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Yong HYF, Batty NJ, Tottenham I, Koch M, Camara-Lemarroy CR. Soluble adhesion molecules: Cognitive worsening biomarkers in primary progressive multiple sclerosis? J Neuroimmunol 2024; 393:578384. [PMID: 38850673 DOI: 10.1016/j.jneuroim.2024.578384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/26/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Heather Y F Yong
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicholas J Batty
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Isabelle Tottenham
- Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcus Koch
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carlos R Camara-Lemarroy
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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2
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Oh J, Giacomini PS, Yong VW, Costello F, Blanchette F, Freedman MS. From progression to progress: The future of multiple sclerosis. J Cent Nerv Syst Dis 2024; 16:11795735241249693. [PMID: 38711957 PMCID: PMC11072059 DOI: 10.1177/11795735241249693] [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: 11/03/2023] [Accepted: 04/08/2024] [Indexed: 05/08/2024] Open
Abstract
Significant advances have been made in the diagnosis and treatment of multiple sclerosis in recent years yet challenges remain. The current classification of MS phenotypes according to disease activity and progression, for example, does not adequately reflect the underlying pathophysiological mechanisms that may be acting in an individual with MS at different time points. Thus, there is a need for clinicians to transition to a management approach based on the underlying pathophysiological mechanisms that drive disability in MS. A Canadian expert panel convened in January 2023 to discuss priorities for clinical discovery and scientific exploration that would help advance the field. Five key areas of focus included: identifying a mechanism-based disease classification system; developing biomarkers (imaging, fluid, digital) to identify pathologic processes; implementing a data-driven approach to integrate genetic/environmental risk factors, clinical findings, imaging and biomarker data, and patient-reported outcomes to better characterize the many factors associated with disability progression; utilizing precision-based treatment strategies to target different disease processes; and potentially preventing disease through Epstein-Barr virus (EBV) vaccination, counselling about environmental risk factors (e.g. obesity, exercise, vitamin D/sun exposure, smoking) and other measures. Many of the tools needed to meet these needs are currently available. Further work is required to validate emerging biomarkers and tailor treatment strategies to the needs of individual patients. The hope is that a more complete view of the individual's pathobiology will enable clinicians to usher in an era of truly personalized medicine, in which more informed treatment decisions throughout the disease course achieve better long-term outcomes.
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Affiliation(s)
- Jiwon Oh
- St. Michael’s Hospital, Toronto, ON, Canada
| | | | - V. Wee Yong
- University of Calgary and Hotchkiss Brain Institute, Calgary, Canada
| | - Fiona Costello
- University of Calgary and Hotchkiss Brain Institute, Calgary, Canada
| | | | - Mark S. Freedman
- Department of Medicine¸ University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, QC, Canada
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3
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Chataway J, Williams T, Li V, Marrie RA, Ontaneda D, Fox RJ. Clinical trials for progressive multiple sclerosis: progress, new lessons learned, and remaining challenges. Lancet Neurol 2024; 23:277-301. [PMID: 38365380 DOI: 10.1016/s1474-4422(24)00027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/04/2023] [Accepted: 01/12/2024] [Indexed: 02/18/2024]
Abstract
Despite the success of disease-modifying treatments in relapsing multiple sclerosis, for many individuals living with multiple sclerosis, progressive disability continues to accrue. How to interrupt the complex pathological processes underlying progression remains a daunting and ongoing challenge. Since 2014, several immunomodulatory approaches that have modest but clinically meaningful effects have been approved for the management of progressive multiple sclerosis, primarily for people who have active inflammatory disease. The approval of these drugs required large phase 3 trials that were sufficiently powered to detect meaningful effects on disability. New classes of drug, such as Bruton tyrosine-kinase inhibitors, are coming to the end of their trial stages, several candidate neuroprotective compounds have been successful in phase 2 trials, and innovative approaches to remyelination are now also being explored in clinical trials. Work continues to define intermediate outcomes that can provide results in phase 2 trials more quickly than disability measures, and more efficient trial designs, such as multi-arm multi-stage and futility approaches, are increasingly being used. Collaborations between patient organisations, pharmaceutical companies, and academic researchers will be crucial to ensure that future trials maintain this momentum and generate results that are relevant for people living with progressive multiple sclerosis.
