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Spelman T, Eichau S, Alroughani R, Ozakbas S, Khoury SJ, Patti F, Kubala Havrdova E, Boz C, Terzi M, Kuhle J, Grammond P, Lechner-Scott J, Gray O, Amato MP, Laureys G, Shaygannejad V, Hyde R, Wang H, Bozin I, Belviso N, Quan C, Zeng F, van der Walt A, Butzkueven H. Comparative effectiveness of dimethyl fumarate versus non-specific immunosuppressants: Real-world evidence from MSBase. Mult Scler J Exp Transl Clin 2024; 10:20552173241247182. [PMID: 38800132 PMCID: PMC11128181 DOI: 10.1177/20552173241247182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/27/2024] [Indexed: 05/29/2024] Open
Abstract
Background The use of non-specific immunosuppressants (NSIS) to treat multiple sclerosis (MS) remains prevalent in certain geographies despite safety concerns, likely due to resource limitations. Objective To use MSBase registry data to compare real-world outcomes in adults with relapsing-remitting MS (RRMS) treated with dimethyl fumarate (DMF) or NSIS (azathioprine, cyclosporine, cyclophosphamide, methotrexate, mitoxantrone or mycophenolate mofetil) between January 1, 2014 and April 1, 2022. Methods Treatment outcomes were compared using inverse probability of treatment weighting (IPTW) Cox regression. Outcomes were annualized relapse rates (ARRs), time to discontinuation, time to first relapse (TTFR) and time to 24-week confirmed disability progression (CDP) or 24-week confirmed disability improvement (CDI; in patients with baseline Expanded Disability Status Scale [EDSS] score ≥2). Results After IPTW, ARR was similar for DMF (0.13) and NSIS (0.16; p = 0.29). There was no difference in TTFR between cohorts (hazard ratio [HR]: 0.98; p = 0.84). The DMF cohort experienced longer times to discontinuation (HR: 0.75; p = 0.001) and CDP (HR: 0.53; p = 0.001), and shorter time to CDI (HR: 1.99; p < 0.008), versus the NSIS cohort. Conclusion This analysis supports the use of DMF to treat patients with relapsing forms of MS, and may have implications for MS practices in countries where NSIS are commonly used to treat RRMS.
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Affiliation(s)
- Tim Spelman
- MSBase Foundation, Melbourne, Australia
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Sara Eichau
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | | | - Samia J Khoury
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy
| | - Eva Kubala Havrdova
- Department of Neurology, First Medical Faculty, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | | | - Jens Kuhle
- Department of Neurology, University Hospital and University of Basel, Basel, Switzerland
- Multiple Sclerosis Centre and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | | | | | - Orla Gray
- South Eastern HSC Trust, Belfast, UK
| | | | | | | | | | | | | | | | - Chao Quan
- Department of Neurology, Huashan Hospital, National Center for Neurological Disorders, Fudan University, Shanghai, China
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Tramacere I, Virgili G, Perduca V, Lucenteforte E, Benedetti MD, Capobussi M, Castellini G, Frau S, Gonzalez-Lorenzo M, Featherstone R, Filippini G. Adverse effects of immunotherapies for multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2023; 11:CD012186. [PMID: 38032059 PMCID: PMC10687854 DOI: 10.1002/14651858.cd012186.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic disease of the central nervous system that affects mainly young adults (two to three times more frequently in women than in men) and causes significant disability after onset. Although it is accepted that immunotherapies for people with MS decrease disease activity, uncertainty regarding their relative safety remains. OBJECTIVES To compare adverse effects of immunotherapies for people with MS or clinically isolated syndrome (CIS), and to rank these treatments according to their relative risks of adverse effects through network meta-analyses (NMAs). SEARCH METHODS We searched CENTRAL, PubMed, Embase, two other databases and trials registers up to March 2022, together with reference checking and citation searching to identify additional studies. SELECTION CRITERIA We included participants 18 years of age or older with a diagnosis of MS or CIS, according to any accepted diagnostic criteria, who were included in randomized controlled trials (RCTs) that examined one or more of the agents used in MS or CIS, and compared them versus placebo or another active agent. We excluded RCTs in which a drug regimen was compared with a different regimen of the same drug without another active agent or placebo as a control arm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for data extraction and pairwise meta-analyses. For NMAs, we used the netmeta suite of commands in R to fit random-effects NMAs assuming a common between-study variance. We used the CINeMA platform to GRADE the certainty of the body of evidence in NMAs. We considered a relative risk (RR) of 1.5 as a non-inferiority safety threshold compared to placebo. We assessed the certainty of evidence for primary outcomes within the NMA according to GRADE, as very low, low, moderate or high. MAIN RESULTS This NMA included 123 trials with 57,682 participants. Serious adverse events (SAEs) Reporting of SAEs was available from 84 studies including 5696 (11%) events in 51,833 (89.9%) participants out of 57,682 participants in all studies. Based on the absolute frequency of SAEs, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 18 additional people would have a SAE compared to placebo. Low-certainty evidence suggested that three drugs may decrease SAEs compared to placebo (relative risk [RR], 95% confidence interval [CI]): interferon beta-1a (Avonex) (0.78, 0.66 to 0.94); dimethyl fumarate (0.79, 0.67 to 0.93), and glatiramer acetate (0.84, 0.72 to 0.98). Several drugs met our non-inferiority criterion versus placebo: moderate-certainty evidence for teriflunomide (1.08, 0.88 to 1.31); low-certainty evidence for ocrelizumab (0.85, 0.67 to 1.07), ozanimod (0.88, 0.59 to 1.33), interferon beta-1b (0.94, 0.78 to 1.12), interferon beta-1a (Rebif) (0.96, 0.80 to 1.15), natalizumab (0.97, 0.79 to 1.19), fingolimod (1.05, 0.92 to 1.20) and laquinimod (1.06, 0.83 to 1.34); very low-certainty evidence for daclizumab (0.83, 0.68 to 1.02). Non-inferiority with placebo was not met due to imprecision for the other drugs: low-certainty evidence for cladribine (1.10, 0.79 to 1.52), siponimod (1.20, 0.95 to 1.51), ofatumumab (1.26, 0.88 to 1.79) and rituximab (1.01, 0.67 to 1.52); very low-certainty evidence for immunoglobulins (1.05, 0.33 to 3.32), diroximel fumarate (1.05, 0.23 to 4.69), peg-interferon beta-1a (1.07, 0.66 to 1.74), alemtuzumab (1.16, 0.85 to 1.60), interferons (1.62, 0.21 to 12.72) and azathioprine (3.62, 0.76 to 17.19). Withdrawals due to adverse events Reporting of withdrawals due to AEs was available from 105 studies (85.4%) including 3537 (6.39%) events in 55,320 (95.9%) patients out of 57,682 patients in all studies. Based on the absolute frequency of withdrawals, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 31 additional people would withdraw compared to placebo. No drug reduced withdrawals due to adverse events when compared with placebo. There was very low-certainty evidence (meaning that estimates are not reliable) that two drugs met our non-inferiority criterion versus placebo, assuming an upper 95% CI RR limit of 1.5: diroximel fumarate (0.38, 0.11 to 1.27) and alemtuzumab (0.63, 0.33 to 1.19). Non-inferiority with placebo was not met due to imprecision for the following drugs: low-certainty evidence for ofatumumab (1.50, 0.87 to 2.59); very low-certainty evidence for methotrexate (0.94, 0.02 to 46.70), corticosteroids (1.05, 0.16 to 7.14), ozanimod (1.06, 0.58 to 1.93), natalizumab (1.20, 0.77 to 1.85), ocrelizumab (1.32, 0.81 to 2.14), dimethyl fumarate (1.34, 0.96 to 1.86), siponimod (1.63, 0.96 to 2.79), rituximab (1.63, 0.53 to 5.00), cladribine (1.80, 0.89 to 3.62), mitoxantrone (2.11, 0.50 to 8.87), interferons (3.47, 0.95 to 12.72), and cyclophosphamide (3.86, 0.45 to 33.50). Eleven drugs may have increased withdrawals due to adverse events compared with placebo: low-certainty evidence for teriflunomide (1.37, 1.01 to 1.85), glatiramer acetate (1.76, 1.36 to 2.26), fingolimod (1.79, 1.40 to 2.28), interferon beta-1a (Rebif) (2.15, 1.58 to 2.93), daclizumab (2.19, 1.31 to 3.65) and interferon beta-1b (2.59, 1.87 to 3.77); very low-certainty evidence for laquinimod (1.42, 1.01 to 2.00), interferon beta-1a (Avonex) (1.54, 1.13 to 2.10), immunoglobulins (1.87, 1.01 to 3.45), peg-interferon beta-1a (3.46, 1.44 to 8.33) and azathioprine (6.95, 2.57 to 18.78); however, very low-certainty evidence is unreliable. Sensitivity analyses including only studies with low attrition bias, drug dose above the group median, or only patients with relapsing remitting MS or CIS, and subgroup analyses by prior disease-modifying treatments did not change these figures. Rankings No drug yielded consistent P scores in the upper quartile of the probability of being better than others for primary and secondary outcomes. AUTHORS' CONCLUSIONS We found mostly low and very low-certainty evidence that drugs used to treat MS may not increase SAEs, but may increase withdrawals compared with placebo. The results suggest that there is no important difference in the occurrence of SAEs between first- and second-line drugs and between oral, injectable, or infused drugs, compared with placebo. Our review, along with other work in the literature, confirms poor-quality reporting of adverse events from RCTs of interventions. At the least, future studies should follow the CONSORT recommendations about reporting harm-related issues. To address adverse effects, future systematic reviews should also include non-randomized studies.
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Affiliation(s)
- Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Ophthalmology, IRCCS - Fondazione Bietti, Rome, Italy
| | - Vittorio Perduca
- Université Paris Cité, CNRS, MAP5, F-75006 Paris, France
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Ersilia Lucenteforte
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Maria Donata Benedetti
- UOC Neurologia B - Policlinico Borgo Roma, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Capobussi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Greta Castellini
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | | | - Marien Gonzalez-Lorenzo
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Department of Oncology, Laboratory of Clinical Research Methodology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
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Evonuk KS, Wang S, Mattie J, Cracchiolo CJ, Mager R, Ferenčić Ž, Sprague E, Carrier B, Schofield K, Martinez E, Stewart Z, Petrosino T, Johnson GA, Yusuf I, Plaisted W, Naiman Z, Delp T, Carter L, Marušić S. Bruton's tyrosine kinase inhibition reduces disease severity in a model of secondary progressive autoimmune demyelination. Acta Neuropathol Commun 2023; 11:115. [PMID: 37438842 PMCID: PMC10337138 DOI: 10.1186/s40478-023-01614-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/29/2023] [Indexed: 07/14/2023] Open
Abstract
Bruton's tyrosine kinase (BTK) is an emerging target in multiple sclerosis (MS). Alongside its role in B cell receptor signaling and B cell development, BTK regulates myeloid cell activation and inflammatory responses. Here we demonstrate efficacy of BTK inhibition in a model of secondary progressive autoimmune demyelination in Biozzi mice with experimental autoimmune encephalomyelitis (EAE). We show that late in the course of disease, EAE severity could not be reduced with a potent relapse inhibitor, FTY720 (fingolimod), indicating that disease was relapse-independent. During this same phase of disease, treatment with a BTK inhibitor reduced both EAE severity and demyelination compared to vehicle treatment. Compared to vehicle treatment, late therapeutic BTK inhibition resulted in fewer spinal cord-infiltrating myeloid cells, with lower expression of CD86, pro-IL-1β, CD206, and Iba1, and higher expression of Arg1, in both tissue-resident and infiltrating myeloid cells, suggesting a less inflammatory myeloid cell milieu. These changes were accompanied by decreased spinal cord axonal damage. We show similar efficacy with two small molecule inhibitors, including a novel, highly selective, central nervous system-penetrant BTK inhibitor, GB7208. These results suggest that through lymphoid and myeloid cell regulation, BTK inhibition reduced neurodegeneration and disease progression during secondary progressive EAE.
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Affiliation(s)
| | - Sen Wang
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Josh Mattie
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - C. J. Cracchiolo
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Reine Mager
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Željko Ferenčić
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Ethan Sprague
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Brandon Carrier
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Kai Schofield
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Evelyn Martinez
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Zachary Stewart
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Tara Petrosino
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | | | - Isharat Yusuf
- Gossamer Bio, 3013 Science Park Road, Suite 200, San Diego, CA 92121 USA
| | - Warren Plaisted
- Gossamer Bio, 3013 Science Park Road, Suite 200, San Diego, CA 92121 USA
| | - Zachary Naiman
- Gossamer Bio, 3013 Science Park Road, Suite 200, San Diego, CA 92121 USA
| | - Timothy Delp
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
| | - Laura Carter
- Gossamer Bio, 3013 Science Park Road, Suite 200, San Diego, CA 92121 USA
| | - Suzana Marušić
- Hooke Laboratories, LLC, 439 South Union Street, Lawrence, MA 01843 USA
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4
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Riera R, Torloni MR, Martimbianco ALC, Pacheco RL. Alemtuzumab for multiple sclerosis. Cochrane Database Syst Rev 2023; 6:CD011203. [PMID: 37272540 PMCID: PMC10240561 DOI: 10.1002/14651858.cd011203.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is an autoimmune, T-cell-dependent, inflammatory, demyelinating disease of the central nervous system, with an unpredictable course. Current MS therapies focus on treating and preventing exacerbations, and avoiding the progression of disability. At present, there is no treatment that is capable of safely and effectively reaching these objectives. Clinical trials suggest that alemtuzumab, a humanized monoclonal antibody, could be a promising option for MS. OBJECTIVES To evaluate the benefits and harms of alemtuzumab alone or associated with other treatments in people with any form of MS. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 21 June 2022. SELECTION CRITERIA We included randomized controlled trials (RCTs) in adults with any subtype of MS comparing alemtuzumab alone or associated with other medications versus placebo; another active drug; or alemtuzumab in another dose, regimen, or duration. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our co-primary outcomes were 1. relapse-free survival, 2. sustained disease progression, and 3. number of participants experiencing at least one adverse event. Our secondary outcomes were 4. participants free of clinical disability, 5. quality of life, 6. change in disability, 7. fatigue, 8. new or enlarging lesions on resonance imaging, and 9. dropouts. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We included three RCTs (1713 participants) comparing intravenous alemtuzumab versus subcutaneous interferon beta-1a for relapsing-remitting MS. Participants were treatment-naive (two studies) or had experienced at least one relapse after interferon or glatiramer (one study). Alemtuzumab was given at doses of 12 mg/day or 24 mg/day for five days at months 0 and 12, or 24 mg/day for three days at months 12 and 24. Participants in the interferon beta-1a group received 44 μg three times weekly. Alemtuzumab 12 mg: 1. may improve relapse-free survival at 36 months (hazard ratio [HR] 0.31, 95% confidence interval [CI] 0.18 to 0.53; 1 study, 221 participants; low-certainty evidence); 2. may improve sustained disease progression-free survival at 36 months (HR 0.25, 95% CI 0.11 to 0.56; 1 study, 223 participants; low-certainty evidence); 3. may make little to no difference on the proportion of participants with at least one adverse event at 36 months (risk ratio [RR] 1.00, 95% CI 0.98 to 1.02; 1 study, 224 participants; low-certainty evidence), although the proportion of participants with at least one adverse event was high with both drugs; 4. may slightly reduce disability at 36 months (mean difference [MD] -0.70, 95% CI -1.04 to -0.36; 1 study, 223 participants; low-certainty evidence). The evidence is very uncertain regarding the risk of dropouts at 36 months (RR 0.81, 95% CI 0.57 to 1.14; 1 study, 224 participants; very low-certainty evidence). Alemtuzumab 24 mg: 1. may improve relapse-free survival at 36 months (HR 0.21, 95% CI 0.11 to 0.40; 1 study, 221 participants; low-certainty evidence); 2. may improve sustained disease progression-free survival at 36 months (HR 0.33, 95% CI 0.16 to 0.69; 1 study, 221 participants; low-certainty evidence); 3. may make little to no difference on the proportion of participants with at least one adverse event at 36 months (RR 0.99, 95% CI 0.97 to 1.02; 1 study, 215 participants; low-certainty evidence), although the proportion of participants with at least one adverse event was high with both drugs; 4. may slightly reduce disability at 36 months (MD -0.83, 95% CI -1.16 to -0.50; 1 study, 221 participants; low-certainty evidence); 5. may reduce the risk of dropouts at 36 months (RR 0.08, 95% CI 0.01 to 0.57; 1 study, 215 participants; low-certainty evidence). For quality of life, fatigue, and participants free of clinical disease activity, the studies either did not consider these outcomes or they used different measuring tools to those planned in this review. AUTHORS' CONCLUSIONS Compared with interferon beta-1a, alemtuzumab may improve relapse-free survival and sustained disease progression-free survival, and make little to no difference on the proportion of participants with at least one adverse event for people with relapsing-remitting MS at 36 months. The certainty of the evidence for these results was very low to low.
