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Abstract
Interferon beta and glatiramer acetate have been mainstays of treatment in relapsingremitting multiple sclerosis for two decades. Remarkable advances in our understanding of immune function and dysfunction as well as increasingly sophisticated clinical trial design have stemmed from efforts to better understand these drugs. In this chapter, we review the history of their development and elaborate on known and theorized mechanisms of action. We describe the pivotal clinical trials that have led to their widespread use. We evaluate the clinical use of the drugs including tolerability, side effects, and efficacy measures. Finally, we look to the future of interferon beta and glatiramer acetate in the context of an ever growing armamentarium of treatments for relapsing remitting multiple sclerosis.
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Affiliation(s)
- Corey A McGraw
- Department of Neurology, Albert Einstein College of Medicine, Division of Multiple Sclerosis, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467, USA.
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Lindsey J, Scott T, Lynch S, Cofield S, Nelson F, Conwit R, Gustafson T, Cutter G, Wolinsky J, Lublin F. The CombiRx trial of combined therapy with interferon and glatiramer cetate in relapsing remitting MS: Design and baseline characteristics. Mult Scler Relat Disord 2012; 1:81-6. [PMID: 22754793 DOI: 10.1016/j.msard.2012.01.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/04/2012] [Accepted: 01/16/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND: Interferon-β1a (IFNB) and glatiramer acetate (GA) are distinct therapies which are both partially effective for relapsing MS. It is not known if combining the two treatments would be more effective. OBJECTIVE: To review the rationale, design, and baseline characteristics of the CombiRx study of combined treatment with IFNB and GA. METHODS: The key inclusion criteria included a diagnosis of relapsing MS, at least 2 episodes of MS activity in the previous 3 years, expanded disability status scale of 0 to 5.5, and no prior treatment with either IFNB or GA. Subjects were randomized to IFNB+GA, IFNB monotherapy, or GA monotherapy in a 2:1:1 ratio. RESULTS: From 2005 to 2009, we enrolled 1008 subjects. The participants were 72.4% female and 87.6% Caucasian with a mean age of 37.7 years. The median duration of symptoms was 2 years at entry into the study, and the mean EDSS was 2.1. On the baseline MRI, the mean total lesion load was 12.2 ml, and 40% of the participants had enhancing lesions. CONCLUSION: We have recruited a population of patients with clinical and MRI characteristics typical for early MS. The study results will aid in deciding on the optimum early treatment. This trial should serve as a model for future studies of combination therapy.
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Affiliation(s)
- Jw Lindsey
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
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The prospects of minocycline in multiple sclerosis. J Neuroimmunol 2011; 235:1-8. [PMID: 21565409 DOI: 10.1016/j.jneuroim.2011.04.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 04/11/2011] [Accepted: 04/12/2011] [Indexed: 12/21/2022]
Abstract
Multiple sclerosis (MS) is the most common inflammatory demyelinating disease of the central nervous system (CNS). Although there are several approved drugs for MS, not all patients respond optimally to these drugs. More effective, well-tolerated therapeutic strategies for MS are necessary, either through the development of new medication or combination of existing ones. Minocycline is a traditional antibiotic with profound anti-inflammatory and neuroprotective effects and good tolerance for long-term use. The encouraging results from the animal model and clinical experiments on minocycline make it a promising candidate for MS treatment whether used alone or combined with other drugs. In this review, we summarized the pharmacological actions of minocycline and focused on its therapeutic effects and safety in experimental autoimmune encephalomyelitis (EAE) and MS. The data obtained here showed that minocycline would be an effective and safe therapy for MS.
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Sättler MB, Bähr M. Future neuroprotective strategies. Exp Neurol 2010; 225:40-7. [DOI: 10.1016/j.expneurol.2009.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 08/18/2009] [Accepted: 08/19/2009] [Indexed: 12/27/2022]
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Niino M, Sasaki H. Update on the treatment options for multiple sclerosis. Expert Rev Clin Immunol 2010; 6:77-88. [PMID: 20383893 DOI: 10.1586/eci.09.75] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recent progress in the treatment of multiple sclerosis (MS) is remarkable, and the introduction of new therapies is yielding improvements in the management of MS. Furthermore, clinical trials with many different types of agents, especially selected monoclonal antibodies, have been undertaken or are ongoing, and some of the agents involved will probably be available as treatments for MS in the near future. Although these new and promising agents include targeted immunotherapies, some of them have limitations such as associated severe adverse events and the development of neutralizing antibodies. With regard to risk-benefit ratios, pharmacogenetics could shed light on inherited differences in drug metabolism and response, which would make individualized therapy possible in MS. Here, we review the recent progress in current therapeutic strategies for MS, and the potential options for future MS treatment.