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Affiliation(s)
- Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK; Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK.
| | - Thomas Williams
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Vivien Li
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Ruth Ann Marrie
- Departments of Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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4
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Baeva ME, Tottenham I, Koch M, Camara-Lemarroy C. Biomarkers of disability worsening in inactive primary progressive multiple sclerosis. J Neuroimmunol 2024; 387:578268. [PMID: 38157653 DOI: 10.1016/j.jneuroim.2023.578268] [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: 09/25/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To investigate serum biomarkers of progression in inactive primary progressive multiple sclerosis (PPMS). METHODS We measured protein biomarkers (growth differentiation factor-15 (GDF-15), dickkopf-1 (DKK-1), neuron specific enolase (NSE) and cathepsin-D) in serum samples from 39 patients with inactive PPMS included in a clinical trial enrolling people with PPMS (clinicaltrials.gov identifier NCT02913157) and investigated the association of these biomarker levels with clinical disability at baseline and during follow-up. We then performed a meta-analysis of publicly available transcriptomic datasets to investigate the gene expression of these biomarkers in the CNS in progressive MS. RESULTS When compared with healthy controls, people with PPMS had higher serum levels of GDF-15, DKK-1 and cathepsin-D at baseline. These findings match those in our meta-analysis which found increased expression of GDF-15 and cathepsin-D in the CNS in progressive MS. At baseline, elevated serum DKK-1 was associated with worse Expanded Disability Status Scale (EDSS) and nine-hole peg test (9HPT) scores. None of the other biomarkers levels significantly correlated with EDSS, Timed 25-Foot Walk Test (T25FWT), 9HPT, or cognitive measures. However, serum GDF-15 and cathepsin-D were higher at baseline in participants who developed worsening disability. Our receiver operating characteristic curve showed that higher serum GDF-15 and cathepsin-D at baseline significantly discriminated between participants who worsened in T25FWT and 9HPT and those who remained stable. CONCLUSIONS Patients with PPMS have altered levels of GDF-15, DKK-1 and cathepsin-D in serum, and GDF-15 and cathepsin-D may have predictive value in progression free of inflammatory activity in PPMS.
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Affiliation(s)
- Maria-Elizabeth Baeva
- Department of Clinical Neurosciences, University of Calgary, Canada; Hotchkiss Brain Institute, University of Calgary, Canada
| | - Isabelle Tottenham
- Department of Clinical Neurosciences, University of Calgary, Canada; Hotchkiss Brain Institute, University of Calgary, Canada
| | - Marcus Koch
- Department of Clinical Neurosciences, University of Calgary, Canada; Hotchkiss Brain Institute, University of Calgary, Canada
| | - Carlos Camara-Lemarroy
- Department of Clinical Neurosciences, University of Calgary, Canada; Hotchkiss Brain Institute, University of Calgary, Canada.
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5
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Carlson AK, Fox RJ. Pathophysiology, Diagnosis, Treatment and Emerging Neurotherapeutic Targets for Progressive Multiple Sclerosis: The Age of PIRA. Neurol Clin 2024; 42:39-54. [PMID: 37980122 DOI: 10.1016/j.ncl.2023.07.002] [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] [Indexed: 11/20/2023]
Abstract
More than one million individuals are impacted by progressive forms of multiple sclerosis. The literature examining the management of MS has focused primarily on relapsing forms of disease, and effective therapies targeting progressive mechanisms in MS remains a significant unmet need. Despite this, there are several encouraging potential therapeutics on the horizon. Improved understanding of mechanisms underlying MS progression, identification and validation of biomarkers, identification of novel therapeutic targets, and improved trial design are needed to further propel progress in the management of individuals with progressive forms of MS.
