1
|
Guger M, Enzinger C, Leutmezer F, Di Pauli F, Kraus J, Kalcher S, Kvas E, Berger T. Early intensive versus escalation treatment in patients with relapsing-remitting multiple sclerosis in Austria. J Neurol 2024; 271:3142-3152. [PMID: 38430270 PMCID: PMC11136709 DOI: 10.1007/s00415-024-12256-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVES To compare the effectiveness of early intensive treatment (EIT) versus escalation treatment (ESC) in a nationwide observational cohort of almost 1000 people with relapsing-remitting multiple sclerosis (RRMS). MATERIALS AND METHODS The EIT cohort started with alemtuzumab (AZM), cladribine (CLAD), fingolimod (FTY), natalizumab (NTZ), ocrelizumab (OCR), or ozanimod (OZA); whereas, the ESC cohort was escalated from dimethylfumarate (DMF) or teriflunomide (TERI) to AZM, CLAD, FTY, NTZ, OCR, or OZA within the Austrian MS Treatment Registry. Patients had to stay on therapy for at least 3 months and up to 16 years. The EIT cohort included 743 and the ESC cohort 227 RRMS patients. We used multinomial propensity scores for inverse probability weighting in generalized linear (GLM) and Cox proportional hazards models to correct for the bias of this non-randomized registry study. RESULTS Estimated mean annualized relapse rates (ARR) were 0.09 for EIT and 0.4 for ESC patients. The incidence rate ratio (IRR) in the GLM model for relapses showed a decreased relapse probability of 78% for the EIT versus ESC cohort [IRR = 0.22, 95% CI (0.16-0.30), p < 0.001]. Analyzing the time to the first relapse by Cox regression, a hazard ratio (HR) of 0.17 [95% CI (0.13-0.22), p < 0.001] revealed a decreased risk of 83% for the EIT group. Regarding sustained Expanded Disability Status Scale (EDSS) progression for 12 weeks, a HR of 0.55 [95% CI (0.40-0.76), p < 0.001] showed a decreased probability of 45% for the EIT cohort. CONCLUSIONS ESC treatment after DMF and TERI revealed a higher relapse and EDSS progression probability compared to EIT in Austrian RRMS patients. Therefore, an early intensive treatment should be started in patients with an active or highly active disease course.
Collapse
Affiliation(s)
- Michael Guger
- Department of Neurology, Pyhrn-Eisenwurzen Hospital Steyr, Sierninger Straße 170, 4400, Steyr, Austria.
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria.
| | | | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Franziska Di Pauli
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jörg Kraus
- Department of Laboratory Medicine, Paracelsus Medical University and Salzburger Landeskliniken, Salzburg, Austria
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | | | | | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
2
|
Guo J, Wu J, Wang L, Liu H, Wu X, Yang H, Li W, Wang H, Bu B, Yang C, Zhou H, Guo S, Zhao Y, Wang Z, Li C, Tian DC, Chen S, Xue H, Zhang Y, Xu Y, Liang H, Wu Z, Zhang Y, Dong Q, Wang J, Quan C. Treatment algorithms of relapsing multiple sclerosis: an exploration based on the available disease-modifying therapies in China. Ther Adv Neurol Disord 2024; 17:17562864241239117. [PMID: 38616782 PMCID: PMC11015775 DOI: 10.1177/17562864241239117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/14/2024] [Indexed: 04/16/2024] Open
Abstract
Multiple sclerosis (MS) was defined as a rare disease in China due to its low prevalence. For a long time, interferon β was the only approved disease-modifying therapy (DMT). Since the first oral DMT was approved in 2018, DMT approval accelerated, and seven DMTs were approved within 5 years. With an increasing number of DMTs being prescribed in clinical practice, it is necessary to discuss the standardized MS treatment algorithms depending on the disease activity and DMT availability. In this review paper, more than 20 Chinese experts in MS have reviewed the therapeutic progress of MS in China and worldwide and discussed algorithms for treating relapsing MS (RMS) based on the available DMTs in China, providing insights for establishing the standardized RMS treatment algorithms in this country.
Collapse
Affiliation(s)
- Jun Guo
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Jiayong Wu
- Department of Neurology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Hongbo Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaomu Wu
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Wenyu Li
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Honghao Wang
- Department of Neurology, Guangzhou First People’s Hospital, Guangzhou, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunsheng Yang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital, Shandong First Medical University, Jinan, China
| | - Yinan Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhanhang Wang
- Department of Neurology, Guangdong 999 Brain Hospital, Guangzhou, China
| | - Chunyang Li
- Department of Neurology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - De-Cai Tian
- Center for Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sheng Chen
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huiru Xue
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Yanlin Zhang
- Department of Neurology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yongfeng Xu
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hui Liang
- Department of Neurology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhe Wu
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | | | - Qiang Dong
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Quan
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, No. 12, Middle Wulumuqi Road, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai, China
| |
Collapse
|
3
|
Spelman T, Eichau S, Alroughani R, Ozakbas S, Khoury SJ, Patti F, Kubala Havrdova E, Boz C, Terzi M, Kuhle J, Grammond P, Lechner-Scott J, Gray O, Amato MP, Laureys G, Shaygannejad V, Hyde R, Wang H, Bozin I, Belviso N, Quan C, Zeng F, van der Walt A, Butzkueven H. Comparative effectiveness of dimethyl fumarate versus non-specific immunosuppressants: Real-world evidence from MSBase. Mult Scler J Exp Transl Clin 2024; 10:20552173241247182. [PMID: 38800132 PMCID: PMC11128181 DOI: 10.1177/20552173241247182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/27/2024] [Indexed: 05/29/2024] Open
Abstract
Background The use of non-specific immunosuppressants (NSIS) to treat multiple sclerosis (MS) remains prevalent in certain geographies despite safety concerns, likely due to resource limitations. Objective To use MSBase registry data to compare real-world outcomes in adults with relapsing-remitting MS (RRMS) treated with dimethyl fumarate (DMF) or NSIS (azathioprine, cyclosporine, cyclophosphamide, methotrexate, mitoxantrone or mycophenolate mofetil) between January 1, 2014 and April 1, 2022. Methods Treatment outcomes were compared using inverse probability of treatment weighting (IPTW) Cox regression. Outcomes were annualized relapse rates (ARRs), time to discontinuation, time to first relapse (TTFR) and time to 24-week confirmed disability progression (CDP) or 24-week confirmed disability improvement (CDI; in patients with baseline Expanded Disability Status Scale [EDSS] score ≥2). Results After IPTW, ARR was similar for DMF (0.13) and NSIS (0.16; p = 0.29). There was no difference in TTFR between cohorts (hazard ratio [HR]: 0.98; p = 0.84). The DMF cohort experienced longer times to discontinuation (HR: 0.75; p = 0.001) and CDP (HR: 0.53; p = 0.001), and shorter time to CDI (HR: 1.99; p < 0.008), versus the NSIS cohort. Conclusion This analysis supports the use of DMF to treat patients with relapsing forms of MS, and may have implications for MS practices in countries where NSIS are commonly used to treat RRMS.
