101
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Tisovic K, Amezcua L. Women's Health: Contemporary Management of MS in Pregnancy and Post-Partum. Biomedicines 2019; 7:biomedicines7020032. [PMID: 31010259 PMCID: PMC6630249 DOI: 10.3390/biomedicines7020032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 11/16/2022] Open
Abstract
Multiple sclerosis (MS) primarily affects women in childbearing age and is associated with an increased risk of adverse post-partum outcomes. Relapses and now fetal exposure to disease modifying treatments in the early phase of pregnancy and thereafter are of concern. Safe and effective contraception is required for women who wish to delay or avoid pregnancy while on disease-modifying treatments. Counseling and planning is essential to assess the risk of both fetal and maternal complications, particularly now in the era of highly efficient and riskier therapies. The purpose of this review is to provide a practical framework using the available data surrounding pregnancy in MS with the goal of optimizing outcomes during this phase in MS.
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Affiliation(s)
- Kelly Tisovic
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
| | - Lilyana Amezcua
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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102
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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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103
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Weng Q, Che J, Zhang Z, Zheng J, Zhan W, Lin S, Tian T, Wang J, Gai R, Hu Y, Yang B, He Q, Dong X. Phenotypic Screening-Based Identification of 3,4-Disubstituted Piperidine Derivatives as Macrophage M2 Polarization Modulators: An Opportunity for Treating Multiple Sclerosis. J Med Chem 2019; 62:3268-3285. [PMID: 30856328 DOI: 10.1021/acs.jmedchem.8b01635] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Multiple sclerosis (MS) is a disease of the autoimmune-mediated disorder in the central nervous system, for which no effective therapeutic agent is currently available. The regulation of macrophage polarization toward M2 is a general benefit for treating MS. The gene biomarker-based phenotypic screening approach was developed, and 3,4-disubstituted piperidine derivative S-28 was identified as a lead compound modulating macrophage M2 polarization. Further SAR studies resulted in the discovery of the most potent modulator D11 that showed good oral bioavailability and significant in vivo therapeutic effects. Mechanistic studies demonstrated that the M2 polarization macrophages modulated by D11 mainly functioned through inhibiting the proliferation of T-cells and activating the phosphorylation of Stat3 and Akt. Therefore, the gene biomarker-based phenotypic screening was demonstrated as a promising tool for the discovery of novel macrophage M2 polarization modulators. Compound D11 may serve as a promising starting point for the development of therapeutics to treat MS.
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104
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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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105
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Achtnichts L, Chan A, Czaplinski A, Derfuss T, Du Pasquier R, Findling O, Gobbi C, Hoepner R, Kamber N, Kamm CP, Kuhle J, Lalive P, Lutterotti A, Martin R, Müller S, Papadopoulou A, Pot C, Salmen A, Schippling S, Zecca C. Specific aspects of immunotherapy for multiple sclerosis in Switzerland: A structured commentary. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x18822073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
More than a dozen substances are meanwhile available for the disease-modifying immunotherapy of multiple sclerosis (MS). However, for some substances, there is a clear difference between approval in Switzerland (Swissmedic) and neighboring countries (European Medicines Agency (EMA)). In addition, limitations imposed by the Swiss Federal Office of Public Health in the specialties list (SL) have significant effects on use in daily clinical practice. In the following, we present consensus recommendations, which were reviewed and agreed upon by the Scientific Advisory Board of the Swiss Multiple Sclerosis Society and the Swiss Neurological Society. We explicitly focus on practice-relevant differences in the approval of MS immunotherapies in Switzerland compared with the EMA area and discuss further limitations (SL) and their impact on the use in clinical practice. Immunotherapies with the same approval in Switzerland and the EMA area and symptomatic therapies are not discussed here.
