1
|
Coerver EM, Kaçar S, Ciccarelli O, Sormani MP, Barkhof F, Arnold DL, Schoonheim MM, Van Kempen ZLE, Mostert J, Koch MW, Killestein J, Eshaghi A, Uitdehaag BM, Strijbis EM. Aging is associated with reduced inflammatory disease activity independent of disease duration in relapsing multiple sclerosis trial populations. Mult Scler 2024; 30:1296-1308. [PMID: 39245991 DOI: 10.1177/13524585241272938] [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: 09/10/2024]
Abstract
BACKGROUND Higher age is associated with less inflammatory disease activity in relapsing-remitting multiple sclerosis (RRMS). It is unknown whether age itself or disease duration underlies this association. OBJECTIVES This study investigated the effects of age, disease duration, and inflammatory disease activity in people with RRMS. METHODS Individual patient-level data from five large phase III randomized controlled trials (RCTs) was utilized to investigate the association of both age and disease duration with annualized relapse rate (ARR), contrast-enhancing lesions (CELs), and new T2 lesions on magnetic resonance imaging (MRI) at baseline and follow-up. RESULTS The data set included 5626 participants. Higher age was associated with lower ARRs, lower CEL number on MRI at baseline and follow-up, and lower new T2 lesion numbers at follow-up. This effect was present in all disease duration groups. For example, we found a lower number of new T2 lesions on MRI during follow-up in higher age groups compared to lower age groups, independent of disease duration. CONCLUSION Aging in RRMS is associated with a lower risk of inflammatory disease activity, across different disease durations. Age should be taken into account when designing clinical trials and future research should investigate how age should be integrated into personalized predictions of treatment response and risk profiling.
Collapse
Affiliation(s)
- Eline Me Coerver
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Sezgi Kaçar
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Olga Ciccarelli
- 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 and Care Research (NIHR) University College London Hospitals (UCLH) Biomedical Research Centre, London, UK
| | - Maria P Sormani
- Department of Health Sciences (DISSAL), University of Genova, Genova, Italy; Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Frederik Barkhof
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Queen Square Institute of Neurology and Centre for Medical Image Computing, University College London, London, UK
- MS Center Amsterdam, Department of Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VU medical center, Amsterdam, The Netherlands
| | - Douglas L Arnold
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- NeuroRx Research and Montreal Neurological Institute, McGill University, Montreal, QC, Canada
- Montreal Neurological Institute, McConnell Brain Imaging Centre, McGill University, Montreal, QC, Canada
| | - Menno M Schoonheim
- MS Center Amsterdam, Anatomy and Neuroscience, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VU medical center, Amsterdam, The Netherlands
| | - Zoé LE Van Kempen
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Jop Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Marcus W Koch
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Joep Killestein
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Arman Eshaghi
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Queen Square Institute of Neurology and Centre for Medical Image Computing, University College London, London, UK
| | - Bernard Mj Uitdehaag
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Eva Mm Strijbis
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Gonzalez-Lorenzo M, Ridley B, Minozzi S, Del Giovane C, Peryer G, Piggott T, Foschi M, Filippini G, Tramacere I, Baldin E, Nonino F. Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD011381. [PMID: 38174776 PMCID: PMC10765473 DOI: 10.1002/14651858.cd011381.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Different therapeutic strategies are available for the treatment of people with relapsing-remitting multiple sclerosis (RRMS), including immunomodulators, immunosuppressants and biological agents. Although each one of these therapies reduces relapse frequency and slows disability accumulation compared to no treatment, their relative benefit remains unclear. This is an update of a Cochrane review published in 2015. OBJECTIVES To compare the efficacy and safety, through network meta-analysis, of interferon beta-1b, interferon beta-1a, glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab, pegylated interferon beta-1a, daclizumab, laquinimod, azathioprine, immunoglobulins, cladribine, cyclophosphamide, diroximel fumarate, fludarabine, interferon beta 1-a and beta 1-b, leflunomide, methotrexate, minocycline, mycophenolate mofetil, ofatumumab, ozanimod, ponesimod, rituximab, siponimod and steroids for the treatment of people with RRMS. SEARCH METHODS CENTRAL, MEDLINE, Embase, and two trials registers were searched on 21 September 2021 together with reference checking, citation searching and contact with study authors to identify additional studies. A top-up search was conducted on 8 August 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) that studied one or more of the available immunomodulators and immunosuppressants as monotherapy in comparison to placebo or to another active agent, in adults with RRMS. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data. We considered both direct and indirect evidence and performed data synthesis by pairwise and network meta-analysis. Certainty of the evidence was assessed by the GRADE approach. MAIN RESULTS We included 50 studies involving 36,541 participants (68.6% female and 31.4% male). Median treatment duration was 24 months, and 25 (50%) studies were placebo-controlled. Considering the risk of bias, the most frequent concern was related to the role of the sponsor in the authorship of the study report or in data management and analysis, for which we judged 68% of the studies were at high risk of other bias. The other frequent concerns were performance bias (34% judged as having high risk) and attrition bias (32% judged as having high risk). Placebo was used as the common comparator for network analysis. Relapses over 12 months: data were provided in 18 studies (9310 participants). Natalizumab results in a large reduction of people with relapses at 12 months (RR 0.52, 95% CI 0.43 to 0.63; high-certainty evidence). Fingolimod (RR 0.48, 95% CI 0.39 to 0.57; moderate-certainty evidence), daclizumab (RR 0.55, 95% CI 0.42 to 0.73; moderate-certainty evidence), and immunoglobulins (RR 0.60, 95% CI 0.47 to 0.79; moderate-certainty evidence) probably result in a large reduction of people with relapses at 12 months. Relapses over 24 months: data were reported in 28 studies (19,869 participants). Cladribine (RR 0.53, 95% CI 0.44 to 0.64; high-certainty evidence), alemtuzumab (RR 0.57, 95% CI 0.47 to 0.68; high-certainty evidence) and natalizumab (RR 0.56, 95% CI 0.48 to 0.65; high-certainty evidence) result in a large decrease of people with relapses at 24 months. Fingolimod (RR 0.54, 95% CI 0.48 to 0.60; moderate-certainty evidence), dimethyl fumarate (RR 0.62, 95% CI 0.55 to 0.70; moderate-certainty evidence), and ponesimod (RR 0.58, 95% CI 0.48 to 0.70; moderate-certainty evidence) probably result in a large decrease of people with relapses at 24 months. Glatiramer acetate (RR 0.84, 95%, CI 0.76 to 0.93; moderate-certainty evidence) and interferon beta-1a (Avonex, Rebif) (RR 0.84, 95% CI 0.78 to 0.91; moderate-certainty evidence) probably moderately decrease people with relapses at 24 months. Relapses over 36 months findings were available from five studies (3087 participants). None of the treatments assessed showed moderate- or high-certainty evidence compared to placebo. Disability worsening over 24 months was assessed in 31 studies (24,303 participants). Natalizumab probably results in a large reduction of disability worsening (RR 0.59, 95% CI 0.46 to 0.75; moderate-certainty evidence) at 24 months. Disability worsening over 36 months was assessed in three studies (2684 participants) but none of the studies used placebo as the comparator. Treatment discontinuation due to adverse events data were available from 43 studies (35,410 participants). Alemtuzumab probably results in a slight reduction of treatment discontinuation due to adverse events (OR 0.39, 95% CI 0.19 to 0.79; moderate-certainty evidence). Daclizumab (OR 2.55, 95% CI 1.40 to 4.63; moderate-certainty evidence), fingolimod (OR 1.84, 95% CI 1.31 to 2.57; moderate-certainty evidence), teriflunomide (OR 1.82, 95% CI 1.19 to 2.79; moderate-certainty evidence), interferon beta-1a (OR 1.48, 95% CI 0.99 to 2.20; moderate-certainty evidence), laquinimod (OR 1.49, 95 % CI 1.00 to 2.15; moderate-certainty evidence), natalizumab (OR 1.57, 95% CI 0.81 to 3.05), and glatiramer acetate (OR 1.48, 95% CI 1.01 to 2.14; moderate-certainty evidence) probably result in a slight increase in the number of people who discontinue treatment due to adverse events. Serious adverse events (SAEs) were reported in 35 studies (33,998 participants). There was probably a trivial reduction in SAEs amongst people with RRMS treated with interferon beta-1b as compared to placebo (OR 0.92, 95% CI 0.55 to 1.54; moderate-certainty evidence). AUTHORS' CONCLUSIONS We are highly confident that, compared to placebo, two-year treatment with natalizumab, cladribine, or alemtuzumab decreases relapses more than with other DMTs. We are moderately confident that a two-year treatment with natalizumab may slow disability progression. Compared to those on placebo, people with RRMS treated with most of the assessed DMTs showed a higher frequency of treatment discontinuation due to AEs: we are moderately confident that this could happen with fingolimod, teriflunomide, interferon beta-1a, laquinimod, natalizumab and daclizumab, while our certainty with other DMTs is lower. We are also moderately certain that treatment with alemtuzumab is associated with fewer discontinuations due to adverse events than placebo, and moderately certain that interferon beta-1b probably results in a slight reduction in people who experience serious adverse events, but our certainty with regard to other DMTs is lower. Insufficient evidence is available to evaluate the efficacy and safety of DMTs in a longer term than two years, and this is a relevant issue for a chronic condition like MS that develops over decades. More than half of the included studies were sponsored by pharmaceutical companies and this may have influenced their results. Further studies should focus on direct comparison between active agents, with follow-up of at least three years, and assess other patient-relevant outcomes, such as quality of life and cognitive status, with particular focus on the impact of sex/gender on treatment effects.
Collapse
Affiliation(s)
- Marien Gonzalez-Lorenzo
- Laboratorio di Metodologia delle revisioni sistematiche e produzione di Linee Guida, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ben Ridley
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Cochrane Italy, Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Guy Peryer
- School of Health Sciences, University of East Anglia (UEA), Norwich, UK
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, Queens University, Kingston, Ontario, Canada
| | - Matteo Foschi
- Department of Neuroscience, Multiple Sclerosis Center - Neurology Unit, S.Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| |
Collapse
|
3
|
Strijbis EM, Coerver E, Mostert J, van Kempen ZLE, Killestein J, Comtois J, Repovic P, Bowen JD, Cutter G, Koch M. Association of age and inflammatory disease activity in the pivotal natalizumab clinical trials in relapsing-remitting multiple sclerosis. J Neurol Neurosurg Psychiatry 2023; 94:792-799. [PMID: 37173129 DOI: 10.1136/jnnp-2022-330887] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Focal inflammatory disease activity in relapsing-remitting multiple sclerosis (RRMS) diminishes with increasing age. Here we use patient-level data from randomised controlled trials (RCTs) of natalizumab treatment in RRMS to investigate the association of age and inflammatory disease activity. METHODS We used patient-level data from the AFFIRM (natalizumab vs placebo in relapsing-remitting MS, NCT00027300) and SENTINEL (natalizumab plus interferon beta vs interferon beta in relapsing remitting MS, NCT00030966) RCTs. We determined the proportion of participants developing new T2 lesions, contrast-enhancing lesions (CELs) and relapses over 2 years of follow-up as a function of age, and investigated the association of age with time to first relapse using time-to-event analyses. RESULTS At baseline, there were no differences between age groups in T2 lesion volume and number of relapses in the year before inclusion. In SENTINEL, older participants had a significantly lower number of CELs. During both trials, the number of new CELs and the proportion of participants developing new CELs were significantly lower in older age groups. The number of new T2 lesions and the proportion of participants with any radiological disease activity during follow-up were also lower in older age groups, especially in the control arms. CONCLUSIONS Older age is associated with a lower prevalence and degree of focal inflammatory disease activity in treated and untreated RRMS. Our findings inform the design of RCTs, and suggest that patient age should be taken into consideration when deciding on immunomodulatory treatment in RRMS.
