The spectrum of multiple sclerosis

Pharmacometrics: The Already-Present Future of Precision Pharmacology

The use of mathematical modeling to represent, analyze, make predictions or providing information on data obtained in drug research and development has made pharmacometrics an area of great prominence and importance. The main purpose of pharmacometrics is to provide information relevant to the search for efficacy and safety improvements in pharmacotherapy. Regulatory agencies have adopted pharmacometrics analysis to justify their regulatory decisions, making those decisions more efficient. Demand for specialists trained in the field is therefore growing. In this review, we describe the meaning, history, and development of pharmacometrics, analyzing the challenges faced in the training of professionals. Examples of applications in current use, perspectives for the future, and the importance of pharmacometrics for the development and growth of precision pharmacology are also presented.

Two Sides to Every Story: Perspectives from Four Patients and a Healthcare Professional on Multiple Sclerosis Disease Progression

Abstract

Multiple sclerosis (MS) is a chronic progressive disease and many patients transition from an initial relapsing–remitting course to a secondary progressive pattern. Accurate classification of disease status is critical to ensure that patients are treated appropriately and kept informed of their prognosis. Consensus terms defining the different forms of MS are available but were developed primarily for healthcare professionals (HCPs) and may be of limited value to patients. This article provides direct insights from four patients with MS, at different points in their disease trajectory, regarding their understanding of, and attitudes toward, MS progression. We also examine the utility of the current classification systems from the perspectives of patients and HCPs. Responses collected during in-depth, structured interviews and questionnaires portrayed the difficulties patients face accepting their MS diagnosis and treatment, revealed how understanding of the term “disease progression” varies considerably, and highlighted the challenges surrounding the period of transition to secondary progressive MS (SPMS). The terms describing different MS types were considered confusing and can make patients feel “compartmentalized” or “labeled”. Patients also struggled to relate these terms to their reality of living with MS, were reluctant to discuss progression with their HCPs, and feared being diagnosed with SPMS owing to concerns about treatment access. These insights highlight the need to develop patient-friendly language to describe MS progression; it may also be preferable for HCPs to describe MS as a disease spectrum in discussions with their patients.

Funding

Novartis Pharmaceuticals Corporation.

Plain Language Summary

Plain language summary available for this article.

Meeting the needs of people with primary progressive multiple sclerosis, their families, and the health-care community

Although major advances have been made in delaying or preventing progression for the relapsing forms of multiple sclerosis (MS), little progress has been made to date in disease management for primary progressive MS (PPMS). Treatment strategies are largely focused on managing the symptoms of the disease and providing counseling and other forms of psychosocial support. The nurse plays a major role in managing these patients. This article summarizes a collaborative effort by the National Multiple Sclerosis Society and the Multiple Sclerosis Association of America to analyze the needs of this patient population and respond with programs that will meet those needs. This approach to developing a needs assessment is broadly applicable to other patient populations.

Autophagy, inflammation and neurodegenerative disease

Autophagy is emerging as a central regulator of cellular health and disease and, in the central nervous system (CNS), this homeostatic process appears to influence synaptic growth and plasticity. Herein, we review the evidence that dysregulation of autophagy may contribute to several neurodegenerative diseases of the CNS. Up-regulation of autophagy may prevent, delay or ameliorate at least some of these disorders, and - based on recent findings from our laboratory - we speculate that this goal may be achieved using a safe, simple and inexpensive approach.

Update on inflammation, neurodegeneration, and immunoregulation in multiple sclerosis: therapeutic implications

Multiple sclerosis (MS) is an inflammatory, demyelinating, and neurodegenerative disease of the central nervous system of uncertain etiology. There is consensus that a dysregulated immune system plays a critical role in the pathogenesis of MS; therefore, we aim to summarize current hypotheses concerning the complex cellular and molecular interactions involved in the immunopathology of MS. Although CD4+ T lymphocytes have long been implicated in the immunopathology of MS, the role of other T-cell subtypes has been recognized. CD4+ and CD8+ cells have been isolated from different locations within MS lesions and gamma/delta T cells have been isolated from early MS lesions. The prevalent dogma has been that CD4+ TH1 cells release cytokines and mediators of inflammation that may cause tissue damage, although CD4+ TH2 cells may be involved in modulation of these effects. Recent evidence, however, suggests that additional T-cell subsets play a prominent role in MS immunopathology: TH17 cells, CD8+ effector T cells, and CD4+CD25+ regulatory T cells. In addition, laboratory and clinical data are accumulating on the prominent role of B lymphocytes and antigen-presenting cells in MS pathogenesis. On the basis of these observations, new therapeutic approaches for MS will need to focus on resetting multiple components of the immune system.

Opticospinal multiple sclerosis in Iran

Clinical course, magnetic resonance imaging (MRI) findings and cerebrospinal fluid data (CSF) on 20 patients among 520 with clinically definite multiple sclerosis (MS) according to the criteria of Poser et al., with opticospinal clinical presentation above 5 years and mean disease duration of 8+/-4.4 years were reviewed. The prevalence rate was 3.8%. The clinical course was relapsing-remitting (RR) for all patients. The mean age of onset was 24+/-8.2 years. The gender ratio was 2.3:1 female:male. First clinical presentation was spinal signs in 12 (60%), optic neuritis in 7 (35%) and simultaneous involvement of both eyes in 1 (5%) patient. No transverse myelitis (TM), sustained severe optic neuritis (SSON) or minor brain stem signs were recorded. No conversion to conventional MS (CMS) or secondary progressive MS (SPMS) was identified during the study period and no case had positive family history for the disease. The yearly number of attacks was 0.66+/-0.84, with mean Kurtzke expanded disability status scale (EDSS) of 2.5+/-1.2. All patients had 1 to 5 hemispheral T2 lesions in brain MRI, non-fulfilled Barkhof criteria for brain lesions. All had preventricular and 14 (70%) had juxtacortical lesions. None had gadolinium T1 enhanced lesions. No involvement of the brainstem or cerebellar structures was detected. Fifteen had 1 cervical lesion, five had 2 and four had 1 concomitant thoracic cord signal, all extending below three vertebral segments in sagittal planes with peripheral white matter location on the axial planes. Spinal fluid contained normal cell and protein with negative oligoclonal bands (OB).

Oligodendroglial impact on axonal function and survival - a hypothesis

PURPOSE OF REVIEW

Although multiple sclerosis is considered the prototype of a primary autoimmune disease in the central nervous system, there is emerging evidence that primary oligodendrocyte dysfunctions can suffice to trigger a secondary immune response in the nervous system. This short review focuses on the possible primary role of oligodendrocytes in axon loss and inflammatory demyelination.

RECENT FINDINGS

The analysis of natural and engineered mouse mutants has provided unexpected insight into oligodendrocyte function beyond that of axonal myelination for rapid impulse propagation. Specifically, mutations in some genes thought to be required for myelin assembly revealed an additional role of oligodendrocytes in supporting long-term axonal function and survival. Other mutations have been reported that cause both central nervous system demyelination and neuroinflammation, with pathological features known from human leukodystrophy patients. In human multiple sclerosis, demyelination leads invariably to axon loss, but the underling pathomechanisms may not be restricted to that of a primary immune-mediated disorder.

SUMMARY

Collectively, experimental and pathological findings point to a primary role of myelinating glia in long-term axonal support and suggest that defects of lipid metabolism in oligodendrocytes contribute to inflammatory myelin diseases.