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Affiliation(s)
- Alise K Carlson
- Cleveland Clinic Mellen Center, 9500 Euclid Avenue U10, Cleveland, OH 44195, USA
| | - Robert J Fox
- Cleveland Clinic Mellen Center, 9500 Euclid Avenue U10, Cleveland, OH 44195, USA.
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6
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Raghib MF, Bernitsas E. From Animal Models to Clinical Trials: The Potential of Antimicrobials in Multiple Sclerosis Treatment. Biomedicines 2023; 11:3069. [PMID: 38002068 PMCID: PMC10668955 DOI: 10.3390/biomedicines11113069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/05/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, autoimmune, demyelinating disease of the central nervous system (CNS). Microbes, including bacteria and certain viruses, particularly Epstein-Barr virus (EBV), have been linked to the pathogenesis of MS. While there is currently no cure for MS, antibiotics and antivirals have been studied as potential treatment options due to their immunomodulatory ability that results in the regulation of the immune process. The current issue addressed in this systematic review is the effect of antimicrobials, including antibiotics, antivirals, and antiparasitic agents in animals and humans. We performed a comprehensive search of PubMed, Google Scholar, and Scopus for articles on antimicrobials in experimental autoimmune encephalomyelitis animal models of MS, as well as in people with MS (pwMS). In animal models, antibiotics tested included beta-lactams, minocycline, rapamycin, macrolides, and doxycycline. Antivirals included acyclovir, valacyclovir, and ganciclovir. Hydroxychloroquine was the only antiparasitic that was tested. In pwMS, we identified a total of 24 studies, 17 of them relevant to antibiotics, 6 to antivirals, and 1 relevant to antiparasitic hydroxychloroquine. While the effect of antimicrobials in animal models was promising, only minocycline and hydroxychloroquine improved outcome measures in pwMS. No favorable effect of the antivirals in humans has been observed yet. The number and size of clinical trials testing antimicrobials have been limited. Large, multicenter, well-designed studies are needed to further evaluate the effect of antimicrobials in MS.
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Affiliation(s)
- Muhammad Faraz Raghib
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI 48201, USA;
| | - Evanthia Bernitsas
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI 48201, USA;
- Sastry Neuroimaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, MI 48201, USA
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7
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Baeva ME, Camara-Lemarroy C. The role of autophagy protein Atg5 in multiple sclerosis. Mult Scler Relat Disord 2023; 79:105029. [PMID: 37778158 DOI: 10.1016/j.msard.2023.105029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/08/2023] [Accepted: 09/23/2023] [Indexed: 10/03/2023]
Abstract
Multiple sclerosis (MS) is a neurological disease which has a strong autoimmune component to its pathology. Although there are currently many approved immunomodulatory treatments that reduce the rate of relapse and slow down the progression of the disease, the cure is still elusive. This may be due to the underlying etiology still being unknown. Autophagy is the potential link between neurodegeneration and autoimmunity. Specifically, this review will focus on the autophagy protein Atg5 and examine the in vitro cell culture, animal and human studies that have examined its expression and effects in the context of MS. The findings of these investigations are summarized, and a model is proposed in which elevated Atg5 levels leads to dysfunctional autophagy, neurodegeneration, inflammation, and eventually clinical disability. While there are currently no drugs that specifically target Atg5, our review recommends that further investigations into the role that Atg5 plays in MS pathophysiology may eventually lead to the development of autophagy-specific treatments of MS.