Collapse
Affiliation(s)
- Tim Spelman
- MSBase Foundation, Melbourne, Australia
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Sara Eichau
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | | | - Samia J Khoury
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy
| | - Eva Kubala Havrdova
- Department of Neurology, First Medical Faculty, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | | | - Jens Kuhle
- Department of Neurology, University Hospital and University of Basel, Basel, Switzerland
- Multiple Sclerosis Centre and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | | | | | - Orla Gray
- South Eastern HSC Trust, Belfast, UK
| | | | | | | | | | | | | | | | - Chao Quan
- Department of Neurology, Huashan Hospital, National Center for Neurological Disorders, Fudan University, Shanghai, China
| | | | | | | |
Collapse
|
4
|
Frahm N, Ellenberger D, Stahmann A, Fneish F, Lüftenegger D, Salmen HC, Schirduan K, Schaak TPA, Flachenecker P, Kleinschnitz C, Paul F, Krefting D, Zettl UK, Peters M, Warnke C. Treatment switches of disease-modifying therapies in people with multiple sclerosis: long-term experience from the German MS Registry. Ther Adv Neurol Disord 2024; 17:17562864241239740. [PMID: 38560408 PMCID: PMC10981260 DOI: 10.1177/17562864241239740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/14/2024] [Indexed: 04/04/2024] Open
Abstract
Background The spectrum of disease-modifying therapies (DMTs) for people with multiple sclerosis (PwMS) has expanded over years, but data on treatment strategies is largely lacking. DMT switches are common clinical practice. Objective To compare switchers and non-switchers, characterize the first DMT switch and identify reasons and predictors for switching the first DMT. Methods Data on 2722 PwMS from the German MS Registry were retrospectively analyzed regarding sociodemographic/clinical differences between 1361 switchers (PwMS discontinuing the first DMT) and non-switchers matched according to age, sex, and observation period. Frequencies of first and second DMTs were calculated and switch reasons identified. Predictors for DMT switches were revealed using univariable and multivariable regression models. Results Switchers and non-switchers differed significantly regarding time to first DMT, education, calendar period of the first DMT start (2014-2017 versus 2018-2021), first DMT class used [mild-to-moderate efficacy (MME) versus high-efficacy (HE) DMT], time on first DMT, and disease activity at first DMT start or cessation/last follow-up. The majority of PwMS started with MME DMTs (77.1%), with the most common being glatiramer acetate, dimethyl/diroximel fumarate, and beta-interferon variants. Switchers changed treatment more often to HE DMTs (39.6%), most commonly sphingosine-1-phosphate receptor modulators, anti-CD20 monoclonal antibodies, and natalizumab. Fewer PwMS switched to MME DMTs (35.9%), with the most common being dimethyl/diroximel fumarate, teriflunomide, or beta-interferon. Among 1045 PwMS with sufficient data (76.8% of 1361 switchers), the most frequent reasons for discontinuing the first DMT were disease activity despite DMT (63.1%), adverse events (17.1%), and patient request (8.3%). Predictors for the first DMT switch were MME DMT as initial treatment [odds ratio (OR) = 2.83 (1.76-4.61), p < 0.001; reference: HE DMT], first DMT initiation between 2014 and 2017 [OR = 11.55 (6.93-19.94), p < 0.001; reference: 2018-2021], and shorter time on first DMT [OR = 0.22 (0.18-0.27), p < 0.001]. Conclusion The initial use of MME DMTs was among the strongest predictors of DMT discontinuation in a large German retrospective MS cohort, arguing for the need for prospective treatment strategy trials, not only but also on the initial broad use of HE DMTs in PwMS.
Collapse
Affiliation(s)
- Niklas Frahm
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, Hannover, Niedersachsen 30171, Germany
| | - David Ellenberger
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Hannover, Germany
| | - Alexander Stahmann
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Hannover, Germany
| | - Firas Fneish
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Hannover, Germany
| | | | | | | | | | | | - Christoph Kleinschnitz
- Department of Neurology and Center of Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Dagmar Krefting
- Department of Medical Informatics, University Medical Center Göttingen, Göttingen, Germany
| | - Uwe K. Zettl
- Department of Neurology, Neuroimmunological Section, University Medical Center of Rostock, Rostock, Germany
| | - Melanie Peters
- German MS Registry, Gesellschaft für Versorgungsforschung mbH (Society for Health Care Research [GfV]), Hannover, Germany
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| |
Collapse
|
5
|
Papukchieva S, Stratil AS, Kahn M, Neß NH, Hollnagel-Schmitz M, Gerencser V, Rustemeier J, Eberl M, Friedrich B, Ziemssen T. Shifting from the treat-to-target to the early highly effective treatment approach in patients with multiple sclerosis - real-world evidence from Germany. Ther Adv Neurol Disord 2024; 17:17562864241237857. [PMID: 38525488 PMCID: PMC10960977 DOI: 10.1177/17562864241237857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/14/2024] [Indexed: 03/26/2024] Open
Abstract
Background While evidence highlights the effectiveness of initiating disease-modifying therapy with a high-efficacy medication for multiple sclerosis (MS) patients with poor prognostic factors, it remains unclear whether this approach has been adopted by a broad range of MS providers in Germany yet. Objective To assess the adoption of the early highly effective treatment (EHT) compared to the treat-to-target treatment approach with the option of escalating treatment efficacy over time in Germany based on real-world evidence data. Design Patient-level pharmacy dispensing data from the Permea platform were analysed from 2020 to 2022. Methods In total, 29,529 therapy beginners (>18 years) were included to analyse shifts in treatment approaches over time and switching behaviour. Medication classification adhered to the German Society of Neurology guidelines and designated fumarates, glatiramer acetate, teriflunomide and interferons as low-efficacy category 1 medications; cladribine and S1P-modulators as medium-efficacy category 2 medications; and alemtuzumab, natalizumab, ocrelizumab, ofatumumab and rituximab (off-label) as high-efficacy category 3 medications. Results Our results show that 70.0% of patients redeemed their first prescription for category 1 medication, 16.3% for category 2 and 13.7% for category 3 medications. The proportion of prescriptions filled shifted from 2020 to 2022 with a decrease of 14.7% for category 1 drugs and an increase of 12.5% for category 3 drugs. 93.2% of patients stayed on their initially prescribed medication category. 3.2% of category 1 and 3.7% of category 2 therapy beginners escalated to category 3 medication. 3.4% of category 3 medication users de-escalated their treatment to category 1 or category 2. Conclusion While most individuals started their treatment according to the treat-to-target approach and remained on their initially prescribed medication category, there has been a steadily increasing shift towards the EHT approach since 2020. These insights demonstrate that, while not officially recommended by German guidelines, MS providers increasingly adopt the EHT approach.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| |
Collapse
|
6
|
Butzkueven H, Kalincik T, Patti F, Slee M, Weinstock-Guttman B, Buzzard K, Skibina O, Alroughani R, Prat A, Girard M, Horakova D, Havrdova EK, Van der Walt A, Eichau S, Hyde R, Campbell N, Bodhinathan K, Spelman T. Long-term clinical outcomes in patients with multiple sclerosis who are initiating disease-modifying therapy with natalizumab compared with BRACETD first-line therapies. Ther Adv Neurol Disord 2024; 17:17562864231221331. [PMID: 38414723 PMCID: PMC10898303 DOI: 10.1177/17562864231221331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 11/05/2023] [Indexed: 02/29/2024] Open
Abstract
Background Aggressive disease control soon after multiple sclerosis (MS) diagnosis may prevent irreversible neurological damage, and therefore early initiation of a high-efficacy disease-modifying therapy (DMT) is of clinical relevance. Objectives Evaluate long-term clinical outcomes in patients with MS who initiated treatment with either natalizumab or a BRACETD therapy (interferon beta, glatiramer acetate, teriflunomide, or dimethyl fumarate). Design This retrospective analysis utilized data from MSBase to create a matched population allowing comparison of first-line natalizumab to first-line BRACETD. Methods This study included patients who initiated treatment either with natalizumab or a BRACETD DMT within 1 year of MS diagnosis and continued treatment for ⩾6 months, after which patients could switch DMTs or discontinue treatment. Patients had a minimum follow-up time of ⩾60 months from initiation. A subgroup analysis compared the natalizumab group to patients in the BRACETD group who escalated therapy after 6 months. Outcomes included unadjusted annualized relapse rates (ARRs), time-to-first relapse, time-to-first confirmed disability improvement (CDI), and time-to-first confirmed disability worsening (CDW). Results After 1:1 propensity score matching, 355 BRACETD patients were matched to 355 natalizumab patients. Patients initiating natalizumab were less likely to experience a relapse over the duration of follow-up, with ARRs [95% confidence interval (CI)] of 0.080 (0.070-0.092) for natalizumab patients and 0.191 (0.178-0.205) for BRACETD patients (p < 0.0001). A Cox regression model of time-to-first relapse showed a reduced risk of relapse for natalizumab patients [hazard ratio (95% CI) of 0.52 (0.42-0.65); p < 0.001] and a more favorable time-to-first CDI. The risk of CDW was similar between groups. The subgroup analysis showed an increased relapse risk as well as a significantly higher risk of CDW for BRACETD patients. Conclusion Early initiation of natalizumab produced long-term benefits in relapse outcomes in comparison with BRACETD, regardless of a subsequent escalation in therapy.