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Affiliation(s)
- Masaaki Niino
- Department of Neurology, Hokkaido University Graduate School of Medicine, Kita-15 Nishi-7, Kita-ku, Sapporo 060-8638, Japan.
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Abstract
Multiple sclerosis is a chronic inflammatory and demyelinating disease of the central nervous system and the leading cause of neurologic disability in young adults. Established therapies, such as interferon and glatiramer, have only partial effects, and they offer limited or no effect on the progression of multiple sclerosis. The etiology of multiple sclerosis is unclear; however, the disease is presumed to be a T-cell-mediated autoimmune disease influenced by genetic and environmental factors. Therefore, targeting of lymphocytes may be a promising means of therapy for multiple sclerosis. Daclizumab is a humanized monoclonal antibody approved for use in preventing renal allograft rejection. The agent is under investigation in phase II trials for the treatment of multiple sclerosis and has demonstrated positive clinical outcomes, including decreased relapse rates. Adverse events included urinary tract infections, respiratory tract infections, paresthesias, mild leukopenia, transient elevations in liver enzyme and bilirubin levels, rash, postinfusion reactions (fever), lymphadenopathy, transient thrombocytopenia, and nausea. Daclizumab may be an alternative or add-on therapy when conventional immunomodulators fail or when existing approved therapies cannot be used. Besides ongoing phase II trials, additional phase II or III trials are required to determine the extended benefits of the agent, as well as clinical outcomes.
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Affiliation(s)
- Sylvia E Kim
- Department of Pharmacy, Madigan Army Medical Center, Tacoma, Washington 98431, USA.
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Paintlia AS, Paintlia MK, Singh I, Skoff RB, Singh AK. Combination therapy of lovastatin and rolipram provides neuroprotection and promotes neurorepair in inflammatory demyelination model of multiple sclerosis. Glia 2009; 57:182-93. [PMID: 18720408 DOI: 10.1002/glia.20745] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Drug combination therapies for central nervous system (CNS) demyelinating diseases including multiple sclerosis (MS) are gaining momentum over monotherapy. Over the past decade, both in vitro and in vivo studies established that statins (HMG-CoA reductase inhibitors) and rolipram (phosphodiesterase-4 inhibitor; blocks the degradation of intracellular cyclic AMP) can prevent the progression of MS in affected individuals via different mechanisms of action. In this study, we evaluated the effectiveness of lovastatin (LOV) and rolipram (RLP) in combination therapy to promote neurorepair in an inflammatory CNS demyelination model of MS, experimental autoimmune encephalomyelitis (EAE). Combination treatment with suboptimal doses of these drugs in an established case of EAE (clinical disease score > or = 2.0) significantly attenuated the infiltration of inflammatory cells and protected myelin sheath and axonal integrity in the CNS. It was accompanied with elevated level of cyclic AMP and activation of its associated protein kinase A. Interestingly, combination treatment with these drugs impeded neurodegeneration and promoted neurorepair in established EAE animals (clinical disease score > or = 3.5) as verified by quantitative real-time polymerase chain reaction, immunohistochemistry and electron microscopic analyses. These effects of combination therapy were minimal and/or absent with either drug alone in these settings. Together, these data suggest that combination therapy with LOV and RLP has the potential to provide neuroprotection and promote neurorepair in MS, and may have uses in other related CNS demyelinating diseases.
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Affiliation(s)
- Ajaib S Paintlia
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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Novel therapeutic strategies for multiple sclerosis--a multifaceted adversary. Nat Rev Drug Discov 2008; 7:909-25. [PMID: 18974749 DOI: 10.1038/nrd2358] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Therapeutic strategies for multiple sclerosis have radically changed in the past 15 years. Five regulatory-approved immunomodulatory agents are reasonably effective in the treatment of relapsing-remitting multiple sclerosis, and appear to delay the time to progression to disabling stages. Inhibiting disease progression remains the central challenge for the development of improved therapies. As understanding of the immunopathogenesis of multiple sclerosis has advanced, a number of novel potential therapeutics have been identified, and are discussed here. It has also become apparent that traditional views of multiple sclerosis simply as a CD4+ T-cell-mediated disease of the central nervous system are incomplete. The pathogenic role of other immune components such as the innate immune system, regulatory T cells, T helper 17 cells and B cells is reaching centre stage, opening up exciting avenues and novel potential targets to affect the natural course of multiple sclerosis.