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Affiliation(s)
- L Achtnichts
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - A Chan
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - T Derfuss
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - R Du Pasquier
- Division of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - O Findling
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - C Gobbi
- Division of Neurology, Multiple Sclerosis Center, Neurocenter of Southern Switzerland, Ospedale Regionale, Lugano, Switzerland
| | - R Hoepner
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - N Kamber
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - CP Kamm
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
- Neurology and Neurorehabilitation Center, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - J Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - P Lalive
- Department of Neurosciences, Division of Neurology, Unit of Neuroimmunology and Neuromuscular Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - A Lutterotti
- Neuroimmunology and Multiple Sclerosis Research (nims), Department of Neurology, University Hospital Zurich and University of Zurich, Zürich, Switzerland
| | - R Martin
- Neuroimmunology and Multiple Sclerosis Research (nims), Department of Neurology, University Hospital Zurich and University of Zurich, Zürich, Switzerland
| | - S Müller
- Department of Neurology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - A Papadopoulou
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - C Pot
- Division of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - A Salmen
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - S Schippling
- Neuroimmunology and Multiple Sclerosis Research (nims), Department of Neurology, University Hospital Zurich and University of Zurich, Zürich, Switzerland
- Neuroscience Center Zurich, University of Zurich and Federal Institute of Technology (ETH) Zurich, Zürich, Switzerland
| | - C Zecca
- Division of Neurology, Multiple Sclerosis Center, Neurocenter of Southern Switzerland, Ospedale Regionale, Lugano, Switzerland
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106
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Linker RA, Chan A. Navigating choice in multiple sclerosis management. Neurol Res Pract 2019; 1:5. [PMID: 33324871 PMCID: PMC7650058 DOI: 10.1186/s42466-019-0005-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 11/21/2018] [Indexed: 01/10/2023] Open
Abstract
Background With the advent of modern immunotherapies for relapsing-remitting multiple sclerosis (RRMS) and the increasing amount of treatment options on the market, MS has evolved as a treatable disease. Yet, at the same time, new challenges for the treating neurologists arise. Main body This review article covers some of these challenges, including when and how to start treatment, treatment monitoring, and finally considerations on what the increasing choice in treatment options brings to disease management and longer-term planning. Among others, these important issues comprise pregnancy, treatment sequencing, switching or even stopping treatment. Conclusion The ultimate goal for navigating choices in RRMS management is to choose the right drug for the right patient at the right time Throughout the article, there is a strong focus on practical aspects and individual decision making in MS to meet the concept of personalized medicine.
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Affiliation(s)
- Ralf A Linker
- Department of Neurology, University of Regensburg, Universitätsstr. 84, 93053 Regensburg, Germany
| | - Andrew Chan
- Ambulantes Neurozentrum, Inselspital, Bern University Hospital, Freiburgstr. 4, 3010 Bern, Switzerland
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107
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Correale J, Marrodan M, Ysrraelit MC. Mechanisms of Neurodegeneration and Axonal Dysfunction in Progressive Multiple Sclerosis. Biomedicines 2019; 7:biomedicines7010014. [PMID: 30791637 PMCID: PMC6466454 DOI: 10.3390/biomedicines7010014] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/14/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
Multiple Sclerosis (MS) is a major cause of neurological disability, which increases predominantly during disease progression as a result of cortical and grey matter structures involvement. The gradual accumulation of disability characteristic of the disease seems to also result from a different set of mechanisms, including in particular immune reactions confined to the Central Nervous System such as: (a) B-cell dysregulation, (b) CD8+ T cells causing demyelination or axonal/neuronal damage, and (c) microglial cell activation associated with neuritic transection found in cortical demyelinating lesions. Other potential drivers of neurodegeneration are generation of oxygen and nitrogen reactive species, and mitochondrial damage, inducing impaired energy production, and intra-axonal accumulation of Ca2+, which in turn activates a variety of catabolic enzymes ultimately leading to progressive proteolytic degradation of cytoskeleton proteins. Loss of axon energy provided by oligodendrocytes determines further axonal degeneration and neuronal loss. Clearly, these different mechanisms are not mutually exclusive and could act in combination. Given the multifactorial pathophysiology of progressive MS, many potential therapeutic targets could be investigated in the future. This remains however, an objective that has yet to be undertaken.
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Affiliation(s)
- Jorge Correale
- Department of Neurology, FLENI, Buenos Aires 1428, Argentina.