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Affiliation(s)
- Maria-Elizabeth Baeva
- Department of Clinical Neurosciences, University of Calgary, Canada; Hotchkiss Brain Institute, University of Calgary, Canada.
| | - Carlos Camara-Lemarroy
- Department of Clinical Neurosciences, University of Calgary, Canada; Hotchkiss Brain Institute, University of Calgary, Canada
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8
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Zierfuss B, Wang Z, Jackson AN, Moezzi D, Yong VW. Iron in multiple sclerosis - Neuropathology, immunology, and real-world considerations. Mult Scler Relat Disord 2023; 78:104934. [PMID: 37579645 DOI: 10.1016/j.msard.2023.104934] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/30/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
Iron is an essential element involved in a multitude of bodily processes. It is tightly regulated, as elevated deposition in tissues is associated with diseases such as multiple sclerosis (MS). Iron accumulation in the central nervous system (CNS) of MS patients is linked to neurotoxicity through mechanisms including oxidative stress, glutamate excitotoxicity, misfolding of proteins, and ferroptosis. In the past decade, the combination of MRI and histopathology has enhanced our understanding of iron deposition in MS pathophysiology, including in the pro-inflammatory and neurotoxicity of iron-laden rims of chronic active lesions. In this regard, iron accumulation may not only have an impact on different CNS-resident cells but may also promote the innate and adaptive immune dysfunctions in MS. Although there are discordant results, most studies indicate lower levels of iron but higher amounts of the iron storage molecule ferritin in the circulation of people with MS. Considering the importance of iron, there is a need for evidence-guided recommendation for dietary intake in people living with MS. Potential novel therapeutic approaches include the regulation of iron levels using next generation iron chelators, as well as therapies to interfere with toxic consequences of iron overload including antioxidants in MS.
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Affiliation(s)
- Bettina Zierfuss
- The Research Center of the Centre Hospitalier de l'Université de Montréal (CRCHUM), Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal H2X 0A9, Québec, Canada
| | - Zitong Wang
- Department of Psychiatry, College of Health Sciences, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta T6G 2B7, Canada
| | - Alexandra N Jackson
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - Dorsa Moezzi
- The Hotchkiss Brain Institute and the Department of Clinical Neurosciences, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta T2N 4N1, Canada
| | - V Wee Yong
- The Hotchkiss Brain Institute and the Department of Clinical Neurosciences, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta T2N 4N1, Canada.
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9
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Marrie RA, Sormani MP, Apap Mangion S, Bovis F, Cheung WY, Cutter GR, Feys P, Hill MD, Koch MW, McCreary M, Mowry EM, Park JJH, Piehl F, Salter A, Chataway J. Improving the efficiency of clinical trials in multiple sclerosis. Mult Scler 2023; 29:1136-1148. [PMID: 37555492 PMCID: PMC10413792 DOI: 10.1177/13524585231189671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Phase 3 clinical trials for disease-modifying therapies in relapsing-remitting multiple sclerosis (RRMS) have utilized a limited number of conventional designs with a high degree of success. However, these designs limit the types of questions that can be addressed, and the time and cost required. Moreover, trials involving people with progressive multiple sclerosis (MS) have been less successful. OBJECTIVE The objective of this paper is to discuss complex innovative trial designs, intermediate and composite outcomes and to improve the efficiency of trial design in MS and broaden questions that can be addressed, particularly as applied to progressive MS. METHODS We held an international workshop with experts in clinical trial design. RESULTS Recommendations include increasing the use of complex innovative designs, developing biomarkers to enrich progressive MS trial populations, prioritize intermediate outcomes for further development that target therapeutic mechanisms of action other than peripherally mediated inflammation, investigate acceptability to people with MS of data linkage for studying long-term outcomes of clinical trials, use Bayesian designs to potentially reduce sample sizes required for pediatric trials, and provide sustained funding for platform trials and registries that can support pragmatic trials. CONCLUSION Novel trial designs and further development of intermediate outcomes may improve clinical trial efficiency in MS and address novel therapeutic questions.