Collapse
Affiliation(s)
- Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Alfred Campus, Monash University, 6/99 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Neurology, Box Hill Hospital, Monash University, Box Hill, VIC, Australia
| | - Tomas Kalincik
- Neuroimmunology Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies 'GF Ingrassia', University of Catania, Catania, Italy
| | - Mark Slee
- Flinders University, Adelaide, SA, Australia
| | | | - Katherine Buzzard
- Department of Neurology, Box Hill Hospital, Melbourne, VIC, Australia
| | - Olga Skibina
- Department of Neurology, Box Hill Hospital, Melbourne, VIC, Australia
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | | | - Marc Girard
- CHUM and Universite de Montreal, Montreal, QC, Canada
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | | | - Sara Eichau
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Robert Hyde
- Biogen, Cambridge, MA, USA, at the time of this analysis
| | | | | | | |
Collapse
|
7
|
Jakimovski D, Bittner S, Zivadinov R, Morrow SA, Benedict RH, Zipp F, Weinstock-Guttman B. Multiple sclerosis. Lancet 2024; 403:183-202. [PMID: 37949093 DOI: 10.1016/s0140-6736(23)01473-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/08/2023] [Accepted: 07/12/2023] [Indexed: 11/12/2023]
Abstract
Multiple sclerosis remains one of the most common causes of neurological disability in the young adult population (aged 18-40 years). Novel pathophysiological findings underline the importance of the interaction between genetics and environment. Improvements in diagnostic criteria, harmonised guidelines for MRI, and globalised treatment recommendations have led to more accurate diagnosis and an earlier start of effective immunomodulatory treatment than previously. Understanding and capturing the long prodromal multiple sclerosis period would further improve diagnostic abilities and thus treatment initiation, eventually improving long-term disease outcomes. The large portfolio of currently available medications paved the way for personalised therapeutic strategies that will balance safety and effectiveness. Incorporation of cognitive interventions, lifestyle recommendations, and management of non-neurological comorbidities could further improve quality of life and outcomes. Future challenges include the development of medications that successfully target the neurodegenerative aspect of the disease and creation of sensitive imaging and fluid biomarkers that can effectively predict and monitor disease changes.
Collapse
Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA; Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA; Center for Biomedical Imaging at the Clinical Translational Science Institute, State University of New York at Buffalo, Buffalo, NY, USA
| | - Sarah A Morrow
- Department of Clinical Neurological Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Ralph Hb Benedict
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - 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, Germany.
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
| |
Collapse
|
8
|
Bellanca CM, Augello E, Mariottini A, Bonaventura G, La Cognata V, Di Benedetto G, Cantone AF, Attaguile G, Di Mauro R, Cantarella G, Massacesi L, Bernardini R. Disease Modifying Strategies in Multiple Sclerosis: New Rays of Hope to Combat Disability? Curr Neuropharmacol 2024; 22:1286-1326. [PMID: 38275058 PMCID: PMC11092922 DOI: 10.2174/1570159x22666240124114126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/21/2023] [Accepted: 09/22/2023] [Indexed: 01/27/2024] Open
Abstract
Multiple sclerosis (MS) is the most prevalent chronic autoimmune inflammatory- demyelinating disorder of the central nervous system (CNS). It usually begins in young adulthood, mainly between the second and fourth decades of life. Usually, the clinical course is characterized by the involvement of multiple CNS functional systems and by different, often overlapping phenotypes. In the last decades, remarkable results have been achieved in the treatment of MS, particularly in the relapsing- remitting (RRMS) form, thus improving the long-term outcome for many patients. As deeper knowledge of MS pathogenesis and respective molecular targets keeps growing, nowadays, several lines of disease-modifying treatments (DMT) are available, an impressive change compared to the relative poverty of options available in the past. Current MS management by DMTs is aimed at reducing relapse frequency, ameliorating symptoms, and preventing clinical disability and progression. Notwithstanding the relevant increase in pharmacological options for the management of RRMS, research is now increasingly pointing to identify new molecules with high efficacy, particularly in progressive forms. Hence, future efforts should be concentrated on achieving a more extensive, if not exhaustive, understanding of the pathogenetic mechanisms underlying this phase of the disease in order to characterize novel molecules for therapeutic intervention. The purpose of this review is to provide a compact overview of the numerous currently approved treatments and future innovative approaches, including neuroprotective treatments as anti-LINGO-1 monoclonal antibody and cell therapies, for effective and safe management of MS, potentially leading to a cure for this disease.
Collapse
Affiliation(s)
- Carlo Maria Bellanca
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Egle Augello
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Alice Mariottini
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Gabriele Bonaventura
- Institute for Biomedical Research and Innovation (IRIB), Italian National Research Council, 95126 Catania, Italy
| | - Valentina La Cognata
- Institute for Biomedical Research and Innovation (IRIB), Italian National Research Council, 95126 Catania, Italy
| | - Giulia Di Benedetto
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Anna Flavia Cantone
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppe Attaguile
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Rosaria Di Mauro
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppina Cantarella
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Luca Massacesi
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Renato Bernardini
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| |
Collapse
|
9
|
Deleu D, Garcia Canibano B, Elalamy O, Sayed Abdelmoneim M, Boshra A. Practical Guidance on the Use of Cladribine Tablets in the Management or Relapsing Multiple Sclerosis: Expert Opinion from Qatar. Degener Neurol Neuromuscul Dis 2023; 13:81-88. [PMID: 38105885 PMCID: PMC10725680 DOI: 10.2147/dnnd.s433459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
The increasing availability of high-efficacy disease-modifying therapies (DMT) for the management of relapsing multiple sclerosis (RMS) has increased the potential for individualised patient management but has added complexity to the design of treatment regimens. The long-term application of immune reconstitution therapy (IRT) is supported by an increasing database of real world studies that have added important information on the long-term safety and efficacy of this approach. Cladribine tablets (CladT) is an IRT given as two annual short courses of treatment, following which a majority of patients then demonstrate no significant MS disease activity over a period of years. Whether, and how, to treat patients beyond the first two years of treatment remains a matter for debate, as clinical evidence accumulates. We, a group of neurologists who manage people with RMS in Qatar, provide our expert consensus recommendations on the application and long-term management of CladT therapy based on our experience with treatment in the last 5 years. These include pragmatic recommendations for people with MS disease activity in years 3 and 4 (ie up to four years following first dose of CladT), and for people with or without MS disease activity in subsequent years. We believe our recommendations will help to ensure the optimal application of CladT-based IRT, with the potential benefit for the patient of achieving prolonged periods free of both MS disease symptoms and the burden of regular applications of immunosuppressive DMT.