Collapse
Affiliation(s)
- Eva M Strijbis
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Eline Coerver
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jop Mostert
- Department of Neurology, Rijnstate Hospital Arnhem, Arnhem, The Netherlands
| | - Zoé L E van Kempen
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jacynthe Comtois
- Department of Medicine, Neurology service, Maisonneuve-Rosemont Hospital, Montreal, Québec, Canada
| | - Pavle Repovic
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - James D Bowen
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Marcus Koch
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
4
|
Coerver E, Janssens S, Ahmed A, Wessels M, van Kempen Z, Jasperse B, Barkhof F, Koch M, Mostert J, Uitdehaag B, Killestein J, Strijbis E. Association between age and inflammatory disease activity on magnetic resonance imaging in relapse onset multiple sclerosis during long-term follow-up. Eur J Neurol 2023; 30:2385-2392. [PMID: 37170817 DOI: 10.1111/ene.15862] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/28/2023] [Accepted: 05/09/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND PURPOSE Inflammatory disease activity in multiple sclerosis (MS) decreases with advancing age. Previous work found a decrease in contrast-enhancing lesions (CELs) with age. Here, we describe the relation of age and magnetic resonance imaging (MRI) measures of inflammatory disease activity during long-term follow-up in a large real-world cohort of people with relapse onset MS. METHODS We investigated MRI data from the long-term observational Amsterdam MS cohort. We used logistic regression models and negative binomial generalized estimating equations to investigate the associations between age and radiological disease activity after a first clinical event. RESULTS We included 1063 participants and 10,651 cranial MRIs. Median follow-up time was 6.1 years (interquartile range = 2.4-10.9 years). Older participants had a significantly lower risk of CELs on baseline MRI (40-50 years vs. <40 years: odds ratio [OR] = 0.640, 95% confidence interval [CI] = 0.45-0.90; >50 years vs. <40 years: OR = 0.601, 95% CI = 0.33-1.08) and a lower risk of new T2 lesions or CELs during follow-up (40-50 years vs. <40 years: OR = 0.563, 95% CI = 0.47-0.67; >50 years vs. <40 years: OR = 0.486, 95% CI = 0.35-0.68). CONCLUSIONS Greater age is associated with a lower risk of inflammatory MRI activity at baseline and during long-term follow-up. In patients aged >50 years, a less aggressive treatment strategy might be appropriate compared to younger patients.
Collapse
Affiliation(s)
- Eline Coerver
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
| | - Sophie Janssens
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
| | - Aroosa Ahmed
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
| | - Mark Wessels
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
| | - Zoé van Kempen
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
| | - Bas Jasperse
- MS Center Amsterdam, Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
| | - Frederik Barkhof
- MS Center Amsterdam, Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
- Queen Square Institute of Neurology and Centre for Medical Image Computing, University College London, London, UK
| | - Marcus Koch
- Departments of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jop Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Bernard Uitdehaag
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
| | - Joep Killestein
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
| | - Eva Strijbis
- MS Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC location VUmc, Amsterdam, The Netherlands, Amsterdam, the Netherlands
| |
Collapse
|
5
|
Mela V, Sayd Gaban A, O’Neill E, Bechet S, Walsh A, Lynch MA. The Modulatory Effects of DMF on Microglia in Aged Mice Are Sex-Specific. Cells 2022; 11:cells11040729. [PMID: 35203379 PMCID: PMC8870377 DOI: 10.3390/cells11040729] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/08/2022] [Accepted: 02/16/2022] [Indexed: 02/01/2023] Open
Abstract
There is a striking sex-related difference in the prevalence of many neurodegenerative diseases, highlighting the need to consider whether treatments may exert sex-specific effects. A change in microglial activation state is a common feature of several neurodegenerative diseases and is considered to be a key factor in driving the inflammation that characterizes these conditions. Among the changes that have been described is a switch in microglial metabolism towards glycolysis which is associated with production of inflammatory mediators and reduced function. Marked sex-related differences in microglial number, phenotype and function have been described in late embryonic and early postnatal life in rodents and some reports suggest that sexual dimorphism extends into adulthood and age and, in models of Alzheimer’s disease, the changes are more profound in microglia from female, compared with male, mice. Dimethyl fumarate (DMF) is a fumaric acid ester used in the treatment of psoriasis and relapsing remitting multiple sclerosis and, while its mechanism of action is unclear, it possesses anti-inflammatory and anti-oxidant properties and also impacts on cell metabolism. Here we treated 16–18-month-old female and male mice with DMF for 1 month and assessed its effect on microglia. The evidence indicates that it exerted sex-specific effects on microglial morphology and metabolism, reducing glycolysis only in microglia from female mice. The data suggest that this may result from its ability to inactivate glyceraldehyde-3-phosphate dehydrogenase (GAPDH).
Collapse
Affiliation(s)
- Virginia Mela
- Department of Medicine and Dermatology, Faculty of Medicine, University of Malaga, 29010 Malaga, Spain;
| | - Aline Sayd Gaban
- Trinity College Institute of Neuroscience, Trinity College Dublin, D02 DK07 Dublin, Ireland; (A.S.G.); (E.O.); (S.B.); (A.W.)
| | - Eoin O’Neill
- Trinity College Institute of Neuroscience, Trinity College Dublin, D02 DK07 Dublin, Ireland; (A.S.G.); (E.O.); (S.B.); (A.W.)
| | - Sibylle Bechet
- Trinity College Institute of Neuroscience, Trinity College Dublin, D02 DK07 Dublin, Ireland; (A.S.G.); (E.O.); (S.B.); (A.W.)
| | - Aífe Walsh
- Trinity College Institute of Neuroscience, Trinity College Dublin, D02 DK07 Dublin, Ireland; (A.S.G.); (E.O.); (S.B.); (A.W.)
| | - Marina A. Lynch
- Trinity College Institute of Neuroscience, Trinity College Dublin, D02 DK07 Dublin, Ireland; (A.S.G.); (E.O.); (S.B.); (A.W.)
- Correspondence:
| |
Collapse
|
6
|
Rahiman N, Mohammadi M, Alavizadeh SH, Arabi L, Badiee A, Jaafari MR. Recent advancements in nanoparticle-mediated approaches for restoration of multiple sclerosis. J Control Release 2022; 343:620-644. [PMID: 35176392 DOI: 10.1016/j.jconrel.2022.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/07/2022] [Indexed: 12/18/2022]
Abstract
Multiple Sclerosis (MS) is an autoimmune disease with complicated immunopathology which necessitates considering multifactorial aspects for its management. Nano-sized pharmaceutical carriers named nanoparticles (NPs) can support impressive management of disease not only in early detection and prognosis level but also in a therapeutic manner. The most prominent initiator of MS is the domination of cellular immunity to humoral immunity and increment of inflammatory cytokines. The administration of several platforms of NPs for MS management holds great promise so far. The efforts for MS management through in vitro and in vivo (experimental animal models) evaluations, pave a new way to a highly efficient therapeutic means and aiding its translation to the clinic in the near future.
Collapse
Affiliation(s)
- Niloufar Rahiman
- Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutical Nanotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Marzieh Mohammadi
- Department of pharmaceutics, School of pharmacy, Mashhad University of Medical sciences, Mashhad, Iran; Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyedeh Hoda Alavizadeh
- Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutical Nanotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Arabi
- Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutical Nanotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Badiee
- Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutical Nanotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahmoud Reza Jaafari
- Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutical Nanotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran; Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
| |
Collapse
|
7
|
Chitosan-alginate core-shell-corona shaped nanoparticles of dimethyl fumarate in orodispersible film to improve bioavailability in treatment of multiple sclerosis: Preparation, characterization and biodistribution in rats. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2021.102645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
8
|
Jakimovski D, Eckert SP, Zivadinov R, Weinstock-Guttman B. Considering patient age when treating multiple sclerosis across the adult lifespan. Expert Rev Neurother 2021; 21:353-364. [PMID: 33595379 DOI: 10.1080/14737175.2021.1886082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: The successful development of anti-inflammatory disease-modifying treatments (DMT) significantly improved disease outcomes and longevity of persons with multiple sclerosis (pwMS). However, the shift toward an elderly MS population has resulted with new concerns regarding DMT efficacy and safety.Areas covered: This review summarizes the evidence of an age-based decrease in the efficacy of MS DMTs and increase in pharmacovigilance concerns. The age effects on pathophysiological MS processes, immunosenescence and its relevance to DMT selection or discontinuation are also reviewed. Lastly, the authors discuss the influence of age-associated comorbidities on DMT initiation and drug-induced events.Expert opinion: There is an age discrepancy between pwMS included in regulatory drug trials and an aging real-world MS population. Most trials demonstrate significantly diminished anti-inflammatory efficacy in patients older than 40 years old. Older age is associated with a greater risk for adverse events including serious infections. Age-associated comorbidities influence the risk-benefit analysis and sometimes cause patients to discontinue DMTs. Instead of chronological age cutoffs, therefore, studies should aim at promoting biologically-based age biomarkers.
Collapse
Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.,Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, NY, USA
| | - Svetlana P Eckert
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.,Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, NY, USA.,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, NY, USA
| |
Collapse
|
9
|
Sempere AP, Berenguer-Ruiz L, Borrego-Soriano I, Burgos-San Jose A, Concepcion-Aramendia L, Volar L, Aragones M, Palazón-Bru A. Ocrelizumab in Multiple Sclerosis: A Real-World Study From Spain. Front Neurol 2021; 11:592304. [PMID: 33519676 PMCID: PMC7844090 DOI: 10.3389/fneur.2020.592304] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022] Open
Abstract
Objectives: The aim of this study was to describe the tolerability, safety, and effectiveness of ocrelizumab for primary progressive multiple sclerosis (PPMS) and relapsing multiple sclerosis (RMS) in a clinical practice setting. Methods: In this retrospective observational study, we analyzed clinical and MRI data in all patients with PPMS and RMS who had received at least one infusion of ocrelizumab in two health areas in south-eastern Spain. Patients involved in any ocrelizumab trial and those patients with a follow-up shorter than 6 months were excluded. Results: The cohort included 70 patients (42 women) who had received ocrelizumab; 30% had PPMS and 70%, RMS. At baseline, patients' mean age was 47.1 years in the PPMS group and 39.2 years in the RMS group, while the median EDSS was 3.0 and 2.5, respectively. Median follow-up was 13.6 months. The median number of treatment cycles was three. Most patients remained free from clinical and MRI activity after ocrelizumab initiation. Baseline MRI showed T1 Gd-enhancing lesions in 57% of the patients; by the first MRI control at 4–6 months, all patients except one were free of T1 Gd-enhancing lesions (69/70, 98.6% P < 0.001). The proportion of patients with NEDA was 94% in the group of RMS patients who were followed for at least 1 year. Ocrelizumab was generally well-tolerated; the most common adverse events were infusion-related reactions and infections, none of which were serious. Conclusions: Our real-world study supports the tolerability, safety, and effectiveness of ocrelizumab in clinical practice.
Collapse
Affiliation(s)
- Angel P Sempere
- Neurology Service, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.,Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
| | | | - Ines Borrego-Soriano
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
| | - Amparo Burgos-San Jose
- Pharmacy Department, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | | | - Lucian Volar
- Department of Radiology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Miguel Aragones
- Neurology Service, Hospital Marina Baixa, Villajoyosa, Spain
| | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
| |
Collapse
|
10
|
Xiao Y, Chen PP, Zhou RL, Zhang Y, Tian Z, Zhang SY. Pathological Mechanisms and Potential Therapeutic Targets of Pulmonary Arterial Hypertension: A Review. Aging Dis 2020; 11:1623-1639. [PMID: 33269111 PMCID: PMC7673851 DOI: 10.14336/ad.2020.0111] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/11/2020] [Indexed: 12/22/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive cardiovascular disease characterized by pulmonary vasculature reconstruction and right ventricular dysfunction. The mortality rate of PAH remains high, although multiple therapeutic strategies have been implemented in clinical practice. These drugs mainly target the endothelin-1, prostacyclin and nitric oxide pathways. Management for PAH treatment includes improving symptoms, enhancing quality of life, and extending survival rate. Existing drugs developed to treat the disease have resulted in enormous economic and healthcare liabilities. The estimated cost for advanced PAH has exceeded $200,000 per year. The pathogenesis of PAH is associated with numerous molecular processes. It mainly includes germline mutation, inflammation, dysfunction of pulmonary arterial endothelial cells, epigenetic modifications, DNA damage, metabolic dysfunction, sex hormone imbalance, and oxidative stress, among others. Findings based on the pathobiology of PAH may have promising therapeutic outcomes. Hence, faced with the challenges of increasing healthcare demands, in this review, we attempted to explore the pathological mechanisms and alternative therapeutic targets, including other auxiliary devices or interventional therapies, in PAH. The article will discuss the potential therapies of PAH in detail, which may require further investigation before implementation.