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Affiliation(s)
- Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sean Apap Mangion
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Francesca Bovis
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Winson Y Cheung
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Feys
- REVAL Rehabilitation Research Center, REVAL, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium/Universitair MS Centrum, UMSC, Hasselt, Belgium
| | - Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine, and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marcus Werner Koch
- Departments of Clinical Neurosciences, Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Morgan McCreary
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jay JH Park
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Amber Salter
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK/Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
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10
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Hydroxychloroquine lowers Alzheimer's disease and related dementias risk and rescues molecular phenotypes related to Alzheimer's disease. Mol Psychiatry 2023; 28:1312-1326. [PMID: 36577843 PMCID: PMC10005941 DOI: 10.1038/s41380-022-01912-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/29/2022]
Abstract
We recently nominated cytokine signaling through the Janus-kinase-signal transducer and activator of transcription (JAK/STAT) pathway as a potential AD drug target. As hydroxychloroquine (HCQ) has recently been shown to inactivate STAT3, we hypothesized that it may impact AD pathogenesis and risk. Among 109,124 rheumatoid arthritis patients from routine clinical care, HCQ initiation was associated with a lower risk of incident AD compared to methotrexate initiation across 4 alternative analyses schemes addressing specific types of biases including informative censoring, reverse causality, and outcome misclassification (hazard ratio [95% confidence interval] of 0.92 [0.83-1.00], 0.87 [0.81-0.93], 0.84 [0.76-0.93], and 0.87 [0.75-1.01]). We additionally show that HCQ exerts dose-dependent effects on late long-term potentiation (LTP) and rescues impaired hippocampal synaptic plasticity prior to significant accumulation of amyloid plaques and neurodegeneration in APP/PS1 mice. Additionally, HCQ treatment enhances microglial clearance of Aβ1-42, lowers neuroinflammation, and reduces tau phosphorylation in cell culture-based phenotypic assays. Finally, we show that HCQ inactivates STAT3 in microglia, neurons, and astrocytes suggesting a plausible mechanism associated with its observed effects on AD pathogenesis. HCQ, a relatively safe and inexpensive drug in current use may be a promising disease-modifying AD treatment. This hypothesis merits testing through adequately powered clinical trials in at-risk individuals during preclinical stages of disease progression.
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11
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Camara-Lemarroy C, Silva C, Gohill J, Yong VW, Koch M. Serum neurofilament-light and glial fibrillary acidic protein levels in hydroxychloroquine-treated primary progressive multiple sclerosis. Eur J Neurol 2023; 30:187-194. [PMID: 36214614 DOI: 10.1111/ene.15588] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/02/2022] [Accepted: 09/29/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In a recent trial, hydroxychloroquine (HCQ) treatment reduced the expected rate of disability worsening at 18 months in primary progressive multiple sclerosis (PPMS). Neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) are emerging biomarkers in multiple sclerosis. METHODS We measured NfL and GFAP levels in serum samples from 39 patients with inactive PPMS included in a phase II clinical trial of HCQ treatment in PPMS at multiple time points over 18 months, and investigated the association of these biomarkers with clinical disability at screening and during follow-up. Screening and 12-month retinal nerve fiber layer (RNFL) thickness was also recorded and analyzed. RESULTS NfL and GFAP levels increased over time, but only significantly from screening to month 6. NfL and GFAP levels did not significantly increase from month 6 up to month 18. At screening, NfL and GFAP levels did not correlate with the Expanded Disability Status Scale (EDSS), and GFAP but not NfL modestly correlated with Timed 25-Foot Walk test (T25FW). Screening NfL and GFAP levels did not predict disability worsening (≥20% worsening on the T25FW) at month 18. RNFL thickness decreased significantly from screening to month 12 and independently predicted disability worsening. CONCLUSIONS In this cohort of people with inactive PPMS, HCQ treatment attenuated the increase of NfL and GFAP after 6 months of treatment and up to 18 months of follow-up, suggesting a treatment effect of HCQ over these biomarkers. RNFL thickness, a marker of neuroaxonal atrophy, was associated with disability worsening, and should be explored further as a prognostic marker in this population.