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Strain-specific susceptibility for neurodegeneration in a rat model of autoimmune optic neuritis. J Neuroimmunol 2008; 193:77-86. [DOI: 10.1016/j.jneuroim.2007.10.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 10/22/2007] [Accepted: 10/22/2007] [Indexed: 11/20/2022]
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Costello F, Stüve O, Weber MS, Zamvil SS, Frohman E. Combination therapies for multiple sclerosis: scientific rationale, clinical trials, and clinical practice. Curr Opin Neurol 2007; 20:281-5. [PMID: 17495621 DOI: 10.1097/wco.0b013e328122de1b] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW To outline the scientific rationale for combination therapy in multiple sclerosis and to discuss the evidence for combination treatment strategies from animal models and clinical trials of multiple sclerosis. RECENT FINDINGS Experiments conducted in experimental autoimmune encephalomyelitis have recently shown beneficial effects of numerous combination therapies. The combination of approved and experimental drugs and two or more experimental agents may positively impact clinical disease activity, inflammation within the central nervous system, and neurorepair. Clinical trials are currently underway to establish the therapeutic efficacy and safety of various combination therapies for multiple sclerosis patients. SUMMARY More effective therapies are needed to treat multiple sclerosis. There are good scientific rationales for the use of combination therapy in multiple sclerosis, and the pharmacologic principles for evaluating and understanding their actions are available. The evaluation of specific combination therapies in the controlled setting of clinical trials should be a priority in clinical multiple sclerosis research.
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Affiliation(s)
- Fiona Costello
- Departments of Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
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Vaknin-Dembinsky A, Weiner HL. Relationship of immunologic abnormalities and disease stage in multiple sclerosis: implications for therapy. J Neurol Sci 2007; 259:90-4. [PMID: 17521671 DOI: 10.1016/j.jns.2006.11.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2006] [Revised: 10/13/2006] [Accepted: 11/10/2006] [Indexed: 11/25/2022]
Abstract
Multiple sclerosis is classified as an inflammatory cell-mediated autoimmune disease directed against central nervous system myelin. Different stages of disease appear to be related to different patterns of inflammation and changes on MRI. It is postulated that the lack of response to anti-inflammatory drugs in the secondary progressive stage relates to a neurodegenerative component that is immune independent. However, there is also evidence that the immune system itself is more abnormal in the secondary progressive phase according to a number of immune measures including dendritic cell function in the peripheral blood. Furthermore, neuropathologic studies suggest that there is inflammation in the brain of MS patients in the progressive stages in which inflammation takes a different form that includes a diffuse inflammatory process in the brain and activation of microglial cells. In summary, this implies that there may be different types of inflammation depending on the stage of MS with abnormalities in adaptive immunity playing an important role in the relapsing-remitting stage and innate immunity a more important role in the progressive stage.
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Affiliation(s)
- Adi Vaknin-Dembinsky
- Center for Neurologic Diseases and Partners Multiple Sclerosis Center, 77 Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 USA
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Argaw AT, Zhang Y, Snyder BJ, Zhao ML, Kopp N, Lee SC, Raine CS, Brosnan CF, John GR. IL-1beta regulates blood-brain barrier permeability via reactivation of the hypoxia-angiogenesis program. THE JOURNAL OF IMMUNOLOGY 2007; 177:5574-84. [PMID: 17015745 DOI: 10.4049/jimmunol.177.8.5574] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Loss of blood-brain barrier (BBB) integrity is believed to be an early and significant event in lesion pathogenesis in the inflammatory demyelinating disease multiple sclerosis (MS), and understanding mechanisms involved may lead to novel therapeutic avenues for this disorder. Well-differentiated endothelium forms the basis of the BBB, while astrocytes control the balance between barrier stability and permeability via production of factors that restrict or promote vessel plasticity. In this study, we report that the proinflammatory cytokine IL-1beta, which is prominently expressed in active MS lesions, causes a shift in the expression of these factors to favor plasticity and permeability. The transcription factor, hypoxia inducible factor-1 (HIF-1), plays a significant role in this switch. Using a microarray-based approach, we found that in human astrocytes, IL-1beta induced the expression of genes favoring vessel plasticity, including HIF-1alpha and its target, vascular endothelial growth factor-A (VEGF-A). Demonstrating relevance to MS, we showed that HIF-1alpha and VEGF-A were expressed by reactive astrocytes in active MS lesions, while the VEGF receptor VEGFR2/flk-1 localized to endothelium and IL-1 to microglia/macrophages. Suggesting functional significance, we found that expression of IL-1beta in the brain induced astrocytic expression of HIF-1alpha, VEGF-A, and BBB permeability. In addition, we confirmed VEGF-A to be a potent inducer of BBB permeability and angiogenesis, and demonstrated the importance of IL-1beta-induced HIF-1alpha in its regulation. These results suggest that IL-1beta contributes to BBB permeability in MS via reactivation of the HIF-VEGF axis. This pathway may represent a potential therapeutic target to restrict lesion formation.