Collapse
Affiliation(s)
- Ying Xiao
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pei-Pei Chen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui-Lin Zhou
- School of Medicine, Tsinghua University, Beijing 100084, China
| | - Yang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Yang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
11
|
Zhang Y, Gonzalez Caldito N, Shirani A, Salter A, Cutter G, Culpepper W, Wallin M, Kosa P, Bielekova B, Lublin F, Stϋve O. Aging and efficacy of disease-modifying therapies in multiple sclerosis: a meta-analysis of clinical trials. Ther Adv Neurol Disord 2020; 13:1756286420969016. [PMID: 33552235 PMCID: PMC7838219 DOI: 10.1177/1756286420969016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Indexed: 12/19/2022] Open
Abstract
Background Disease-modifying therapies (DMTs) for multiple sclerosis (MS) are approved for the treatment of disease activity and are effective in reducing relapses and new magnetic resonance imaging (MRI) lesions. However, disease activity generally subsides with time, and age-dependent changes in DMT efficacy are not well-established. We aimed to investigate whether age impacts the efficacy of DMTs in treating disease activity in patients with relapsing-remitting MS (RRMS). Methods DMT efficacy related to age was assessed through a meta-analysis of clinical trials that evaluated the efficacy of DMTs in RRMS patients as measured by reductions in the annualized relapse rate (ARR), new T2 lesions, and gadolinium-enhanced lesions on MRI. Using the mean baseline patient age from each trial, a weighted linear regression was fitted to determine whether age was associated with treatment efficacy on a group level. Results Group-level data from a total of 28,082 patients from 26 trials of 14 different DMTs were included in the meta-analysis. There were no statistically significant associations between age and reductions in ARR, new T2 lesions, and gadolinium-enhanced lesions of the treatment group compared with placebo. Conclusion DMTs for RRMS show efficacy in treating disease activity independent of age as demonstrated by group-level data from DMT clinical trials. Nevertheless, clinical trials select for patients with baseline disease activity regardless of age, thereby not representing real-world patients with RRMS, where disease activity declines with age.
Collapse
Affiliation(s)
- Yinan Zhang
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Natalia Gonzalez Caldito
- Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Afsaneh Shirani
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Amber Salter
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William Culpepper
- Department of Neurology, University of Maryland School of Medicine, VA Multiple Sclerosis Center of Excellence-East and VA Post Deployment Health Services, Washington, DC, USA
| | - Mitchell Wallin
- Department of Neurology, George Washington University School of Medicine, Director, VA Multiple Sclerosis Center of Excellence-East, Washington, DC, USA
| | - Peter Kosa
- Neuroimmunological Diseases Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Bibiana Bielekova
- Neuroimmunological Diseases Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Fred Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Olaf Stϋve
- Neurology Section, VA North Texas Health Care System, Medical Service, 4500 South Lancaster Rd., Dallas, TX 75216, USA
| |
Collapse
|
12
|
Yagishita Y, Gatbonton-Schwager TN, McCallum ML, Kensler TW. Current Landscape of NRF2 Biomarkers in Clinical Trials. Antioxidants (Basel) 2020; 9:antiox9080716. [PMID: 32784785 PMCID: PMC7464243 DOI: 10.3390/antiox9080716] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/02/2020] [Accepted: 08/05/2020] [Indexed: 12/12/2022] Open
Abstract
The transcription factor NF-E2 p45-related factor 2 (NRF2; encoded by NFE2L2) plays a critical role in the maintenance of cellular redox and metabolic homeostasis, as well as the regulation of inflammation and cellular detoxication pathways. The contribution of the NRF2 pathway to organismal homeostasis is seen in many studies using cell lines and animal models, raising intense attention towards targeting its clinical promise. Over the last three decades, an expanding number of clinical studies have examined NRF2 inducers targeting an ever-widening range of diseases. Full understanding of the pharmacokinetic and pharmacodynamic properties of drug candidates rely partly on the identification, validation, and use of biomarkers to optimize clinical applications. This review focuses on results from clinical trials with four agents known to target NRF2 signaling in preclinical studies (dimethyl fumarate, bardoxolone methyl, oltipraz, and sulforaphane), and evaluates the successes and limitations of biomarkers focused on expression of NRF2 target genes and others, inflammation and oxidative stress biomarkers, carcinogen metabolism and adduct biomarkers in unavoidably exposed populations, and targeted and untargeted metabolomics. While no biomarkers excel at defining pharmacodynamic actions in this setting, it is clear that these four lead clinical compounds do touch the NRF2 pathway in humans.
Collapse
|
13
|
Arrambide G, Iacobaeus E, Amato MP, Derfuss T, Vukusic S, Hemmer B, Brundin L, Tintore M. Aggressive multiple sclerosis (2): Treatment. Mult Scler 2020; 26:1352458520924595. [PMID: 32530366 PMCID: PMC7412878 DOI: 10.1177/1352458520924595] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/18/2020] [Accepted: 04/16/2020] [Indexed: 01/04/2023]
Abstract
The natural history of multiple sclerosis (MS) is highly heterogeneous. A subgroup of patients has what might be termed aggressive MS. These patients may have frequent, severe relapses with incomplete recovery and are at risk of developing greater and permanent disability at the earlier stages of the disease. Their therapeutic window of opportunity may be narrow, and while it is generally considered that they will benefit from starting early with a highly efficacious treatment, a unified definition of aggressive MS does not exist and data on its treatment are largely lacking. Based on discussions at an international focused workshop sponsored by the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS), we review our current knowledge about treatment of individuals with aggressive MS. We analyse the available evidence, identify gaps in knowledge and suggest future research needed to fill those gaps. A companion paper details the difficulties in developing a consensus about what defines aggressive MS.
Collapse
Affiliation(s)
- Georgina Arrambide
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Vall d’Hebron Institut de Recerca, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ellen Iacobaeus
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Tobias Derfuss
- Departments of Neurology and Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sandra Vukusic
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France/Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR5292, Lyon, France/Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany/Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Lou Brundin
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Mar Tintore
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Vall d’Hebron Institut de Recerca, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
14
|
Abstract
Dimethyl fumarate (Tecfidera®) is approved for the treatment of relapsing forms of multiple sclerosis (MS). Based on evidence from the clinical trial and real-world settings, dimethyl fumarate is an effective treatment in this patient population, with benefits maintained over the longer term. In the pivotal, placebo-controlled phase III DEFINE and CONFIRM trials in adults with relapsing-remitting multiple sclerosis (RRMS), twice-daily dimethyl fumarate reduced clinical relapse and MRI measures of disease activity and improved some aspects of health-related quality of life (HR-QoL). Reduced disability progression was also observed with dimethyl fumarate in DEFINE. Results in predominantly East Asian patients (APEX trial) were reflective of those seen in DEFINE and CONFIRM. Dimethyl fumarate had an acceptable tolerability profile. The most common adverse events were flushing and gastrointestinal events, which were of mild or moderate severity and appear to be largely manageable. Thus twice-daily dimethyl fumarate remains an effective treatment option for use in patients with RRMS, with the convenience of oral administration.
Collapse
|
15
|
Grzegorski T, Losy J. Multiple sclerosis - the remarkable story of a baffling disease. Rev Neurosci 2020; 30:511-526. [PMID: 30645198 DOI: 10.1515/revneuro-2018-0074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 10/18/2018] [Indexed: 11/15/2022]
Abstract
Multiple sclerosis has always been an enigma to its sufferers, their families, medical investigators, and clinicians. For many centuries, there have been attempts to understand its causes and nature, and to discover treatment methods. In the Middle Ages, the disease was claimed to be sent directly from God. A significant development in exploring multiple sclerosis took place in the 19th century, when Jean-Martin Charcot and his colleagues distinguished the disease, precisely described its symptoms, attempted to explain its pathophysiology, and introduced the first methods of symptomatic treatment. The 20th century was a period of discovery and development of diagnostic techniques, such as cerebrospinal fluid analysis, evoked potentials, and magnetic resonance imaging as well as an era of introducing steroid therapy for acute treatment. Currently, the dynamic development of disease modifying therapy and neuroimaging can be observed. The paper aims to delve into the remarkable history of multiple sclerosis by focusing on the earliest case reports and discovery of the disease and exploring its nature, diagnostic methods, and treatment.
Collapse
Affiliation(s)
- Tomasz Grzegorski
- Department of Clinical Neuroimmunology, Chair of Neurology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznan, Poland
| | - Jacek Losy
- Department of Clinical Neuroimmunology, Chair of Neurology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznan, Poland
| |
Collapse
|
16
|
Sun X, Qian LL, Li Y, Pfiefer TM, Wang XL, Lee HC, Lu T. Regulation of KCNMA1 transcription by Nrf2 in coronary arterial smooth muscle cells. J Mol Cell Cardiol 2020; 140:68-76. [PMID: 32147517 DOI: 10.1016/j.yjmcc.2020.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 02/21/2020] [Accepted: 03/03/2020] [Indexed: 02/08/2023]
Abstract
The large conductance Ca2+-activated K+ (BK) channels, composed of the pore-forming α subunits (BK-α, encoded by KCNMA1 gene) and the regulatory β1 subunits (BK-β1, encoded by KCNMB1 gene), play a unique role in the regulation of coronary vascular tone and myocardial perfusion by linking intracellular Ca2+ homeostasis with excitation-contraction coupling in coronary arterial smooth muscle cells (SMCs). The nuclear factor erythroid 2-related factor 2 (Nrf2) belongs to a member of basic leucine zipper transcription factor family that regulates the expression of antioxidant and detoxification enzymes by binding to the antioxidant response elements (AREs) of these target genes. We have previously reported that vascular BK-β1 protein expression was tightly regulated by Nrf2. However, the molecular mechanism underlying the regulation of BK channel expression by Nrf2, particularly at transcription level, is unknown. In this study, we hypothesized that KCNMA1 and KCNMB1 are the target genes of Nrf2 transcriptional regulation. We found that BK channel protein expression and current density were diminished in freshly isolated coronary arterial SMCs of Nrf2 knockout (KO) mice. However, BK-α mRNA expression was reduced, but not that of BK-β1 mRNA expression, in the arteries of Nrf2 KO mice. Promoter-Nrf2 luciferase reporter assay confirmed that Nrf2 binds to the ARE of KCNMA1 promoter, but not that of KCNMB1. Adenoviral expression and pharmacological activation of Nrf2 increased BK-α and BK-β1 protein levels and enhanced BK channel activity in coronary arterial SMCs. Hence, our results indicate that Nrf2 is a key determinant of BK channel expression and function in vascular SMCs. Nrf2 facilitates BK-α expression through a direct increase in gene transcription, whereas that on BK-β1 is through a different mechanism.
Collapse
Affiliation(s)
- Xiaojing Sun
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester 55905, MN, USA
| | - Ling-Ling Qian
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester 55905, MN, USA; The Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, 299 Qingyang Road, Wuxi 214023, Jiangsu Province, PR China
| | - Yong Li
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester 55905, MN, USA; The Department of Cardiology, the Affiliated Wujin Hospital of Jiangsu University, Changzhou 213017, Jiangsu Province, PR China
| | - Teresa M Pfiefer
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester 55905, MN, USA
| | - Xiao-Li Wang
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester 55905, MN, USA
| | - Hon-Chi Lee
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester 55905, MN, USA
| | - Tong Lu
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester 55905, MN, USA.
| |
Collapse
|
17
|
Turner B, Cree BAC, Kappos L, Montalban X, Papeix C, Wolinsky JS, Buffels R, Fiore D, Garren H, Han J, Hauser SL. Ocrelizumab efficacy in subgroups of patients with relapsing multiple sclerosis. J Neurol 2019; 266:1182-1193. [PMID: 30820738 PMCID: PMC6469695 DOI: 10.1007/s00415-019-09248-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 11/02/2022]
Abstract
OBJECTIVE The efficacy and safety of ocrelizumab, versus interferon (IFN) β-1a, for the treatment of relapsing multiple sclerosis (RMS) from the identically designed OPERA I (NCT01247324) and OPERA II (NCT01412333) phase III studies has been reported; here we present subgroup analyses of efficacy endpoints from the pooled OPERA I and OPERA II populations. METHODS Patients with RMS were randomized to either ocrelizumab 600 mg administered by intravenous infusion every 24 weeks or subcutaneous IFN β-1a 44 µg three times per week throughout the 96-week treatment period. Relapse, disability, and MRI outcomes were analyzed for predefined and post hoc subgroups based on demographic and disease characteristics along with prior treatment using appropriate statistical tests to determine the treatment effect in subgroups and treatment-by-subgroup interactions. RESULTS The significant treatment benefit of ocrelizumab, versus IFN β-1a, observed in the overall OPERA I and OPERA II pooled populations was maintained across most subgroup strata for all endpoints, including annualized relapse rate, disability progression, and MRI outputs. CONCLUSIONS The treatment effect of ocrelizumab versus IFN β-1a, measured by clinical and MRI outcomes, was maintained across most of the subgroups and strata of interest, and the pattern of treatment benefit across all subgroups was consistent with that from the pooled OPERA studies.
