Effects on cognition of DMTs in multiple sclerosis: moving beyond the prevention of inflammatory activity

Managing cognitive impairment and its impact in multiple sclerosis: An Australian multidisciplinary perspective

Cognitive impairment in multiple sclerosis (MS) affects approximately 40-70% of patients and can have varying degrees of severity. Even mild cognitive impairment can impact on quality of life and productivity. Despite this, patients are not routinely screened or monitored for cognitive impairment in Australia due to a range of issues, with time and space being the main limiting factors. This Australian multidisciplinary perspective provides recommendations on cognition management in Australia. It gives a broad overview of cognition in MS, advice on the screening and monitoring tools available to clinicians, and strategies that can be implemented in clinics to help monitor for cognitive impairment in patients with MS. We suggest a routine baseline assessment and multidomain cognitive battery in regular intervals; a change should trigger a thorough investigation of the cause.

Depressive symptoms, anxiety and cognitive impairment: emerging evidence in multiple sclerosis

Neuropsychiatric abnormalities may be broadly divided in two categories: disorders of mood, affect, and behavior and abnormalities affecting cognition. Among these conditions, clinical depression, anxiety and neurocognitive disorders are the most common in multiple sclerosis (MS), with a substantial impact on patients' quality of life and adherence to treatments. Such manifestations may occur from the earliest phases of the disease but become more frequent in MS patients with a progressive disease course and more severe clinical disability. Although the pathogenesis of these neuropsychiatric manifestations has not been fully defined yet, brain structural and functional abnormalities, consistently observed with magnetic resonance imaging (MRI), together with genetic and immunologic factors, have been suggested to be key players. Even though the detrimental clinical impact of such manifestations in MS patients is a matter of crucial importance, at present, they are often overlooked in the clinical setting. Moreover, the efficacy of pharmacologic and non-pharmacologic approaches for their amelioration has been poorly investigated, with the majority of studies showing marginal or no beneficial effect of different therapeutic approaches, possibly due to the presence of multiple and heterogeneous underlying pathological mechanisms and intrinsic methodological limitations. A better evaluation of these manifestations in the clinical setting and improvements in the understanding of their pathophysiology may offer the potential to develop tools for differentiating these mechanisms in individual patients and ultimately provide a principled basis for treatment selection. This review provides an updated overview regarding the pathophysiology of the most common neuropsychiatric symptoms in MS, the clinical and MRI characteristics that have been associated with mood disorders (i.e., depression and anxiety) and cognitive impairment, and the treatment approaches currently available or under investigation.

Does Ocrelizumab Limit Multiple Sclerosis Progression? Current Evidence from Clinical, MRI, and Fluid Biomarkers

Multiple sclerosis (MS) is a chronic inflammatory, demyelinating, and neurodegenerative disease affecting the central nervous system, often characterized by the accumulation of irreversible clinical disability over time. In recent years, there has been a dramatic evolution in several key concepts of MS treatment. The demonstration of the effects of ocrelizumab, a selective monoclonal antibody against CD20+ B cells, has significantly modified our knowledge of the immune-pathophysiology of MS and has provided a new therapeutic target for relapsing and progressive MS patients. Emerging findings suggest that, besides its strong anti-inflammatory activity, ocrelizumab may limit disability progression and may exert beneficial effects on cognitive function, fatigue, and quality of life of MS patients. The significant reductions of the rate of global and regional brain atrophy and of serum neurofilament light chain levels, which were found to be partially independent of overt inflammatory activity, suggest that this treatment may also limit neuro-axonal damage. By discussing the most recent evidence regarding the effects of ocrelizumab on clinical measures as well as on magnetic resonance imaging and fluid biomarkers, this review summarizes current knowledge on the possible mechanisms underlying the effects of ocrelizumab in limiting MS progression and neurodegeneration.

Early use of high-efficacy disease‑modifying therapies makes the difference in people with multiple sclerosis: an expert opinion

Multiple sclerosis (MS) is a chronic and progressive neurological disease that is characterized by neuroinflammation, demyelination and neurodegeneration occurring from the earliest phases of the disease and that may be underestimated. MS patients accumulate disability through relapse-associated worsening or progression independent of relapse activity. Early intervention with high-efficacy disease-modifying therapies (HE-DMTs) may represent the best window of opportunity to delay irreversible central nervous system damage and MS-related disability progression by hindering underlying heterogeneous pathophysiological processes contributing to disability progression. In line with this, growing evidence suggests that early use of HE-DMTs is associated with a significant greater reduction not only of inflammatory activity (clinical relapses and new lesion formation at magnetic resonance imaging) but also of disease progression, in terms of accumulation of irreversible clinical disability and neurodegeneration compared to delayed HE-DMT use or escalation strategy. These beneficial effects seem to be associated with acceptable long-term safety risks, thus configuring this treatment approach as that with the most positive benefit/risk profile. Accordingly, it should be mandatory to treat people with MS early with HE-DMTs in case of prognostic factors suggestive of aggressive disease, and it may be advisable to offer an HE-DMT to MS patients early after diagnosis, taking into account drug safety profile, disease severity, clinical and/or radiological activity, and patient-related factors, including possible comorbidities, family planning, and patients’ preference in agreement with the EAN/ECTRIMS and AAN guidelines. Barriers for an early use of HE-DMTs include concerns for long-term safety, challenges in the management of treatment initiation and monitoring, negative MS patients’ preferences, restricted access to HE-DMTs according to guidelines and regulatory rules, and sustainability. However, these barriers do not apply to each HE-DMT and none of these appear insuperable.

Comparing diagnostic criteria for the diagnosis of neurocognitive disorders in multiple sclerosis

BACKGROUND

People with multiple sclerosis (MS) commonly experience cognitive impairment associated with the disease, but there is currently no agreed-upon operational definition for identifying the presence of that impairment, in either research or clinic contexts. The International MS Cognition Society (IMSCOGS) established a task force to begin to examine this issue and this paper represents the results of an initial pilot investigation. The aim of this paper was to compare two criterion sets to determine how to identify cognitive impairment among people with MS: the general Diagnostic and Statistical Manual (DSM-5) Criteria for neurocognitive disorders and criteria derived from existing MS research (scores in two domains fall 1.5 standard deviations below normative controls).

METHODS

Two hundred and ten people with MS presented for a brief cognitive evaluation in an MS Multidisciplinary Clinic at a midwestern academic medical center in the United States. Participants were generally middle aged (average 51.5 years), female (73.8%), and white (93.3%). McNemar's test was computed to compare the number of individuals whose cognitive test score performance was deemed cognitively normal, mildly impaired, or more significantly impaired.

RESULTS

DSM-5 criteria classified 87.2% of the sample as cognitively impaired, where 66.7% were more mildly impaired and 20.5% more significantly impaired. By contrast, research-based criteria classified 63.3% of the sample as cognitively impaired, with 49.5% as mildly impaired and 13.8% as more significantly impaired.

CONCLUSIONS

These findings indicate that compared to research criteria, the DSM-5 criteria classified far more people with MS as having cognitive impairment secondary to the disease. The paper discusses the potential benefits and drawbacks of the two diagnostic methods, highlighting that more work will be needed in order to establish a standardized and validated method for characterizing these impairments.