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108
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Autologous Hematopoietic Cell Transplantation for Treatment-Refractory Relapsing Multiple Sclerosis: Position Statement from the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2019; 25:845-854. [PMID: 30794930 DOI: 10.1016/j.bbmt.2019.02.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 12/29/2022]
Abstract
Multiple sclerosis (MS) is a chronic, disabling, immune-mediated, demyelinating and degenerative disease of the central nervous system. Approved disease-modifying therapies may be incompletely effective in some patients with highly active relapsing disease and high risk of disability. The use of immunoablative or myeloablative therapy followed by autologous hematopoietic cell transplantation (AHCT) has been investigated in retrospective studies, clinical trials, and meta-analyses/systematic reviews as an approach to address this unmet clinical need. On behalf of the American Society for Blood and Bone Marrow Transplantation (ASBMT), a panel of experts in AHCT and MS convened to review available evidence and make recommendations on MS as an indication for AHCT. A review of recent literature identified 8 retrospective studies, 8 clinical trials, and 3 meta-analyses/systematic reviews. In aggregate, these studies indicate that AHCT is an efficacious and safe treatment for active relapsing forms of MS to prevent clinical relapse, magnetic resonance imaging-detectable lesion activity, and worsening disability and to reverse disability without unexpected adverse events. Based on the available evidence, the ASBMT recommends that treatment-refractory relapsing MS with high risk of future disability be considered a "standard of care, clinical evidence available" indication for AHCT. Collaboration of neurologists with expertise in treating MS and transplantation physicians with experience performing AHCT for autoimmune disease is crucial for ensuring appropriate patient selection and optimizing transplantation procedures to improve patient outcomes. Transplantation centers in the United States and Canada are strongly encouraged to report baseline and outcomes data on patients receiving AHCT for multiple sclerosis to the Center for International Blood and Marrow Transplant Research.
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109
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Baker D, Pryce G, Herrod SS, Schmierer K. Potential mechanisms of action related to the efficacy and safety of cladribine. Mult Scler Relat Disord 2019; 30:176-186. [PMID: 30785074 DOI: 10.1016/j.msard.2019.02.018] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/09/2019] [Accepted: 02/12/2019] [Indexed: 12/31/2022]
Abstract
Oral cladribine is a novel treatment for relapsing multiple sclerosis (MS). This appears to be a semi-selective immune-reconstitution therapy that induces long-term therapy from short treatment cycles. It has a relatively good safety profile that currently does not require extensive monitoring associated with some continuous immunosuppressive and relatively non-selective immune reconstitution therapies. The efficacy and safety of cladribine relates to its particular physicochemical properties, the function of the lymphocyte subsets that are selectively targeted by the drug and the repopulation kinetics of these subsets. As such, there is marked and long-term depletion of memory B cell subsets, which probably relates to the therapeutic efficacy. This is also coupled with a more limited, but likewise long-term, depletion of CD4 T subsets. There is limited depletion of cells of the innate immune system and modest effects on CD8 and probably plasma cells, which provide immediate and durable protection from infection. Targeting of CD4 T regulatory cells, CD8 T suppressor cells and regulatory B cell subsets appears more limited as these populations recover rapidly and so repopulating pathogenic cells re-emerge into a regulatory environment. This appears to lead to re-establishment of immune-tolerance that produces long-term control of MS. Although this hypothesis contains a number of unknown details, it is based on knowledge about the biology of cladribine, basic immunology and the effects of other high-efficacy B and T cell depleting agents that exhibit stereotyped repopulation behaviours. These concepts are relatively simple to interrogate, and can be modified as new knowledge about the durability of disease control and safety with cladribine emerges.
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Affiliation(s)
- David Baker
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom.
| | - Gareth Pryce
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom
| | - Samuel S Herrod
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom
| | - Klaus Schmierer
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London E1 1BB, United Kingdom
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110
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D'Amico E, Zanghì A, Serra A, Murabito P, Zappia M, Patti F, Cocuzza S. Management of dysphagia in multiple sclerosis: current best practice. Expert Rev Gastroenterol Hepatol 2019; 13:47-54. [PMID: 30791843 DOI: 10.1080/17474124.2019.1544890] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Multiple sclerosis (MS) is characterized by extreme variability in both severity and clinical course. It can show severe disabling symptoms, and among them dysphagia is frequently described. However, its management still represents a challenge in the daily care. Areas covered: In this review, we will focus on the clinical recognition and therapeutic strategies to identify and manage dysphagia in people with MS. In the view of a personalized approach, different interventions should be tailored to every single patient. Expert commentary: Multidisciplinary evaluation is mandatory in MS management, and dysphagia represents a perfect model of taking care of a disabling symptom in a chronic disease. Further research is required to better organize a personalized and long-term management of dysphagia phenomenon, through the different subtypes of MS.