Collapse
Affiliation(s)
- Benjamin Turner
- Department of Neurology, The Royal London Hospital, London, E1 1BB, UK.
| | - Bruce A C Cree
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Ludwig Kappos
- University Hospital Basel, University of Basel, Basel, Switzerland
| | - Xavier Montalban
- Vall d'Hebron University Hospital, Barcelona, Spain.,Division of Neurology, St Michael's Hospital, University of Toronto, Toronto, Canada
| | | | - Jerry S Wolinsky
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | | | | | | | - Jian Han
- Genentech, Inc., South San Francisco, CA, USA
| | - Stephen L Hauser
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
18
|
Hosseini A, Masjedi A, Baradaran B, Hojjat‐Farsangi M, Ghalamfarsa G, Anvari E, Jadidi‐Niaragh F. Dimethyl fumarate: Regulatory effects on the immune system in the treatment of multiple sclerosis. J Cell Physiol 2018; 234:9943-9955. [DOI: 10.1002/jcp.27930] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 10/24/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Arezoo Hosseini
- Drug Applied Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Ali Masjedi
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Mohammad Hojjat‐Farsangi
- Immune and Gene therapy Lab Department of Oncology‐Pathology Cancer Center Karolinska (CCK), Karolinska University Hospital Solna and Karolinska Institute Stockholm Sweden
- Department of Immunology School of Medicine, Bushehr University of Medical Sciences Bushehr Iran
| | - Ghasem Ghalamfarsa
- Cellular and Molecular Research Center, Yasuj University of Medical Sciences Yasuj Iran
| | - Enayat Anvari
- Department of Physiology Faculty of Medicine, Ilam University of Medical Sciences Ilam Iran
| | - Farhad Jadidi‐Niaragh
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| |
Collapse
|
19
|
Vollmer B, Ontaneda D, Bandyopadhyay A, Cohn S, Nair K, Sillau S, Bermel RA, Corboy JR, Fox RJ, Vollmer T, Cohen JA, Alvarez E, Hersh CM. Discontinuation and comparative effectiveness of dimethyl fumarate and fingolimod in 2 centers. Neurol Clin Pract 2018; 8:292-301. [PMID: 30140580 PMCID: PMC6105060 DOI: 10.1212/cpj.0000000000000487] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Dimethyl fumarate (DMF) and fingolimod (FTY) are approved oral disease-modifying therapies for relapsing multiple sclerosis (MS). Observational studies are valuable when randomized clinical trials cannot be done due to ethical or practical reasons. Two-site studies allow investigators to further ascertain external validity of previously examined treatment effect differences. Limited head-to-head 2-site studies exist comparing DMF and FTY. Methods Patients prescribed DMF (n = 737) and FTY (n = 535) from 2 academic multiple sclerosis (MS) centers (Cleveland Clinic and University of Colorado) were identified. Discontinuation and disease activity endpoints were assessed using propensity score (PS) weighting. Covariates used in the PS model included demographics and clinical and MRI characteristics. Results PS weighting demonstrated excellent covariate balance. Discontinuation was more common in DMF (44.2%) compared to FTY (34.8%) over 24 months (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.21–1.99, p < 0.001). The leading cause for discontinuation was intolerability for both DMF (56.1% of DMF discontinuations) and FTY (46.2% of FTY discontinuations) (OR 1.65, 95% CI 1.21–2.25, p = 0.002). The proportion of patients with clinical relapses was low for both medications (DMF, 15.1%; FTY, 13.1%). There was no difference in the proportion of patients with relapses (OR 1.27, 95% CI 0.90–1.80, p = 0.174), gadolinium-enhancing lesions (OR 1.42, 95% CI 0.92–2.20, p = 0.114), or new T2 lesions on brain MRI (OR 1.13, 95% CI 0.83–1.55, p = 0.433). Conclusions This combined analysis suggests DMF and FTY have similar effectiveness in a large, 2-site clinical population over 24 months. Discontinuation of both DMTs was common and occurred more frequently with DMF, largely driven by intolerability.
Collapse
Affiliation(s)
- Brandi Vollmer
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Daniel Ontaneda
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Anasua Bandyopadhyay
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Sam Cohn
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Kavita Nair
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Stefan Sillau
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Robert A Bermel
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - John R Corboy
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Robert J Fox
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Timothy Vollmer
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Jeffrey A Cohen
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Enrique Alvarez
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| | - Carrie M Hersh
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus (BV, KN, SS, JRC, TV, EA), University of Colorado, Denver; Mellen Center for Multiple Sclerosis Treatment and Research (DO, RAB, RJF, JAC), Cleveland Clinic, OH; Emory University (AB), Atlanta, GA; Department of Neurology (SC), Cleveland Clinic, OH; and Lou Ruvo Center for Brain Health (CMH), Cleveland Clinic, Las Vegas, NV
| |
Collapse
|
20
|
Houtchens MK, Bove R. A case for gender-based approach to multiple sclerosis therapeutics. Front Neuroendocrinol 2018; 50:123-134. [PMID: 30040969 DOI: 10.1016/j.yfrne.2018.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 11/29/2022]
Abstract
Despite established sex differences in multiple sclerosis (MS) risk and course, sex-specific efficacy and toxicity of existing MS therapies, and possible sex-specific therapeutic approaches, remain underexplored. We systematically reviewed published sex differences from Phase III pivotal trials for FDA or EMA-approved MS disease modifying therapies (DMTs), along with additional information from pharmaceutical companies, for pre-specified or post-hoc baseline characteristics, efficacy and safety outcomes by sex, and sex-specific concerns. Then, we reviewed trials testing hormonal therapies in MS. None of the Phase III clinical trials performed baseline sex-specific analyses or were powered to evaluated DMTs in menopausal/older populations. Some recent trials performed pre-specified or post-hoc stratification of outcomes by sex. Sex-specific hormonal intervention trials were limited. Adequately powered, pre-specified analyses accounting for baseline sex and age are required to maximize safety and efficacy in specific patient populations.
Collapse
Affiliation(s)
- Maria K Houtchens
- Women's Health Program, Partners MS Center, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Riley Bove
- Weill Institute for the Neurosciences, Department of Neurology, University of California, San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158, USA.
| |
Collapse
|
21
|
Graetz C, Groppa S, Zipp F, Siller N. Preservation of neuronal function as measured by clinical and MRI endpoints in relapsing-remitting multiple sclerosis: how effective are current treatment strategies? Expert Rev Neurother 2018; 18:203-219. [PMID: 29411688 DOI: 10.1080/14737175.2018.1438190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Approved medications for relapsing-remitting multiple sclerosis have shown to be effective in terms of their anti-inflammatory potential. However, it is also crucial to evaluate what long-term effects a patient can expect from current MS drugs in terms of preventing neurodegeneration. Here we aim to provide an overview of the current treatment strategies in MS with a specific focus on potential neuroprotective effects. Areas covered: Randomized, double-blind and placebo or referral-drug controlled phase 2a/b and phase 3 trials were examined; non-blinded phase 4 studies (extension studies) were included to provide long-term data, if not otherwise available. Endpoints considered were expanded disability status scale, various neuropsychological tests, percent brain volume change and T1-hypointense lesions as well as multiple sclerosis functional composite, confirmed disease progression, and no evidence of disease activity. Expert commentary: Overall, neuroprotective functions of classical MS therapeutics are not sufficiently investigated, but available data show limited effects. Thus, further research and development in neuroprotection are warranted. When counselling patients, potential long-term beneficial effects should be presented more conservatively.
Collapse
Affiliation(s)
- Christiane Graetz
- a Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2) , University Medical Center of the Johannes Gutenberg University Mainz , Mainz , Germany
| | - Sergiu Groppa
- a Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2) , University Medical Center of the Johannes Gutenberg University Mainz , Mainz , Germany
| | - Frauke Zipp
- a Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2) , University Medical Center of the Johannes Gutenberg University Mainz , Mainz , Germany
| | - Nelly Siller
- a Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2) , University Medical Center of the Johannes Gutenberg University Mainz , Mainz , Germany
| |
Collapse
|
22
|
Lu T, Sun X, Li Y, Chai Q, Wang XL, Lee HC. Role of Nrf2 Signaling in the Regulation of Vascular BK Channel β1 Subunit Expression and BK Channel Function in High-Fat Diet-Induced Diabetic Mice. Diabetes 2017; 66:2681-2690. [PMID: 28465407 PMCID: PMC5606315 DOI: 10.2337/db17-0181] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/17/2017] [Indexed: 01/13/2023]
Abstract
The large conductance Ca2+-activated K+ (BK) channel β1-subunit (BK-β1) is a key modulator of BK channel electrophysiology and the downregulation of BK-β1 protein expression in vascular smooth muscle cells (SMCs) underlies diabetic vascular dysfunction. In this study, we hypothesized that the nuclear factor erythroid-2-related factor 2 (Nrf2) signaling pathway plays a significant role in the regulation of coronary BK channel function and vasodilation in high-fat diet (HFD)-induced obese/diabetic mice. We found that the protein expressions of BK-β1 and Nrf2 were markedly downregulated, whereas those of the nuclear factor-κB (NF-κB) and the muscle ring finger protein 1 (MuRF1 [a ubiquitin E3 ligase for BK-β1]) were significantly upregulated in HFD mouse arteries. Adenoviral expression of Nrf2 suppressed the protein expressions of NF-κB and MuRF1 but enhanced BK-β1 mRNA and protein expressions in cultured coronary SMCs. Knockdown of Nrf2 resulted in reciprocal changes of these proteins. Patch-clamp studies showed that coronary BK-β1-mediated channel activation was diminished in HFD mice. Importantly, the activation of Nrf2 by dimethyl fumarate significantly reduced the body weight and blood glucose levels of HFD mice, enhanced BK-β1 transcription, and attenuated MuRF1-dependent BK-β1 protein degradation, which in turn restored coronary BK channel function and BK channel-mediated coronary vasodilation in HFD mice. Hence, Nrf2 is a novel regulator of BK channel function with therapeutic implications in diabetic vasculopathy.
Collapse
Affiliation(s)
- Tong Lu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Xiaojing Sun
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Yong Li
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
- Department of Cardiology, The Affiliated Wujin Hospital of Jiangsu University, Changzhou, Jiangsu, People's Republic of China
| | - Qiang Chai
- Department of Physiology, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, Shandong, People's Republic of China
| | - Xiao-Li Wang
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Hon-Chi Lee
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| |
Collapse
|
23
|
Li Y, Wang XL, Sun X, Chai Q, Li J, Thompson B, Shen WK, Lu T, Lee HC. Regulation of vascular large-conductance calcium-activated potassium channels by Nrf2 signalling. Diab Vasc Dis Res 2017; 14:353-362. [PMID: 28429615 DOI: 10.1177/1479164117703903] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BK channels are major ionic determinants of vasodilation. BK channel function is impaired in diabetic vessels due to accelerated proteolysis of its beta-1 (BK-β1) subunits in response to increased oxidative stress. The nuclear factor E2-related factor-2 (Nrf2) signalling pathway has emerged as a master regulator of cellular redox status, and we hypothesized that it plays a central role in regulating BK channel function in diabetic vessels. We found that Nrf2 expression was markedly reduced in db/db diabetic mouse aortas, and this was associated with significant downregulation of BK-β1. In addition, the muscle ring finger protein 1 (MuRF1), a known E-3 ligase targeting BK-β1 ubiquitination and proteasomal degradation, was significantly augmented. These findings were reproduced by knockdown of Nrf2 by siRNA in cultured human coronary artery smooth muscle cells. In contrast, adenoviral transfer of Nrf2 gene in these cells downregulated MuRF1 and upregulated BK-β1 expression. Activation of Nrf2 by dimethyl fumarate preserved BK-β1 expression and protected BK channel and vascular function in db/db coronary arteries. These results indicate that expression of BK-β1 is closely regulated by Nrf2 and vascular BK channel function can be restored by Nrf2 activation. Nrf2 should be considered a novel therapeutic target in the treatment of diabetic vasculopathy.