Collapse
Affiliation(s)
- Dirk Deleu
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Osama Elalamy
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Amir Boshra
- Merck Serono Middle East FZ-Ltd., Dubai, UAE, an affiliate of Merck KGaA, Dubai, United Arab Emirates
| |
Collapse
|
10
|
Tramacere I, Virgili G, Perduca V, Lucenteforte E, Benedetti MD, Capobussi M, Castellini G, Frau S, Gonzalez-Lorenzo M, Featherstone R, Filippini G. Adverse effects of immunotherapies for multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2023; 11:CD012186. [PMID: 38032059 PMCID: PMC10687854 DOI: 10.1002/14651858.cd012186.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic disease of the central nervous system that affects mainly young adults (two to three times more frequently in women than in men) and causes significant disability after onset. Although it is accepted that immunotherapies for people with MS decrease disease activity, uncertainty regarding their relative safety remains. OBJECTIVES To compare adverse effects of immunotherapies for people with MS or clinically isolated syndrome (CIS), and to rank these treatments according to their relative risks of adverse effects through network meta-analyses (NMAs). SEARCH METHODS We searched CENTRAL, PubMed, Embase, two other databases and trials registers up to March 2022, together with reference checking and citation searching to identify additional studies. SELECTION CRITERIA We included participants 18 years of age or older with a diagnosis of MS or CIS, according to any accepted diagnostic criteria, who were included in randomized controlled trials (RCTs) that examined one or more of the agents used in MS or CIS, and compared them versus placebo or another active agent. We excluded RCTs in which a drug regimen was compared with a different regimen of the same drug without another active agent or placebo as a control arm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for data extraction and pairwise meta-analyses. For NMAs, we used the netmeta suite of commands in R to fit random-effects NMAs assuming a common between-study variance. We used the CINeMA platform to GRADE the certainty of the body of evidence in NMAs. We considered a relative risk (RR) of 1.5 as a non-inferiority safety threshold compared to placebo. We assessed the certainty of evidence for primary outcomes within the NMA according to GRADE, as very low, low, moderate or high. MAIN RESULTS This NMA included 123 trials with 57,682 participants. Serious adverse events (SAEs) Reporting of SAEs was available from 84 studies including 5696 (11%) events in 51,833 (89.9%) participants out of 57,682 participants in all studies. Based on the absolute frequency of SAEs, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 18 additional people would have a SAE compared to placebo. Low-certainty evidence suggested that three drugs may decrease SAEs compared to placebo (relative risk [RR], 95% confidence interval [CI]): interferon beta-1a (Avonex) (0.78, 0.66 to 0.94); dimethyl fumarate (0.79, 0.67 to 0.93), and glatiramer acetate (0.84, 0.72 to 0.98). Several drugs met our non-inferiority criterion versus placebo: moderate-certainty evidence for teriflunomide (1.08, 0.88 to 1.31); low-certainty evidence for ocrelizumab (0.85, 0.67 to 1.07), ozanimod (0.88, 0.59 to 1.33), interferon beta-1b (0.94, 0.78 to 1.12), interferon beta-1a (Rebif) (0.96, 0.80 to 1.15), natalizumab (0.97, 0.79 to 1.19), fingolimod (1.05, 0.92 to 1.20) and laquinimod (1.06, 0.83 to 1.34); very low-certainty evidence for daclizumab (0.83, 0.68 to 1.02). Non-inferiority with placebo was not met due to imprecision for the other drugs: low-certainty evidence for cladribine (1.10, 0.79 to 1.52), siponimod (1.20, 0.95 to 1.51), ofatumumab (1.26, 0.88 to 1.79) and rituximab (1.01, 0.67 to 1.52); very low-certainty evidence for immunoglobulins (1.05, 0.33 to 3.32), diroximel fumarate (1.05, 0.23 to 4.69), peg-interferon beta-1a (1.07, 0.66 to 1.74), alemtuzumab (1.16, 0.85 to 1.60), interferons (1.62, 0.21 to 12.72) and azathioprine (3.62, 0.76 to 17.19). Withdrawals due to adverse events Reporting of withdrawals due to AEs was available from 105 studies (85.4%) including 3537 (6.39%) events in 55,320 (95.9%) patients out of 57,682 patients in all studies. Based on the absolute frequency of withdrawals, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 31 additional people would withdraw compared to placebo. No drug reduced withdrawals due to adverse events when compared with placebo. There was very low-certainty evidence (meaning that estimates are not reliable) that two drugs met our non-inferiority criterion versus placebo, assuming an upper 95% CI RR limit of 1.5: diroximel fumarate (0.38, 0.11 to 1.27) and alemtuzumab (0.63, 0.33 to 1.19). Non-inferiority with placebo was not met due to imprecision for the following drugs: low-certainty evidence for ofatumumab (1.50, 0.87 to 2.59); very low-certainty evidence for methotrexate (0.94, 0.02 to 46.70), corticosteroids (1.05, 0.16 to 7.14), ozanimod (1.06, 0.58 to 1.93), natalizumab (1.20, 0.77 to 1.85), ocrelizumab (1.32, 0.81 to 2.14), dimethyl fumarate (1.34, 0.96 to 1.86), siponimod (1.63, 0.96 to 2.79), rituximab (1.63, 0.53 to 5.00), cladribine (1.80, 0.89 to 3.62), mitoxantrone (2.11, 0.50 to 8.87), interferons (3.47, 0.95 to 12.72), and cyclophosphamide (3.86, 0.45 to 33.50). Eleven drugs may have increased withdrawals due to adverse events compared with placebo: low-certainty evidence for teriflunomide (1.37, 1.01 to 1.85), glatiramer acetate (1.76, 1.36 to 2.26), fingolimod (1.79, 1.40 to 2.28), interferon beta-1a (Rebif) (2.15, 1.58 to 2.93), daclizumab (2.19, 1.31 to 3.65) and interferon beta-1b (2.59, 1.87 to 3.77); very low-certainty evidence for laquinimod (1.42, 1.01 to 2.00), interferon beta-1a (Avonex) (1.54, 1.13 to 2.10), immunoglobulins (1.87, 1.01 to 3.45), peg-interferon beta-1a (3.46, 1.44 to 8.33) and azathioprine (6.95, 2.57 to 18.78); however, very low-certainty evidence is unreliable. Sensitivity analyses including only studies with low attrition bias, drug dose above the group median, or only patients with relapsing remitting MS or CIS, and subgroup analyses by prior disease-modifying treatments did not change these figures. Rankings No drug yielded consistent P scores in the upper quartile of the probability of being better than others for primary and secondary outcomes. AUTHORS' CONCLUSIONS We found mostly low and very low-certainty evidence that drugs used to treat MS may not increase SAEs, but may increase withdrawals compared with placebo. The results suggest that there is no important difference in the occurrence of SAEs between first- and second-line drugs and between oral, injectable, or infused drugs, compared with placebo. Our review, along with other work in the literature, confirms poor-quality reporting of adverse events from RCTs of interventions. At the least, future studies should follow the CONSORT recommendations about reporting harm-related issues. To address adverse effects, future systematic reviews should also include non-randomized studies.
Collapse
Affiliation(s)
- Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Ophthalmology, IRCCS - Fondazione Bietti, Rome, Italy
| | - Vittorio Perduca
- Université Paris Cité, CNRS, MAP5, F-75006 Paris, France
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Ersilia Lucenteforte
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Maria Donata Benedetti
- UOC Neurologia B - Policlinico Borgo Roma, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Capobussi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Greta Castellini
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | | | - Marien Gonzalez-Lorenzo
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Department of Oncology, Laboratory of Clinical Research Methodology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| |
Collapse
|
11
|
Edan G, Le Page E. Escalation Versus Induction/High-Efficacy Treatment Strategies for Relapsing Multiple Sclerosis: Which is Best for Patients? Drugs 2023; 83:1351-1363. [PMID: 37725259 PMCID: PMC10582148 DOI: 10.1007/s40265-023-01942-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
After more than 2 decades of recommending an escalating strategy for the treatment of most patients with multiple sclerosis, there has recently been considerable interest in the use of high-efficacy therapies in the early stage of the disease. Early intervention with induction/high-efficacy disease-modifying therapy may have the best risk-benefit profile for patients with relapsing-remitting multiple sclerosis who are young and have active disease, numerous focal T2 lesions on spinal and brain magnetic resonance imaging, and no irreversible disability. Although we have no curative treatment, at least seven classes of high-efficacy drugs are available, with two main strategies. The first strategy involves the use of high-efficacy drugs (e.g., natalizumab, sphingosine 1-phosphate receptor modulators, or anti-CD20 drugs) to achieve sustained immunosuppression. These can be used as a first-line therapy in many countries. The second strategy entails the use of one of the induction drugs (short-term use of mitoxantrone, alemtuzumab, cladribine, or autologous hematopoietic stem cell transplant) that are mainly recommended as a second-line or third-line treatment in patients with very active or aggressive multiple sclerosis disease. Early sustained immunosuppression exposes patients to heightened risks of infection and cancer proportionate to cumulative exposure, and induction drugs expose patients to similar risks during the initial post-treatment period, although these risks decrease over time. Their initial potential safety risks should now be revisited, taking account of long-term data and some major changes in their regimens: natalizumab with the long-term monitoring of John Cunningham virus; use of monthly courses of mitoxantrone with maximum cumulative doses of 36-72 mg/m2, followed by a safer disease-modifying drug; cladribine with only 2-weekly treatment courses required in years 1 and 2 and no systematic treatment for the following 2 years; alemtuzumab, whose safety and clinical impacts have now been documented for more than 6 years after the last infusion; and autologous haematopoietic stem cell transplant, which dramatically reduces transplantation-related mortality with a new regimen and guidelines. Escalation and induction/high-efficacy treatments need rigorous magnetic resonance imaging monitoring. Monitoring over the first few years, using the MAGNIMS score or American Academy of Neurology guidelines, considerably improves prediction accuracy and facilitates the selection of patients with relapsing-remitting multiple sclerosis requiring aggressive treatment.