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Affiliation(s)
- Emanuele D'Amico
- a Department "G.F. Ingrassia", MS center , University of Catania , Catania , Italy
| | - Aurora Zanghì
- a Department "G.F. Ingrassia", MS center , University of Catania , Catania , Italy
| | - Agostino Serra
- b Department of Medical and Surgery Specialties , University of Catania , Catania , Italy
| | - Paolo Murabito
- c MED/41 Anesthesiology , University of Catania , Catania , Italy
| | - Mario Zappia
- a Department "G.F. Ingrassia", MS center , University of Catania , Catania , Italy
| | - Francesco Patti
- a Department "G.F. Ingrassia", MS center , University of Catania , Catania , Italy
| | - Salvatore Cocuzza
- b Department of Medical and Surgery Specialties , University of Catania , Catania , Italy
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111
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Abstract
Multiple sclerosis (MS) is an inflammatory demyelinating disorder. Although all MS patients initially show a relapsing-remitting course, 20-50% subsequently enter a chronic progressive course at 10-20 years after onset that greatly influences their activities of daily living. There are 2.5 million MS patients worldwide with large regional and racial differences. In particular, there are many MS patients among Caucasians living in Europe, while the disease is relatively rare in Asians and Africans.Although MS is regarded as an autoimmune disease, many factors such as genetic background, environmental factors, and sex are involved in its pathogenesis. While the immunological mechanisms remain to be fully elucidated, invasion of autoreactive T cells into the central nervous system (CNS) tissue is considered the first step of the disease. These T cells react with myelin antigens and initiate demyelination of the CNS by activating cytotoxic T cells, macrophages, and B cells through the release of inflammatory cytokines. As a treatment option, disease-modifying therapies have recently been developed to prevent the recurrence of MS in addition to conventional treatment with corticosteroids for acute relapse. However, there are still few effective treatments for the chronic progressive phase, and it is thus imperative to decipher the mechanism for chronic progression.
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112
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Dumitrescu L, Constantinescu CS, Tanasescu R. Siponimod for the treatment of secondary progressive multiple sclerosis. Expert Opin Pharmacother 2018; 20:143-150. [PMID: 30517042 DOI: 10.1080/14656566.2018.1551363] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic central nervous system immune-mediated disease with an important inflammatory component associated with focal demyelination and widespread neurodegeneration. In most cases, the clinical presentation is relapsing-remitting, followed by a secondary progressive phase, characterized by disability accrual unrelated to relapses. In a minority, the phenotype is progressive from the beginning. Major therapeutic achievements have been made concerning the relapsing phase but modifying the evolution of progressive MS remains an unmet need. Areas covered: This review covers siponimod (BAF312), a new sphingosine 1-phosphate receptor modulator, and its role in the treatment of secondary progressive MS. The authors reviewed PubMed English literature using the keywords 'siponimod' or 'BAF312' and 'multiple sclerosis.' They also present the pharmacological profile of siponimod, as well as clinical efficacy and safety, with emphasis on the recently published results of a Phase III trial. Phase II data in relapsing MS are also summarized. Expert opinion: Siponimod may reduce the activity of the disease and has a modest effect on the gradual disability accrual. If approved, it may become one of the few available therapy options for secondary progressive MS.