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Affiliation(s)
- Rachel Riera
- Cochrane Brazil Rio de Janeiro, Petrópolis Medical School, Petrópolis, Brazil
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (Nepsbeats), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maria Regina Torloni
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - Ana Luiza C Martimbianco
- Cochrane Brazil Rio de Janeiro, Petrópolis Medical School, Petrópolis, Brazil
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (Nepsbeats), Universidade Federal de São Paulo, São Paulo, Brazil
- Postgraduate Program in Health and Environment, Universidade Metropolitana de Santos (UNIMES), Santos, Brazil
| | - Rafael L Pacheco
- Cochrane Brazil Rio de Janeiro, Petrópolis Medical School, Petrópolis, Brazil
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (Nepsbeats), Universidade Federal de São Paulo, São Paulo, Brazil
- Centro Universitário São Camilo, São Paulo, Brazil
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Rashid Khan M, Fayaz Ahmad S, Nadeem A, Imam F, Al-Harbi NO, Shahnawaz Khan M, Alsahli M, Alhosaini K. Cathepsin-B inhibitor CA-074 attenuates retinopathy and optic neuritis in experimental autoimmune encephalomyelitis induced in SJL/J mice. Saudi Pharm J 2023; 31:147-153. [PMID: 36685301 PMCID: PMC9845124 DOI: 10.1016/j.jsps.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
The complicated multiple sclerosis (MS) can exhibit subacute sight deterioration and can lead to total deprivation of vision. In the current work, we explored the therapeutic outcome of Cathepsin B inhibitor (CA-074) against retinopathy and optic neuritis (ON) caused by experimental autoimmune encephalomyelitis (EAE) induced by proteolipid protein peptide (PLP) in female SJL/J mice. A daily dose of 10 mg/kg CA-074 was administered to the EAE mice intraperitoneally for 14 days from day 14 post-immunization until day 28. The Western blot and immunofluorescence analyses show inflammation in the optic nerve through the elevation of iNOS and NFkB markers in EAE mice. Optic neuritis was reported which is a consequence of demyelination and axon injury, estimated with the reduction in myelin basic protein (MBP). The glial fibrillary acidic protein (GFAP) expression level was found to be elevated in the retina of EAE mice which confirmed the retinopathy. The administration of CA-074 ameliorated optic neuritis and retinopathy by reducing inflammation. The treatment with CA-074 also reduced the demyelination and axonal injuries in the EAE mice. The findings of this study have shown the protective effect of CA-074 in the case of retinopathy and ON inflicted by EAE in SJL/J mice.
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Affiliation(s)
- Mohammad Rashid Khan
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Saudi Arabia
| | - Sheikh Fayaz Ahmad
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Saudi Arabia
| | - Ahmed Nadeem
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Saudi Arabia
| | - Faisal Imam
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Saudi Arabia
| | - Naif O. Al-Harbi
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Saudi Arabia
| | - Mohd Shahnawaz Khan
- Department of Biochemistry, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Meshal Alsahli
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Saudi Arabia
| | - Khaled Alhosaini
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Saudi Arabia,Corresponding author at: College of Pharmacy, King Saud University, P.O. Box 2475, Riyadh 11451, Saudi Arabia.
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6
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Ridley B, Minozzi S, Gonzalez-Lorenzo M, Del Giovane C, Filippini G, Peryer G, Foschi M, Nonino F, Tramacere I, Baldin E. Immunomodulators and immunosuppressants for progressive multiple sclerosis: a network meta‐analysis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022; 2022:CD015443. [PMCID: PMC9632686 DOI: 10.1002/14651858.cd015443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: We will perform a network meta‐analysis to assess the relative effectiveness and safety of immunomodulatory and immunosuppressive treatments for people with multiple sclerosis in progressive forms of the condition.
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Affiliation(s)
| | - Ben Ridley
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Silvia Minozzi
- Department of EpidemiologyLazio Regional Health ServiceRomeItaly
| | | | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM)BernSwitzerland,Department of Medical and Surgical SciencesUniversity of Modena and Reggio EmiliaModenaItaly
| | - Graziella Filippini
- Scientific Director’s OfficeFondazione IRCCS, Istituto Neurologico Carlo BestaMilanItaly
| | - Guy Peryer
- School of Health SciencesUniversity of East Anglia (UEA)NorwichUK
| | - Matteo Foschi
- Department of Neuroscience, AUSL RomagnaSanta Maria delle Croci HospitalRavennaItaly
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific DirectorateFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
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7
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Biernacki T, Kokas Z, Sandi D, Füvesi J, Fricska-Nagy Z, Faragó P, Kincses TZ, Klivényi P, Bencsik K, Vécsei L. Emerging Biomarkers of Multiple Sclerosis in the Blood and the CSF: A Focus on Neurofilaments and Therapeutic Considerations. Int J Mol Sci 2022; 23:ijms23063383. [PMID: 35328802 PMCID: PMC8951485 DOI: 10.3390/ijms23063383] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Multiple Sclerosis (MS) is the most common immune-mediated chronic neurodegenerative disease of the central nervous system (CNS) affecting young people. This is due to the permanent disability, cognitive impairment, and the enormous detrimental impact MS can exert on a patient's health-related quality of life. It is of great importance to recognise it in time and commence adequate treatment at an early stage. The currently used disease-modifying therapies (DMT) aim to reduce disease activity and thus halt disability development, which in current clinical practice are monitored by clinical and imaging parameters but not by biomarkers found in blood and/or the cerebrospinal fluid (CSF). Both clinical and radiological measures routinely used to monitor disease activity lack information on the fundamental pathophysiological features and mechanisms of MS. Furthermore, they lag behind the disease process itself. By the time a clinical relapse becomes evident or a new lesion appears on the MRI scan, potentially irreversible damage has already occurred in the CNS. In recent years, several biomarkers that previously have been linked to other neurological and immunological diseases have received increased attention in MS. Additionally, other novel, potential biomarkers with prognostic and diagnostic properties have been detected in the CSF and blood of MS patients. AREAS COVERED In this review, we summarise the most up-to-date knowledge and research conducted on the already known and most promising new biomarker candidates found in the CSF and blood of MS patients. DISCUSSION the current diagnostic criteria of MS relies on three pillars: MRI imaging, clinical events, and the presence of oligoclonal bands in the CSF (which was reinstated into the diagnostic criteria by the most recent revision). Even though the most recent McDonald criteria made the diagnosis of MS faster than the prior iteration, it is still not an infallible diagnostic toolset, especially at the very early stage of the clinically isolated syndrome. Together with the gold standard MRI and clinical measures, ancillary blood and CSF biomarkers may not just improve diagnostic accuracy and speed but very well may become agents to monitor therapeutic efficacy and make even more personalised treatment in MS a reality in the near future. The major disadvantage of these biomarkers in the past has been the need to obtain CSF to measure them. However, the recent advances in extremely sensitive immunoassays made their measurement possible from peripheral blood even when present only in minuscule concentrations. This should mark the beginning of a new biomarker research and utilisation era in MS.
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Affiliation(s)
- Tamás Biernacki
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
| | - Zsófia Kokas
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
| | - Dániel Sandi
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
| | - Judit Füvesi
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
| | - Zsanett Fricska-Nagy
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
| | - Péter Faragó
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
| | - Tamás Zsigmond Kincses
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
- Albert Szent-Györgyi Clinical Centre, Department of Radiology, Albert Szent-Györgyi Faculty of Medicine, University of Szeged, 6725 Szeged, Hungary
| | - Péter Klivényi
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
| | - Krisztina Bencsik
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
| | - László Vécsei
- Albert Szent-Györgyi Clinical Centre, Department of Neurology, Faculty of General Medicine, University of Szeged, 6725 Szeged, Hungary; (T.B.); (Z.K.); (D.S.); (J.F.); (Z.F.-N.); (P.F.); (T.Z.K.); (P.K.); (K.B.)
- MTA-SZTE Neuroscience Research Group, University of Szeged, 6725 Szeged, Hungary
- Correspondence: ; Tel.: +36-62-545-356; Fax: +36-62-545-597
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Radulović S, Sunkara S, Maurer C, Leitinger G. Digging Deeper: Advancements in Visualization of Inhibitory Synapses in Neurodegenerative Disorders. Int J Mol Sci 2021; 22:12470. [PMID: 34830352 PMCID: PMC8623765 DOI: 10.3390/ijms222212470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 12/02/2022] Open
Abstract
Recent research has provided strong evidence that neurodegeneration may develop from an imbalance between synaptic structural components in the brain. Lately, inhibitory synapses communicating via the neurotransmitters GABA or glycine have come to the center of attention. Increasing evidence suggests that imbalance in the structural composition of inhibitory synapses affect deeply the ability of neurons to communicate effectively over synaptic connections. Progressive failure of synaptic plasticity and memory are thus hallmarks of neurodegenerative diseases. In order to prove that structural changes at synapses contribute to neurodegeneration, we need to visualize single-molecule interactions at synaptic sites in an exact spatial and time frame. This visualization has been restricted in terms of spatial and temporal resolution. New developments in electron microscopy and super-resolution microscopy have improved spatial and time resolution tremendously, opening up numerous possibilities. Here we critically review current and recently developed methods for high-resolution visualization of inhibitory synapses in the context of neurodegenerative diseases. We present advantages, strengths, weaknesses, and current limitations for selected methods in research, as well as present a future perspective. A range of new options has become available that will soon help understand the involvement of inhibitory synapses in neurodegenerative disorders.
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Affiliation(s)
- Snježana Radulović
- Gottfried Schatz Research Center, Division of Cell Biology, Histology and Embryology, Medical University of Graz, 8010 Graz, Austria; (S.R.); (S.S.)
| | - Sowmya Sunkara
- Gottfried Schatz Research Center, Division of Cell Biology, Histology and Embryology, Medical University of Graz, 8010 Graz, Austria; (S.R.); (S.S.)
| | - Christa Maurer
- Gottfried Schatz Research Center, Division of Macroscopic and Clinical Anatomy, Medical University of Graz, 8010 Graz, Austria;
| | - Gerd Leitinger
- Gottfried Schatz Research Center, Division of Cell Biology, Histology and Embryology, Medical University of Graz, 8010 Graz, Austria; (S.R.); (S.S.)
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Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system, with an unpredictable course. Current MS therapies such as disease-modifying therapies focus on treating exacerbations, preventing new exacerbations and avoiding the progression of disability. Siponimod (BAF312) is an oral treatment, a selective sphingosine-1-phosphate (S1P) receptor modulator, for the treatment of adults with relapsing forms of MS including active, secondary progressive MS with relapses. OBJECTIVES To assess the benefits and adverse effects of siponimod as monotherapy or combination therapy versus placebo or any active comparator for people diagnosed with MS. SEARCH METHODS On 18 June 2020, we searched the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Trials Register, which contains studies from CENTRAL, MEDLINE and Embase, and the trials registry databases ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). We also handsearched relevant journals and screened the reference lists of published reviews and retrieved articles and searched reports (2004 to June 2020) from the MS societies in Europe and America. SELECTION CRITERIA We included randomised parallel controlled clinical trials (RCTs) that evaluated siponimod, as monotherapy or combination therapy, versus placebo or any active comparator in people with MS. There were no restrictions on dose or administration frequency. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We discussed disagreements and resolved them by consensus among the review authors. Our primary outcomes wereworsening disability , relapse and adverse events, and secondary outcomes were annualised relapse rate, gadolinium-enhancing lesions, new lesions or enlarged pre-existing lesions and mean change of brain volume. We independently evaluated the certainty of evidence using the GRADE approach. We contacted principal investigators of included studies for additional data or confirmation of data. MAIN RESULTS Two studies (1948 participants) met our selection criteria, 608 controls and 1334 treated with siponimod. The included studies compared siponimod with placebo. Overall, all studies had a high risk of bias due to selective reporting and attrition bias. Comparing siponimod administered at a dose of 2 mg to placebo, we found that siponimod may reduce the number of participants with disability progression at six months (56 fewer people per 1000; risk ratio (RR) 0.78, 95% confidence interval (CI) 0.65 to 0.94; 1 study, 1641 participants; low-certainty evidence) and annualised relapse rate (RR 0.43, 95% CI 0.34 to 0.56; 2 studies, 1739 participants; low-certainty evidence). But it might lead to little reduction in the number of participants with new relapse (166 fewer people per 1000; RR 0.38, 95% CI 0.15 to 1.00; 1 study, 94 participants; very low-certainty evidence). We observed no evidence of a difference due to adverse events for siponimod at 2 mg compared to placebo (14 more people per 1000; RR 1.52, 95% CI 0.85 to 2.71; 2 studies, 1739 participants, low-certainty evidence). In addition, due to the high risk of inaccurate magnetic resonance imaging (MRI) data in the two included studies, we could not combine data for active lesions on MRI scans. Both studies had high attrition bias resulting from the unbalanced reasons for dropouts among groups and high risk of bias due to conflicts of interest. Siponimod may reduce the number of gadolinium-enhancing T1-weighted lesions at two years of follow-up (RR 0.14, 95% CI 0.10 to 0.19; P < 0.0001; 1 study, 1641 participants; very low-certainty evidence). There may be no evidence of a difference between groups in the number of participants with at least one serious adverse event excluding relapses (113 more people per 1000; RR 1.80, 95% CI 0.37 to 8.77; 2 studies, 1739 participants; low-certainty evidence) at six months. No data were available regarding cardiac adverse events. In terms of safety profile, the most common adverse events associated with siponimod were headache, back pain, bradycardia, dizziness, fatigue, influenza, urinary tract infection, lymphopenia, nausea, alanine amino transferase increase and upper respiratory tract infection. These adverse events have dose-related effects and rarely led to discontinuation of treatment. AUTHORS' CONCLUSIONS Based on the findings of the RCTs included in this review, we are uncertain whether siponimod interventions are beneficial for people with MS. There was low-certainty evidence to support that siponimod at a dose of 2 mg orally once daily as monotherapy compared with placebo may reduce the annualised relapse rate and the number of participants who experienced disability worsening, at 6 months. However, the certainty of the evidence to support the benefit in reducing the number of people with a relapse is very low. The risk of withdrawals due to adverse events requires careful monitoring of participants over time. The duration of all studies was less than 24 months, so the efficacy and safety of siponimod over 24 months are still uncertain, and further exploration is needed in the future. There is no high-certainty data available to evaluate the benefit on MRI outcomes. We assessed the certainty of the body of evidence for all outcomes was low to very low, downgraded due to serious study limitations, imprecision and indirectness. We are uncertain whether siponimod is beneficial for people with MS. More new studies with robust methodology and longer follow-up are needed to evaluate the benefit of siponimod for the management of MS and to observe long-term adverse effects. Also, in addition to comparing with placebo, more new studies are needed to evaluate siponimod versus other therapeutic options.