Collapse
Affiliation(s)
- Yong Li
- 1 Department of Cardiology, Affiliated Wujin Hospital of Jiangsu University, Changzhou, China
- 2 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Xiao-Li Wang
- 2 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Xiaojing Sun
- 2 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Qiang Chai
- 2 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- 3 Department of Physiology, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, P.R. China
| | - Jingchao Li
- 2 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- 4 Department of Emergency Medicine, Henan Provincial People's Hospital, Affiliated Hospital of Zhengzhou University, Zhengzhou, P.R. China
| | - Benjamin Thompson
- 2 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Win-Kuang Shen
- 5 Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Tong Lu
- 2 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hon-Chi Lee
- 2 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
24
|
Esposito E, Cortesi R, Drechsler M, Fan J, Fu BM, Calderan L, Mannucci S, Boschi F, Nastruzzi C. Nanoformulations for dimethyl fumarate: Physicochemical characterization and in vitro / in vivo behavior. Eur J Pharm Biopharm 2017; 115:285-296. [DOI: 10.1016/j.ejpb.2017.04.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 11/24/2016] [Accepted: 04/11/2017] [Indexed: 12/27/2022]
|
25
|
Stojić-Vukanić Z, Kotur-Stevuljević J, Nacka-Aleksić M, Kosec D, Vujnović I, Pilipović I, Dimitrijević M, Leposavić G. Sex Bias in Pathogenesis of Autoimmune Neuroinflammation: Relevance for Dimethyl Fumarate Immunomodulatory/Anti-oxidant Action. Mol Neurobiol 2017; 55:3755-3774. [PMID: 28534275 DOI: 10.1007/s12035-017-0595-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 05/02/2017] [Indexed: 01/22/2023]
Abstract
In the present study, upon showing sexual dimorphism in dimethyl fumarate (DMF) efficacy to moderate the clinical severity of experimental autoimmune encephalomyelitis (EAE) in Dark Agouti rats, cellular and molecular substrate of this dimorphism was explored. In rats of both sexes, DMF administration from the day of immunization attenuated EAE severity, but this effect was more prominent in males leading to loss of the sexual dimorphism observed in vehicle-administered controls. Consistently, in male rats, DMF was more efficient in diminishing the number of CD4+ T lymphocytes infiltrating spinal cord (SC) and their reactivation, the number of IL-17+ T lymphocytes and particularly cellularity of their highly pathogenic IFN-γ+GM-CSF+IL-17+ subset. This was linked with changes in SC CD11b+CD45+TCRαβ- microglia/proinflammatory monocyte progeny, substantiated in a more prominent increase in the frequency of anti-inflammatory phygocyting CD163+ cells and the cells expressing high surface levels of immunoregulatory CD83 molecule (associated with apoptotic cells phagocytosis and implicated in downregulation of CD4+ T lymphocyte reactivation) among CD11b+CD45+TCRαβ- cells in male rat SC. These changes were associated with greater increase in the nuclear factor (erythroid-derived 2)-like 2 expression in male rats administered with DMF. In accordance with the previous findings, DMF diminished reactive nitrogen and oxygen species generation and consistently, SC level of advanced oxidation protein products, to the greater extent in male rats. Overall, our study indicates sex-specificity in the sensitivity of DMF cellular and molecular targets and encourages sex-based clinical research to define significance of sex for action of therapeutic agents moderating autoimmune neuroinflammation-/oxidative stress-related nervous tissue damage.
Collapse
Affiliation(s)
- Zorica Stojić-Vukanić
- Department of Microbiology and Immunology, Faculty of Pharmacy, University of Belgrade, 450 Vojvode Stepe, Belgrade, 11221, Serbia
| | - Jelena Kotur-Stevuljević
- Department for Medical Biochemistry, Faculty of Pharmacy, University of Belgrade, 450 Vojvode Stepe, Belgrade, 11221, Serbia
| | - Mirjana Nacka-Aleksić
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, 450 Vojvode Stepe, Belgrade, 11221, Serbia
| | - Duško Kosec
- Immunology Research Centre "Branislav Janković", Institute of Virology, Vaccines and Sera "Torlak", 458 Vojvode Stepe, Belgrade, 11221, Serbia
| | - Ivana Vujnović
- Immunology Research Centre "Branislav Janković", Institute of Virology, Vaccines and Sera "Torlak", 458 Vojvode Stepe, Belgrade, 11221, Serbia
| | - Ivan Pilipović
- Immunology Research Centre "Branislav Janković", Institute of Virology, Vaccines and Sera "Torlak", 458 Vojvode Stepe, Belgrade, 11221, Serbia
| | - Mirjana Dimitrijević
- Department of Immunology, Institute for Biological Research "Siniša Stanković", University of Belgrade, Bulevar despota Stefana 142, Belgrade, 11060, Serbia
| | - Gordana Leposavić
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, 450 Vojvode Stepe, Belgrade, 11221, Serbia.
| |
Collapse
|
26
|
Soini E, Joutseno J, Sumelahti ML. Cost-utility of First-line Disease-modifying Treatments for Relapsing-Remitting Multiple Sclerosis. Clin Ther 2017; 39:537-557.e10. [PMID: 28209373 DOI: 10.1016/j.clinthera.2017.01.028] [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] [Received: 10/13/2016] [Revised: 11/29/2016] [Accepted: 01/18/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE This study evaluated the cost-effectiveness of first-line treatments of relapsing-remitting multiple sclerosis (RRMS) (dimethyl fumarate [DMF] 240 mg PO BID, teriflunomide 14 mg once daily, glatiramer acetate 20 mg SC once daily, interferon [IFN]-β1a 44 µg TIW, IFN-β1b 250 µg EOD, and IFN-β1a 30 µg IM QW) and best supportive care (BSC) in the health care payer setting in Finland. METHODS The primary outcome was the modeled incremental cost-effectiveness ratio (ICER; €/quality-adjusted life-year [QALY] gained, 3%/y discounting). Markov cohort modeling with a 15-year time horizon was employed. During each 1-year modeling cycle, patients either maintained the Expanded Disability Status Scale (EDSS) score or experienced progression, developed secondary progressive MS (SPMS) or showed EDSS progression in SPMS, experienced relapse with/without hospitalization, experienced an adverse event (AE), or died. Patients׳ characteristics, RRMS progression probabilities, and standardized mortality ratios were derived from a registry of patients with MS in Finland. A mixed-treatment comparison (MTC) informed the treatment effects. Finnish EuroQol Five-Dimensional Questionnaire, Three-Level Version quality-of-life and direct-cost estimates associated with EDSS scores, relapses, and AEs were applied. Four approaches were used to assess the outcomes: cost-effectiveness plane and efficiency frontiers (relative value of efficient treatments); cost-effectiveness acceptability frontier, which demonstrated optimal treatment to maximize net benefit; Bayesian treatment ranking (BTR); and an impact investment assessment (IIA; a cost-benefit assessment), which increased the clinical interpretation and appeal of modeled outcomes in terms of absolute benefit gained with fixed drug-related budget. Robustness of results was tested extensively with sensitivity analyses. FINDINGS Based on the modeled results, teriflunomide was less costly, with greater QALYs, versus glatiramer acetate and the IFNs. Teriflunomide had the lowest ICER (24,081) versus BSC. DMF brought marginally more QALYs (0.089) than did teriflunomide, with greater costs over the 15 years. The ICER for DMF versus teriflunomide was 75,431. Teriflunomide had >50% cost-effectiveness probabilities with a willingness-to-pay threshold of <€77,416/QALY gained. According to BTR, teriflunomide was first-best among the disease-modifying therapies, with potential willingness-to-pay thresholds of up to €68,000/QALY gained. In the IIA, teriflunomide was associated with the longest incremental quality-adjusted survival and time without cane use. Generally, primary outcomes results were robust, based on the sensitivity analyses. The results were sensitive only to large changes in analysis perspective or mixed-treatment comparison. IMPLICATIONS The results were sensitive only to large changes in analysis perspective or MTC. Based on the analyses, teriflunomide was cost-effective versus BSC or DMF with the common threshold values, was dominant versus other first-line RRMS treatments, and provided the greatest impact on investment. Teriflunomide is potentially the most cost-effective option among first-line treatments of RRMS in Finland.
Collapse
|
27
|
Sex differences in outcomes of disease-modifying treatments for multiple sclerosis: A systematic review. Mult Scler Relat Disord 2017; 12:23-28. [DOI: 10.1016/j.msard.2017.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 12/01/2016] [Accepted: 01/01/2017] [Indexed: 12/11/2022]
|
28
|
Li R, Rezk A, Ghadiri M, Luessi F, Zipp F, Li H, Giacomini PS, Antel J, Bar-Or A. Dimethyl Fumarate Treatment Mediates an Anti-Inflammatory Shift in B Cell Subsets of Patients with Multiple Sclerosis. THE JOURNAL OF IMMUNOLOGY 2016; 198:691-698. [PMID: 27974457 DOI: 10.4049/jimmunol.1601649] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/14/2016] [Indexed: 11/19/2022]
Abstract
The therapeutic mode of action of dimethyl fumarate (DMF), approved for treating patients with relapsing-remitting multiple sclerosis, is not fully understood. Recently, we and others demonstrated that Ab-independent functions of distinct B cell subsets are important in mediating multiple sclerosis (MS) relapsing disease activity. Our objective was to test whether and how DMF influences both the phenotype and functional responses of disease-implicated B cell subsets in patients with MS. High-quality PBMC were obtained from relapsing-remitting MS patients prior to and serially after initiation of DMF treatment. Multiparametric flow cytometry was used to monitor the phenotype and functional response-profiles of distinct B cell subsets. Total B cell counts decreased following DMF treatment, largely reflecting losses of circulating mature/differentiated (but not of immature transitional) B cells. Within the mature B cell pool, DMF had a greater impact on memory than naive B cells. In keeping with these in vivo effects, DMF treatment in vitro remarkably diminished mature (but not transitional B cell) survival, mediated by inducing apoptotic cell death. Although DMF treatment (both in vivo and in vitro) minimally impacted B cell IL-10 expression, it strongly reduced B cell expression of GM-CSF, IL-6, and TNF-α, resulting in a significant anti-inflammatory shift of B cell response profiles. The DMF-mediated decrease in B cell proinflammatory cytokine responses was further associated with reduced phosphorylation of STAT5/6 and NF-κB in surviving B cells. Together, these data implicate novel mechanisms by which DMF may modulate MS disease activity through shifting the balance between pro- and anti-inflammatory B cell responses.
Collapse
Affiliation(s)
- Rui Li
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Ayman Rezk
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Mathab Ghadiri
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Felix Luessi
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada.,Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine-Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz 55131, Germany; and
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine-Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz 55131, Germany; and
| | - Hulun Li
- Department of Neurobiology, Harbin Medical University, NanGang District, Harbin 150086, Heilongjiang, China
| | - Paul S Giacomini
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Jack Antel
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Amit Bar-Or
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada;
| |
Collapse
|
29
|
Freedman MS, Montalban X, Miller AE, Dive-Pouletty C, Hass S, Thangavelu K, Leist TP. Comparing outcomes from clinical studies of oral disease-modifying therapies (dimethyl fumarate, fingolimod, and teriflunomide) in relapsing MS: Assessing absolute differences using a number needed to treat analysis. Mult Scler Relat Disord 2016; 10:204-212. [DOI: 10.1016/j.msard.2016.10.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/30/2016] [Accepted: 10/31/2016] [Indexed: 11/16/2022]
|
30
|
Zhovtis Ryerson L, Green R, Confident G, Pandey K, Richter B, Bacon T, Sammarco C, Laing L, Kalina J, Kister I. Efficacy and tolerability of dimethyl fumarate in White-, African- and Hispanic- Americans with multiple sclerosis. Ther Adv Neurol Disord 2016; 9:454-461. [PMID: 27800021 DOI: 10.1177/1756285616661929] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dimethyl fumarate (DMF) was approved by the US Food and Drug Administration (FDA) for treatment of relapsing-remitting multiple sclerosis (RRMS) based on two phase III randomized clinical trials (RCTs). There were not enough non-White patients enrolled in these RCTs to allow for subgroup analysis based on race. Efficacy and tolerability of DMF therapy across various racial groups is unknown. METHODS Retrospective chart review was performed on all patients with RRMS who were started on DMF in two tertiary multiple sclerosis (MS) clinics. Efficacy and tolerability of DMF was compared across three self-identified racial groups: White-American (WA), African-American (AA) and Hispanic-American (HA). RESULTS A total of 390 RRMS patients were included in the study: 261 (66.9%) WA, 69 (17.7%) AA and 52 (13.3%) HA. When comparing 'pre-DMF' (1 year) and 'on DMF' (mean follow up of 14 months) periods, statistically significant reduction in rates of annualized relapses (WA from 0.44 to 0.19, AA from 0.39 to 0.15, and HA from 0.39 to 0.14; no differences between groups), new T2 lesions (WA from 45% to 23%, AA from 39% to 23%, HA from 52% to 26%; no difference between groups), and Gd+ lesions (WA from 25% to 13%, AA from 24% to 7%, HA from 23% to 12%; no difference between groups) were seen. DMF was relatively well tolerated across all groups, with an overall discontinuation rate of 20% (no difference between the three groups). CONCLUSION Efficacy of DMF in our clinic population did not differ across three major ethnic groups, WA, AA and HA, and was comparable with results observed in the pivotal studies. These 'real-life' data suggest that race is not a factor that needs to be taken into account when initiating DMF.