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Affiliation(s)
- Laura Dumitrescu
- a Department of Neurosciences, University of Medicine and Pharmacy Carol Davila, Department of Neurology , Colentina Hospital , Bucharest , Romania
| | - Cris S Constantinescu
- b Academic Clinical Neurology, Division of Clinical Neuroscience , University of Nottingham , Nottingham , UK
| | - Radu Tanasescu
- a Department of Neurosciences, University of Medicine and Pharmacy Carol Davila, Department of Neurology , Colentina Hospital , Bucharest , Romania.,b Academic Clinical Neurology, Division of Clinical Neuroscience , University of Nottingham , Nottingham , UK
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113
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Affiliation(s)
- Floriana De Angelis
- Queen Square MS Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, London, UK
| | - Nevin A John
- Queen Square MS Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, London, UK
| | - Wallace J Brownlee
- Queen Square MS Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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114
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Understanding treatment decisions from the perspective of people with relapsing remitting multiple Sclerosis: A critical interpretive synthesis. Mult Scler Relat Disord 2018; 27:370-377. [PMID: 30476873 DOI: 10.1016/j.msard.2018.11.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 10/31/2018] [Accepted: 11/16/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Multiple Sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system that mainly affects young adults. While there is no cure for MS, disease modifying treatments (DMTs) reduce the relapse rate and partial accrual of disability. More effective DMTs may have higher risks including life-threatening infections or secondary autoimmunity. The complexity and novelty of available treatments cause challenges for clinicians when prescribing treatments and for people with MS (PwMS) when deciding what trade-offs they are willing and ready to make. OBJECTIVE To explore the experience of people with relapsing remitting MS (PwRRMS) and their perspectives in choosing treatments. METHODS Critical interpretive synthesis was employed to review and synthesis the published literature. Eighty-three publications were selected in a multi-step systematic process. RESULTS Findings are presented in four interrelated areas: the influence of the clinical evidence-base in decision making; the meaning of DMT efficacy for PwRRMS; the influence of models of decision-making and information acquisition practices in PwRRMS; and the importance of psychosocial dimensions in DMT decision making. Synthesis of the findings revealed that alongside medical and individual reasoning, contextual circumstances play an important role in making treatment decisions. CONCLUSION This review identifies and explains the importance of diverse contextual circumstances (clinical, social, psychological) that are important for PwRRMS when making treatment decisions. The findings demonstrate the importance of eliciting, understanding and addressing such contextual factors.
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Köpke S, Solari A, Rahn A, Khan F, Heesen C, Giordano A. Information provision for people with multiple sclerosis. Cochrane Database Syst Rev 2018; 10:CD008757. [PMID: 30317542 PMCID: PMC6517040 DOI: 10.1002/14651858.cd008757.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND People with multiple sclerosis (MS) are confronted with a number of important uncertainties concerning many aspects of the disease. These include diagnosis, prognosis, disease course, disease-modifying therapies, symptomatic therapies, and non-pharmacological interventions, among others. While people with MS demand adequate information to be able to actively participate in medical decision making and to self manage their disease, it has been shown that patients' disease-related knowledge is poor, therefore guidelines recommend clear and concise high-quality information at all stages of the disease. Several studies have outlined communication and information deficits in the care of people with MS. However, only a few information and decision support programmes have been published. OBJECTIVES The primary objectives of this updated review was to evaluate the effectiveness of information provision interventions for people with MS that aim to promote informed choice and improve patient-relevant outcomes, Further objectives were to evaluate the components and the developmental processes of the complex interventions used, to highlight the quantity and the certainty of the research evidence available, and to set an agenda for future research. SEARCH METHODS For this update, we searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register, which contains trials from CENTRAL (the Cochrane Library 2017, Issue 11), MEDLINE, Embase, CINAHL, LILACS, PEDro, and clinical trials registries (29 November 2017) as well as other sources. We also searched reference lists of identified articles and contacted trialists. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-randomised controlled trials, and quasi-randomised trials comparing information provision for people with MS or suspected MS (intervention groups) with usual care or other types of information provision (control groups) were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the retrieved articles for relevance and methodological quality and extracted data. Critical appraisal of studies addressed the risk of selection bias, performance bias, attrition bias, and detection bias. We contacted authors of relevant studies for additional information. MAIN RESULTS We identified one new RCT (73 participants), which when added to the 10 previously included RCTs resulted in a total of 11 RCTs that met the inclusion criteria and were analysed (1387 participants overall; mean age, range: 31 to 51; percentage women, range: 63% to 100%; percentage relapsing-remitting MS course, range: 45% to 100%). The interventions addressed a variety of topics using different approaches for information provision in different settings. Topics included disease-modifying therapy, relapse management, self care strategies, fatigue management, family planning, and general health promotion. The active intervention components included decision aids, decision coaching, educational programmes, self care programmes, and personal interviews with physicians. All studies used one or more components, but the number and extent differed markedly between studies. The studies had a variable risk of bias. We did not perform meta-analyses due to marked clinical heterogeneity. All five studies assessing MS-related knowledge (505 participants; moderate-certainty evidence) detected significant differences between groups as a result of the interventions, indicating that information provision may successfully increase participants' knowledge. There were mixed results on decision making (five studies, 793 participants; low-certainty evidence) and quality of life (six studies, 671 participants; low-certainty evidence). No adverse events were detected in the seven studies reporting this outcome. AUTHORS' CONCLUSIONS Information provision for people with MS seems to increase disease-related knowledge, with less clear results on decision making and quality of life. The included studies in this review reported no negative side effects of providing disease-related information to people with MS. Interpretation of study results remains challenging due to the marked heterogeneity of interventions and outcome measures.