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Affiliation(s)
- Liujiao Cao
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
- School of Public Health, Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou , China
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methodology, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Peijing Yan
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Xiaoqin Wang
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | - Zhen Yang
- Department of Rheumatology, Tung Wah Group of Hospitals, Hong Kong, China
| | - Yongfeng Lao
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Huijuan Li
- School of Public Health, Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou City, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Lanzhou University Institute of Health Data Science, Lanzhou University, Lanzhou, China
| | - Ka Li
- West China School of Nursing /West China Hospital, Sichuan University, Chengdu, China
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10
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Lees S, Dicker M, Ku JE, Chaganti V, Mew-Sum M, Wang N, Smith A, Oldmeadow C, Goon WL, Bevan M, Lang D, Hinwood M. Impact of disease-modifying therapies on MRI and neurocognitive outcomes in relapsing-remitting multiple sclerosis: a protocol for a systematic review and network meta-analysis. BMJ Open 2021; 11:e051509. [PMID: 34728450 PMCID: PMC8565566 DOI: 10.1136/bmjopen-2021-051509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Disease-modifying therapies (DMTs) are the mainstay of treatment for relapsing-remitting multiple sclerosis (RRMS). There is established evidence that DMTs are effective at reducing relapse rate and disease progression in RRMS, but there has been less consideration to the synthesis of MRI and neurocognitive outcomes, which play an increasingly important role in treatment decisions. The aim of this systematic review and network meta-analysis is to examine the relative efficacy, acceptability and tolerability of DMTs for RRMS, using MRI and neurocognitive outcomes. METHODS AND ANALYSIS We will search electronic databases, including MEDLINE, Embase and the Cochrane Central Register of Controlled Trials, with no date restrictions. We will also search the websites of international regulatory bodies for pharmaceuticals and international trial registries. We will include parallel group randomised controlled trials of DMTs including interferon beta-1a intramuscular, interferon beta-1a subcutaneous, interferon beta-1b, peginterferon beta-1a, glatiramer acetate, natalizumab, ocrelizumab, alemtuzumab, dimethyl fumarate, teriflunomide, fingolimod, cladribine, ozanimod, mitoxantrone and rituximab, either head-to-head or against placebo in adults with RRMS. Primary outcomes include efficacy (MRI outcomes including new T1/hypointense lesions and T2/hyperintense lesions) and acceptability (all-cause dropouts). Secondary outcomes include gadolinium-enhancing lesions, cerebral atrophy and tolerability (dropouts due to adverse events). Neurocognitive measures across three domains including processing speed, working memory and verbal learning will be included as exploratory outcomes. Data will be analysed using a random-effects pairwise meta-analysis and a Bayesian hierarchical random effects network meta-analysis to evaluate the efficacy, acceptability and tolerability of the included DMTs. Subgroup and sensitivity analyses will be conducted to assess the robustness of the findings. The review will be reported using the Preferred Reporting Items for Systematic Reviews incorporating Network Meta-Analyses statement. ETHICS AND DISSEMINATION This protocol does not require ethics approval. Results will be disseminated in a peer-reviewed academic journal. PROSPERO REGISTRATION NUMBER CRD42021239630.
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Affiliation(s)
- Samuel Lees
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Mathew Dicker
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Jie En Ku
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Varun Chaganti
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Matthew Mew-Sum
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Nick Wang
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Angela Smith
- HNEHealth Libraries, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | | | - Wooi Lynn Goon
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Marc Bevan
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Danielle Lang
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Madeleine Hinwood
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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11
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Cyclophosphamide treatment in active multiple sclerosis. Neurol Sci 2021; 42:3775-3780. [PMID: 33452657 DOI: 10.1007/s10072-021-05052-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 01/09/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Cyclophosphamide (CYC) is an alkylating agent with immunosuppressive effect by inhibiting DNA synthesis and producing apoptosis used in many autoimmune diseases, including multiple sclerosis (MS). Here, we analyze the efficacy of CYC treatment in relapsing-remitting (RRMS) and active secondary progressive MS (SPMS) in our center with a monthly scheme. METHODS Patients with MS treated with CYC and a follow up of at least 36 months were eligible for inclusion. All participants had received a standard CYC regimen. The EDSS score mean annualized relapse rate (ARR) and progression index (PI) were measured as efficacy outcomes at 12, 24, and 36 months. Outcomes were also analyzed comparing disease course and activity. RESULTS A total of 16 patients were included (50% male, 18.75% RRMS and 81.25% SPMS). EDSS remained stable along the follow-up period, with 62.5% improving or maintaining the same EDSS score at 12 months. PI decreased 14% and 21% at 12 and 24-36 months of follow-up, respectively. ARR decreased 20% after 12 months, 19% after 24 months, and 30.23% after 36 months. Median differences in ARR were higher in patients with high relapse activity (0.60 vs 0.07, p = 0.001) and malignant course (0.60 vs 0.17, p = 0.027). PI also differed with higher mean differences in patients with high relapse activity (0.70 vs 0.03, p = 0.016) and malignant course (1.17 vs 0.03, p = 0.003). CONCLUSIONS CYC continues to be a valid therapeutic option, especially in regions with limited access to high-efficiency therapies particularly in patients with high relapsing activity and malignant course.
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12
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Pardo G, Coates S, Okuda DT. Outcome measures assisting treatment optimization in multiple sclerosis. J Neurol 2021; 269:1282-1297. [PMID: 34338857 PMCID: PMC8857110 DOI: 10.1007/s00415-021-10674-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 11/30/2022]
Abstract
Objective To review instruments used to assess disease stability or progression in persons with multiple sclerosis (pwMS) that can guide clinicians in optimizing therapy. Methods A non-systematic review of scientific literature was undertaken to explore modalities of monitoring symptoms and the disease evolution of MS. Results Multiple outcome measures, or tools, have been developed for use in MS research as well as for the clinical management of pwMS. Beginning with the Expanded Disability Status Scale, introduced in 1983, clinicians and researchers have developed monitoring modalities to assess all aspects of MS and the neurological impairment it causes. Conclusions Much progress has been made in recent decades for the management of MS and for the evaluation of disease progression. New technology, such as wearable sensors, will provide new opportunities to better understand changes in function, dexterity, and cognition. Essential work over the decades since EDSS was introduced continues to improve our ability to treat this debilitating disease.
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Affiliation(s)
- Gabriel Pardo
- OMRF Multiple Sclerosis Center of Excellence, Oklahoma Medical Research Foundation, 820 NE 15th Street, Oklahoma City, OK, 73104, USA.
| | | | - Darin T Okuda
- Department of Neurology, University of Texas Southwestern, Dallas, TX, USA
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13
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Esmaeili S, Abbasi MH, Abolmaali M, Mojtahed M, Alavi SNR, Soleimani S, Mokhtari M, Hatam J, Khotbehsara ST, Motamed MR, Joghataei MT, Mirzaasgari Z, Moghaddasi M. Rituximab and risk of COVID-19 infection and its severity in patients with MS and NMOSD. BMC Neurol 2021; 21:183. [PMID: 33933026 PMCID: PMC8087518 DOI: 10.1186/s12883-021-02218-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/26/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Choosing a safe disease modifying therapy during the COVID-19 pandemic is challenging. This case series study was conducted to determine the incidence rate and the course of Covid-19 infection in MS/NMOSD patients treated with Rituximab. METHODS In this study, we designed a web-based questionnaire. Baseline information such as patient- reported walking disability, total number of Rituximab infusions received, delayed injections, occurrence of any relapse, and the use of corticosteroids during the pandemic were collected. Also, information regarding the Covid-19 pandemic such as adherence to self-isolation, any recent exposure to an infected individual and the presence of suggestive symptoms were collected. In case of positive test results, patients were grouped into 2 categories; mild to moderate and seriously ill and outcomes were evaluated as favorable (improved/ discharged) and unfavorable (expired). RESULTS Two hundred fifty-eight patients with Multiple Sclerosis were enrolled in this study, 9 of the subjects (3.4%) were confirmed positive for Covid-19, five of which required hospitalizations (55.5%), two patients required ICU admission (22.2%) and 2 two patients died (22.2%). None of these patients ever mentioned using corticosteroids during the pandemic. In comparison to MS patients who were not receiving disease modifying therapy (DMT), our study indicated a higher incidence of Covid-19 infection, higher ratio of serious illness and a higher fatality ratio. CONCLUSIONS Rituximab seems not to be safe enough during the pandemic.
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Affiliation(s)
- Sara Esmaeili
- Cellular and Molecular Research Center, Iran university of medical sciences, Tehran, Iran
- School of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Abbasi
- Cellular and Molecular Research Center, Iran university of medical sciences, Tehran, Iran
- School of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Meysam Abolmaali
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mojtahed
- School of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | | | - Sevim Soleimani
- School of Medicine, Shahid Beheshti Medical University, Tehran, Iran
| | - Mahisa Mokhtari
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Jaber Hatam
- Department of Neurosurgery, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Mohammad Taghi Joghataei
- Cellular and Molecular Research Center, Iran university of medical sciences, Tehran, Iran
- School of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Mirzaasgari
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Moghaddasi
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
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D'Amico E, Zanghì A, Romeo M, Cocco E, Maniscalco GT, Brescia Morra V, Paolicelli D, De Luca G, Galgani S, Amato MP, Salemi G, Inglese M, Confalonieri PA, Lus G, Avolio C, Gallo A, Vianello M, Onofrj M, Filippi M, Trojano M, Patti F. Injectable Versus Oral First-Line Disease-Modifying Therapies: Results from the Italian MS Register. Neurotherapeutics 2021; 18:905-919. [PMID: 33528815 PMCID: PMC8423935 DOI: 10.1007/s13311-020-01001-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
The current study aims to compare injectable and oral first-line disease-modifying therapies (DMTs) for time to first relapse, time to confirmed disability progression (CDP), and time to discontinuation using a cohort of relapsing remitting multiple sclerosis (RRMS) patients, with data extracted from the Italian MS Register. This multicenter, observational, retrospectively acquired, and propensity-adjusted cohort study utilized RRMS-naïve patients from the Italian MS Register who started either injectable or oral first-line DMTs between January 1, 2010, and December 31, 2017, to evaluate the impact on disability outcomes in patients. Enrolled patients were divided into two groups, namely the injectable group (IG) and the oral group (OG). Of a cohort of 11,416 patients, 4602 were enrolled (3919 in the IG and 683 in the OG). The IG had a higher rate of women (67.3% vs 63.4%, p < 0.05) and a lower mean age (36.1 ± 10.9 vs 38.9 ± 11.8, p < 0.001). The event time to first relapse demonstrated a lower risk in the OG (HR = 0.58; CI 95% 0.48-0.72, p < 0.001). However, no differences were found between the two groups with respect to the risk of CDP (HR = 0.94; CI 95% 0.76-1.29, p = 0.941), while a lower risk of DMT was found in the OG (HR = 0.72; CI 95% 0.58-0.88, p = 0.002) for the event time to discontinuation. Real-world data from the Italian MS Register suggests that first-line oral DMTs are associated with a lower risk of experiencing a new relapse and of therapy discontinuation compared to injectable DMTs.
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Affiliation(s)
- Emanuele D'Amico
- Department "G.F. Ingrassia", MS center, University of Catania, Policlinico G. Rodolico, V. Santa Sofia 78, 95123, Catania, Italy.
| | - Aurora Zanghì
- Department "G.F. Ingrassia", MS center, University of Catania, Policlinico G. Rodolico, V. Santa Sofia 78, 95123, Catania, Italy
| | - Marzia Romeo
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eleonora Cocco
- Department "Medical Science and Public Health", University of Cagliari, Cagliari, Italy
| | - Giorgia Teresa Maniscalco
- Multiple Sclerosis Center and Neurological Clinic Stroke Unit , "A. Cardarelli" Hospital, Naples, Italy
| | | | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico, Bari, Italy
| | - Giovanna De Luca
- Neurology Unit, University G. D'Annunzio, Policlinico SS Annunziata, Chieti, Italy
| | - Simonetta Galgani
- Multiple Sclerosis Center - Az. Osp. S. Camillo Forlanini, Rome, Italy
| | - Maria Pia Amato
- Department NEUROFARBA University of Florence, Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Matilde Inglese
- Dipartimento Di Neuroscienze, Riabilitazione, Oftalmologia, Genetica E Scienze Materno - Infantili, Clinica Neurologica (DiNOGMI), Genoa, Italy
- Ospedale Policlinico San Martino, IRCCS, Genoa, Italy
| | | | - Giacomo Lus
- MS Center, II Division of Neurology, University della Campania "L. Vanvitelli", Naples, Italy
| | - Carlo Avolio
- Centro Interdipartimentale Malattie Demielinizzanti, AOU Ospedali Riuniti Di Foggia, Foggia, Italy
| | - Antonio Gallo
- MS Center, I Division of Neurology, University della Campania "L. Vanvitelli", Naples, Italy
| | - Marika Vianello
- O.U. Neurology "Ca' Foncello" Hospital - Treviso - MS Unit, Treviso, Italy
| | - Marco Onofrj
- Neurology Unit, University G. D'Annunzio, Policlinico SS Annunziata, Chieti, Italy
| | - Massimo Filippi
- Neurology Unit, Neurorehabilitation Unit, Neurophysiology Service, and Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico, Bari, Italy
| | - Francesco Patti
- Department "G.F. Ingrassia", MS center, University of Catania, Policlinico G. Rodolico, V. Santa Sofia 78, 95123, Catania, Italy
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15
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Pavelek Z, Sobíšek L, Šarláková J, Potužník P, Peterka M, Štětkárová I, Štourač P, Mareš J, Hradílek P, Ampapa R, Grünermelová M, Vachová M, Recmanová E, Angelucci F, Halúsková S, Vališ M. Comparison of Therapies in MS Patients After the First Demyelinating Event in Real Clinical Practice in the Czech Republic: Data From the National Registry ReMuS. Front Neurol 2021; 11:593527. [PMID: 33510704 PMCID: PMC7835499 DOI: 10.3389/fneur.2020.593527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/08/2020] [Indexed: 01/25/2023] Open
Abstract
Background: Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system. Well-established drugs used for MS patients after the first demyelinating event in the Czech Republic include glatiramer acetate (GA), interferon beta-1a (IFNβ-1a), IFN beta-1b (IFNβ-1b), peginterferon beta-1a (peg-IFNβ-1a), and teriflunomide. Objective: The objective of this observational study was to compare the effectiveness of the abovementioned drugs in patients with MS who initiated their therapy after the first demyelinating event. Patients were followed for up to 2 years in real clinical practice in the Czech Republic. Methods: A total of 1,654 MS patients treated after the first demyelinating event and followed up for 2 years were enrolled. Evaluation parameters (endpoints) included the annualized relapse rate (ARR), time to next relapse, change in the Expanded Disability Status Scale (EDSS) score, and time of confirmed disease progression (CDP). When patients ended the therapy before the observational period, the reason for ending the therapy among different treatments was compared. Results: No significant difference was found among the groups of patients treated with IFNβ-1a/1b, GA, or teriflunomide for the following parameters: time to the first relapse, change in the EDSS score, and the proportion of patients with CDP. Compared to IFNβ-1a (44 mcg), a significant increase in the percentage of relapse-free patients was found for GA, but this treatment effect was not confirmed by the validation analysis. Compared to the other drugs, there was a significant difference in the reasons for terminating GA therapy. Conclusion: Small differences were found among GA, IFNβ and teriflunomide therapies, with no significant impact on the final outcome after 2 years. Therefore, in clinical practice, we recommend choosing the drug based on individual potential risk from long-term therapy and on patient preferences and clinical characteristics.