Collapse
Affiliation(s)
- Gilles Edan
- Empenn IRISA Research Group, INSERM Clinical Investigation Center, Pontchaillou University Hospital, Rennes, France.
| | - Emmanuelle Le Page
- Neurology Department, INSERM Clinical Investigation Center, Pontchaillou University Hospital, Rennes, France
| |
Collapse
|
12
|
Seifer G, Arun T, Capela C, Laureys G, Jones E, Dominguez-Castro P, Sanchez-de la Rosa R, Hiltl S, Iaffaldano P. Influence of physicians' risk perception on switching treatments between high- efficacy and non-high-efficacy disease‑modifying therapies in multiple sclerosis. Mult Scler Relat Disord 2023; 76:104770. [PMID: 37307690 DOI: 10.1016/j.msard.2023.104770] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 05/11/2023] [Accepted: 05/19/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND The decision of initiating treatment for multiple sclerosis (MS) with a high-efficacy DMT (HE DMT) or non-high-efficacy DMT (non-HE DMT) is influenced by several factors, including risk perception of patients and physicians. OBJECTIVE Investigate the influence of physicians' risk perception on decision-making when switching treatments for MS and the reasons for switching. METHODS Data were drawn from the Adelphi Real-World MS Disease-Specific Program (a retrospective survey) and analysis included people with RMS identified between 2017- 2021. RESULTS Of 4129 patients with reasons for switch available, 3538 switched from non-HE DMT and 591 from HE DMT. Overall, 4.7% of patients were switched treatment by their physicians due to the risk of malignancies and infections including PML risk. The proportion of switches that were made due to the risk of PML were 23.9% in the HE DMT and 0.5% in the non-HE DMT groups. The top reasons for switching were relapse frequency (non-HE DMT vs HE-DMT: 26.8% vs 15.2%), lack of efficacy (20.9 vs 11.7) and increased number of MRI lesions (20.3% vs 12.4%). CONCLUSIONS Physicians' risk perception of malignancies and infection excluding PML was not a leading factor when switching treatment. The risk of PML was a key factor, especially for switching patients from HE DMTs. In both groups, lack of efficacy was the key contributing factor for switching. Initiating the treatment with HE DMTs may potentially reduce the number of switches due to sub-optimal efficacy. These findings might help physicians to engage more in discussions with patients about the benefit/risk profile of DMTs.
Collapse
Affiliation(s)
| | - Tarunya Arun
- Department of Neurosciences, University Hospitals of Coventry and Warwickshire, Level 4, Central Wing, Coventry CV2 2DX, UK
| | - Carlos Capela
- Department of Neurology, Central Lisbon University Hospital Centre, Lisbon, Portugal
| | - Guy Laureys
- Department of Neurology, University Hospital Ghent, Ghent, Belgium
| | | | | | | | | | - Pietro Iaffaldano
- Department of Translational Biomedicine and Neuroscience, University of Bari Aldo Moro, Bari, Italy
| |
Collapse
|
13
|
McGuire J, Muto C, Marcello C. Multiple sclerosis: Implications for the primary care NP. Nurse Pract 2023; 48:38-47. [PMID: 37487047 DOI: 10.1097/01.npr.0000000000000083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
ABSTRACT Multiple sclerosis is a demyelinating disease of the central nervous system. It contributes to a variety of symptoms affecting different areas of the body. The primary care NP must be familiar with the disease, therapies, and social impact to provide proper care to affected patients.
Collapse
|
14
|
Tumani H, Coyle PK, Cárcamo C, Cordioli C, López PA, Peterka M, Ramo-Tello C, Zuluaga MI, Koster T, Vignos M. Treatment of older patients with multiple sclerosis: Results of an International Delphi Survey. Mult Scler J Exp Transl Clin 2023; 9:20552173231198588. [PMID: 37720692 PMCID: PMC10501080 DOI: 10.1177/20552173231198588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Background People over age 50-55 have historically been excluded from randomized clinical trials for multiple sclerosis (MS). However, more than half of those living with an MS diagnosis are over 55. Objective Explore the unique considerations of treating older people with MS (PwMS) using an iterative and structured Delphi-based assessment to gather expert opinions. Methods Eight MS neurologists with an interest in older PwMS developed a 2-round survey. Survey respondents were qualified neurologists with ≥3 years' experience, personally responsible for treatment decisions, and treating ≥20 patients per month, of whom ≥10% were ≥50 years old. Consensus was defined as ≥75% agreement on questions with categorical responses or as a mean score ≥4 on questions with numerical responses. Results In Survey 1, 224 neurologists responded; 180 of these completed Survey 2. Limited consensus was reached with varying levels of agreement on several topics including identification and assessment of older patients; factors relating to treatment decisions including immunosenescence and comorbidities; considerations for high-efficacy treatments; de-escalation or discontinuation of treatment; effects of COVID-19; and unmet needs for treating this population. Conclusion The results of this Delphi process highlight the need for targeted studies to create guidance for the care of older PwMS.
Collapse
Affiliation(s)
| | - Patricia K Coyle
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Claudia Cárcamo
- Department of Neurology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cinzia Cordioli
- Multiple Sclerosis Center, ASST Spedali Civili Di Brescia, Montichiari (Brescia), Italy
| | - Pablo A López
- Neuroimmunology Unit, Department of Neuroscience, Hospital Alemán, Buenos Aires, Argentina
| | - Marek Peterka
- Department of Neurology, Charles University, Prague, Czech Republic
- Faculty of Medicine and University Hospital, Pilsen, Czech Republic
| | - Cristina Ramo-Tello
- Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Faculty of Medicine and University Hospital, Pilsen, Czech Republic
| | | | - Thijs Koster
- Biogen, Cambridge, MA, USA, at the time of this study
| | | |
Collapse
|
15
|
Bellucci G, Albanese A, Rizzi C, Rinaldi V, Salvetti M, Ristori G. The value of Interferon β in multiple sclerosis and novel opportunities for its anti-viral activity: a narrative literature review. Front Immunol 2023; 14:1161849. [PMID: 37334371 PMCID: PMC10275407 DOI: 10.3389/fimmu.2023.1161849] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/24/2023] [Indexed: 06/20/2023] Open
Abstract
Interferon-beta (IFN-β) for Multiple Sclerosis (MS) is turning 30. The COVID-19 pandemic rejuvenated the interest in interferon biology in health and disease, opening translational opportunities beyond neuroinflammation. The antiviral properties of this molecule are in accord with the hypothesis of a viral etiology of MS, for which a credible culprit has been identified in the Epstein-Barr Virus. Likely, IFNs are crucial in the acute phase of SARS-CoV-2 infection, as demonstrated by inherited and acquired impairments of the interferon response that predispose to a severe COVID-19 course. Accordingly, IFN-β exerted protection against SARS-CoV-2 in people with MS (pwMS). In this viewpoint, we summarize the evidence on IFN-β mechanisms of action in MS with a focus on its antiviral properties, especially against EBV. We synopsize the role of IFNs in COVID-19 and the opportunities and challenges of IFN-β usage for this condition. Finally, we leverage the lessons learned in the pandemic to suggest a role of IFN-β in long-COVID-19 and in special MS subpopulations.