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Affiliation(s)
- Sascha Köpke
- University of LübeckNursing Research Group, Institute of Social Medicine and EpidemiologyRatzeburger Allee 160LübeckGermanyD‐23538
| | - Alessandra Solari
- Fondazione I.R.C.C.S. ‐ Neurological Institute Carlo BestaNeuroepidemiology UnitVia Celoria 11MilanItaly20133
| | - Anne Rahn
- University Medical CenterInstitute of Neuroimmunology and Multiple SclerosisMartinistr 52HamburgGermany20246
| | - Fary Khan
- Royal Melbourne Hospital, Royal Park CampusDepartment of Rehabilitation MedicinePoplar RoadParkvilleMelbourneVictoriaAustralia3052
| | - Christoph Heesen
- University Medical CenterInstitute of Neuroimmunology and Multiple SclerosisMartinistr 52HamburgGermany20246
| | - Andrea Giordano
- Fondazione I.R.C.C.S. ‐ Neurological Institute Carlo BestaNeuroepidemiology UnitVia Celoria 11MilanItaly20133
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Sąsiadek M, Katulska K, Majos A, Siger M, Hartel M, Kalinowska A, Walecki J. Guidelines of the Polish Medical Society of radiology for the routinely used MRI protocol in patients with multiple sclerosis. Neurol Neurochir Pol 2018; 52:638-642. [PMID: 30447859 DOI: 10.1016/j.pjnns.2018.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 08/17/2018] [Accepted: 09/25/2018] [Indexed: 11/28/2022]
Abstract
Magnetic resonance imaging is widely used in diagnosing multiple sclerosis as a basic method for detecting and monitoring the disease. INTRODUCTION: Polish Medical Society of Radiology presents the second version of the recommendations for the routinely conducted MRI in multiple sclerosis, which include new data and practical remarks for radiographers and radiologists. The recommended protocol aims to improve the imaging procedure and, most importantly, to standardize conducting MRI scans in all MRI departments. This is crucial for monitoring the patients with MS, which directly contributes to essential clinical decisions. AIM OF THE GUIDELINES: Multiple sclerosis (MS) is a chronic inflammatory demyelinating and degenerative disease of the central nervous system (CNS) with its etiology still unknown. The fundamental requirement of the disease is the CNS destruction process disseminated in time (DIT) and space (DIS). MR imaging detects focal lesions in white and gray matter with high sensitivity and is the best way to assess brain atrophy in MS patients. It is unquestionably the best diagnostic tool to follow-up the clinical course of the disease and treatment of MS patients. However, to achieve a diagnosis based on MRI scans, and follow-up MS patients according to the latest standards, an MRI scan has to meet certain quality criteria that are the subject of this work.
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Affiliation(s)
- Marek Sąsiadek
- Department of General and Interventional Radiology and Neuroradiology, Wroclaw Medical University, Poland.
| | - Katarzyna Katulska
- Department of Neuroradiology, Poznan University of Medical Sciences, Poznan, Poland.
| | - Agata Majos
- Department of Radiological and Isotopic Diagnosis and Therapy, Medical University of Lodz, Poland
| | | | | | - Alicja Kalinowska
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poland
| | - Jerzy Walecki
- Department of Radiology, Medical Centre for Postgraduate Education, Warsaw, Poland
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Abstract
Ocrelizumab (Ocrevus®) is a humanized anti-CD20 monoclonal antibody approved for the treatment of adults with relapsing multiple sclerosis (RMS) or primary progressive multiple sclerosis (PPMS). In the two identically designed, 96-week OPERA I and II trials in patients with RMS, ocrelizumab significantly reduced annualized relapse rates versus interferon β-1a. In the ≥ 120-week ORATORIO trial in patients with PPMS, ocrelizumab significantly reduced the risk of ≥ 12-week confirmed disability progression relative to placebo. These primary endpoint results were supported by a number of secondary outcomes, including disease activity in the brain assessed by magnetic resonance imaging. Ocrelizumab was generally well tolerated in these studies, with infusion-related reactions and infections being the most common adverse events, which were mostly mild to moderate in severity. In summary, ocrelizumab is a novel high-efficacy disease-modifying therapy for RMS that is more effective than interferon β-1a and also a valuable new treatment option for delaying progression in early PPMS. It offers a convenient once every 6 months treatment regimen, with no need for routine monitoring.