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Affiliation(s)
- Zbyšek Pavelek
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Lukáš Sobíšek
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Jana Šarláková
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Pavel Potužník
- Department of Neurology, Faculty of Medicine and University Hospital Plzen, Charles University in Prague, Plzeň, Czechia
| | - Marek Peterka
- Department of Neurology, Faculty of Medicine and University Hospital Plzen, Charles University in Prague, Plzeň, Czechia
| | - Ivana Štětkárová
- Third Faculty of Medicine, Charles University and Hospital Kralovské Vinohrady, Charles University in Prague, Prague, Czechia
| | - Pavel Štourač
- Department of Neurology, University Hospital and Masaryk University, Brno, Czechia
| | - Jan Mareš
- Department of Neurology, Faculty of Medicine, Palacky University and University Hospital Olomouc, Olomouc, Czechia
| | - Pavel Hradílek
- Clinic of Neurology, University Hospital Ostrava, Ostrava, Czechia
| | - Radek Ampapa
- Department of Neurology, Hospital of Jihlava, Jihlava, Czechia
| | | | - Marta Vachová
- Department of Neurology, KZ a.s., Hospital Teplice, Teplice, Czechia
| | - Eva Recmanová
- Department of Neurology, Tomas Bata Regional Hospital, Zlín, Czechia
| | - Francesco Angelucci
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia.,Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
| | - Simona Halúsková
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Martin Vališ
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
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16
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Imamura M, Scott NW, Wallace SA, Ogah JA, Ford AA, Dubos YA, Brazzelli M. Interventions for treating people with symptoms of bladder pain syndrome: a network meta-analysis. Cochrane Database Syst Rev 2020; 7:CD013325. [PMID: 32734597 PMCID: PMC8094454 DOI: 10.1002/14651858.cd013325.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide-ranging treatment options, used alone or in combination, with limited evidence. A network meta-analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS. OBJECTIVES To conduct a network meta-analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS). SEARCH METHODS We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible. DATA COLLECTION AND ANALYSIS We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random-effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta-analysis of head-to-head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories. MAIN RESULTS We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low-certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD -1.27, 95% CrI -3.25 to 0.71; low-certainty evidence), daytime frequency (MD -2.41, 95% CrI -6.85 to 2.05; very low-certainty evidence) or nocturia (MD 0.01, 95% CrI -2.53 to 2.50; very low-certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low-certainty evidence) or reduced pain (MD 0.42, 95% CrI -1.04 to 1.91; low-certainty evidence), frequency (MD -0.37, 95% CrI -5.00 to 3.44; very low-certainty evidence) or nocturia (MD -1.20, 95% CrI -3.62 to 1.28; very low-certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD -0.33, 95% CrI -1.71 to 1.03), frequency (MD -0.91, 95% CrI -3.24, 1.29) or nocturia (MD -0.04, 95% CrI -1.35 to 1.27). The certainty of this evidence was always very low. AUTHORS' CONCLUSIONS We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base.
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Affiliation(s)
- Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Neil W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Sheila A Wallace
- Evidence Synthesis Group, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Joseph A Ogah
- Obstetrics and Gynaecology, University Hospitals of Morecambe Bay NHS Foundation Trust, Barrow in Furness, UK
| | - Abigail A Ford
- Department of Urogynaecology, Imperial Healthcare Trust, St Mary's Hospital, London, UK
| | - Yann A Dubos
- c/o Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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17
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Cao L, Lao Y, Yao L, Yan P, Wang X, Yang Z, Li M, Li H, Yang K. Siponimod for multiple sclerosis. Cochrane Database Syst Rev 2020. [DOI: 10.1002/14651858.cd013647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Liujiao Cao
- School of Public Health, Evidence-Based Social Science Research Center; Lanzhou University; Lanzhou City China
| | - Yongfeng Lao
- The Second Clinical Medical College; Lanzhou University; Lanzhou China
| | - Liang Yao
- Department of Health Research Methodology, Evidence and Impact; McMaster University; Hamilton Canada
| | - Peijing Yan
- Department of Clinical Research Management; West China Hospital, Sichuan University; Chengdu China
| | - Xiaoqin Wang
- The Michael G. DeGroote Institute for Pain Research and Care; McMaster University; Hamilton Canada
| | - Zhen Yang
- Department of Rheumatology; Tung Wah Group of Hospitals; Hong Kong China
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences; Lanzhou University; Lanzhou China
| | - Huijuan Li
- School of Public Health, Evidence-Based Social Science Research Center; Lanzhou University; Lanzhou City China
| | - Kehu Yang
- School of Public Health, Evidence-Based Social Science Research Center; Lanzhou University; Lanzhou City China
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18
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Desai RA, Davies AL, Del Rossi N, Tachrount M, Dyson A, Gustavson B, Kaynezhad P, Mackenzie L, van der Putten MA, McElroy D, Schiza D, Linington C, Singer M, Harvey AR, Tachtsidis I, Golay X, Smith KJ. Nimodipine Reduces Dysfunction and Demyelination in Models of Multiple Sclerosis. Ann Neurol 2020; 88:123-136. [PMID: 32293054 PMCID: PMC7737229 DOI: 10.1002/ana.25749] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 12/22/2022]
Abstract
Objective Treatment of relapses in multiple sclerosis (MS) has not advanced beyond steroid use, which reduces acute loss of function, but has little effect on residual disability. Acute loss of function in an MS model (experimental autoimmune encephalomyelitis [EAE]) is partly due to central nervous system (CNS) hypoxia, and function can promptly improve upon breathing oxygen. Here, we investigate the cause of the hypoxia and whether it is due to a deficit in oxygen supply arising from impaired vascular perfusion. We also explore whether the CNS‐selective vasodilating agent, nimodipine, may provide a therapy to restore function, and protect from demyelination in 2 MS models. Methods A variety of methods have been used to measure basic cardiovascular physiology, spinal oxygenation, mitochondrial function, and tissue perfusion in EAE. Results We report that the tissue hypoxia in EAE is associated with a profound hypoperfusion of the inflamed spinal cord. Treatment with nimodipine restores spinal oxygenation and can rapidly improve function. Nimodipine therapy also reduces demyelination in both EAE and a model of the early MS lesion. Interpretation Loss of function in EAE, and demyelination in EAE, and the model of the early MS lesion, seem to be due, at least in part, to tissue hypoxia due to local spinal hypoperfusion. Therapy to improve blood flow not only protects neurological function but also reduces demyelination. We conclude that nimodipine could be repurposed to offer substantial clinical benefit in MS. ANN NEUROL 2020 ANN NEUROL 2020;88:123–136
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Affiliation(s)
- Roshni A Desai
- Department of Neuroinflammation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Andrew L Davies
- Department of Neuroinflammation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Natalie Del Rossi
- Department of Neuroinflammation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Mohamed Tachrount
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.,Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Alex Dyson
- Bloomsbury Institute for Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Britta Gustavson
- Department of Neuroinflammation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Pardis Kaynezhad
- Biomedical Optics Research Laboratory, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Lewis Mackenzie
- School of Physics & Astronomy, University of Glasgow, Glasgow, UK.,Department of Chemistry, Durham University, Durham, UK
| | - Marieke A van der Putten
- School of Physics & Astronomy, University of Glasgow, Glasgow, UK.,Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - Daniel McElroy
- Glasgow Biomedical Research Centre, Room B3-19, 120 University Place, University of Glasgow, Glasgow, UK
| | - Dimitra Schiza
- Department of Neuroinflammation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Christopher Linington
- Glasgow Biomedical Research Centre, Room B3-19, 120 University Place, University of Glasgow, Glasgow, UK
| | - Mervyn Singer
- Bloomsbury Institute for Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Andrew R Harvey
- School of Physics & Astronomy, University of Glasgow, Glasgow, UK
| | - Ilias Tachtsidis
- Biomedical Optics Research Laboratory, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Xavier Golay
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Kenneth J Smith
- Department of Neuroinflammation, UCL Queen Square Institute of Neurology, University College London, London, UK
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A Pilot Study Identifying Brain-Targeting Adaptive Immunity in Pediatric Extracorporeal Membrane Oxygenation Patients With Acquired Brain Injury. Crit Care Med 2020; 47:e206-e213. [PMID: 30640221 PMCID: PMC6377324 DOI: 10.1097/ccm.0000000000003621] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Supplemental Digital Content is available in the text. Objectives: Extracorporeal membrane oxygenation provides short-term cardiopulmonary life support, but is associated with peripheral innate inflammation, disruptions in cerebral autoregulation, and acquired brain injury. We tested the hypothesis that extracorporeal membrane oxygenation also induces CNS-directed adaptive immune responses which may exacerbate extracorporeal membrane oxygenation-associated brain injury. Design: A single center prospective observational study. Setting: Pediatric and cardiac ICUs at a single tertiary care, academic center. Patients: Twenty pediatric extracorporeal membrane oxygenation patients (0–14 yr; 13 females, 7 males) and five nonextracorporeal membrane oxygenation Pediatric Logistic Organ Dysfunction score matched patients Interventions: None. Measurements and Main Results: Venous blood samples were collected from the extracorporeal membrane oxygenation circuit at day 1 (10–23 hr), day 3, and day 7 of extracorporeal membrane oxygenation. Flow cytometry quantified circulating innate and adaptive immune cells, and CNS-directed autoreactivity was detected using an in vitro recall response assay. Disruption of cerebral autoregulation was determined using continuous bedside near-infrared spectroscopy and acquired brain injury confirmed by MRI. Extracorporeal membrane oxygenation patients with acquired brain injury (n = 9) presented with a 10-fold increase in interleukin-8 over extracorporeal membrane oxygenation patients without brain injury (p < 0.01). Furthermore, brain injury within extracorporeal membrane oxygenation patients potentiated an inflammatory phenotype in adaptive immune cells and selective autoreactivity to brain peptides in circulating B cell and cytotoxic T cell populations. Correlation analysis revealed a significant relationship between adaptive immune responses of extracorporeal membrane oxygenation patients with acquired brain injury and loss of cerebral autoregulation. Conclusions: We show that pediatric extracorporeal membrane oxygenation patients with acquired brain injury exhibit an induction of pro-inflammatory cell signaling, a robust activation of adaptive immune cells, and CNS-targeting adaptive immune responses. As these patients experience developmental delays for years after extracorporeal membrane oxygenation, it is critical to identify and characterize adaptive immune cell mechanisms that target the developing CNS.
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20
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The 5-year Tysabri global observational program in safety (TYGRIS) study confirms the long-term safety profile of natalizumab treatment in multiple sclerosis. Mult Scler Relat Disord 2019; 39:101863. [PMID: 31901758 DOI: 10.1016/j.msard.2019.101863] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/13/2019] [Accepted: 11/20/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Natalizumab is an effective treatment for multiple sclerosis (MS) and has a well-characterized safety profile, with more than 10 years of postmarketing experience. TYGRIS was a 5-year observational cohort study designed to obtain long-term safety data in natalizumab-treated MS patients. We examined the incidence and pattern of serious adverse events (SAEs) in this large postmarketing sample of natalizumab-treated patients. METHODS Investigators reported SAEs in natalizumab-treated patients. Malignancy incidence rates were compared with rates in the general population using external databases. RESULTS Of 6508 enrolled patients, 4938 (75.9%) completed the study. SAEs occurring in more than 0.5% of patients included urinary tract infection (n = 50; 0.8%), pneumonia (n = 46; 0.7%), progressive multifocal leukoencephalopathy (PML; n = 44; 0.7%), and immune reconstitution inflammatory syndrome (n = 44; 0.7%). Fifty-five patients (0.9%) experienced treatment-emergent serious opportunistic infections, 44 of which were PML. Two patients with PML died. The overall malignancy incidence rate was 449.0 per 100,000 patient-years (95% confidence interval [CI], 375.1-533.1). With few exceptions, incidence rates for individual malignancies had 95% CIs encompassing incidence rates in the general population. Hepatotoxic events occurred in 6 patients; 4 patients had evidence of alternative cause or confounders. Of 96 fatal events, investigators considered 81 unrelated or unlikely to be related to treatment and 5 related or possibly related; causality was not provided for 10. CONCLUSION Data from this large, long-term study indicate that the nature, character, and frequency of SAEs in real-world settings are consistent with natalizumab's known safety profile. (Funded by Biogen; ClinicalTrials.gov identifiers: NCT00477113 and NCT00483847.).
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21
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Berardi A, Siddiqui MK, Treharne C, Harty G, Wong SL. Estimating the comparative efficacy of cladribine tablets versus alternative disease modifying treatments in active relapsing-remitting multiple sclerosis: adjusting for patient characteristics using meta-regression and matching-adjusted indirect treatment comparison approaches. Curr Med Res Opin 2019; 35:1371-1378. [PMID: 30786783 DOI: 10.1080/03007995.2019.1585779] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: To estimate the comparative efficacy of cladribine tablets versus alternative disease modifying therapies (DMTs) - fingolimod, natalizumab, alemtuzumab and ocrelizumab - in adults with active relapsing-remitting multiple sclerosis (RRMS), using meta-regression to provide subpopulation-specific estimates of drug effect. Additionally, to determine the feasibility of conducting a matching-adjusted indirect comparison (MAIC) to validate the meta-regression results. Methods: A published systematic literature review (SLR) identified studies evaluating the efficacy of cladribine tablets and alternative DMTs in the management of active RRMS. A series of meta-regression models were run with adjustment for baseline risk, fitted to data from the intention-to-treat cohorts of trials identified in the SLR. A non-parametric MAIC analysis adjusted for differences between studies by reweighting patient-level data from the index trial to match the mean baseline characteristics reported for trials with only aggregate data. Results: The meta-regression analysis showed significant overlap in credible intervals for the hazard ratios of 6 month confirmed disability progression (CDP-6M) and annualized relapse rate (ARR), with no therapy statistically dominating in terms of efficacy and all therapies estimated to reduce the ARR compared to placebo in all subpopulations. In the MAIC analysis, cladribine tablets showed a reduction in CDP-6M and ARR comparable to alemtuzumab before and after matching. Conclusion: This analysis has demonstrated that cladribine tablets have comparable relative efficacy to other highly efficacious DMTs in active RRMS across all subpopulations, thus validating the comparative effectiveness results from previous network meta-analysis. The MAIC analysis showed that cladribine tablets are comparable in efficacy to alemtuzumab in the treatment of patients with RRMS.
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Affiliation(s)
| | | | | | - Gerard Harty
- c EMD Serono Research and Development , Billerica , USA
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22
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Historical and Current Concepts Regarding Urodynamics in Multiple Sclerosis Patients. CURRENT BLADDER DYSFUNCTION REPORTS 2019. [DOI: 10.1007/s11884-019-00525-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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23
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Skaper SD, Barbierato M, Facci L, Borri M, Contarini G, Zusso M, Giusti P. Co-Ultramicronized Palmitoylethanolamide/Luteolin Facilitates the Development of Differentiating and Undifferentiated Rat Oligodendrocyte Progenitor Cells. Mol Neurobiol 2019; 55:103-114. [PMID: 28822061 DOI: 10.1007/s12035-017-0722-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Oligodendrocytes, the myelin-producing cells of the central nervous system (CNS), have limited capability to bring about repair in chronic CNS neuroinflammatory demyelinating disorders such as multiple sclerosis (MS). MS lesions are characterized by a compromised pool of undifferentiated oligodendrocyte progenitor cells (OPCs) unable to mature into myelin-producing oligodendrocytes. An attractive strategy may be to replace lost OLs and/or promote their maturation. N-palmitoylethanolamine (PEA) is an endogenous fatty acid amide signaling molecule with anti-inflammatory and neuroprotective actions. Recent studies show a co-ultramicronized composite of PEA and the flavonoid luteolin (co-ultraPEALut) to be more efficacious than PEA in improving outcome in CNS injury models. Here, we examined the effects of co-ultraPEALut on development of OPCs from newborn rat cortex cultured under conditions favoring either differentiation (Sato medium) or proliferation (fibroblast growth factor-2 and platelet-derived growth factor (PDGF)-AA-supplemented serum-free medium ("SFM")). OPCs in SFM displayed high expression of PDGF receptor alpha gene and the proliferation marker Ki-67. In Sato medium, in contrast, OPCs showed rapid decreases in PDGF receptor alpha and Ki-67 expression with a concomitant rise in myelin basic protein (MBP) expression. In these conditions, co-ultraPEALut (10 μM) enhanced OPC morphological complexity and expression of MBP and the transcription factor TCF7l2. Surprisingly, co-ultraPEALut also up-regulated MBP mRNA expression in OPCs in SFM. MBP expression in all cases was sensitive to inhibition of mammalian target of rapamycin. Within the context of strategies to promote endogenous remyelination in MS which focus on enhancing long-term survival of OPCs and stimulating their differentiation into remyelinating oligodendrocytes, co-ultraPEALut may represent a novel pharmacological approach.
