | - Lucia Margari
- Child Neuropsychiatry Unit, Department of Basic Medical Sciences, Neurosciences, and Sense Organs; University of Bari Aldo Moro; Bari Italy
| | - Maria Pia Amato
- Department of NEUROFARBA; University of Florence; Florence Italy
| | - Giancarlo Comi
- Department of Neurology; Vita-Salute San Raffaele University, San Raffaele Scientific Institute; Milan Italy
| | - Helmut Butzkueven
- Department of Neurology, Box Hill Hospital; Monash University; Melbourne Victoria Australia
- Department of Medicine at Royal Melbourne Hospital; University of Melbourne; Parkville Victoria Australia
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences, and Sense Organs; University of Bari Aldo Moro; Bari Italy
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Filippini G, Del Giovane C, Clerico M, Beiki O, Mattoscio M, Piazza F, Fredrikson S, Tramacere I, Scalfari A, Salanti G. Treatment with disease-modifying drugs for people with a first clinical attack suggestive of multiple sclerosis. Cochrane Database Syst Rev 2017; 4:CD012200. [PMID: 28440858 PMCID: PMC6478290 DOI: 10.1002/14651858.cd012200.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The treatment of multiple sclerosis has changed over the last 20 years. The advent of disease-modifying drugs in the mid-1990s heralded a period of rapid progress in the understanding and management of multiple sclerosis. With the support of magnetic resonance imaging early diagnosis is possible, enabling treatment initiation at the time of the first clinical attack. As most of the disease-modifying drugs are associated with adverse events, patients and clinicians need to weigh the benefit and safety of the various early treatment options before taking informed decisions. OBJECTIVES 1. to estimate the benefit and safety of disease-modifying drugs that have been evaluated in all studies (randomised or non-randomised) for the treatment of a first clinical attack suggestive of MS compared either with placebo or no treatment;2. to assess the relative efficacy and safety of disease-modifying drugs according to their benefit and safety;3. to estimate the benefit and safety of disease-modifying drugs that have been evaluated in all studies (randomised or non-randomised) for treatment started after a first attack ('early treatment') compared with treatment started after a second attack or at another later time point ('delayed treatment'). SEARCH METHODS We searched the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group Trials Register, MEDLINE, Embase, CINAHL, LILACS, clinicaltrials.gov, the WHO trials registry, and US Food and Drug Administration (FDA) reports, and searched for unpublished studies (until December 2016). SELECTION CRITERIA We included randomised and observational studies that evaluated one or more drugs as monotherapy in adult participants with a first clinical attack suggestive of MS. We considered evidence on alemtuzumab, azathioprine, cladribine, daclizumab, dimethyl fumarate, fingolimod, glatiramer acetate, immunoglobulins, interferon beta-1b, interferon beta-1a (Rebif®, Avonex®), laquinimod, mitoxantrone, natalizumab, ocrelizumab, pegylated interferon beta-1a, rituximab and teriflunomide. DATA COLLECTION AND ANALYSIS Two teams of three authors each independently selected studies and extracted data. The primary outcomes were disability-worsening, relapses, occurrence of at least one serious adverse event (AE) and withdrawing from the study or discontinuing the drug because of AEs. Time to conversion to clinically definite MS (CDMS) defined by Poser diagnostic criteria, and probability to discontinue the treatment or dropout for any reason were recorded as secondary outcomes. We synthesized study data using random-effects meta-analyses and performed indirect comparisons between drugs. We calculated odds ratios (OR) and hazard ratios (HR) along with relative 95% confidence intervals (CI) for all outcomes. We estimated the absolute effects only for primary outcomes. We evaluated the credibility of the evidence using the GRADE system. MAIN RESULTS We included 10 randomised trials, eight open-label extension studies (OLEs) and four cohort studies published between 2010 and 2016. The overall risk of bias was high and the reporting of AEs was scarce. The quality of the evidence associated with the results ranges from low to very low. Early treatment versus placebo during the first 24 months' follow-upThere was a small, non-significant advantage of early treatment compared with placebo in disability-worsening (6.4% fewer (13.9 fewer to 3 more) participants with disability-worsening with interferon beta-1a (Rebif®) or teriflunomide) and in relapses (10% fewer (20.3 fewer to 2.8 more) participants with relapses with teriflunomide). Early treatment was associated with 1.6% fewer participants with at least one serious AE (3 fewer to 0.2 more). Participants on early treatment were on average 4.6% times (0.3 fewer to 15.4 more) more likely to withdraw from the study due to AEs. This result was mostly driven by studies on interferon beta 1-b, glatiramer acetate and cladribine that were associated with significantly more withdrawals for AEs. Early treatment decreased the hazard of conversion to CDMS (HR 0.53, 95% CI 0.47 to 0.60). Comparing active interventions during the first 24 months' follow-upIndirect comparison of interferon beta-1a (Rebif®) with teriflunomide did not show any difference on reducing disability-worsening (OR 0.84, 95% CI 0.43 to 1.66). We found no differences between the included drugs with respect to the hazard of conversion to CDMS. Interferon beta-1a (Rebif®) and teriflunomide were associated with fewer dropouts because of AEs compared with interferon beta-1b, cladribine and glatiramer acetate (ORs range between 0.03 and 0.29, with substantial uncertainty). Early versus delayed treatmentWe did not find evidence of differences between early and delayed treatments for disability-worsening at a maximum of five years' follow-up (3% fewer participants with early treatment (15 fewer to 11.1 more)). There was important variability across interventions; early treatment with interferon beta-1b considerably reduced the odds of participants with disability-worsening during three and five years' follow-up (OR 0.52, 95% CI 0.32 to 0.84 and OR 0.57, 95% CI 0.36 to 0.89). The early treatment group had 19.6% fewer participants with relapses (26.7 fewer to 12.7 fewer) compared to late treatment at a maximum of five years' follow-up and early treatment decreased the hazard of conversion to CDMS at any follow-up up to 10 years (i.e. over five years' follow-up HR 0.62, 95% CI 0.53 to 0.73). We did not draw any conclusions on long-term serious AEs or discontinuation due to AEs because of inadequacies in the available data both in the included OLEs and cohort studies. AUTHORS' CONCLUSIONS Very low-quality evidence suggests a small and uncertain benefit with early treatment compared with placebo in reducing disability-worsening and relapses. The advantage of early treatment compared with delayed on disability-worsening was heterogeneous depending on the actual drug used and based on very low-quality evidence. Low-quality evidence suggests that the chances of relapse are less with early treatment compared with delayed. Early treatment reduced the hazard of conversion to CDMS compared either with placebo, no treatment or delayed treatment, both in short- and long-term follow-up. Low-quality evidence suggests that early treatment is associated with fewer participants with at least one serious AE compared with placebo. Very low-quality evidence suggests that, compared with placebo, early treatment leads to more withdrawals or treatment discontinuation due to AEs. Difference between drugs on short-term benefit and safety was uncertain because few studies and only indirect comparisons were available. Long-term safety of early treatment is uncertain because of inadequately reported or unavailable data.
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Affiliation(s)
- Graziella Filippini
- Fondazione IRCCS, Istituto Neurologico Carlo BestaScientific Directionvia Celoria, 11MilanItaly20133
| | - Cinzia Del Giovane
- University of Modena and Reggio EmiliaCochrane Italy, Department of Diagnostic, Clinical and Public Health MedicineVia del Pozzo 71ModenaItaly41124
| | - Marinella Clerico
- AOU San Luigi GonzagaUniversity of Turin, Division of NeurologyRegione Gonzole, 13OrbassanoItaly10043
| | | | - Miriam Mattoscio
- Imperial College LondonDepartment of Medicine, Division of Brain Sciences, Centre for Neuroscience, Wolfson Neuroscience LaboratoriesDu Cane RoadLondonUKW12 0NN
| | - Federico Piazza
- AOU San Luigi GonzagaUniversity of Turin, Division of NeurologyRegione Gonzole, 13OrbassanoItaly10043
| | - Sten Fredrikson
- Karolinska InstitutetDepartment of Clinical NeuroscienceStockholmSweden17177
| | - Irene Tramacere
- Fondazione IRCCS, Istituto Neurologico Carlo BestaScientific Directionvia Celoria, 11MilanItaly20133
| | - Antonio Scalfari
- Imperial College LondonDepartment of Medicine, Division of Brain Sciences, Centre for Neuroscience, Wolfson Neuroscience LaboratoriesDu Cane RoadLondonUKW12 0NN
| | - Georgia Salanti
- University of BernInstitute of Social and Preventive Medicine (ISPM)Finkenhubelweg 11BernSwitzerland3005
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