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Affiliation(s)
- Yahiya Y Syed
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Macaron G, Cohen JA. Integrating multiple sclerosis guidelines into practice. Lancet Neurol 2018; 17:658-660. [PMID: 30033052 DOI: 10.1016/s1474-4422(18)30248-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 06/11/2018] [Accepted: 06/18/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Jeffrey A Cohen
- Neurologic Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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De Angelis F, Plantone D, Chataway J. Pharmacotherapy in Secondary Progressive Multiple Sclerosis: An Overview. CNS Drugs 2018; 32:499-526. [PMID: 29968175 DOI: 10.1007/s40263-018-0538-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Multiple sclerosis is an immune-mediated inflammatory disease of the central nervous system characterised by demyelination, neuroaxonal loss and a heterogeneous clinical course. Multiple sclerosis presents with different phenotypes, most commonly a relapsing-remitting course and, less frequently, a progressive accumulation of disability from disease onset (primary progressive multiple sclerosis). The majority of people with relapsing-remitting multiple sclerosis, after a variable time, switch to a stage characterised by gradual neurological worsening known as secondary progressive multiple sclerosis. We have a limited understanding of the mechanisms underlying multiple sclerosis, and it is believed that multiple genetic, environmental and endogenous factors are elements driving inflammation and ultimately neurodegeneration. Axonal loss and grey matter damage have been regarded as amongst the leading causes of irreversible neurological disability in the progressive stages. There are over a dozen disease-modifying therapies currently licenced for relapsing-remitting multiple sclerosis, but none of these has provided evidence of effectiveness in secondary progressive multiple sclerosis. Recently, there has been some early modest success with siponimod in secondary progressive multiple sclerosis and ocrelizumab in primary progressive multiple sclerosis. Finding treatments to delay or prevent the courses of secondary progressive multiple sclerosis is an unmet and essential goal of the research in multiple sclerosis. In this review, we discuss new findings regarding drugs with immunomodulatory, neuroprotective or regenerative properties and possible treatment strategies for secondary progressive multiple sclerosis. We examine the field broadly to include trials where participants have progressive or relapsing phenotypes. We summarise the most relevant results from newer investigations from phase II and III randomised controlled trials over the past decade, with particular attention to the last 5 years.
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Affiliation(s)
- Floriana De Angelis
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK.
| | - Domenico Plantone
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK
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Zivadinov R, Medin J, Khan N, Korn JR, Bergsland N, Dwyer MG, Chitnis T, Naismith RT, Alvarez E, Kinkel P, Cohan S, Hunter SF, Silva D, Weinstock-Guttman B. Fingolimod's Impact on MRI Brain Volume Measures in Multiple Sclerosis: Results from MS-MRIUS. J Neuroimaging 2018; 28:399-405. [DOI: 10.1111/jon.12518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/13/2018] [Accepted: 04/14/2018] [Indexed: 12/16/2022] Open
Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Buffalo, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences; University at Buffalo, The State University of New York; Buffalo NY
- Center for Biomedical Imaging, Clinical Translational Science Institute; University at Buffalo, The State University of New York; Buffalo NY
| | | | | | | | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, Buffalo, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences; University at Buffalo, The State University of New York; Buffalo NY
| | - Michael G. Dwyer
- Buffalo Neuroimaging Analysis Center, Buffalo, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences; University at Buffalo, The State University of New York; Buffalo NY
| | - Tanuja Chitnis
- Partners MS Center, Brigham and Women's Hospital; Boston MA
| | | | - Enrique Alvarez
- Department of Neurology; University of Colorado School of Medicine; CO
| | | | | | | | | | - Bianca Weinstock-Guttman
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences; University at Buffalo, The State University of New York; Buffalo NY
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Sandi D, Bereg E, Biernacki T, Vörös E, Klivényi P, Bereczki C, Vécsei L, Bencsik K. Pediatric multiple sclerosis and fulminant disease course: Features and approaches to treatment - A case report and review of the literature. J Clin Neurosci 2018; 53:13-19. [PMID: 29731272 DOI: 10.1016/j.jocn.2018.04.053] [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: 03/03/2018] [Accepted: 04/23/2018] [Indexed: 10/17/2022]