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Affiliation(s)
- Stephen D Skaper
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Largo "Egidio Meneghetti" 2, 35131, Padua, Italy.
| | - Massimo Barbierato
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Largo "Egidio Meneghetti" 2, 35131, Padua, Italy
| | - Laura Facci
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Largo "Egidio Meneghetti" 2, 35131, Padua, Italy
| | - Mila Borri
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Largo "Egidio Meneghetti" 2, 35131, Padua, Italy
| | - Gabriella Contarini
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Largo "Egidio Meneghetti" 2, 35131, Padua, Italy
| | - Morena Zusso
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Largo "Egidio Meneghetti" 2, 35131, Padua, Italy
| | - Pietro Giusti
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Largo "Egidio Meneghetti" 2, 35131, Padua, Italy
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Claflin SB, Broadley S, Taylor BV. The Effect of Disease Modifying Therapies on Disability Progression in Multiple Sclerosis: A Systematic Overview of Meta-Analyses. Front Neurol 2019; 9:1150. [PMID: 30687214 PMCID: PMC6335290 DOI: 10.3389/fneur.2018.01150] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/11/2018] [Indexed: 12/28/2022] Open
Abstract
Background: Disease modifying therapy (DMT) efficacy trials make an essential contribution to the development of evidence-based clinical treatments and practices for people with multiple sclerosis (MS). Meta-analysis is a critical part of this process and provides a powerful tool to assess the effects of DMT on MS progression. However, although there have been several meta-analyses on the effect of DMT on MS disease progression, they often do not reach the same conclusions. Objective: Our aim was to better understand and contextualize the results of meta-analyses evaluating DMT, identify differences in methodology that might explain their differing conclusions, and highlight areas for future research that will improve our ability to develop clinical recommendations. Methods: We conducted an overview of systematic reviews with meta-analyses assessing the efficacy of DMT on disability progression in people with MS in PubMed (Medline) and the Cochrane Database of Systematic Reviews. Results: We included 22 meta-analyses in this overview: eight general (on >3 DMT), 11 specific (on ≤3 DMT), 2 that evaluated subsets, and 1 that evaluated long-term effects. We found that there is good evidence that DMT improve short-term (≤2–3 years) disability progression outcomes relative to placebo in people with relapsing-remitting MS. However, results varied substantially between meta-analyses, and there is little evidence of their efficacy in other populations or over longer periods. The relative effects of individual DMT also remain unclear. The variance in results between meta-analyses may be related to the substantial differences in inclusion criteria, which was reflected in the limited overlap in included studies, as well as the year of meta-analysis publication. Of the 123 total unique studies included in the general meta-analyses, 77 (62.6%) were included in only one meta-analysis. This incongruence was also evident in the included DMT. Six of the 16 (37.5%) DMT evaluated in the general meta-analyses were only included in one meta-analysis. Conclusions: Translating DMT efficacy studies into evidence-based clinical practice requires greater methodological consistency in meta-analyses, more data on the relative effects of DMT through head-to-head clinical trials, and better reporting of adverse events.
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Affiliation(s)
- Suzi B Claflin
- Menzies Institute for Medical Research, University of Tasmanian, Hobart, TAS, Australia
| | - Simon Broadley
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Bruce V Taylor
- Menzies Institute for Medical Research, University of Tasmanian, Hobart, TAS, Australia
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25
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Spineli LM, Yepes-Nuñez JJ, Schünemann HJ. A systematic survey shows that reporting and handling of missing outcome data in networks of interventions is poor. BMC Med Res Methodol 2018; 18:115. [PMID: 30355280 PMCID: PMC6201503 DOI: 10.1186/s12874-018-0576-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 10/15/2018] [Indexed: 11/30/2022] Open
Abstract
Background To provide empirical evidence about prevalence, reporting and handling of missing outcome data in systematic reviews with network meta-analysis and acknowledgement of their impact on the conclusions. Methods We conducted a systematic survey including all published systematic reviews of randomized controlled trials comparing at least three interventions from January 1, 2009 until March 31, 2017. Results We retrieved 387 systematic reviews with network meta-analysis. Description of missing outcome data was available in 63 reviews. Intention-to-treat analysis was the most prevalent method (71%), followed by missing outcome data investigated as secondary outcome (e.g., acceptability) (40%). Bias due to missing outcome data was evaluated in half the reviews with explicit judgments in 18 (10%) reviews. Only 88 reviews interpreted their results acknowledging the implications of missing outcome data and mostly using the network meta-analysis results on missing outcome data as secondary outcome. We were unable to judge the actual strategy applied to deal with missing outcome data in 65% of the reviews due to insufficient information. Six percent of network meta-analyses were re-analyzed in sensitivity analysis considering missing outcome data, while 4% explicitly justified the strategy for dealing with missing outcome data. Conclusions The description and handling of missing outcome data as well as the acknowledgment of their implications for the conclusions from network meta-analysis are deemed underreported. Electronic supplementary material The online version of this article (10.1186/s12874-018-0576-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Loukia M Spineli
- Institut für Biometrie (OE 8410), Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Juan J Yepes-Nuñez
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.,School of Medicine, University of Antioquia, Calle 70 No. 52 - 21, Medellín, Colombia
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.,Department of Medicine, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
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26
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Melendez-Torres GJ, Armoiry X, Court R, Patterson J, Kan A, Auguste P, Madan J, Counsell C, Ciccarelli O, Clarke A. Comparative effectiveness of beta-interferons and glatiramer acetate for relapsing-remitting multiple sclerosis: systematic review and network meta-analysis of trials including recommended dosages. BMC Neurol 2018; 18:162. [PMID: 30285675 PMCID: PMC6169084 DOI: 10.1186/s12883-018-1162-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 09/21/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND We systematically reviewed the comparative effectiveness of injectable beta-interferons (IFN-β) and glatiramer acetate (GA) on annualised relapse rate (ARR), progression and discontinuation due to adverse events (AEs) in RRMS, using evidence from within the drugs' recommended dosages. METHODS We updated prior comprehensive reviews, checked references of included studies, contacted experts in the field, and screened websites for relevant publications to locate randomised trials of IFN-β and GA with recommended dosages in RRMS populations, compared against placebo or other recommended dosages. Abstracts were screened and assessed for inclusion in duplicate and independently. Studies were appraised using the Cochrane risk of bias tool. Rate ratios for ARR, hazard ratios for time to progression, and risk ratios for discontinuation due to AEs were synthesised in separate models using random effects network meta-analysis. RESULTS We identified 24 studies reported in 42 publications. Most studies were at high risk of bias in at least one domain. All drugs had a beneficial effect on ARR as compared to placebo, but not compared to each other, and findings were robust to sensitivity analysis. We considered time to progression confirmed at 3 months and confirmed at 6 months in separate models; while both models suggested that the included drugs were effective, findings were not consistent between models. Discontinuation due to AEs did not appear to be different between drugs. CONCLUSIONS Meta-analyses confirmed that IFN-β and GA reduce ARR and generally delay progression as defined in these trials, though there was no clear 'winner' across outcomes. Findings are additionally tempered by the high risk of bias across studies, and the use of an impairment/mobility scale to measure disease progression. Future research should consider more relevant measures of disability and, given that most trials have been short-term, consider a longitudinal approach to comparative effectiveness. REVIEW REGISTRATION PROSPERO CRD42016043278 .
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Affiliation(s)
- G. J. Melendez-Torres
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Xavier Armoiry
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Rachel Court
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | | | - Alan Kan
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Peter Auguste
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Jason Madan
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Carl Counsell
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Olga Ciccarelli
- Queen Square Multiple Sclerosis Centre, University College London Institute of Neurology, London, UK
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Aileen Clarke
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
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27
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Defer G, de Seze J, Bouee S, Courouve L, Longin J, Payet M, Deleglise AJ. Outcomes and treatment management of a French cohort suffering from multiple sclerosis: A retrospective epidemiological study. Mult Scler Relat Disord 2018; 25:276-281. [DOI: 10.1016/j.msard.2018.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/13/2018] [Accepted: 08/03/2018] [Indexed: 11/26/2022]
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28
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Abstract
In this review article, typical imaging findings of diseases elicited by immunomodulatory drugs are presented. Progressive multifocal leucoencephalopathy (PML), a subacute infection due to reactivation of the JC virus, has a typical magnetic resonance imaging (MRI) pattern, which must be considered in the framework of immunomodulatory multiple sclerosis (MS) treatment with natalizumab, fingolimod, rituximab and fumarate and also in lymphoproliferative diseases or other forms of immunosuppression. Restoration of the immune system may result in an overlapping and overwhelming immune response in terms of an immune reconstitution inflammatory syndrome (IRIS). Further conditions with typical MRI patterns comprise methotrexate-associated leucoencephalopathy and posterior reversible encephalopathy syndrome (PRES). In immunotherapy with activation of T‑lymphocytes, attention should always be paid to the fact that the T‑lymphocytes activated by different processes not only target the diseased tissue but also normal brain tissue.
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Affiliation(s)
| | - H Urbach
- Klinik für Neuroradiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland.
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29
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Mao Z, Álvarez-Gonzalez C, De Trane S, Yildiz O, Albor C, Doctor G, Soon D, Pepper G, Turner BP, Marta M, Mathews J, Giovannoni G, Baker D, Schmierer K. Cladribine: Off-label disease modification for people with multiple sclerosis in resource-poor settings? Mult Scler J Exp Transl Clin 2018; 4:2055217318783767. [PMID: 30090639 PMCID: PMC6077935 DOI: 10.1177/2055217318783767] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/19/2018] [Accepted: 05/04/2018] [Indexed: 01/13/2023] Open
Abstract
Background A considerable number of people with multiple sclerosis (pwMS) live in low- and middle-income countries (LMIC), where lack of resource adversely affects access to effective disease-modifying treatment. Objective The objective of this commentary is to propose a useful cost-effective disease-modifying treatment option for pwMS in LMIC with potential high efficacy and high convenience to the pwMS and treating physician. Viewpoint: We propose using generic 2-chloro-2’-deoxyadenosine (cladribine), a small molecule licensed for treatment of people with hairy cell leukaemia, as a solution of this significant equity imbalance. Cladribine has been shown in phase II and III trials to be a highly effective disease-modifying treatment for pwMS, and its adverse effect profile is comparable with any DMT currently licensed in high-income economies where an oral preparation has recently been licensed by the European Medicines Agency. Conclusion Our viewpoint takes into account experience we have gathered over the past three years in the use of generic cladribine to treat pwMS. Whilst here we focus on MS, there is significant potential for use of cladribine in other conditions that could benefit from its mechanism of action.
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Affiliation(s)
- Zhifeng Mao
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-Sen University, China.,BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom
| | - César Álvarez-Gonzalez
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Stefania De Trane
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Ozlem Yildiz
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Christo Albor
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom
| | - Gabriel Doctor
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom
| | - Derek Soon
- Division of Neurology, National University Hospital, Singapore
| | | | - Benjamin P Turner
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Monica Marta
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Joela Mathews
- Barts Health NHS Trust, Pharmacy, The Royal London Hospital, United Kingdom
| | - Gavin Giovannoni
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - David Baker
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom
| | - Klaus Schmierer
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, United Kingdom
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30
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Melendez-Torres GJ, Auguste P, Armoiry X, Maheswaran H, Court R, Madan J, Kan A, Lin S, Counsell C, Patterson J, Rodrigues J, Ciccarelli O, Fraser H, Clarke A. Clinical effectiveness and cost-effectiveness of beta-interferon and glatiramer acetate for treating multiple sclerosis: systematic review and economic evaluation. Health Technol Assess 2018; 21:1-352. [PMID: 28914229 DOI: 10.3310/hta21520] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND At the time of publication of the most recent National Institute for Health and Care Excellence (NICE) guidance [technology appraisal (TA) 32] in 2002 on beta-interferon (IFN-β) and glatiramer acetate (GA) for multiple sclerosis, there was insufficient evidence of their clinical effectiveness and cost-effectiveness. OBJECTIVES To undertake (1) systematic reviews of the clinical effectiveness and cost-effectiveness of IFN-β and GA in relapsing-remitting multiple sclerosis (RRMS), secondary progressive multiple sclerosis (SPMS) and clinically isolated syndrome (CIS) compared with best supportive care (BSC) and each other, investigating annualised relapse rate (ARR) and time to disability progression confirmed at 3 months and 6 months and (2) cost-effectiveness assessments of disease-modifying therapies (DMTs) for CIS and RRMS compared with BSC and each other. REVIEW METHODS Searches were undertaken in January and February 2016 in databases including The Cochrane Library, MEDLINE and the Science Citation Index. We limited some database searches to specific start dates based on previous, relevant systematic reviews. Two reviewers screened titles and abstracts with recourse to a third when needed. The Cochrane tool and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and Philips checklists were used for appraisal. Narrative synthesis and, when possible, random-effects meta-analysis and network meta-analysis (NMA) were performed. Cost-effectiveness analysis used published literature, findings from the Department of Health's risk-sharing scheme (RSS) and expert opinion. A de novo economic model was built for CIS. The base case used updated RSS data, a NHS and Personal Social Services perspective, a 50-year time horizon, 2014/15 prices and a discount rate of 3.5%. Outcomes are reported as incremental cost-effectiveness ratios (ICERs). We undertook probabilistic sensitivity analysis. RESULTS In total, 6420 publications were identified, of which 63 relating to 35 randomised controlled trials (RCTs) were included. In total, 86% had a high risk of bias. There was very little difference between drugs in reducing moderate or severe relapse rates in RRMS. All were beneficial compared with BSC, giving a pooled rate ratio of 0.65 [95% confidence interval (CI) 0.56 to 0.76] for ARR and a hazard ratio of 0.70 (95% CI, 0.55 to 0.87) for time to disability progression confirmed at 3 months. NMA suggested that 20 mg of GA given subcutaneously had the highest probability of being the best at reducing ARR. Three separate cost-effectiveness searches identified > 2500 publications, with 26 included studies informing the narrative synthesis and model inputs. In the base case using a modified RSS the mean incremental cost was £31,900 for pooled DMTs compared with BSC and the mean incremental quality-adjusted life-years (QALYs) were 0.943, giving an ICER of £33,800 per QALY gained for people with RRMS. In probabilistic sensitivity analysis the ICER was £34,000 per QALY gained. In sensitivity analysis, using the assessment group inputs gave an ICER of £12,800 per QALY gained for pooled DMTs compared with BSC. Pegylated IFN-β-1 (125 µg) was the most cost-effective option of the individual DMTs compared with BSC (ICER £7000 per QALY gained); GA (20 mg) was the most cost-effective treatment for CIS (ICER £16,500 per QALY gained). LIMITATIONS Although we built a de novo model for CIS that incorporated evidence from our systematic review of clinical effectiveness, our findings relied on a population diagnosed with CIS before implementation of the revised 2010 McDonald criteria. CONCLUSIONS DMTs were clinically effective for RRMS and CIS but cost-effective only for CIS. Both RCT evidence and RSS data are at high risk of bias. Research priorities include comparative studies with longer follow-up and systematic review and meta-synthesis of qualitative studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42016043278. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- G J Melendez-Torres
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Auguste
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Xavier Armoiry
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Hendramoorthy Maheswaran
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jason Madan
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Alan Kan
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Stephanie Lin
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carl Counsell
- Divison of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Jeremy Rodrigues
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Olga Ciccarelli
- Department of Neuroinflammation, Institute of Neurology, University College London, London, UK
| | - Hannah Fraser
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Aileen Clarke
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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31
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Synnot AJ, Hawkins M, Merner BA, Summers MP, Filippini G, Osborne RH, Shapland SD, Cherry CL, Stuckey R, Milne CA, Mosconi P, Colombo C, Hill SJ. Producing an evidence-based treatment information website in partnership with people affected by multiple sclerosis. Health Sci Rep 2018; 1:e24. [PMID: 30623063 PMCID: PMC6266475 DOI: 10.1002/hsr2.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/29/2017] [Accepted: 12/12/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND AIMS In earlier work, we identified that people affected by multiple sclerosis (MS) can have difficulty finding online treatment information that is up to date, trustworthy, understandable, and applicable to personal circumstances, but does not provoke confusion or negative emotional consequences. The objective was to develop online consumer summaries of MS treatment evidence (derived from Cochrane Reviews) that respond to identified treatment information needs of people affected by MS. METHODS A 2-phase mixed-methods project, conducted in partnership with consumers and an MS organisation. Phase 1 included review panels with consumers (Australians affected by MS) and health professionals to test paper-based treatment summaries before development, and pilot testing of the website. Phase 2 involved an online survey after website launch. RESULTS Eighty-three participants (85% affected by MS) took part. Phase 1 participants strongly endorsed key review summary components, including layering information, and additional sections to aid personal applicability. Participants additionally suggested questions for health professionals. Participants across both phases were receptive to the idea of being provided with Cochrane Review summaries online but were seeking other types of evidence and information, such as personal experiences and the latest experimental treatments, which could not be provided. While the small survey sample size (n = 58) limits application of the results to a broader population, the website was viewed favourably, as a useful, understandable, and trustworthy information source. CONCLUSION We describe a partnership approach to developing online evidence-based treatment information, underpinned by an in-depth understanding of consumers' information needs.