Collapse
Affiliation(s)
- Lana Zhovtis Ryerson
- NYU Multiple Sclerosis Comprehensive Care Center, 240 East 38 Street, New York, NY 10016, USA
| | - Rivka Green
- NYU Multiple Sclerosis Care Center, NYU Langone Medical Center, New York, NY, USA
| | - Gladyne Confident
- NYU Multiple Sclerosis Care Center, NYU Langone Medical Center, New York, NY, USA
| | - Krupa Pandey
- Barnabas Multiple Sclerosis Care Center, Livingston, NJ, USA
| | | | - Tamar Bacon
- NYU Multiple Sclerosis Care Center, NYU Langone Medical Center, New York, NY, USA
| | - Carrie Sammarco
- NYU Multiple Sclerosis Care Center, NYU Langone Medical Center, New York, NY, USA
| | - Lisa Laing
- NYU Multiple Sclerosis Care Center, NYU Langone Medical Center, New York, NY, USA
| | - Jennifer Kalina
- NYU Multiple Sclerosis Care Center, NYU Langone Medical Center, New York, NY, USA
| | - Ilya Kister
- NYU Multiple Sclerosis Care Center, NYU Langone Medical Center, New York, NY, USA
| |
Collapse
|
31
|
Comi G, Amato MP, Bertolotto A, Centonze D, De Stefano N, Farina C, Gallo P, Ghezzi A, Grimaldi LM, Mancardi G, Marrosu MG, Montanari E, Patti F, Pozzilli C, Provinciali L, Salvetti M, Tedeschi G, Trojano M. The heritage of glatiramer acetate and its use in multiple sclerosis. ACTA ACUST UNITED AC 2016. [DOI: 10.1186/s40893-016-0010-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
32
|
Linker RA, Haghikia A. Dimethyl fumarate in multiple sclerosis: latest developments, evidence and place in therapy. Ther Adv Chronic Dis 2016; 7:198-207. [PMID: 27433310 DOI: 10.1177/2040622316653307] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Dimethyl fumarate (DMF) is one of the newer additions to the armamentarium of potent immunomodulators for the treatment of relapsing-remitting multiple sclerosis (RRMS). After more than 2 years of real-world experience and more than 190,000 patients currently treated with DMF worldwide, it is a good timepoint to review the experience gathered so far and to re-evaluate the potential of this first-line oral multiple sclerosis (MS) drug. Post-hoc analyses of clinical and magnetic resonance imaging (MRI) data, some comprising more than 6 years of drug exposure including patients from the clinical trials, and the overall notion in clinical practice widely confirm the good efficacy of DMF in RRMS. Despite an overall good safety profile, it became also clear that the necessary clinical vigilance while using DMF may not be neglected. So far, four reported cases of progressive multifocal leukoencephalopathy (PML), a towering shadow over many MS therapies, warrant proper attention in newly-updated risk management plans. This review recapitulates efficacy and safety aspects of DMF therapy in relation to reported data from the pivotal clinical trials. In addition, we summarize recent insights into DMF mechanisms of action drawn from the field of basic research which may have important implications for clinical practice.
Collapse
Affiliation(s)
- Ralf A Linker
- Department of Neurology, Friedrich-Alexander-University Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Aiden Haghikia
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital Bochum, Bochum, Germany
| |
Collapse
|
33
|
Prosperini L, Pontecorvo S. Dimethyl fumarate in the management of multiple sclerosis: appropriate patient selection and special considerations. Ther Clin Risk Manag 2016; 12:339-50. [PMID: 27042079 PMCID: PMC4780395 DOI: 10.2147/tcrm.s85099] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Delayed-release dimethyl fumarate (DMF), also known as gastroresistant DMF, is the most recently approved oral disease-modifying treatment (DMT) for relapsing multiple sclerosis. Two randomized clinical trials (Determination of the Efficacy and Safety of Oral Fumarate in Relapsing-Remitting MS [DEFINE] and Comparator and an Oral Fumarate in Relapsing-Remitting Multiple Sclerosis [CONFIRM]) demonstrated significant efficacy in reducing relapse rate and radiological signs of disease activity, as seen on magnetic resonance imaging. The DEFINE study also indicated a significant effect of DMF on disability worsening, while the low incidence of confirmed disability worsening in the CONFIRM trial rendered an insignificant reduction among the DMF-treated groups when compared to placebo. DMF also demonstrated a good safety profile and acceptable tolerability, since the most common side effects (gastrointestinal events and flushing reactions) are usually transient and mild to moderate in severity. Here, we discuss the place in therapy of DMF for individuals with relapsing multiple sclerosis, providing a tentative therapeutic algorithm to manage newly diagnosed patients and those who do not adequately respond to self-injectable DMTs. Literature data supporting the potential role of DMF as a first-line therapy are presented. The possibility of using DMF as switching treatment or even as an add-on strategy in patients with breakthrough disease despite self-injectable DMTs will also be discussed. Lastly, we argue about the role of DMF as an exit strategy from natalizumab-treated patients who are considered at risk for developing multifocal progressive leukoencephalopathy.
Collapse
Affiliation(s)
- Luca Prosperini
- Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Simona Pontecorvo
- Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| |
Collapse
|
34
|
|
35
|
Phillips JT, Selmaj K, Gold R, Fox RJ, Havrdova E, Giovannoni G, Abourjaily H, Pace A, Novas M, Hotermans C, Viglietta V, Meltzer L. Clinical Significance of Gastrointestinal and Flushing Events in Patients with Multiple Sclerosis Treated with Delayed-Release Dimethyl Fumarate. Int J MS Care 2015; 17:236-43. [PMID: 26472945 DOI: 10.7224/1537-2073.2014-069] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the phase 3 DEFINE and CONFIRM trials, flushing and gastrointestinal (GI) events were associated with delayed-release dimethyl fumarate (DMF; also known as gastroresistant DMF) treatment in people with relapsing-remitting multiple sclerosis (MS). To investigate these events, a post hoc analysis of integrated data from these trials was conducted, focusing on the initial treatment period (months 0-3) with the recommended DMF dosage (240 mg twice daily). METHODS Eligibility criteria included age 18 to 55 years, relapsing-remitting MS diagnosis, and Expanded Disability Status Scale score 0 to 5.0. Patients were randomized and received treatment with placebo (n = 771) or DMF (n = 769) for up to 2 years. Adverse events were recorded at scheduled clinic visits every 4 weeks. RESULTS The incidence of GI and flushing events was highest in the first month of treatment. In months 0 to 3, the incidence of GI events was 17% in the placebo group and 27% in the DMF group and the incidence of flushing and related symptoms was 5% in the placebo group and 37% in the DMF group. Most GI and flushing events were of mild or moderate severity and resolved during the study. The events were temporally associated with the use of diverse symptomatic therapies (efficacy not assessed) and infrequently led to DMF discontinuation. CONCLUSIONS This integrated analysis indicates that in a clinical trial setting, GI and flushing events associated with DMF treatment are generally transient and mild or moderate in severity and uncommonly lead to treatment discontinuation.
Collapse
Affiliation(s)
- J Theodore Phillips
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Krzysztof Selmaj
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Ralf Gold
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Robert J Fox
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Eva Havrdova
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Gavin Giovannoni
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Heather Abourjaily
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Amy Pace
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Mark Novas
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Christophe Hotermans
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Vissia Viglietta
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| | - Leslie Meltzer
- Multiple Sclerosis Program, Baylor Institute for Immunology Research, Dallas, TX, USA (JTP); Medical University of Lodz, Lodz, Poland (KS); St. Josef Hospital, Ruhr University, Bochum, Germany (RG); Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF); Department of Neurology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic (EH); Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK (GG); and Biogen, Cambridge, MA, USA (HA, AP, MN, CH, VV, LM)
| |
Collapse
|
36
|
Kihara Y, Groves A, Rivera RR, Chun J. Dimethyl fumarate inhibits integrin α4 expression in multiple sclerosis models. Ann Clin Transl Neurol 2015; 2:978-83. [PMID: 26478898 PMCID: PMC4603381 DOI: 10.1002/acn3.251] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 08/14/2015] [Accepted: 08/21/2015] [Indexed: 12/25/2022] Open
Abstract
Dimethyl fumarate is an orally bioavailable compound for the treatment of multiple sclerosis and psoriasis. A mechanism involving nuclear factor erythroid 2-like 2 activation has been proposed to account for its efficacy in multiple sclerosis. Here, we report that dimethyl fumarate inhibits expression of integrin α4 on circulating lymphocytes in experimental autoimmune encephalomyelitis mice and also on activated human Jurkat T cells in a manner distinct from nuclear factor erythroid 2-like 2 activation. Our results offer an alternative mechanism for the efficacy of dimethyl fumarate in multiple sclerosis.
Collapse
Affiliation(s)
- Yasuyuki Kihara
- Department of Molecular and Cellular Neuroscience, Dorris Neuroscience Center, The Scripps Research Institute 10550 N. Torrey Pines Rd., DNC-118, La Jolla, California, 92037
| | - Aran Groves
- Department of Molecular and Cellular Neuroscience, Dorris Neuroscience Center, The Scripps Research Institute 10550 N. Torrey Pines Rd., DNC-118, La Jolla, California, 92037
| | - Richard R Rivera
- Department of Molecular and Cellular Neuroscience, Dorris Neuroscience Center, The Scripps Research Institute 10550 N. Torrey Pines Rd., DNC-118, La Jolla, California, 92037
| | - Jerold Chun
- Department of Molecular and Cellular Neuroscience, Dorris Neuroscience Center, The Scripps Research Institute 10550 N. Torrey Pines Rd., DNC-118, La Jolla, California, 92037
| |
Collapse
|
37
|
Ziemssen T, De Stefano N, Sormani MP, Van Wijmeersch B, Wiendl H, Kieseier BC. Optimizing therapy early in multiple sclerosis: An evidence-based view. Mult Scler Relat Disord 2015; 4:460-469. [DOI: 10.1016/j.msard.2015.07.007] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/01/2015] [Accepted: 07/15/2015] [Indexed: 01/26/2023]
|
38
|
Abstract
BACKGROUND Multiple sclerosis (MS) often leads to severe neurological disability and a serious decline in quality of life. The ideal target of disease-modifying therapy for MS is to prevent disability worsening and improve quality of life. Dimethyl fumarate is considered to have an immunomodulatory activity and neuroprotective effect. It has been approved by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency as a first-line therapy for adult patients with relapsing-remitting MS (RMSS). OBJECTIVES To assess the benefit and safety of dimethyl fumarate as monotherapy or combination therapy versus placebo or other approved disease-modifying drugs (interferon beta, glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, alemtuzumab) for patients with MS. SEARCH METHODS The Trials Search Co-ordinator searched the Trials Specialised Register of the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group (4 June 2014). We checked reference lists of published reviews and retrieved articles and searched reports (2004 to June 2014) from the MS societies in Europe and America. We also communicated with investigators participating in trials of dimethyl fumarate and the Biogen Idec Medical Information. SELECTION CRITERIA We included randomised, controlled, parallel-group clinical trials (RCTs) with a length of follow-up equal to or greater than one year evaluating dimethyl fumarate, as monotherapy or combination therapy, versus placebo or other approved disease-modifying drugs for patients with MS without restrictions regarding dosage, administration frequency and duration of treatment. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures of The Cochrane Collaboration. Two review authors independently assessed trial quality and extracted data. Disagreements were discussed and resolved by consensus among the review authors. We contacted the principal investigators of included studies for additional data or confirmation of data. MAIN RESULTS Two RCTs were included, involving 2667 adult patients with RRMS to evaluate the efficacy and safety of two dosages of dimethyl fumarate (240 mg orally three times daily or twice daily) by direct comparison with placebo for two years. Among them, a subsample of 1221 (45.8%) patients were selected to participate in MRI evaluations by each study site with MRI capabilities itself. No powered head-to-head study with an active treatment comparator has been found. Meta-analyses showed that dimethyl fumarate both three times daily and twice daily reduced the number of patients with a relapse (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.50 to 0.66, P < 0.00001 and 0.64, 95% CI 0.54 to 0.77, P < 0.00001, respectively) or disability worsening (RR 0.70, 95% CI 0.57 to 0.87, P = 0.0009 and 0.65, 95% CI 0.53 to 0.81, P = 0.0001, respectively) over two years, compared to placebo. The treatment effects were decreased in the likely-case scenario analyses taking the effect of dropouts into consideration. Both dosages also reduced the annualised relapse rate. Data of active lesions on MRI scans were not combined because there was a high risk of selection bias for MRI outcomes and imprecision of MRI data in both studies, as well as an obvious heterogeneity between the studies. In terms of safety profile, both dosages increased the risk for adverse events and the risk for drug discontinuation due to adverse events. The most common adverse events included flushing and gastrointestinal events (upper abdominal pain, nausea and diarrhoea). Uncommon adverse events included lymphopenia and leukopenia, but they were more likely to happen with dimethyl fumarate than with placebo (high dosage: RR 5.25, 95% CI 2.20 to 12.51, P = 0.0002 and 5.23, 95% CI 2.47 to 11.07, P < 0.0001, respectively; low dosage: RR 5.69, 95% CI 2.40 to 13.46, P < 0.0001 and 6.53, 95% CI 3.13 to 13.64, P < 0.00001, respectively). Both studies had a high attrition bias resulting from the unbalanced reasons for dropouts among groups. Quality of evidence for relapse outcome was moderate, but for disability worsening was low. AUTHORS' CONCLUSIONS There is moderate-quality evidence to support that dimethyl fumarate at a dose of 240 mg orally three times daily or twice daily reduces both the number of patients with a relapse and the annualised relapse rate over two years of treatment in comparison with placebo. However, the quality of the evidence to support the benefit in reducing the number of patients with disability worsening is low. There is no high-quality data available to evaluate the benefit on MRI outcomes. The common adverse effects such as flushing and gastrointestinal events are mild-to-moderate for most patients. Lymphopenia and leukopenia are uncommon adverse events but significantly associated with dimethyl fumarate. Both dosages of dimethyl fumarate have similar benefit and safety profile, which supports the option of low-dose administration. New studies of high quality and long-term follow-up are needed to evaluate the benefit of dimethyl fumarate on prevention of disability worsening and to observe the long-term adverse effects including progressive multifocal leukoencephalopathy.