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Affiliation(s)
- Carlos Camara-Lemarroy
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,UANL School of Medicine, Monterrey, Mexico
| | - Claudia Silva
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jit Gohill
- Section of Ophthalmology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - V Wee Yong
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Marcus Koch
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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12
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Yong VW. Microglia in multiple sclerosis: Protectors turn destroyers. Neuron 2022; 110:3534-3548. [PMID: 35882229 DOI: 10.1016/j.neuron.2022.06.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022]
Abstract
Microglia are implicated in all stages of multiple sclerosis (MS). Microglia alterations are detected by positron emission tomography in people living with MS prior to the formation of structural lesions determined through magnetic resonance imaging. In histological specimens, clusters of microglia form in normal-appearing tissue likely predating the development of lesions. Features of degeneration-associated/pro-inflammatory states of microglia increase with chronicity of MS. However, microglia play many beneficial roles including the removal of neurotoxins and in fostering repair. The protector-gone-rogue microglia in MS is featured herein. We consider mechanisms of microglia neurotoxicity and discuss factors, including aging, osteopontin, and iron metabolism, that cause microglia to lose their protective states and become injurious. We evaluate medications to affect microglia in MS, such as the emerging class of Bruton's tyrosine kinase inhibitors. The framework of microglia-turned-destroyers may instigate new approaches to counter microglia-driven neurodegeneration in MS.
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Affiliation(s)
- V Wee Yong
- Hotchkiss Brain Institute and the Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.
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13
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Abstract
Purpose of Review COVID-19 has posed a continuously evolving challenge for providers caring for patients with multiple sclerosis (MS). While guidelines from national and international organizations came quickly, these have required constant reassessment and modification as the pandemic has progressed. This review aims to assess the first 2 years of literature on COVID-19 relevant to the clinical management of patients with MS. In particular, we will review how MS impacts the risk of COVID-19 infection, how disease-modifying therapies may alter this risk, and explore considerations regarding disease-modifying therapy (DMT) and vaccination for COVID-19. We will also explore potential ways in which a COVID-19 infection may impact multiple sclerosis. Our goal is to provide an overarching review of the major findings at this stage of the pandemic relevant to those that care for patients with MS. Recent Findings Over the course of the COVID-19 pandemic, providers have had to re-evaluate the priorities in the management of MS. A growing number of studies have evaluated the relevant risk factors and considerations regarding MS and particular disease-modifying therapies. Summary The long-term impacts of the pandemic on the health of those with MS will continue to be revealed. In general, most patients with MS do not need major revisions to their treatment plan due to COVID-19 risk. However, individuals who are older, more disabled, and on more potent therapies may need to consider strategies for decreasing their overall risk. Regardless, continued improvement in our understanding of interactions between infections, disease-modifying therapy, and MS are paramount to optimizing the care of those with MS going forward.
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Abstract
PURPOSE OF REVIEW Microglia normally protects the central nervous system (CNS) against insults. However, their persistent activation in multiple sclerosis (MS) contributes to injury. Here, we review microglia activation in MS and their detection using positron emission tomography (PET). RECENT FINDINGS During lesion evolution and the progression of MS, microglia activity may contribute to neurotoxicity through the release of pro-inflammatory cytokines, reactive oxidative species, proteases and glutamate. A means to detect and monitor microglia activation in individuals living with MS is provided by positron emission tomography (PET) imaging using the mitochondrial 18-kDa translocator protein (TSPO) ligand. TSPO PET imaging shows increased microglial activation within the normal appearing white matter that precedes radiological signs of neurodegeneration measured by T2 lesion enlargement. PET-detected microglia activation increases with progression of MS. These findings demand the use of CNS penetrant inhibitors that affect microglia. Such therapies may include hydroxychloroquine that is recently reported in a small study to reduce the expected progression in primary progressive MS, and Bruton's tyrosine kinase inhibitors for which there are now eleven Phase 3 registered trials in MS. SUMMARY Microglial activation drives injury in MS. PET imaging with microglia-specific ligands offer new insights into progression of MS and as a monitor for treatment responses.