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Affiliation(s)
- Anneliese J. Synnot
- Centre for Health Communication and Participation, School of Psychology and Public HealthLa Trobe UniversityMelbourneAustralia
- Cochrane Australia, School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
| | - Melanie Hawkins
- Health Systems Improvement Unit, Centre for Population Health Research, School of Health and Social DevelopmentDeakin UniversityGeelongAustralia
| | - Bronwen A. Merner
- Centre for Health Communication and Participation, School of Psychology and Public HealthLa Trobe UniversityMelbourneAustralia
| | - Michael P. Summers
- Centre for Health Communication and Participation, School of Psychology and Public HealthLa Trobe UniversityMelbourneAustralia
| | - Graziella Filippini
- Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Review Group, Scientific DirectionIRCCS Foundation Neurological Institute Carlo BestaMilanItaly
| | - Richard H. Osborne
- Health Systems Improvement Unit, Centre for Population Health Research, School of Health and Social DevelopmentDeakin UniversityGeelongAustralia
| | | | - Catherine L. Cherry
- Burnet Institute, Department of Infectious DiseasesThe Alfred Hospital and Monash UniversityMelbourneAustralia
- Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Rwth Stuckey
- Centre for Ergonomics and Human Factors, School of Psychology and Public HealthLa Trobe UniversityMelbourneAustralia
| | - Catherine A. Milne
- Centre for Values, Ethics and Law in MedicineUniversity of SydneySydneyNew South WalesAustralia
| | - Paola Mosconi
- Laboratory for Medical Research and Consumer Involvement, Department of Public HealthIRCCS Istituto di Ricerche Farmacologiche Mario NegriMilanItaly
| | - Cinzia Colombo
- Laboratory for Medical Research and Consumer Involvement, Department of Public HealthIRCCS Istituto di Ricerche Farmacologiche Mario NegriMilanItaly
| | - Sophie J. Hill
- Centre for Health Communication and Participation, School of Psychology and Public HealthLa Trobe UniversityMelbourneAustralia
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Tilling K, Lawton M, Robertson N, Tremlett H, Zhu F, Harding K, Oger J, Ben-Shlomo Y. Modelling disease progression in relapsing-remitting onset multiple sclerosis using multilevel models applied to longitudinal data from two natural history cohorts and one treated cohort. Health Technol Assess 2018; 20:1-48. [PMID: 27817792 DOI: 10.3310/hta20810] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The ability to better predict disease progression represents a major unmet need in multiple sclerosis (MS), and would help to inform therapeutic and management choices. OBJECTIVES To develop multilevel models using longitudinal data on disease progression in patients with relapsing-remitting MS (RRMS) or secondary-progressive MS (SPMS); and to use these models to estimate the association of disease-modifying therapy (DMT) with progression. DESIGN Secondary analysis of three MS cohorts. SETTING Two natural history cohorts: University of Wales Multiple Sclerosis (UoWMS) cohort, UK, and British Columbia Multiple Sclerosis (BCMS) cohort, Canada. One observational DMT-treated cohort: UK MS risk-sharing scheme (RSS). PARTICIPANTS The UoWMS database has > 2000 MS patients and the BCMS database (as of 2009) has > 5900 MS patients. All participants who had definite MS (RRMS/SPMS), who reached the criteria set out by the Association of British Neurologists (ABN) for eligibility for DMT [i.e. age ≥ 18 years, Expanded Disability Status Scale (EDSS) score of ≤ 6.5, occurrence of two or more relapses in the previous 2 years] and who had at least two repeated outcome measures were included: 404 patients for the UoWMS cohort and 978 patients for the BCMS cohort. Through the UK MS RSS scheme, 5583 DMT-treated patients were recruited, with the analysis sample being the 4137 who had RRMS and were eligible and treated at baseline, with at least one valid EDSS score post baseline. MAIN OUTCOME MEASURES EDSS score observations post ABN eligibility. METHODS We used multilevel models in the development cohort (UoWMS) to develop a model for EDSS score with time since ABN eligibility, allowing for covariates and appropriate transformation of outcome and/or time. These methods were then applied to the BCMS cohort to obtain a 'natural history' model for changes in the EDSS score with time. We then used this natural history model to predict the trajectories of EDSS score in treated patients in the UK MS RSS database. Differences between the progression predicted by the natural history model and the progression observed at 6 years' follow-up for the UK MS RSS cohort were used as indicators of the effectiveness of the DMTs. Previously developed utility scores were assigned to each EDSS score, and differences in utility also examined. RESULTS The model best fitting the UoWMS data showed a non-linear increase in EDSS score over time since ABN eligibility. This model fitted the BCMS cohort data well, with similar coefficients, and the BCMS model predicted EDSS score in UoWMS data with little evidence of bias. Using the natural history model predicts EDSS score in a treated cohort (UK MS RSS) higher than that observed [by 0.59 points (95% confidence interval 0.54 to 0.64 points)] at 6 years post treatment. LIMITATIONS Only two natural history cohorts were compared, limiting generalisability. The comparison of a treated cohort with untreated cohorts is observational, thus limiting conclusions about causality. CONCLUSIONS EDSS score progression in two natural history cohorts of MS patients showed a similar pattern. Progression in the natural history cohorts was slightly faster than EDSS score progression in the DMT-treated cohort, up to 6 years post treatment. FUTURE WORK Long-term follow-up of randomised controlled trials is needed to replicate these findings and examine duration of any treatment effect. FUNDING DETAILS The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Kate Tilling
- School of Social and Community Medicine, Bristol University, Bristol, UK
| | - Michael Lawton
- School of Social and Community Medicine, Bristol University, Bristol, UK
| | - Neil Robertson
- Department of Neurology, Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Helen Tremlett
- Faculty of Medicine, Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Feng Zhu
- Faculty of Medicine, Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Katharine Harding
- Department of Neurology, Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Joel Oger
- Faculty of Medicine, Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Yoav Ben-Shlomo
- School of Social and Community Medicine, Bristol University, Bristol, UK
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33
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Latorraca COC, Martimbianco ALC, Pachito DV, Torloni MR, Pacheco RL, Pereira JG, Riera R. Palliative care interventions for people with multiple sclerosis. Hippokratia 2018. [DOI: 10.1002/14651858.cd012936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Carolina OC Latorraca
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Cochrane Brazil; Rua Borges Lagoa, 564 cj 63 São Paulo SP Brazil 04038-000
| | - Ana Luiza C Martimbianco
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Cochrane Brazil; Rua Borges Lagoa, 564 cj 63 São Paulo SP Brazil 04038-000
| | - Daniela V Pachito
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Rua Borges Lagoa, 754 Vila Clementino São Paulo Sao Paulo Brazil 04038001
| | - Maria Regina Torloni
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Cochrane Brazil; Rua Borges Lagoa, 564 cj 63 São Paulo SP Brazil 04038-000
| | - Rafael L Pacheco
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Cochrane Brazil; Rua Borges Lagoa, 564 cj 63 São Paulo SP Brazil 04038-000
| | | | - Rachel Riera
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Cochrane Brazil; Rua Borges Lagoa, 564 cj 63 São Paulo SP Brazil 04038-000
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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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Oligodendrocyte Progenitor Cell Cultures: A Model to Screen Neurotrophic Compounds for Myelin Repair. Methods Mol Biol 2018; 1727:155-166. [PMID: 29222780 DOI: 10.1007/978-1-4939-7571-6_12] [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] [Indexed: 12/09/2022]
Abstract
The protocol presented in this chapter covers the application of rat cortical oligodendrocyte progenitor cells cultured under conditions of differentiation for the evaluation of agents with potential trophic activity, that is, which are capable of promoting maturation under such conditions. As an example we have chosen a co-ultramicronized N-palmitoylethanolamine/luteolin composite, a formulation described in the literature as possessing anti-inflammatory, neuroprotective, and neuroregenerative actions.
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Lycke J, Zetterberg H. The role of blood and CSF biomarkers in the evaluation of new treatments against multiple sclerosis. Expert Rev Clin Immunol 2017; 13:1143-1153. [PMID: 29090607 DOI: 10.1080/1744666x.2017.1400380] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an immune-mediated chronic neurodegenerative disease of the central nervous system (CNS). Therapeutic interventions with immunomodulatory agents reduce disease activity and disability development, which are monitored clinically and by magnetic resonance imaging (MRI). However, these measures largely lack information on the impact from these therapies on inflammation, demyelination and axonal injury, the essential pathophysiological features of MS. Several biomarkers for inflammation and neurodegeneration have been detected in cerebrospinal fluid (CSF). In MS, some of these biomarkers seem to reflect disease activity, disability progression, and therapeutic response. Areas covered: In this review, we describe the most promising CSF biomarkers of inflammation and degeneration for monitoring therapeutic interventions in MS. We also describe the evolution of highly sensitive immunoassays that enable determination of neuron-specific biomarkers in blood. Expert commentary: Together with clinical and MRI measures, CSF biomarkers may improve the assessment of therapeutic efficacy and make personalized treatment possible. One disadvantage has been the need of repetitive lumbar punctures to obtain CSF. However, the technical development of highly sensitive immunoassays allows determination of extremely low quantities of neuron-specific proteins in blood. This will potentially open a new era for monitoring disease activity and treatment response in MS.
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Affiliation(s)
- Jan Lycke
- a Department of Clinical Neuroscience, Institute of Neuroscience and Physiology , The Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Henrik Zetterberg
- b Department of Psychiatry and Neurochemistry; Institute of Neuroscience and Physiology at Sahlgrenska Academy , University of Gothenburg , Gothenburg , Sweden.,c Clinical Neurochemistry Laboratory , Sahlgrenska University Hospital , Mölndal , Sweden.,d Department of Molecular Neuroscience , UCL Institute of Neurology , London , UK.,e UK Dementia Research Institute , London , UK
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Devasahayam AJ, Downer MB, Ploughman M. The Effects of Aerobic Exercise on the Recovery of Walking Ability and Neuroplasticity in People with Multiple Sclerosis: A Systematic Review of Animal and Clinical Studies. Mult Scler Int 2017; 2017:4815958. [PMID: 29181199 PMCID: PMC5664281 DOI: 10.1155/2017/4815958] [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: 05/19/2017] [Revised: 07/19/2017] [Accepted: 08/21/2017] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Walking is of high priority for people with multiple sclerosis (PwMS). It remains unclear whether aerobic exercise can improve walking ability and upregulate neurotrophins. This review aims to consolidate evidence to develop optimal aerobic training parameters to enhance walking outcomes and neuroplasticity in PwMS. METHODS Clinical studies examining aerobic exercise for ≥3 weeks, having outcomes on walking with or without neurotrophic markers, were included. Studies utilizing animal models of MS were included if they employed aerobic exercise with outcomes on neurological recovery and neurotrophins. From a total of 1783 articles, 12 clinical and 5 animal studies were included. RESULTS Eleven clinical studies reported improvements in walking ability. Only two clinical studies evaluated both walking and neurotrophins, and neither found an increase in neurotrophins despite improvements in walking. Patients with significant walking impairments were underrepresented. Long-term follow-up revealed mixed results. Two animal studies reported a positive change in both neurological recovery and neurotrophins. CONCLUSION Aerobic exercise improves walking ability in PwMS. Gains are not consistently maintained at 2- to 9-month follow-up. Studies examining levels of neurotrophins are inconclusive, necessitating further research. Aerobic exercise enhances both neurological recovery and neurotrophins in animal studies when started 2 weeks before induction of MS.
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Affiliation(s)
- Augustine Joshua Devasahayam
- The Recovery and Performance Laboratory, Faculty of Medicine, Memorial University of Newfoundland, Room 400, L.A. Miller Centre, 100 Forest Road, St. John's, NL, Canada A1A 1E5
| | - Matthew Bruce Downer
- The Recovery and Performance Laboratory, Faculty of Medicine, Memorial University of Newfoundland, Room 400, L.A. Miller Centre, 100 Forest Road, St. John's, NL, Canada A1A 1E5
| | - Michelle Ploughman
- The Recovery and Performance Laboratory, Faculty of Medicine, Memorial University of Newfoundland, Room 400, L.A. Miller Centre, 100 Forest Road, St. John's, NL, Canada A1A 1E5
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Zhang T, Kingwell E, Zhu F, Petkau J, Kastrukoff LF, Marrie RA, Tremlett H, Evans C. Effect of adherence to the first-generation injectable immunomodulatory drugs on disability accumulation in multiple sclerosis: a longitudinal cohort study. BMJ Open 2017; 7:e018612. [PMID: 28965103 PMCID: PMC5640095 DOI: 10.1136/bmjopen-2017-018612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 08/22/2017] [Accepted: 08/24/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the association between optimal adherence to the first-generation injectable immunomodulatory drugs (IMDs) for multiple sclerosis (MS) and subsequent disability accumulation. METHODS We accessed prospectively collected linked clinical and administrative health data from British Columbia, Canada. Subjects with MS treated with a first-generation injectable IMD at an MS clinic (1996-2004) were followed until their last clinic visit before 2009. Adherence was estimated using the proportion of days covered (PDC). The primary outcome was disability accumulation, defined as an increase in the Expanded Disability Status Scale (EDSS) score as recorded during each year of follow-up. Generalised estimating equation models, adjusted for baseline sex, age, EDSS and time between scores, were used to measure associations between optimal adherence (≥80% PDC) during the first year of treatment and subsequent disability accumulation. The relationship between early IMD adherence and the secondary outcome, time to sustained EDSS 6, was examined using Cox proportional hazards regression. RESULTS Among 801 subjects, 598 (74.7%) had optimal adherence over the first year of IMD treatment and 487 (39.0%) demonstrated one or more instances of disability accumulation. Early optimal adherence was not associated with disability accumulation (adjusted OR 0.94; 95% CI 0.78 to 1.15), nor with time to sustained EDSS 6 (adjusted HR 0.91; 95% CI 0.57 to 1.44). CONCLUSION Almost three-quarters of subjects with MS had optimal early adherence to their first-line injectable IMD. There was no evidence that this was associated with disability accumulation in the following years.