Collapse
Affiliation(s)
- Gianmarco Bellucci
- Department of Neurosciences, Mental Health and Sensory Organs, Centre for Experimental Neurological Therapies (CENTERS), Sapienza University of Rome, Rome, Italy
| | - Angela Albanese
- Merck Serono S.p.A., An Affiliate of Merck KGaA, Rome, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Caterina Rizzi
- Merck Serono S.p.A., An Affiliate of Merck KGaA, Rome, Italy
| | - Virginia Rinaldi
- Department of Neurosciences, Mental Health and Sensory Organs, Centre for Experimental Neurological Therapies (CENTERS), Sapienza University of Rome, Rome, Italy
| | - Marco Salvetti
- Department of Neurosciences, Mental Health and Sensory Organs, Centre for Experimental Neurological Therapies (CENTERS), Sapienza University of Rome, Rome, Italy
- Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy
| | - Giovanni Ristori
- Department of Neurosciences, Mental Health and Sensory Organs, Centre for Experimental Neurological Therapies (CENTERS), Sapienza University of Rome, Rome, Italy
- Neuroimmunology Unit, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Santa Lucia, Rome, Italy
| |
Collapse
|
16
|
Stastna D, Drahota J, Lauer M, Mazouchova A, Menkyova I, Adamkova J, Ampapa R, Dufek M, Grunermelova M, Hradilek P, Kubala Havrdova E, Mares J, Martinkova A, Pavelek Z, Peterka M, Recmanova E, Rockova P, Stetkarova I, Stourac P, Vachova M, Horakova D. The Czech National MS Registry (ReMuS): Data trends in multiple sclerosis patients whose first disease-modifying therapies were initiated from 2013 to 2021. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023. [PMID: 37114703 DOI: 10.5507/bp.2023.015] [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: 04/29/2023] Open
Abstract
AIMS Multiple sclerosis treatment strategies are changing in the Czech Republic. According to data from 2013-2021, the proportion of patients starting high-efficacy disease-modifying therapies is increasing. In this survey, we describe the actual data trends in multiple sclerosis (MS) patients beginning their first disease‑modifying therapies (DMTs) from 2013 to 2021. The secondary objective was to present the history, data collection, and scientific potential of the Czech National MS registry (ReMuS). METHODS First, using descriptive statistics, we analysed the data for patients starting their first DMTs, either platform (including dimethyl fumarate) or high-efficacy DMTs (HE-DMTs), for each successive year. Second, a detailed description of the history, data collection, completeness, quality optimising procedures, and legal policies of ReMuS is provided. RESULTS Based on the dataset from December 31, 2021, the total number of monitored patients with MS in ReMuS increased from 9,019 in 2013 (referred from 7 of 15 MS centres) to 12,940 in 2016 (referred from all 15 Czech MS centres) to 17,478 in 2021. In these years, the percentage of patients treated with DMTs in the registry ranged from 76 to 83%, but the proportion of patients treated with HE-DMTs changed from 16.2% in 2013 to 37.1% in 2021. During the follow-up period, a total of 8,491 treatment-naive patients received DMTs. The proportion of patients (all MS phenotypes) starting HE-DMTs increased from 2.1% in 2013 to 18.5% in 2021. CONCLUSION Patient registries, including ReMuS, provide an essential quality data source, especially in light of the increasing percentage of patients on HE-DMTs. Although early initiation of HE-DMT can provide considerable benefits, it also carries greater potential risks. Consistent long-term follow-up of patients in real‑world clinical practice, which only registries allow, is therefore crucial to evaluate the efficacy and safety of therapeutic strategies, for epidemiological research and to assist decision making by healthcare providers and regulatory bodies.
Collapse
Affiliation(s)
- Dominika Stastna
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Jiri Drahota
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
- Endowment Fund IMPULS, Prague, Czech Republic
| | - Michal Lauer
- Endowment Fund IMPULS, Prague, Czech Republic
- Department of Economic Statistics, Prague University of Economics and Business, Prague, Czech Republic
| | - Aneta Mazouchova
- Endowment Fund IMPULS, Prague, Czech Republic
- Department of Economic Statistics, Prague University of Economics and Business, Prague, Czech Republic
| | - Ingrid Menkyova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
- 2nd Department of Neurology, Faculty of Medicine, Comenius University, Bratislava, Slovak Republic
| | - Jana Adamkova
- Department of Neurology, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Radek Ampapa
- Department of Neurology, Hospital of Jihlava, Jihlava, Czech Republic
| | - Michal Dufek
- First Department of Neurology, Masaryk University, St. Anne's University Hospital, Brno, Czech Republic
| | | | - Pavel Hradilek
- Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Jan Mares
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Alena Martinkova
- Department of Neurology, Hospitals of the Pardubice Region, Hospital of Pardubice, Pardubice, Czech Republic
| | - Zbysek Pavelek
- Department of Neurology, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Marek Peterka
- Department of Neurology, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Department of Neurology, Charles University in Prague, Faculty of Medicine in Pilsen and University Hospital Pilsen, Pilsen, Czech Republic
| | - Eva Recmanova
- Department of Neurology, Tomas Bata Regional Hospital, Zlin, Czech Republic
| | - Petra Rockova
- Department of Neurology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Ivana Stetkarova
- Charles University in Prague, Third Faculty of Medicine, Charles University and Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Pavel Stourac
- Department of Neurology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marta Vachova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
- Department of Neurology, KZ a.s., Hospital Teplice, Teplice, Czech Republic
| | - Dana Horakova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| |
Collapse
|
17
|
Rispoli MG, D'Apolito M, Pozzilli V, Tomassini V. Lessons from immunotherapies in multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 193:293-311. [PMID: 36803817 DOI: 10.1016/b978-0-323-85555-6.00013-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
The improved understanding of multiple sclerosis (MS) neurobiology alongside the development of novel markers of disease will allow precision medicine to be applied to MS patients, bringing the promise of improved care. Combinations of clinical and paraclinical data are currently used for diagnosis and prognosis. The addition of advanced magnetic resonance imaging and biofluid markers has been strongly encouraged, since classifying patients according to the underlying biology will improve monitoring and treatment strategies. For example, silent progression seems to contribute significantly more than relapses to overall disability accumulation, but currently approved treatments for MS act mainly on neuroinflammation and offer only a partial protection against neurodegeneration. Further research, involving traditional and adaptive trial designs, should strive to halt, repair or protect against central nervous system damage. To personalize new treatments, their selectivity, tolerability, ease of administration, and safety must be considered, while to personalize treatment approaches, patient preferences, risk-aversion, and lifestyle must be factored in, and patient feedback used to indicate real-world treatment efficacy. The use of biosensors and machine-learning approaches to integrate biological, anatomical, and physiological parameters will take personalized medicine a step closer toward the patient's virtual twin, in which treatments can be tried before they are applied.
Collapse
Affiliation(s)
- Marianna G Rispoli
- Institute for Advanced Biomedical Technologies (ITAB) and Department of Neurosciences, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy; MS Centre, SS. Annunziata University Hospital, Chieti, Italy
| | - Maria D'Apolito
- Institute for Advanced Biomedical Technologies (ITAB) and Department of Neurosciences, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy; MS Centre, SS. Annunziata University Hospital, Chieti, Italy
| | - Valeria Pozzilli
- Institute for Advanced Biomedical Technologies (ITAB) and Department of Neurosciences, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy; MS Centre, SS. Annunziata University Hospital, Chieti, Italy
| | - Valentina Tomassini
- Institute for Advanced Biomedical Technologies (ITAB) and Department of Neurosciences, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy; MS Centre, SS. Annunziata University Hospital, Chieti, Italy.