Collapse
Affiliation(s)
- Zhu Xu
- Affiliated Hospital of Guiyang Medical CollegeDepartment of NeurologyNo. 28, Gui Yi StreetGuiyangGuizhou ProcinceChina550004
| | - Feng Zhang
- Jinan No. 6 People's HospitalDepartment of NeurologyNo. 38, Hui Quan RoadJinanShandong ProvinceChina250200
| | - FangLi Sun
- Jinan No. 6 People's HospitalDepartment of Medical ImagingNo. 38, Hui Quan RoadJinanShandong ProvinceChina250200
| | - KeFeng Gu
- Jinan No. 6 People's HospitalDepartment of Interventional RadiologyNo. 38, Hui Quan RoadJinanShandong ProvinceChina250200
| | - Shuai Dong
- Jinan No. 6 People's HospitalDepartment of NeurologyNo. 38, Hui Quan RoadJinanShandong ProvinceChina250200
| | - Dian He
- Affiliated Hospital of Guiyang Medical CollegeDepartment of NeurologyNo. 28, Gui Yi StreetGuiyangGuizhou ProcinceChina550004
| | | |
Collapse
|
39
|
English C, Aloi JJ. New FDA-Approved Disease-Modifying Therapies for Multiple Sclerosis. Clin Ther 2015; 37:691-715. [DOI: 10.1016/j.clinthera.2015.03.001] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/28/2015] [Accepted: 03/03/2015] [Indexed: 12/21/2022]
|
40
|
Signori A, Schiavetti I, Gallo F, Sormani MP. Subgroups of multiple sclerosis patients with larger treatment benefits: a meta-analysis of randomized trials. Eur J Neurol 2015; 22:960-6. [DOI: 10.1111/ene.12690] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 01/13/2015] [Indexed: 01/21/2023]
Affiliation(s)
- A. Signori
- Biostatistics Unit; Department of Health Sciences; University of Genoa; Genoa Italy
| | - I. Schiavetti
- Biostatistics Unit; Department of Health Sciences; University of Genoa; Genoa Italy
| | - F. Gallo
- Biostatistics Unit; Department of Health Sciences; University of Genoa; Genoa Italy
| | - M. P. Sormani
- Biostatistics Unit; Department of Health Sciences; University of Genoa; Genoa Italy
| |
Collapse
|
41
|
Bomprezzi R. Dimethyl fumarate in the treatment of relapsing-remitting multiple sclerosis: an overview. Ther Adv Neurol Disord 2015; 8:20-30. [PMID: 25584071 DOI: 10.1177/1756285614564152] [Citation(s) in RCA: 212] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Multiple sclerosis (MS) shares an immune-mediated origin with psoriasis. Long-term safety and efficacy data generated in Europe from usage of fumaric acid formulations in the latter disease constituted grounds to investigate their effects in MS patients. Dimethyl fumarate (DMF) was found to be the active principle in those formulations and in vitro studies have demonstrated that DMF has immune-modulatory properties exerted through abilities to divert cytokine production toward a Th2 profile, both on lymphocytes and microglial cells. More importantly, DMF was discovered to impact the anti-oxidative stress cell machinery promoting the transcription of genes downstream to the activation of the nuclear factor (erythroid derived 2)-like2 (NRF2). DMF exposure increases the cytosol concentrations of NRF2, which besides immune regulatory effects, has the potential for cytoprotection on glial cells, oligodendrocytes and neurons. Extensive and rigorous clinical trials have assessed the efficacy and safety of DMF at the dose of 240 mg twice and three times a day in relapsing-remitting MS patients during one phase IIb and two phase III trials. Robust, positive results were obtained across a number of clinical and paraclinical parameters. In one study (DEFINE), the relative reductions of the adjusted annualized relapse rate of the low and high dose regimens in comparison with placebo were 53% and 48%, respectively (p < 0.001 for both comparisons). In the other trial (CONFIRM), DMF decreased the annualized relapse rate in comparison with placebo by 44% in the lower and by 51% in higher dosage group (also p < 0.001). The number and size of lesions as detected by magnetic resonance imaging were also significantly decreased in comparison with the patients receiving DMF at every dosage. Multiple post hoc and subgroup analyses corroborated the clinical data, rendering DMF an appealing medication whose potential for impacting the degenerative aspects of MS remains to be explored.
Collapse
Affiliation(s)
- Roberto Bomprezzi
- Department of Neurology, University of Massachusetts, 55 Lake Avenue North, Worcester, MA 01655, USA
| |
Collapse
|
42
|
Kappos L, Giovannoni G, Gold R, Phillips JT, Arnold DL, Hotermans C, Zhang A, Viglietta V, Fox RJ. Time course of clinical and neuroradiological effects of delayed-release dimethyl fumarate in multiple sclerosis. Eur J Neurol 2015; 22:664-71. [PMID: 25557371 PMCID: PMC4674988 DOI: 10.1111/ene.12624] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 10/17/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Delayed-release dimethyl fumarate (DMF, also known as gastro-resistant DMF), demonstrated efficacy and safety in relapsing-remitting multiple sclerosis in the 2-year, randomized, placebo-controlled, phase 3 DEFINE and CONFIRM trials. A post hoc analysis of integrated data from DEFINE and CONFIRM was conducted to determine the temporal profile of the clinical and neuroradiological effects of DMF. METHODS Eligible patients were randomized to receive placebo, DMF 240 mg twice (BID) or three times (TID) daily or glatiramer acetate (GA; reference comparator; CONFIRM only) for up to 96 weeks. Patients in the GA group were excluded from this analysis. RESULTS A total of 2301 patients were randomized and received treatment with placebo (n = 771) or DMF BID (n = 769) or TID (n = 761). DMF significantly reduced the annualized relapse rate beginning in weeks 0-12 (BID, P = 0.0159; TID, P = 0.0314); the proportion of patients relapsed beginning at week 10 (BID, P = 0.0427) and week 12 (TID, P = 0.0451); and the proportion of patients with 12-week confirmed disability progression beginning at week 62 (BID, P = 0.0454) and week 72 (TID, P = 0.0399), compared with placebo. These effects were sustained throughout the 2-year study period. DMF significantly reduced the odds of having a higher number of gadolinium-enhancing lesions by 88% (BID) and 75% (TID) and the mean number of new or enlarging T2 lesions by 72% (BID) and 67% (TID), from the first post-baseline magnetic resonance imaging assessment at 24 weeks (all P < 0.0001 versus placebo). CONCLUSIONS In phase 3 clinical trials, DMF demonstrated rapid and sustained clinical and neuroradiological efficacy in relapsing-remitting multiple sclerosis.
Collapse
Affiliation(s)
- L Kappos
- Neurology, University Hospital, Basel, Switzerland
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Viglietta V, Miller D, Bar-Or A, Phillips JT, Arnold DL, Selmaj K, Kita M, Hutchinson M, Yang M, Zhang R, Dawson KT, Sheikh SI, Fox RJ, Gold R. Efficacy of delayed-release dimethyl fumarate in relapsing-remitting multiple sclerosis: integrated analysis of the phase 3 trials. Ann Clin Transl Neurol 2014; 2:103-18. [PMID: 25750916 PMCID: PMC4338952 DOI: 10.1002/acn3.148] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 10/23/2014] [Accepted: 10/28/2014] [Indexed: 11/27/2022] Open
Abstract
Objective Obtain a more precise estimate of the efficacy of delayed-release dimethyl fumarate (DMF; also known as gastro-resistant DMF) in relapsing multiple sclerosis (MS) and examine the consistency of DMF's effects across patient subgroups stratified by baseline demographic and disease characteristics. Methods A prespecified integrated analysis of the randomized, double-blind, placebo-controlled, Phase 3 DEFINE and CONFIRM trials was conducted. Results The intent-to-treat population comprised 2301 patients randomized to receive placebo (n = 771) or DMF 240 mg twice daily (BID; n = 769) or three times daily (TID; n = 761). At 2 years, DMF BID and TID reduced the annualized relapse rate by 49% and 49% (both P < 0.0001), risk of relapse by 43% and 47% (both P < 0.0001), risk of 12-week confirmed disability progression by 32% (P = 0.0034) and 30% (P = 0.0059), and risk of 24-week confirmed disability progression by 29% (P = 0.0278) and 32% (P = 0.0177), respectively, compared with placebo. In a subset of patients (MRI cohort), DMF BID and TID reduced the mean number of new/enlarging T2-hyperintense lesions by 78% and 73%, gadolinium-enhancing lesion activity by 83% and 70%, and mean number of new nonenhancing T1-hypointense lesions by 65% and 64% (all P < 0.0001 vs. placebo). Effects were generally consistent across patient subgroups. Interpretation The integrated analysis provides a more precise estimate of DMF's efficacy. DMF demonstrated a robust reduction in disease activity and a consistent therapeutic effect across patient subgroups.