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Affiliation(s)
- Tingting Zhang
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Elaine Kingwell
- Department of Medicine (Neurology) and the Centre for Brain Health, University of British Columbia, Columbia, Canada
| | - Feng Zhu
- Department of Medicine (Neurology) and the Centre for Brain Health, University of British Columbia, Columbia, Canada
| | - John Petkau
- Department of Statistics, University of British Columbia, Columbia, Canada
| | - Lorne F Kastrukoff
- Department of Medicine (Neurology) and the Centre for Brain Health, University of British Columbia, Columbia, Canada
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Helen Tremlett
- Department of Medicine (Neurology) and the Centre for Brain Health, University of British Columbia, Columbia, Canada
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
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Vollmer B, Nair KV, Sillau SH, Corboy J, Vollmer T, Alvarez E. Comparison of fingolimod and dimethyl fumarate in the treatment of multiple sclerosis: Two-year experience. Mult Scler J Exp Transl Clin 2017; 3:2055217317725102. [PMID: 28839949 PMCID: PMC5564884 DOI: 10.1177/2055217317725102] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/06/2017] [Indexed: 11/22/2022] Open
Abstract
Background Fingolimod (FTY) and dimethyl fumarate (DMF) are multiple sclerosis (MS) oral therapies that became available in 2010 and 2013, respectively. Objective The objective of this article is to compare discontinuation rates, efficacy, and adverse events (AEs) of FTY and DMF over two years. Methods Patients prescribed FTY or DMF at the Rocky Mountain MS Center at University of Colorado prior to October 2013 were identified. Clinician-reported data were retrospectively collected. Primary outcome was discontinuation of drug by the end of year two. Reasons for discontinuation were evaluated. Results A total of 271 FTY and 342 DMF patients were evaluated. Patients had a mean age of 42.5 (FTY) and 45.8 (DMF) years and were predominantly female (72.0% FTY; 69.6% DMF) and white (86.3% FTY; 82.2% DMF). At ≤24 months, 93 (34.3%) and 161 (47.1%) discontinued FTY and DMF, respectively, with an unadjusted odds ratio (OR) of 1.70 (1.23–2.37, p = 0.002), or 1.69 (1.16–2.46, p = 0.006) for the doubly robust propensity score weighted estimator. Primary reason for discontinuation was AEs, which were less likely for FTY 46 (17.0%) compared to DMF 82 (24.0%) (OR 1.54, 1.03–2.31, p = 0.035). Discontinuation due to disease activity (FTY (10%) DMF (11.1%); OR 1.13, 0.67–1.90, p = 0.647) and breakthrough disease activity, regardless of discontinuation (FTY (34.7%) DMF (33.6%); OR 0.95, 0.68–1.34, p = 0.783), were similar. Conclusions The odds of discontinuation were less for FTY than DMF, and were driven by AEs for both drugs.
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Affiliation(s)
| | - Kavita V Nair
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver, United States
| | | | - John Corboy
- Rocky Mountain MS Center at University of Colorado, USA
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Paediatric Multiple Sclerosis: Update on Diagnostic Criteria, Imaging, Histopathology and Treatment Choices. Curr Neurol Neurosci Rep 2017; 16:68. [PMID: 27271748 PMCID: PMC4894922 DOI: 10.1007/s11910-016-0663-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Paediatric multiple sclerosis (MS) represents less than 5 % of the MS population, but patients with paediatric-onset disease reach permanent disability at a younger age than adult-onset patients. Accurate diagnosis at presentation and optimal long-term treatment are vital to mitigate ongoing neuroinflammation and irreversible neurodegeneration. However, it may be difficult to early differentiate paediatric MS from acute disseminated encephalomyelitis (ADEM) and neuromyelitis optica spectrum disorders (NMOSD), as they often have atypical presentation that differs from that of adult-onset MS. The purpose of this review is to summarize the updated views on diagnostic criteria, imaging, histopathology and treatment choices.
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McKay KA, Evans C, Fisk JD, Patten SB, Fiest K, Marrie RA, Tremlett H. Disease-Modifying Therapies and Adherence in Multiple Sclerosis: Comparing Patient Self-Report with Pharmacy Records. Neuroepidemiology 2017; 48:124-130. [PMID: 28683461 DOI: 10.1159/000477771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/21/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Self-report and pharmacy records are often used to measure adherence rates to disease-modifying therapies (DMTs) in multiple sclerosis (MS), but little is known about how the sources compare. OBJECTIVE Compare self-report and pharmacy records for assessing DMT use and adherence rates. METHODS Demographic information, self-reported DMT use, and missed DMT doses in the previous 30 days were obtained from consecutive MS patients attending an MS clinic and linked to pharmacy records. A medication possession ratio (MPR) was calculated using pharmacy records for the year before and after the visit; MPR <80% defined nonadherence. Agreement between self-report and pharmacy records was assessed using Cohen's kappa (κ). RESULTS Of 326 participants, 135 reported using an injectable DMT. There was near-perfect and perfect agreement between self-report and pharmacy records for DMT use (κ = 0.95; 95% CI 0.91-0.98) and DMT agent (κ = 1.00). Nonadherence was estimated at 13% (17/128) from the 30-days self-report compared to 30% (34/113) and 43% (53/123) in the year pre- and post-clinic visit from pharmacy records, indicating moderate to fair agreement (year prior: κ = 0.41; 95% CI 0.22-0.59; year post: κ = 0.22; 95% CI 0.09-0.36). CONCLUSIONS Patients self-reports closely reflected pharmacy records when assessing DMT use and product. Moderate to fair agreement was found when comparing adherence rates between sources.
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Affiliation(s)
- Kyla A McKay
- Faculty of Medicine (Neurology), Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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de Jong HJI, Kingwell E, Shirani A, Cohen Tervaert JW, Hupperts R, Zhao Y, Zhu F, Evans C, van der Kop ML, Traboulsee A, Gustafson P, Petkau J, Marrie RA, Tremlett H. Evaluating the safety of β-interferons in MS: A series of nested case-control studies. Neurology 2017; 88:2310-2320. [PMID: 28500224 PMCID: PMC5567323 DOI: 10.1212/wnl.0000000000004037] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 03/21/2017] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To examine the association between interferon-β (IFN-β) and potential adverse events using population-based health administrative data in British Columbia, Canada. METHODS Patients with relapsing-remitting multiple sclerosis (RRMS) who were registered at a British Columbia Multiple Sclerosis Clinic (1995-2004) were eligible for inclusion and were followed up until death, absence from British Columbia, exposure to a non-IFN-β disease-modifying drug, or December 31, 2008. Incidence rates were estimated for each potential adverse event (selected a priori and defined with ICD-9/10 diagnosis codes from physician and hospital claims). A nested case-control study was conducted to assess the odds of previous IFN-β exposure for each potential adverse event with at least 30 cases. Cases were matched by age (±5 years), sex, and year of cohort entry, with up to 20 randomly selected (by incidence density sampling) controls. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were estimated with conditional logistic regression adjusted for age at cohort entry. RESULTS Of the 2,485 eligible patients, 77.9% were women, and 1,031 were treated with IFN-β during follow-up. From the incidence analyses, 27 of the 47 potential adverse events had at least 30 cases. Patients with incident stroke (ORadj 1.83, 95% CI 1.16-2.89), migraine (ORadj 1.55, 95% CI 1.18-2.04), depression (ORadj 1.33, 95% CI 1.13-1.56), and hematologic abnormalities (ORadj 1.32, 95% CI 1.01-1.72) were more likely to have previous exposure to IFN-β than controls. CONCLUSIONS Among patients with RRMS, IFN-β was associated with a 1.8- and 1.6-fold increase in the risk of stroke and migraine and 1.3-fold increases in depression and hematologic abnormalities.
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Affiliation(s)
- Hilda J I de Jong
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Elaine Kingwell
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Afsaneh Shirani
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Jan Willem Cohen Tervaert
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Raymond Hupperts
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Yinshan Zhao
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Feng Zhu
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Charity Evans
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Mia L van der Kop
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Anthony Traboulsee
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Paul Gustafson
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - John Petkau
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ruth Ann Marrie
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Helen Tremlett
- From the Division of Neurology and Centre for Brain Health (H.J.I.d.J., E.K., A.S., Y.Z., F.Z., M.L.v.d.K., A.T., H.T.), Department of Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Canada; School for Mental Health and Neuroscience (H.J.I.d.J., J.W.C.T., R.H.), Maastricht University Medical Center, the Netherlands; College of Pharmacy and Nutrition (C.E.), University of Saskatchewan, Saskatoon, Canada; Department Public Health Sciences (M.L.v.d.K.), Karolinska Institutet, Stockholm, Sweden; Department of Statistics (P.G., J.P.), University of British Columbia, Vancouver, Canada; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Bargiela D, Bianchi MT, Westover MB, Chibnik LB, Healy BC, De Jager PL, Xia Z. Selection of first-line therapy in multiple sclerosis using risk-benefit decision analysis. Neurology 2017; 88:677-684. [PMID: 28087821 DOI: 10.1212/wnl.0000000000003612] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/23/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To integrate long-term measures of disease-modifying drug efficacy and risk to guide selection of first-line treatment of multiple sclerosis. METHODS We created a Markov decision model to evaluate disability worsening and progressive multifocal leukoencephalopathy (PML) risk in patients receiving natalizumab (NTZ), fingolimod (FGL), or glatiramer acetate (GA) over 30 years. Leveraging publicly available data, we integrated treatment utility, disability worsening, and risk of PML into quality-adjusted life-years (QALYs). We performed sensitivity analyses varying PML risk, mortality and morbidity, and relative risk of disease worsening across clinically relevant ranges. RESULTS Over the entire reported range of NTZ-associated PML risk, NTZ as first-line therapy is predicted to provide a greater net benefit (15.06 QALYs) than FGL (13.99 QALYs) or GA (12.71 QALYs) treatment over 30 years, after accounting for loss of QALYs due to PML or death (resulting from all causes). NTZ treatment is associated with delayed worsening to an Expanded Disability Status Scale score ≥6.0 vs FGL or GA (22.7, 17.0, and 12.4 years, respectively). Compared to untreated patients, NTZ-treated patients have a greater relative risk of death in the early years of treatment that varies according to PML risk profile. CONCLUSIONS NTZ as a first-line treatment is associated with the highest net benefit across full ranges of PML risk, mortality, and morbidity compared to FGL or GA. Integrated modeling of long-term treatment risks and benefits informs stratified clinical decision-making and can support patient counseling on selection of first-line treatment options.
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Affiliation(s)
- David Bargiela
- From the Ann Romney Center for Neurologic Diseases (D.B., B.C.H., P.L.D.J., Z.X.), Department of Neurology, and Program in Translational Neuropsychiatric Genomics (D.B., P.L.D.J., Z.X.), Institute for the Neurosciences, Department of Neurology, Brigham and Women's Hospital, Boston; Program for Medical and Population Genetics (D.B., L.B.C., P.L.D.J., Z.X.), Broad Institute, Cambridge; Harvard Medical School (D.B., M.T.B., M.B.W., L.B.C., P.L.D.J., Z.X.); Department of Neurology (M.T.B., M.B.W.) and Biostatistics Center (B.C.H.), Massachusetts General Hospital; Harvard T.H. Chan School of Public Health (L.B.C.), Boston, MA; and Department of Neurology (Z.X.), University of Pittsburgh, PA
| | - Matthew T Bianchi
- From the Ann Romney Center for Neurologic Diseases (D.B., B.C.H., P.L.D.J., Z.X.), Department of Neurology, and Program in Translational Neuropsychiatric Genomics (D.B., P.L.D.J., Z.X.), Institute for the Neurosciences, Department of Neurology, Brigham and Women's Hospital, Boston; Program for Medical and Population Genetics (D.B., L.B.C., P.L.D.J., Z.X.), Broad Institute, Cambridge; Harvard Medical School (D.B., M.T.B., M.B.W., L.B.C., P.L.D.J., Z.X.); Department of Neurology (M.T.B., M.B.W.) and Biostatistics Center (B.C.H.), Massachusetts General Hospital; Harvard T.H. Chan School of Public Health (L.B.C.), Boston, MA; and Department of Neurology (Z.X.), University of Pittsburgh, PA
| | - M Brandon Westover
- From the Ann Romney Center for Neurologic Diseases (D.B., B.C.H., P.L.D.J., Z.X.), Department of Neurology, and Program in Translational Neuropsychiatric Genomics (D.B., P.L.D.J., Z.X.), Institute for the Neurosciences, Department of Neurology, Brigham and Women's Hospital, Boston; Program for Medical and Population Genetics (D.B., L.B.C., P.L.D.J., Z.X.), Broad Institute, Cambridge; Harvard Medical School (D.B., M.T.B., M.B.W., L.B.C., P.L.D.J., Z.X.); Department of Neurology (M.T.B., M.B.W.) and Biostatistics Center (B.C.H.), Massachusetts General Hospital; Harvard T.H. Chan School of Public Health (L.B.C.), Boston, MA; and Department of Neurology (Z.X.), University of Pittsburgh, PA
| | - Lori B Chibnik
- From the Ann Romney Center for Neurologic Diseases (D.B., B.C.H., P.L.D.J., Z.X.), Department of Neurology, and Program in Translational Neuropsychiatric Genomics (D.B., P.L.D.J., Z.X.), Institute for the Neurosciences, Department of Neurology, Brigham and Women's Hospital, Boston; Program for Medical and Population Genetics (D.B., L.B.C., P.L.D.J., Z.X.), Broad Institute, Cambridge; Harvard Medical School (D.B., M.T.B., M.B.W., L.B.C., P.L.D.J., Z.X.); Department of Neurology (M.T.B., M.B.W.) and Biostatistics Center (B.C.H.), Massachusetts General Hospital; Harvard T.H. Chan School of Public Health (L.B.C.), Boston, MA; and Department of Neurology (Z.X.), University of Pittsburgh, PA
| | - Brian C Healy
- From the Ann Romney Center for Neurologic Diseases (D.B., B.C.H., P.L.D.J., Z.X.), Department of Neurology, and Program in Translational Neuropsychiatric Genomics (D.B., P.L.D.J., Z.X.), Institute for the Neurosciences, Department of Neurology, Brigham and Women's Hospital, Boston; Program for Medical and Population Genetics (D.B., L.B.C., P.L.D.J., Z.X.), Broad Institute, Cambridge; Harvard Medical School (D.B., M.T.B., M.B.W., L.B.C., P.L.D.J., Z.X.); Department of Neurology (M.T.B., M.B.W.) and Biostatistics Center (B.C.H.), Massachusetts General Hospital; Harvard T.H. Chan School of Public Health (L.B.C.), Boston, MA; and Department of Neurology (Z.X.), University of Pittsburgh, PA
| | - Philip L De Jager
- From the Ann Romney Center for Neurologic Diseases (D.B., B.C.H., P.L.D.J., Z.X.), Department of Neurology, and Program in Translational Neuropsychiatric Genomics (D.B., P.L.D.J., Z.X.), Institute for the Neurosciences, Department of Neurology, Brigham and Women's Hospital, Boston; Program for Medical and Population Genetics (D.B., L.B.C., P.L.D.J., Z.X.), Broad Institute, Cambridge; Harvard Medical School (D.B., M.T.B., M.B.W., L.B.C., P.L.D.J., Z.X.); Department of Neurology (M.T.B., M.B.W.) and Biostatistics Center (B.C.H.), Massachusetts General Hospital; Harvard T.H. Chan School of Public Health (L.B.C.), Boston, MA; and Department of Neurology (Z.X.), University of Pittsburgh, PA
| | - Zongqi Xia
- From the Ann Romney Center for Neurologic Diseases (D.B., B.C.H., P.L.D.J., Z.X.), Department of Neurology, and Program in Translational Neuropsychiatric Genomics (D.B., P.L.D.J., Z.X.), Institute for the Neurosciences, Department of Neurology, Brigham and Women's Hospital, Boston; Program for Medical and Population Genetics (D.B., L.B.C., P.L.D.J., Z.X.), Broad Institute, Cambridge; Harvard Medical School (D.B., M.T.B., M.B.W., L.B.C., P.L.D.J., Z.X.); Department of Neurology (M.T.B., M.B.W.) and Biostatistics Center (B.C.H.), Massachusetts General Hospital; Harvard T.H. Chan School of Public Health (L.B.C.), Boston, MA; and Department of Neurology (Z.X.), University of Pittsburgh, PA.