Abstract
Multiple sclerosis (MS) is the autoimmune, neurodegenerative disease of the central nervous system (CNS). Typically, it affects the young adult population, however, up to 10% of the cases, it can develop in childhood. Atypical manifestations, such as the tumefactive variant (tMS) or acute disseminated encephalomyelitis (ADEM), especially coupled with fulminant disease course, are even more rare and pose a considerable differential diagnostic and therapeutic challenge. Recently, the therapeutic strategy on the use of disease modifying therapies (DMTs) in MS has shifted to the direction of a more individualized approach, that takes the personal differences heavily into account, in particular regard to the activity and prognosis of the disease. Despite this change has only been applied to adults yet, it is plausible to predict, that it will soon be applied to pediatric patients as well, particularly, as several randomized studies are under way concerning DMTs in pediatric populations. To our best knowledge, we are the first to report a successful natalizumab treatment of pediatric fulminant tMS, in case of a 13.5 years old girl. We feel that this report demonstrates the need of early and adequate treatment in such an aggressive case, because it can reverse the course of a possibly fatal disease.
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Affiliation(s)
- Dániel Sandi
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Edit Bereg
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Tamás Biernacki
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Erika Vörös
- Department of Radiology, University of Szeged, Szeged, Hungary
| | - Péter Klivényi
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Csaba Bereczki
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - László Vécsei
- Department of Neurology, University of Szeged, Szeged, Hungary; MTA-SZTE Neuroscience Research Group, University of Szeged, Szeged, Hungary
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Dumitrescu L, Constantinescu CS, Tanasescu R. Recent developments in interferon-based therapies for multiple sclerosis. Expert Opin Biol Ther 2018; 18:665-680. [PMID: 29624084 DOI: 10.1080/14712598.2018.1462793] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic and disabling immune-mediated disease of the central nervous system. Beta-interferons are the first approved and still the most widely used first-line disease-modifying treatment in MS. AREAS COVERED Here we focus on recent developments in pharmacology and delivery systems of beta-interferons, and discuss their place within current state of the art therapeutic approaches. We briefly review the clinical trials for classical and PEGylated formulations, emphasizing effectiveness, safety concerns, and tolerability. The mechanisms of action of IFN-β in view of MS pathogenesis are also debated EXPERT OPINION Though only modestly efficient in reducing the annualized relapse rate, beta-interferons remain a valid first-line option due to their good long-term safety profile and cost-efficacy. Moreover, they are endogenous class II cytokines essential for mounting an effective antiviral response, and they may interact with putative MS triggering factors such as Epstein-Barr virus infection and human endogenous retroviruses. Recent improvements in formulations, delivery devices and drug regimens tackle the tolerability and adherence issues frequently seen with these drugs, and scientific advances may offer means for a better selection of patients. Although a well-established immunomodulatory treatment, beta-interferons have not said their last word in the management of MS.
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Affiliation(s)
- Laura Dumitrescu
- a Department of Clinical Neurosciences , University of Medicine and Pharmacy Carol Davila , Bucharest , Romania.,b Department of Neurology , Colentina Hospital , Bucharest , Romania
| | - Cris S Constantinescu
- c Academic Clinical Neurology, Division of Clinical Neuroscience , University of Nottingham , UK
| | - Radu Tanasescu
- a Department of Clinical Neurosciences , University of Medicine and Pharmacy Carol Davila , Bucharest , Romania.,b Department of Neurology , Colentina Hospital , Bucharest , Romania.,c Academic Clinical Neurology, Division of Clinical Neuroscience , University of Nottingham , UK
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Thompson AJ. Commentary on the ECTRIMS-EAN guideline for pharmacological treatment of multiple sclerosis. Ther Adv Neurol Disord 2018; 11:1756286418770378. [PMID: 29707041 PMCID: PMC5912310 DOI: 10.1177/1756286418770378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Alan J Thompson
- Faculty of Brain Sciences, University College London, Institute of Neurology, Queen Square, London, WC1N 3BG, UK
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Corrigendum. Eur J Neurol 2018; 25:605. [DOI: 10.1111/ene.13590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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