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The timed 25-foot walk is a more sensitive outcome measure than the EDSS for PPMS trials: an analysis of the PROMISE clinical trial dataset. J Neurol 2022; 269:5319-5327. [DOI: 10.1007/s00415-022-11171-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/29/2022] [Accepted: 05/01/2022] [Indexed: 10/18/2022]
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Combined drug triads for synergic neuroprotection in retinal degeneration. Biomed Pharmacother 2022; 149:112911. [DOI: 10.1016/j.biopha.2022.112911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
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Hu Y, Li Z, Chen G, Li Z, Huang J, Huang H, Xie Y, Chen Q, Zhu W, Wang M, Chen J, Su W, Chen X, Liang D. Hydroxychloroquine Alleviates EAU by Inhibiting Uveitogenic T Cells and Ameliorating Retinal Vascular Endothelial Cells Dysfunction. Front Immunol 2022; 13:859260. [PMID: 35401507 PMCID: PMC8989724 DOI: 10.3389/fimmu.2022.859260] [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: 01/21/2022] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Inflammation triggers the activation of CD4+T cells and the breakdown of blood–retinal barrier, thus contributing to the pathology of experimental autoimmune uveitis (EAU). We explored the anti-inflammatory effect of hydroxychloroquine (HCQ) on EAU and the potential mechanisms active in T cells and retinal vascular endothelial cells (RVECs). Methods C57BL/6J mice were immunized with interphotoreceptor retinoid binding protein 1-20 (IRBP1–20) to induce EAU and then treated with the vehicle or HCQ (100 mg/kg/day). On day 7, 14, 21, 30 and 60 after immunization, clinical scores were evaluated. On day 14, histopathological scores were assessed, and retinas, spleens, and lymph nodes were collected for quantitative polymerase chain reaction or flow cytometry analysis. RVEC dysfunction was induced by tumor necrosis factor α (TNF-α) stimulation. The expression of cytokines, chemokines, adhesion molecules, and lectin-like oxidized LDL receptor-1 (LOX-1)/nuclear factor κB (NF-κB) was measured in RVECs with or without HCQ. Results HCQ treatment protected mice from uveitis, evidenced by reduced expression of inflammatory factors, chemokines, and adhesion molecules in the retina. In systemic immune response, HCQ inhibited the activation of naïve CD4+T cells and frequencies of T effector cells, and promoted T regulatory cells. HCQ decreased IRBP1-20–specific T cell responses and proliferation of CD4+T cells in vitro. Further studies established that TNF-α induced RVECs to express inflammatory cytokines, chemokines, and adhesion molecules, whereas HCQ alleviated the alterations via the LOX-1/NF-κB pathways. Conclusions HCQ alleviates EAU by regulating the Teff/Treg balance and ameliorating RVECs dysfunction via the LOX-1/NF-κB axis. HCQ may be a promising therapeutic candidate for uveitis.
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Affiliation(s)
- Yunwei Hu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Zuoyi Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Guanyu Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Zhuang Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Jun Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Haixiang Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Yanyan Xie
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Qian Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Wenjie Zhu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Minzhen Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Jianping Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Wenru Su
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Xiaoqing Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Dan Liang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
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Fan W, Huang W, Chen J, Li N, Mao L, Hou S. Retinal microglia: Functions and diseases. Immunology 2022; 166:268-286. [PMID: 35403700 DOI: 10.1111/imm.13479] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/26/2022] [Accepted: 02/22/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Wei Fan
- The First Affiliated Hospital of Chongqing Medical University Chongqing China
- Chongqing Key Laboratory of Ophthalmology Chongqing China
- Chongqing Eye Institute Chongqing China
- Chongqing Branch of National Clinical Research Center for Ocular Diseases Chongqing China
| | - Weidi Huang
- The First Affiliated Hospital of Chongqing Medical University Chongqing China
- Department of Ophthalmology, Second Xiangya Hospital Central South University Changsha Hunan China
| | - Jiayi Chen
- The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Na Li