Collapse
Affiliation(s)
| | - David Miller
- Queen Square MS Centre, Institute of Neurology, University College London London, United Kingdom
| | - Amit Bar-Or
- Montreal Neurological Institute and Hospital, McGill University Montreal, Quebec, Canada
| | - J Theodore Phillips
- Multiple Sclerosis Program, Baylor Institute for Immunology Research Dallas, Texas
| | - Douglas L Arnold
- Montreal Neurological Institute and Hospital, McGill University Montreal, Quebec, Canada ; NeuroRx Research Montreal, Quebec, Canada
| | | | - Mariko Kita
- Virginia Mason Multiple Sclerosis Center Seattle, Washington
| | | | | | - Ray Zhang
- Biogen Idec, Inc. Cambridge, Massachusetts
| | | | | | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic Cleveland, Ohio
| | - Ralf Gold
- St Josef Hospital, Ruhr University Bochum, Germany
| |
Collapse
|
44
|
Nixon R, Bergvall N, Tomic D, Sfikas N, Cutter G, Giovannoni G. No evidence of disease activity: indirect comparisons of oral therapies for the treatment of relapsing-remitting multiple sclerosis. Adv Ther 2014; 31:1134-54. [PMID: 25414048 PMCID: PMC4245493 DOI: 10.1007/s12325-014-0167-z] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Indexed: 02/07/2023]
Abstract
Introduction No head-to-head trials have compared the efficacy of the oral therapies, fingolimod, dimethyl fumarate and teriflunomide, in multiple sclerosis. Statistical modeling approaches, which control for differences in patient characteristics, can improve indirect comparisons of the efficacy of these therapies. Methods No evidence of disease activity (NEDA) was evaluated as the proportion of patients free from relapses and 3-month confirmed disability progression (clinical composite), free from gadolinium-enhancing T1 lesions and new or newly enlarged T2 lesions (magnetic resonance imaging composite), or free from all disease measures (overall composite). For each measure, the efficacy of fingolimod was estimated by analyzing individual patient data from fingolimod phase 3 trials using methodologies from studies of other oral therapies. These data were then used to build binomial regression models, which adjusted for differences in baseline characteristics between the studies. Models predicted the indirect relative risk of achieving NEDA status for fingolimod versus dimethyl fumarate or teriflunomide in an average patient from their respective phase 3 trials. Results The estimated relative risks of achieving NEDA status for fingolimod versus placebo in a pooled fingolimod trial population were numerically greater (i.e., fingolimod more efficacious) than the estimated relative risks for dimethyl fumarate or teriflunomide versus placebo in each respective trial population. In indirect comparisons, the predicted relative risks for all composite measures were better for fingolimod than comparator when tested against the trial populations of those treated with dimethyl fumarate (relative risk, clinical: 1.21 [95% confidence interval 1.06–1.39]; overall: 1.67 [1.08–2.57]), teriflunomide 7 mg (clinical: 1.22 [1.02–1.46]; overall: 2.01 [1.38–2.93]) and teriflunomide 14 mg (clinical: 1.14 [0.96–1.36]; overall: 1.61 [1.12–2.31]). Conclusion Our modeling approach suggests that fingolimod therapy results in a higher probability of NEDA than dimethyl fumarate and teriflunomide therapy when phase 3 trial data are indirectly compared and differences between trials are adjusted for. Electronic supplementary material The online version of this article (doi:10.1007/s12325-014-0167-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Richard Nixon
- Novartis Pharma AG, Postfach, 4002, Basel, Switzerland,
| | | | | | | | | | | |
Collapse
|
45
|
Kolb-Sobieraj C, Gupta S, Weinstock-Guttman B. Laquinimod therapy in multiple sclerosis: a comprehensive review. Neurol Ther 2014; 3:29-39. [PMID: 26000222 PMCID: PMC4381916 DOI: 10.1007/s40120-014-0017-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Indexed: 01/19/2023] Open
Abstract
Introduction Multiple sclerosis (MS) is considered an autoimmune disease with inflammatory and neurodegenerative underlying processes that affect the central nervous system. The available disease-modifying therapies (DMTs) approved to treat MS have only shown partial benefit in controlling the disease progression, primarily impeding its inflammatory component, while the parenteral administration of most of these therapies has shown to affect patient compliance. Laquinimod is a promising new oral drug recently evaluated in a third phase III clinical trial that demonstrated beneficial effects in delaying disease progression and preventing brain atrophy, suggesting a potential neuroprotective effect and a favorable safety profile. Areas Covered This is a comprehensive review covering clinical efficacy and safety data obtained from two phase III clinical trials, as well as the presumed beneficial mechanism of action, of laquinimod. This article also provides a short overview of the oral DMTs recently approved for the treatment of relapsing MS, as well as challenges that still remain to be overcome to fully control the relentless course of MS. Conclusion Laquinimod has been shown to have a novel immunomodulatory and potential neuroprotective mechanism of action as suggested from animal models and in vitro experimental data. Phase III clinical trials ALLEGRO (Clinicaltrials.gov #NCT00509145) and BRAVO (Clinicaltrials.gov #NCT00605215) have demonstrated clinical efficacy and tolerability, while the third phase III study is currently evaluating the safety and efficacy of laquinimod at a higher dosage. Emerging oral treatments like laquinimod will provide new options for patients to consider that can lead to better patient adherence and improved outcomes. Electronic supplementary material The online version of this article (doi:10.1007/s40120-014-0017-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Channa Kolb-Sobieraj
- Department of Neurology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, New York, USA ; Baird MS Center, Jacobs Neurological Institute, Buffalo General Medical Center, New York, USA
| | - Sahil Gupta
- Department of Neurology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, New York, USA ; Baird MS Center, Jacobs Neurological Institute, Buffalo General Medical Center, New York, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, New York, USA ; Baird MS Center, Jacobs Neurological Institute, Buffalo General Medical Center, New York, USA
| |
Collapse
|
46
|
Kawalec P, Mikrut A, Wiśniewska N, Pilc A. The effectiveness of dimethyl fumarate monotherapy in the treatment of relapsing-remitting multiple sclerosis: a systematic review and meta-analysis. Curr Neuropharmacol 2014; 12:256-68. [PMID: 24851089 PMCID: PMC4023455 DOI: 10.2174/1570159x12666140115214801] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 12/27/2013] [Accepted: 01/13/2014] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Dimethyl fumarate (BG-12, Tecfidera®) is a new oral drug approved by FDA and EMA in March 2013 for relapsing - remitting multiple sclerosis (RRMS). The drug was much anticipated because of its possible superiority over currently available medications: fingolimod and teriflunomide as the only MS treatments currently available in oral form. OBJECTIVE The aim of this systematic review with meta-analysis was to assess the efficacy and safety of BG-12 in the treatment of RRMS. METHODS A systematic literature search was conducted in Medline/PubMed, EMBASE, and Cochrane Library up till 3(rd) November, 2013. We sought all published randomized clinical trials evaluating the use of dimethyl fumarate for the treatment of patients with RRMS. All included studies were critically appraised and analyzed with the use of Review Manager 5.1.0. software according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement protocol. RESULTS Two trials, DEFINE and CONFIRM involved 2 651 patients and compared dimethyl fumarate taken either two or three times daily with placebo in patients with RRMS. Additionally in CONFIRM trial third group of patients received glatiramer acetate. The overall results of the meta-analysis showed that BG-12 (at both dosages) given to patients with RRMS is safe and statistically significantly more effective than placebo in reducing the proportion of patients who had a relapse by 2 years, the rate of disability progression and the mean number of gadolinium-enhancing lesions at 2 years. The comparison between BG-12 and glatiramer acetate revealed that the analyzed agent could potentially be more effective in the treatment of RRMS. CONCLUSIONS Despite limited RCTs data available, both analyzed BG-12 regimens showed their efficacy on clinical disease parameters and other measures of disease activity in RRMS. The safety profile of the study agent was acceptable.
Collapse
Affiliation(s)
- Paweł Kawalec
- Jagiellonian University Medical College, Faculty of Health Sciences, Institute of Public Health, Department of Drug
Management, Krakow, Poland
| | | | | | - Andrzej Pilc
- Jagiellonian University Medical College, Faculty of Health Sciences, Institute of Public Health, Department of Drug
Management, Krakow, Poland
- Institute of Pharmacology, Polish Academy of Sciences, 31-343 Kraków, Poland
| |
Collapse
|
47
|
Dimethyl fumarate for treatment of multiple sclerosis: mechanism of action, effectiveness, and side effects. Curr Neurol Neurosci Rep 2014; 13:394. [PMID: 24061646 DOI: 10.1007/s11910-013-0394-8] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Dimethyl fumarate is an orally available treatment option for relapsing-remitting multiple sclerosis (MS) in a new formulation with improved gastroenteric coating. The mode of action comprises immunomodulatory effects and an activation of nuclear (erythroid-derived 2) related factor mediated antioxidative response pathways leading to additional cytoprotective effects. In two pivotal phase III trials, dimethyl fumarate, 240 mg twice daily, reduced relapse rates by about 50 % as compared with placebo. In the DEFINE trial, progression of disability was also significantly reduced. Both trials demonstrated a significant reduction of gadolinium-enhanced lesions as well as T2 lesions on cranial MRI. The studies revealed a beneficial safety profile of dimethyl fumarate. The most prevalent side effects were transient flushing and gastrointestinal tract irritation. Dimethyl fumarate has recently been approved in the USA for the treatment of relapsing-remitting MS. The compound is a welcome addition to the immunomodulatory treatment armamentarium for MS patients and physicians alike.
Collapse
|
48
|
Xu Z, Zhang F, Sun F, Gu K, Dong S, He D. Dimethyl fumarate for multiple sclerosis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
49
|
Abstract
Dimethyl fumarate (Tecfidera®) is a novel oral therapy that has recently been approved for the treatment of relapsing forms of multiple sclerosis (MS) and relapsing-remitting MS (RRMS). In preclinical studies, dimethyl fumarate exhibited anti-inflammatory and cytoprotective properties that are generally thought to be mediated via activation of the nuclear factor (erythroid-derived 2)-like 2 transcriptional pathway, which is involved in the cellular response to oxidative stress. In the large, double-blind, multinational, 2-year DEFINE and CONFIRM trials conducted in over 2,600 adult patients with RRMS, twice-daily oral dimethyl fumarate 240 mg was effective in reducing the proportion of patients with MS relapse at 2 years (primary endpoint of DEFINE) and the annualized relapse rate (primary endpoint of CONFIRM) compared with placebo, with reduced disability progression also observed with the drug versus placebo in DEFINE. Dimethyl fumarate also reduced disease activity measures relative to placebo in these trials, as assessed by magnetic resonance imaging. Dimethyl fumarate was generally well tolerated in patients with RRMS; adverse events that occurred more frequently in dimethyl fumarate than in placebo recipients included flushing and gastrointestinal events. The long-term efficacy and tolerability of dimethyl fumarate is currently being investigated in the ENDORSE trial, with interim results demonstrating that dimethyl fumarate was associated with continued efficacy for up to 4 years of treatment, with no new tolerability concerns. In conclusion, although more comparative data are needed to fully establish the relative efficacy and tolerability of dimethyl fumarate compared with other therapies, oral dimethyl fumarate is an important addition to the therapeutic options available for RRMS.
Collapse
|
50
|
Bar-Or A, Gold R, Kappos L, Arnold DL, Giovannoni G, Selmaj K, O'Gorman J, Stephan M, Dawson KT. Clinical efficacy of BG-12 (dimethyl fumarate) in patients with relapsing-remitting multiple sclerosis: subgroup analyses of the DEFINE study. J Neurol 2014; 260:2297-305. [PMID: 23797999 DOI: 10.1007/s00415-013-6954-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 05/02/2013] [Accepted: 05/03/2013] [Indexed: 01/21/2023]
Abstract
In the double-blind, placebo-controlled, Phase 3 DEFINE study in patients with relapsing–remitting multiple sclerosis, oral BG-12 (dimethyl fumarate) significantly reduced the proportion of patients relapsed (primary endpoint), the annualized relapse rate (ARR), and confirmed disability progression (secondary endpoints) at two years compared with placebo. We investigated the efficacy of BG-12 240 mg twice daily (BID) and three times daily (TID) in patient subgroups stratified according to baseline demographic and disease characteristics including gender, age, relapse history, McDonald criteria, treatment history, expanded disability status scale score, T2 lesion volume, and gadolinium-enhancing lesions. The clinical efficacy of BG-12 was generally consistent across patient subgroups and reflected positive findings in the overall DEFINE study population. Treatment with BG-12 BID and TID reduced the proportion of patients relapsed and the ARR at two years compared with placebo in all patient subgroups. Reductions in the risk of relapse with BG-12 BID vs. placebo ranged from 68% [hazard ratio 0.32 (95% confidence interval (CI) 0.16-0.62)] to 26% [0.74 (0.51-1.09)] and from 66% [0.34 (0.23-0.50)] to 25% [0.75 (0.42-1.36)] with BG-12 TID vs. placebo. BG-12 also reduced the risk of disability progression at two years compared with placebo in most subgroups of patients treated with the BID dosing regimen and in all subgroups treated with the TID regimen. These analyses indicate that treatment with BG-12 is consistently effective across a wide spectrum of patients with relapsing–remitting multiple sclerosis with varied demographic and disease characteristics.
Collapse
Affiliation(s)
- Amit Bar-Or
- Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|