| |
Collapse
|
18
|
Alonso R, Casas M, Lazaro L, Fernandez Liguori N, Pita C, Cohen L, Rojas JI, Pappolla A, Patrucco L, Cristiano E, Burgos M, Vrech C, Piedrabuena R, Pablo L, Deri N, Luetic G, Miguez J, Cabrera M, Martinez A, Zanga G, Tkachuk V, Tizio S, Carnero Contentti E, Knorre E, Leguizamon F, Mainella C, Nofal P, Liwacki S, Hryb J, Menichini M, Pestchanker C, Alonso M, Garcea O, Silva B. Achieving no evidence of disease activity-3 in highly active multiple sclerosis patients treated with cladribine and monoclonal antibodies. Mult Scler J Exp Transl Clin 2023; 9:20552173231154712. [PMID: 36846108 PMCID: PMC9950613 DOI: 10.1177/20552173231154712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/01/2023] [Indexed: 02/24/2023] Open
Abstract
Background We aimed to determine the proportion of highly active multiple sclerosis patients under high-efficacy therapies (HETs) achieve no evidence of disease activity-3 (NEDA-3) at 1 and 2 years, and to identify factors associated with failing to meet no evidence of disease activity 3 at 2 years. Methods This retrospective cohort study based on Argentina Multiple Sclerosis patient registry (RelevarEM), includes highly active multiple sclerosis patients who received HETs. Results In total, 254 (78.51%) achieved NEDA-3 at year 1 and 220 (68.12%) achieved NEDA-3 at year 2. Patients who achieved NEDA-3 at 2 years had a shorter duration of multiple sclerosis (p < 0.01) and a shorter time between first treatment and current treatment (p = 0.01). Early high-efficacy strategy patients reached NEDA-3 more frequently (p < 0.01). Being a naïve patient (odds ratio: 3.78, 95% confidence interval 1.50-9.86, p < 0.01) was an independent predictor to reach NEDA-3 at 2 years. No association was found between type of HETs and NEDA-3 at 2 years when adjusted for potential confounders (odds ratio: 1.73; 95% confidence interval 0.51-6.06, p 0.57). Conclusion We found a high proportion of patients who achieved NEDA-3 at 1 and 2 years. Early high-efficacy strategy patients had a higher probability of achieving NEDA-3 at 2 years.
Collapse
Affiliation(s)
- Ricardo Alonso
- Ricardo Alonso, Centro Universitario
Esclerosis Múltiple CUEM, Hospital Ramos Mejía, Urquiza 609, CP (1221) Ciudad de
Buenos Aires, Argentina; Facultad de Medicina, Universidad de Buenos Aires,
Ciudad de Buenos Aires, Argentina.
| | | | - Luciana Lazaro
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos
Mejía, Buenos Aires, Argentina
| | - Nora Fernandez Liguori
- Servicio de Neurología, Sanatorio Güemes, Buenos Aires, Argentina,Servicio de Neurología, Hospital Tornú, Buenos
Aires, Argentina
| | | | - Leila Cohen
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos
Mejía, Buenos Aires, Argentina
| | - Juan Ignacio Rojas
- Centro de esclerosis Múltiple Buenos Aires,
Buenos Aires, Argentina,Servicio de Neurología, CEMIC, Buenos Aires,
Argentina
| | | | | | | | - Marcos Burgos
- Servicio de Neurología, Hospital San Bernardo,
Salta, Argentina
| | - Carlos Vrech
- Servicio de Neurología, Sanatorio Allende,
Córdoba, Spain
| | - Raul Piedrabuena
- Servicio de Neurología, Clínica Universitaria
Reina Fabiola, Córdoba, Spain
| | - Lopez Pablo
- Sección de nueroinmunología, Hospital Alemán,
Buenos Aires, Argentina
| | | | | | - Jimena Miguez
- Servicio de neurología, Hospital Italiano,
Buenos Aires, Argentina
| | - Mariela Cabrera
- Servicio de neurología, Hospital Militar,
Campo de Mayo, Buenos Aires, Argentina
| | | | - Gisela Zanga
- Servicio de neurología, Hospital Cesar
Milstein, Buenos Aires, Argentina
| | - Verónica Tkachuk
- Servicio de neurología, Hospital de Clínica José de San
Martín, Buenos Aires, Argentina
| | - Santiago Tizio
- Servicio de neurología, Hospital Español, La Plata, Argentina
| | | | | | | | | | - Pedro Nofal
- Servicio de neurología, Hospital Nuestra
Señora del Carmen, Tucumán, Argentina
| | - Susana Liwacki
- Servicio de neurología, Hospital Córdoba,
Córdoba, Spain
| | - Javier Hryb
- Servicio de neurología, Hospital Durand,
Buenos Aires, Argentina
| | | | | | | | - Orlando Garcea
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos
Mejía, Buenos Aires, Argentina
| | - Berenice Silva
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos
Mejía, Buenos Aires, Argentina,Servicio de neurología, Hospital Italiano,
Buenos Aires, Argentina
| |
Collapse
|
19
|
Pipek LZ, Mahler JV, Nascimento RFV, Apóstolos-Pereira SL, Silva GD, Callegaro D. Cost, efficacy, and safety comparison between early intensive and escalating strategies for multiple sclerosis: A systematic review and meta-analysis. Mult Scler Relat Disord 2023; 71:104581. [PMID: 36848839 DOI: 10.1016/j.msard.2023.104581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/07/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND The optimal treatment strategy of multiple sclerosis (MS) is a matter of debate. The classical approach is the escalating (ESC) strategy, which consists of starting with low- to moderate-efficacy disease-modifying drugs (DMDs) and upscale to high-efficacy DMDs when noting some evidence of active disease. Another approach, the early intensive (EIT) strategy, is starting with high-efficiency DMDs as first-line therapy. Our goal was to compare effectiveness, safety, and cost of ESC and EIT strategies. METHODS We searched MEDLINE, EMBASE and SCOPUS until September 2022, for studies comparing EIT and ESC strategies in adult participants with relapsing-remitting MS and a minimum follow-up of 5 years. We examined the Expanded Disability Severity Scale (EDSS), the proportion of severe adverse events, and cost in a 5-year period. Random-effects meta-analysis summarized the efficacy and safety and an EDSS-based Markov model estimated the cost. RESULTS Seven studies with 3,467 participants showed a 30% reduction in EDSS worsening in 5 years (RR 0.7; [0.59-0.83]; p < 0.001) in the EIT group vs in the ESC group. Two studies with 1,118 participants suggested a similar safety profile for these strategies (RR 1.92; [0.38-9.72]; p = 0.4324). EIT with natalizumab in extended interval dosing, rituximab, alemtuzumab, and cladribine demonstrated cost-effectiveness in our model. DISCUSSION EIT presents higher efficacy in preventing disability progression, a similar safety profile, and can be cost-effective within a 5-year timeline.
Collapse
Affiliation(s)
- Leonardo Zumerkorn Pipek
- Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, BR, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP 01246-903, Brazil.
| | - João Vitor Mahler
- Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, BR, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP 01246-903, Brazil
| | | | | | - Guilherme Diogo Silva
- Department of Neurology Hospital of Clinics, University of São Paulo, São Paulo, Brazil
| | - Dagoberto Callegaro
- Department of Neurology Hospital of Clinics, University of São Paulo, São Paulo, Brazil
| |
Collapse
|
20
|
Bourre B, Casez O, Ciron J, Gueguen A, Kwiatkowski A, Moisset X, Montcuquet A, Ayrignac X. Paradigm shifts in multiple sclerosis management: Implications for daily clinical practice. Rev Neurol (Paris) 2023; 179:256-264. [PMID: 36621364 DOI: 10.1016/j.neurol.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 01/09/2023]
Abstract
Multiple sclerosis (MS) is the most common chronic inflammatory neurological disease. The emergence of disease-modifying therapies (DMTs) has greatly improved disease activity control and progression of disability in MS patients. DMTs differ in their mode of action, route of administration, efficacy, and safety profiles, offering multiple options for clinicians. Personalized medicine aims at tailoring the therapeutic strategy to patients' characteristics and disease activity but also patients' needs and preferences. New therapeutic options have already changed treatment paradigms for patients with active relapsing MS (RMS). The traditional approach consists in initiating treatment with moderate-efficacy DMTs and subsequently, escalating to higher-efficacy DMTs when there is evidence of clinical and/or radiological breakthrough activity. Recent real-world studies suggest that initiation of high-efficacy DMTs from disease onset can improve long-term outcomes for RMS patients. In this article, we review different treatment strategies and discuss challenges associated with personalized therapy.