- College of Basic Medicine Chongqing Medical University Chongqing China
| | - Liming Mao
- Department of Immunology School of Medicine, Nantong University, 19 Qixiu Road Nantong Jiangsu China
| | - Shengping Hou
- The First Affiliated Hospital of Chongqing Medical University Chongqing China
- Chongqing Key Laboratory of Ophthalmology Chongqing China
- Chongqing Eye Institute Chongqing China
- Chongqing Branch of National Clinical Research Center for Ocular Diseases Chongqing China
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The central vein sign helps in differentiating multiple sclerosis from its mimickers: lessons from Fabry disease. Eur Radiol 2022; 32:3846-3854. [PMID: 35029733 DOI: 10.1007/s00330-021-08487-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/26/2021] [Accepted: 11/28/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Although the use of specific MRI criteria has significantly increased the diagnostic accuracy of multiple sclerosis (MS), reaching a correct neuroradiological diagnosis remains a challenging task, and therefore the search for new imaging biomarkers is crucial. This study aims to evaluate the incidence of one of the emerging neuroradiological signs highly suggestive of MS, the central vein sign (CVS), using data from Fabry disease (FD) patients as an index of microvascular disorder that could mimic MS. METHODS In this retrospective study, after the application of inclusion and exclusion criteria, MRI scans of 36 FD patients and 73 relapsing-remitting (RR) MS patients were evaluated. Among the RRMS participants, 32 subjects with a disease duration inferior to 5 years (early MS) were also analyzed. For all subjects, a Fazekas score (FS) was recorded, excluding patients with FS = 0. Different neuroradiological signs, including CVS, were evaluated on FLAIR T2-weighted and spoiled gradient recalled echo sequences. RESULTS Among all the recorded neuroradiological signs, the most striking difference was found for the CVS, with a detectable prevalence of 78.1% (57/73) in RRMS and of 71.4% (25/32) in early MS patients, while this sign was absent in FD (0/36). CONCLUSIONS Our results confirm the high incidence of CVS in MS, also in the early phases of the disease, while it seems to be absent in conditions with a different etiology. These results corroborate the possible role of CVS as a useful neuroradiological sign highly suggestive of MS. KEY POINTS • The search for new imaging biomarkers is crucial to achieve a correct neuroradiological diagnosis of MS. • The CVS shows an incidence superior to 70% in MS patients, even in the early phases of the disease, while it appears to be absent in FD. • These findings further corroborate the possible future central role of CVS in distinguishing between MS and its mimickers.
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Mechanism-based criteria to improve therapeutic outcomes in progressive multiple sclerosis. Nat Rev Neurol 2021; 18:40-55. [PMID: 34732831 DOI: 10.1038/s41582-021-00581-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 02/07/2023]
Abstract
In contrast to the multiple disease-modifying therapies that are available for relapsing-remitting multiple sclerosis (MS), the therapeutic options for progressive MS (PMS) are limited. Recent advances in our understanding of the neuroimmunology of PMS, including the mechanisms that drive slowly expanding lesions, have fuelled optimism for improved treatment of this condition. In this Review, we highlight the commonly observed neuropathology of PMS and discuss the associated mechanisms of CNS injury. We then apply this knowledge to formulate criteria for therapeutic efficacy in PMS, beginning with the need for early treatment owing to the substantial neuropathology that is already present at the initial clinical presentation. Other requirements include: antagonism of neuroaxonal injury mediators such as pro-inflammatory microglia and lymphocytes; remediation of oxidative stress resulting from iron deposition and mitochondrial dysfunction; and promotion of neuroprotection through remyelination. We consider whether current disease-modifying therapies for relapsing-remitting MS meet the criteria for successful therapeutics in PMS and suggest that the evidence favours the early introduction of sphingosine 1-phosphate receptor modulators. Finally, we weigh up emerging medications, including repurposed generic medications and Bruton's tyrosine kinase inhibitors, against these fundamental criteria. In this new therapeutic era in PMS, success depends collectively on understanding disease mechanisms, drug characteristics (including brain penetration) and rational use.
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