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Affiliation(s)
- Azeb Tadesse Argaw
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY 10029, USA
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Paintlia AS, Paintlia MK, Singh I, Singh AK. Immunomodulatory effect of combination therapy with lovastatin and 5-aminoimidazole-4-carboxamide-1-beta-D-ribofuranoside alleviates neurodegeneration in experimental autoimmune encephalomyelitis. THE AMERICAN JOURNAL OF PATHOLOGY 2006; 169:1012-25. [PMID: 16936274 PMCID: PMC1698815 DOI: 10.2353/ajpath.2006.051309] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Combination therapy with multiple sclerosis (MS) therapeutics is gaining momentum over monotherapy for improving MS. Lovastatin, an HMG-CoA reductase inhibitor (statin), was immunomodulatory in an experimental autoimmune encephalomyelitis (EAE) model of MS. Lovastatin biases the immune response from Th1 to a protective Th2 response in EAE by a different mechanism than 5-aminoimidazole-4-carboxamide-1-beta-D-ribofuranoside, an immunomodulating agent that activates AMP-activated protein kinase. Here we tested these agents in combination in an EAE model of MS. Suboptimal doses of these drugs in combination were additive in efficacy against the induction of EAE; clinical symptoms were delayed and severity and duration of disease was reduced. In the central nervous system, the cellular infiltration and proinflammatory immune response was decreased while the anti-inflammatory immune response was increased. Combination treatment biased the class of elicited myelin basic protein antibodies from IgG2a to IgG1 and IgG2b, suggesting a shift from Th1 to Th2 response. In addition, combination therapy lessened inflammation-associated neurodegeneration in the central nervous system of EAE animals. These effects were absent in EAE animals treated with either drug alone at the same dose. Thus, our data suggest that agents with different mechanisms of action such as lovastatin and 5-aminoimidazole-4-carboxamide-1-beta-D-ribofuranoside, when used in combination, could improve therapy for central nervous system demyelinating diseases and provide a rationale for testing them in MS patients.
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MESH Headings
- AMP-Activated Protein Kinases
- Aminoimidazole Carboxamide/administration & dosage
- Aminoimidazole Carboxamide/analogs & derivatives
- Animals
- Dose-Response Relationship, Drug
- Drug Evaluation, Preclinical
- Drug Therapy, Combination
- Encephalomyelitis, Autoimmune, Experimental/drug therapy
- Encephalomyelitis, Autoimmune, Experimental/immunology
- Encephalomyelitis, Autoimmune, Experimental/pathology
- Enzyme Activation/drug effects
- Enzyme Activation/immunology
- Female
- Humans
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/administration & dosage
- Hypoglycemic Agents/administration & dosage
- Immunoglobulin G/immunology
- Immunologic Factors/administration & dosage
- Lovastatin/administration & dosage
- Multienzyme Complexes/immunology
- Multiple Sclerosis/drug therapy
- Multiple Sclerosis/immunology
- Multiple Sclerosis/pathology
- Myelin Basic Protein/immunology
- Protein Serine-Threonine Kinases/immunology
- Rats
- Rats, Inbred Lew
- Ribonucleotides/administration & dosage
- Th1 Cells/immunology
- Th1 Cells/pathology
- Th2 Cells/immunology
- Th2 Cells/pathology
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Affiliation(s)
- Ajaib S Paintlia
- Medical University of South Carolina, Department of Pediatrics, 173 Ashley Ave., Charleston, SC 29425, USA
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