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Berkovich R, Bakshi R, Amezcua L, Axtell RC, Cen SY, Tauhid S, Neema M, Steinman L. Adrenocorticotropic hormone versus methylprednisolone added to interferon β in patients with multiple sclerosis experiencing breakthrough disease: a randomized, rater-blinded trial. Ther Adv Neurol Disord 2017; 10:3-17. [PMID: 28450891 PMCID: PMC5400152 DOI: 10.1177/1756285616670060] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The objective of this study was to evaluate monthly intramuscular adrenocorticotropic hormone (ACTH) gel versus intravenous methylprednisolone (IVMP) add-on therapy to interferon β for breakthrough disease in patients with relapsing forms of multiple sclerosis. METHODS This was a prospective, open-label, examiner-blinded, 15-month pilot study evaluating patients with Expanded Disability Status Scale (EDSS) score 3.0-6.5 and at least one clinical relapse or new T2 or gadolinium-enhanced lesion in the previous year. Twenty-three patients were randomized to ACTH (n = 12) or IVMP (n = 11) and completed the study. The primary outcome measure was the cumulative number of relapses. Secondary outcomes included EDSS, Mental Health Inventory (MHI), plasma cytokines, MS Functional Composite (MSFC), Quality-of-Life (MS-QOL) score, bone mineral density (BMD), and new or worsened psychiatric symptoms per month. Brain magnetic resonance imaging was analyzed post hoc. This was a preliminary and small-scale study. RESULTS Relapse rates differed significantly [ACTH 0.08, 95% confidence interval (CI) 0.01-0.54 versus IVMP 0.80, 95% CI 0.36-1.75; rate ratio, IVMP versus ACTH: 9.56, 95% CI 1.23-74.6; p = 0.03]. ACTH improved (p = 0.03) MHI (slope 0.95 ± 0.38 points/month; p = 0.02 versus slope -0.38 ± 0.43 points/month; p = 0.39). On-study decreases (all p < 0.05) in eight cytokine levels occurred only in the ACTH group. However, on-study EDSS, MSFC, MS-QOL, BMD, and MRI lesion changes were not significant between groups. Psychiatric symptoms per patient were greater with IVMP than ACTH (0.55, 95% CI 0.12-2.6 versus 0; p < 0.0001). Other common adverse events were insomnia and urinary tract infections (IVMP, seven events each) and fatigue or flu symptoms (ACTH, five events each). CONCLUSIONS This study provided class II evidence that ACTH produced better examiner-assessed cumulative rates of relapses per patient than IVMP in the adjunctive treatment of breakthrough disease in multiple sclerosis.
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Affiliation(s)
- Regina Berkovich
- USC MS Comprehensive Care Center and Research Group, 1520 San Pablo Street, Suite 3000, Los Angeles, CA 90033, USA
| | - Rohit Bakshi
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lilyana Amezcua
- University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | | | - Steven Y. Cen
- University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Shahamat Tauhid
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mohit Neema
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Benešová Y, Tvaroh A. Cognition and fatigue in patients with relapsing multiple sclerosis treated by subcutaneous interferon β-1a: an observational study SKORE. Ther Adv Neurol Disord 2017; 10:18-32. [PMID: 28450892 PMCID: PMC5400153 DOI: 10.1177/1756285616671882] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system, which often causes progressive neurological disability. In addition to motor and sensory dysfunction, cognitive decline and fatigue are frequent manifestations of the disease. Fatigue is probably the most common symptom, with up to 90% of MS individuals reporting fatigue at some point. Cognitive impairment affects about 50% of patients and may be present at all MS stages. The aim of this observational study was to evaluate changes in cognition, fatigue, and disability status in 300 relapsing-remitting MS (RRMS) patients, treated with subcutaneous (sc) interferon (IFN) β-1a over 2 years. METHODS The study was designed as an observational, multicentre, prospective, single-arm, phase IV study carried out in 13 MS centres in the Czech Republic. Cognition status was assessed using the Paced Auditory Serial Addition Task (PASAT), fatigue using the Fatigue Descriptive Scale (FDS), and disability using the Expanded Disability Status Scale (EDSS), at baseline, and after 6, 12 and 24 months. The percentage of patients with changed versus stable cognition, fatigue status and disability was calculated at each time point and the changes in these scores were evaluated. RESULTS The proportion of patients with cognitive improvement was higher compared with those with a stable or decreased PASAT scores at all time points, and the average cognitive performance improved during the follow-up period. Also the proportion of patients with stable or improved fatigue and EDSS scores was higher compared with those in which FDS or EDSS scores declined, this was found at all time points of the analysed sample. However, the direct effect of IFN β-1a on cognition and fatigue cannot be concluded from this study. CONCLUSIONS The results of this observational study have demonstrated a stable or improved cognitive performance, fatigue status, and disability level in the majority of RRMS patients treated with sc IFN β-1a over a two-year follow-up period, in a real life setting, in the Czech Republic.
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Affiliation(s)
- Yvonne Benešová
- Department of Neurology, University Hospital Brno and Faculty of Medicine, Masaryk University, Jihlavská 20, Brno 625 00, Czech Republic
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Comini-Frota ER, Vasconcelos CCF, Mendes MF. Guideline for multiple sclerosis treatment in Brazil: Consensus from the Neuroimmunology Scientific Department of the Brazilian Academy of Neurology. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:57-65. [DOI: 10.1590/0004-282x20160185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 09/22/2016] [Indexed: 12/17/2022]
Abstract
ABSTRACT Multiple sclerosis has become an ever-increasing challenge to neurologists. With the release of the latest medications on the market, Brazilian neurologists feel divided between following their patients’ evolution in accordance with the strict rules established by the Brazilian Ministry of Health regarding drug distribution, or following disease progression and worsening in accordance with the evidence in the literature. Therefore, a systematic review of the main published treatment guidelines was conducted and an escalating therapy proposed for guiding multiple sclerosis patient treatment in Brazil.
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La Mantia L, Di Pietrantonj C, Rovaris M, Rigon G, Frau S, Berardo F, Gandini A, Longobardi A, Weinstock‐Guttman B, Vaona A. Interferons-beta versus glatiramer acetate for relapsing-remitting multiple sclerosis. Cochrane Database Syst Rev 2016; 11:CD009333. [PMID: 27880972 PMCID: PMC6464642 DOI: 10.1002/14651858.cd009333.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Interferons-beta (IFNs-beta) and glatiramer acetate (GA) were the first two disease-modifying therapies (DMTs) approved 20 years ago for the treatment of multiple sclerosis (MS). DMTs' prescription rates as first or switching therapies and their costs have both increased substantially over the past decade. As more DMTs become available, the choice of a specific DMT should reflect the risk/benefit profile, as well as the impact on quality of life. As MS cohorts enrolled in different studies can vary significantly, head-to-head trials are considered the best approach for gaining objective reliable data when two different drugs are compared. The purpose of this systematic review is to summarise available evidence on the comparative effectiveness of IFNs-beta and GA on disease course through the analysis of head-to-head trials.This is an update of the Cochrane review 'Interferons-beta versus glatiramer acetate for relapsing-remitting multiple sclerosis' (first published in the Cochrane Library 2014, Issue 7). OBJECTIVES To assess whether IFNs-beta and GA differ in terms of safety and efficacy in the treatment of people with relapsing-remitting (RR) MS. SEARCH METHODS We searched the Trials Register of the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group (08 August 2016) and the reference lists of retrieved articles. We contacted authors and pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing directly IFNs-beta versus GA in study participants affected by RRMS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS Six trials were included and five trials contributed to this review with data. A total of 2904 participants were randomly assigned to IFNs (1704) and GA (1200). The treatment duration was three years for one study, two years for the other four RCTs while one study was stopped early (after one year). The IFNs analysed in comparison with GA were IFN-beta 1b 250 mcg (two trials, 933 participants), IFN-beta 1a 44 mcg (three trials, 466 participants) and IFN-beta 1a 30 mcg (two trials, 305 participants). Enrolled participants were affected by active RRMS. All studies were at high risk for attrition bias. Three trials are still ongoing, one of them completed.Both therapies showed similar clinical efficacy at 24 months, given the primary outcome variables (number of participants with relapse (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.87 to 1.24) or progression (RR 1.11, 95% CI 0.91 to 1.35). However at 36 months, evidence from a single study suggests that relapse rates were higher in the group given IFNs than in the GA group (RR 1.40, 95% CI 1.13 to 1.74, P value 0.002).Secondary magnetic resonance imaging (MRI) outcomes analysis showed that effects on new or enlarging T2- or new contrast-enhancing T1 lesions at 24 months were similar (mean difference (MD) -0.15, 95% CI -0.68 to 0.39, and MD -0.14, 95% CI -0.30 to 0.02, respectively). However, the reduction in T2- and T1-weighted lesion volume was significantly greater in the groups given IFNs than in the GA groups (MD -0.58, 95% CI -0.99 to -0.18, P value 0.004, and MD -0.20, 95% CI -0.33 to -0.07, P value 0.003, respectively).The number of participants who dropped out of the study because of adverse events was similar in the two groups (RR 0.95, 95% CI 0.64 to 1.40).The quality of evidence for primary outcomes was judged as moderate for clinical end points, but for safety and some MRI outcomes (number of active T2 lesions), quality was judged as low. AUTHORS' CONCLUSIONS The effects of IFNs-beta and GA in the treatment of people with RRMS, including clinical (e.g. people with relapse, risk to progression) and MRI (Gd-enhancing lesions) measures, seem to be similar or to show only small differences. When MRI lesion load accrual is considered, the effect of the two treatments differs, in that IFNs-beta were found to limit the increase in lesion burden as compared with GA. Evidence was insufficient for a comparison of the effects of the two treatments on patient-reported outcomes, such as quality-of-life measures.
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Affiliation(s)
- Loredana La Mantia
- I.R.C.C.S. Santa Maria Nascente ‐ Fondazione Don GnocchiUnit of Neurorehabilitation ‐ Multiple Sclerosis CenterVia Capecelatro, 66MilanoItaly20148
| | - Carlo Di Pietrantonj
- Local Health Unit Alessandria‐ ASL ALRegional Epidemiology Unit SeREMIVia Venezia 6AlessandriaAlessandriaItaly15121
| | - Marco Rovaris
- I.R.C.C.S. Santa Maria Nascente ‐ Fondazione Don GnocchiUnit of Neurorehabilitation ‐ Multiple Sclerosis CenterVia Capecelatro, 66MilanoItaly20148
| | - Giulio Rigon
- Azienda ULSS 20 ‐ VeronaPrimary CareVia Vivaldi, 11VeronaItaly37138
| | | | - Francesco Berardo
- Azienda Ospedaliera di Verona ‐ Department of PharmacyDrug Efficacy Evaluation Unit (UVEF) ‐ Veneto Regional Drug Information CenterPiazzale Stefani 1VeronaItaly37126
| | - Anna Gandini
- Azienda ULSS 21 ‐ LegnagoRegional Health ServiceVia Gianella 1LegnagoVareseItaly37045
| | - Anna Longobardi
- Azienda ULSS 20 ‐ VeronaPrimary CareVia Vivaldi, 11VeronaItaly37138
| | - Bianca Weinstock‐Guttman
- SUNY University of BuffaloDirector, Jacobs MS Center and Pediatric MS Center of Excellence100 High StreetBuffaloNew YorkUSA14203
| | - Alberto Vaona
- Azienda ULSS 20 ‐ VeronaPrimary CareVia Vivaldi, 11VeronaItaly37138
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Csillik A, Bruce J, Catley D, Gay MC, Goggin KJ, Swaggart KR, Thomas PW, Thomas S. Psychological interventions for enhancing adherence to disease-modifying therapies (DMTs) in multiple sclerosis. Hippokratia 2016. [DOI: 10.1002/14651858.cd012443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Antonia Csillik
- University of Paris Ouest Nanterre; Department of Psychology; 200, Avenue de la République Nanterre La Dèfense Cedex France F-92001
| | - Jared Bruce
- University of Missouri-Kansas City; Department of Psychology; 5030 Cherry Street, Room 313 Kansas City Missouri USA 64110
| | - Delwyn Catley
- Children's Mercy Hospital & University of Missouri-Kansas City; 2401 Giham Road Kansas City MO USA 64108
| | - Marie-Claire Gay
- University of Paris Ouest Nanterre; Department of Psychology; 200, Avenue de la République Nanterre La Dèfense Cedex France F-92001
| | - Kathleen J Goggin
- Children's Mercy Hospital & University of Missouri; Health Services and Outcomes Research & Schools of Medicine and Pharmacy; 2401 Giham Road Kansas City MO USA 64108
| | - Keri R Swaggart
- The Children's Mercy Hospital and Clinics; Library Services; 2401 Gillham Road Kansas City MO USA 64108
| | - Peter W Thomas
- School of Health and Social Care, Bournemouth University; Bournemouth University, Clinical Research Unit, Faculty of Health and Social Sciences; R506A Royal London House Christchurch Road Bournemouth Dorset UK BH1 3LT
| | - Sarah Thomas
- School of Health and Social Care, Bournemouth University; Bournemouth University, Clinical Research Unit, Faculty of Health and Social Sciences; R506A Royal London House Christchurch Road Bournemouth Dorset UK BH1 3LT
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McKay KA, Tremlett H, Patten SB, Fisk JD, Evans C, Fiest K, Campbell T, Marrie RA. Determinants of non-adherence to disease-modifying therapies in multiple sclerosis: A cross-Canada prospective study. Mult Scler 2016; 23:588-596. [PMID: 27357507 PMCID: PMC5407504 DOI: 10.1177/1352458516657440] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background: Poor adherence to the disease-modifying therapies (DMTs) for multiple sclerosis (MS) may attenuate clinical benefit. A better understanding of characteristics associated with non-adherence could improve outcomes. Objective: To evaluate characteristics associated with non-adherence to injectable DMTs. Methods: Consecutive patients from four Canadian MS Clinics were assessed at three time points over two years. Clinical and demographic information included self-reported DMT use, missed doses in the previous 30 days, health behaviors, and comorbidities. Non-adherence was defined as <80% of expected doses taken. We employed generalized estimating equations to examine characteristics associated with non-adherence at all time points with findings reported as adjusted odds ratios (OR). Results: In all, 485 participants reported use of an injectable DMT, of whom 107 (22.1%) were non-adherent over the study period. Non-adherence was associated with a lower Expanded Disability Status Scale score (0–2.5 vs 3.0–5.5, OR: 1.80; 95% confidence interval (CI): 1.06–3.04), disease duration (⩽5 vs <5 years, OR: 2.23; 95% CI: 1.10–4.52), alcohol dependence (OR: 2.14; 95% CI: 1.23–3.75), and self-reported cognitive difficulties, measured by the Health Utilities Index-3 (OR: 1.55; 95% CI: 1.08–2.22). Conclusions: Nearly one-quarter of participants were non-adherent during the study. Alcohol dependence, perceived cognitive difficulties, longer disease duration, and mild disability status were associated with non-adherence. These characteristics may help healthcare professionals identify patients at greatest risk of poor adherence.
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Affiliation(s)
- Kyla A McKay
- Division of Neurology, Faculty of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Helen Tremlett
- Division of Neurology, Faculty of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Scott B Patten
- Departments of Psychiatry and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - John D Fisk
- Departments of Psychiatry, Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada
| | - Kirsten Fiest
- Departments of Critical Care Medicine & Community Health Sciences, O'Brien Institute for Public Health, and Hotchkiss Brain Institute, University of Calgary, Canada
| | - Trudy Campbell
- School of Nursing, Faculty of Health Professions, Dalhousie University, Halifax, NS, Canada
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Health Sciences Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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50
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Dalbjerg SM, Tsakiri A, Frederiksen JL. Rhabdomyolysis following interferon-beta treatment in a patient with multiple sclerosis – A case report. Mult Scler Relat Disord 2016; 8:93-5. [PMID: 27456881 DOI: 10.1016/j.msard.2016.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/02/2016] [Accepted: 05/04/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Sara Maria Dalbjerg
- Department of Neurology, Glostrup Hospital, University of Copenhagen, Nordre Ringvej 57, 2600 Glostrup, Denmark.
| | - Anna Tsakiri
- Department of Neurology, Glostrup Hospital, University of Copenhagen, Nordre Ringvej 57, 2600 Glostrup, Denmark.
| | - Jette Lautrup Frederiksen
- Department of Neurology, Glostrup Hospital, University of Copenhagen, Nordre Ringvej 57, 2600 Glostrup, Denmark.
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