Collapse
Affiliation(s)
- B Bourre
- Rouen University Hospital, Rouen, France.
| | - O Casez
- Pathologies Inflammatoires du Système Nerveux, Neurologie, Department of Neurology, CRC-SEP, CHU of Grenoble-Alpes and T-RAIG (Translational Research in Autoimmunity and Inflammation Group), University of Grenoble-Alpes, Rouen, France
| | - J Ciron
- Toulouse University Hospital, Toulouse, France
| | - A Gueguen
- Department of Neurology, Rothschild Foundation, Paris, France
| | - A Kwiatkowski
- Department of Neurology, Lille Catholic University, Lille Catholic Hospitals, Lille, France
| | - X Moisset
- Inserm, NEURODOL, CHU of Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand, France
| | - A Montcuquet
- Department of Neurology, CHU of Limoges, Limoges, France
| | - X Ayrignac
- Inserm, INM, Department of Neurology, MS Center and National Reference Center of Adult Leukodystrophies, University of Montpellier, Montpellier University Hospital, Montpellier, France
| |
Collapse
|
21
|
Vudumula U, Patidar M, Gudala K, Karpf E, Adlard N. Evaluating the impact of early vs delayed ofatumumab initiation and estimating the long-term outcomes of ofatumumab vs teriflunomide in relapsing multiple sclerosis patients in Spain. J Med Econ 2023; 26:11-18. [PMID: 36472139 DOI: 10.1080/13696998.2022.2151270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the impact of early (at first-line) vs delayed (3-year delay) ofatumumab initiation and long-term clinical, societal, and economic outcomes of ofatumumab vs teriflunomide in relapsing multiple sclerosis (RMS) patients from a Spanish societal perspective. METHODS A cost-consequence analysis was conducted using an Expanded Disability Status Scale (EDSS)-based Markov model. Inputs were sourced from ASCLEPIOS I and II trials and published literature. RESULTS At the end of 10 years, compared with first-line teriflunomide treatment, early first-line ofatumumab initiation was projected to result in 35.6% fewer patients progressing to EDSS ≥ 7 and 27.8% fewer relapses. The ofatumumab cohort required 7.3% reduced informal care time and had 19% fewer disability-adjusted life years (DALYs) than the teriflunomide cohort. A 3-year delay in ofatumumab treatment (3-year teriflunomide + 7-year ofatumumab) was projected to result in 32.2% more patients progressing to EDSS ≥ 7, 20.2% more relapses, 5.4% increased informal care time, and 16.6% more DALYs compared with early ofatumumab initiation. Early ofatumumab initiation was associated with total annual cost savings (excluding disease-modifying-therapies' acquisition costs) of €35,328 ($34,549; conversion factor 1€= $1.02255) and €24,373 ($23,836) per patient vs teriflunomide and 3-year delayed ofatumumab initiation, respectively. CONCLUSIONS This study highlights the benefits of early initiation of high-efficacy therapy such as ofatumumab vs its delayed initiation for improving the outcomes in RMS patients (having characteristics similar to those of patients included in the ASCLEPIOS trials). Ofatumumab treatment was projected to provide improved long-term clinical, societal, and economic outcomes vs teriflunomide treatment in RMS patients from a Spanish societal perspective.
Collapse
Affiliation(s)
| | - Mausam Patidar
- Patient Access Services, Novartis Healthcare Pvt. Ltd, Hyderabad, India
| | - Kapil Gudala
- Patient Access Services, Novartis Healthcare Pvt. Ltd, Hyderabad, India
| | | | - Nicholas Adlard
- Health Economics and Outcomes Research, Novartis Pharma AG, Basel, Switzerland
| |
Collapse
|
22
|
Treatment with Cladribine Tablets Beyond Year 4: A Position Statement by Southeast European Multiple Sclerosis Centers. Neurol Ther 2022; 12:25-37. [PMID: 36394714 PMCID: PMC9672547 DOI: 10.1007/s40120-022-00422-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022] Open
Abstract
Based on the results of the pivotal CLARITY study, cladribine tablets were approved for use in the European Union in 2017 as a high-efficacy therapy for highly active relapsing-remitting multiple sclerosis (MS). Cladribine tablets are used as an induction therapy: half of the total dose is given in year 1 and the other half in year 2. In the CLARITY Extension trials, repeating the dose routinely in years 3 and 4, was not associated with significantly improved disease control. However, there is very limited evidence on how to manage people with MS (pwMS) beyond year 4, which is increasingly important because more and more patients are now ≥ 4 years after cladribine treatment. Overall, postapproval data show that treatment with two cladribine cycles effectively controls disease activity in the long term. However, there is general agreement that some pwMS with suboptimal response could benefit from retreatment. This study reviews the practical aspects of using cladribine tablets, summarizes the evidence from clinical trials and real-world studies on the safety and efficacy of cladribine, and proposes a treatment algorithm developed by expert consensus for pwMS previously treated with cladribine. In brief, we propose that additional courses of cladribine tablets should be considered in patients with minimal (no relapses, 1-2 new lesions) or moderate (1 relapse, 3-4 new lesions) disease activity, while significant disease activity (> 1 relapse, > 3 new lesions) or progression should warrant a switch to another high-efficacy treatment (HET). More evidence is needed to improve the treatment guidelines for pwMS who previously received cladribine.
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW To discuss recent changes in the multiple sclerosis (MS) treatment algorithm and to present therapies currently in MS clinical trials. RECENT FINDINGS High efficacy disease modifying therapies are optimally beneficial when used in the early, inflammatory phase of MS. Bruton's tyrosine kinase has emerged as an important therapeutic target for both relapsing and progressive forms of MS. Multiple therapies targeting remyelination failed to provide conclusive evidence of broad therapeutic benefit; however, more targeted approaches offer hope that myelin repair might be achieved resulting in specific clinical improvements. Strategies targeting chronic Epstein-Barr virus infection and dysbiosis of the gut microbiome are the first to link microbial risk factors for MS and therapeutic interventions. SUMMARY A striking number of diverse treatments under investigation bodes well for development of better and more effective therapies in MS.
Collapse
|
24
|
Romero-Pinel L, Bau L, Matas E, León I, Juvany R, Jódar R, Martínez-Yélamos A, Martínez-Yélamos S. Cost associated with a relapse-free patient in multiple sclerosis: A real-world health indicator. PLoS One 2022; 17:e0267504. [PMID: 35486620 PMCID: PMC9053779 DOI: 10.1371/journal.pone.0267504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 04/08/2022] [Indexed: 12/03/2022] Open
Abstract
Background The efficacy and safety of disease-modifying therapies (DMTs) in multiple sclerosis (MS) are well known; however, owing to their high costs, determining real-world outcomes is essential to evaluate the cost-effectiveness of different therapeutic strategies. This study aimed to investigate the variability in the annual cost of DMTs associated with a relapse-free patient in a representative population cohort of relapsing-remitting MS (RRMS), and whether this could serve as an appropriate health indicator. Methods We analyzed the patients followed up in our MS clinic during the years 2016 and 2019, and selected patients belonging to our health district diagnosed with RRMS. The treatment cost associated with a relapse-free patient was the ratio between the total cost of DMTs and the number of relapse-free patients, treated and not treated, during the year of the study. Results A total of 158 patients with RRMS in 2016 and 183 in 2019 were included in our study. In 2016, 101 patients with RRMS (63.9%) received treatment with DMTs and 120 patients (75.9%) remained relapse-free. The mean cost of DMTs per patient in 2016 was €7414.3 (95% confidence interval [CI]: 6325.2–8503.4) considering all the patients (treated and not treated). In 2019, 126 patients (68.9%) received DMTs and 151 patients (82.5%) remained relapse-free. The mean cost of DMTs per patient in 2019 was €6985.4 (95% CI: 5986.9–7983.9) considering all the patients. The cost per year of DMTs to achieve a relapse-free patient was €9762.2 in 2016 and €8465.8 in 2019. Conclusions The treatment cost per year to achieve a relapse-free patient was stable during successive measurements in the same population. Therefore, it may be considered a good real-world health indicator for patients with RRMS treated with DMTs.
Collapse
Affiliation(s)
- Lucía Romero-Pinel
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge–Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
- * E-mail:
| | - Laura Bau
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge–Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Elisabet Matas
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge–Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Isabel León
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge–Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Roser Juvany
- Department of Pharmacy, Hospital Universitari de Bellvitge–Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Ramon Jódar
- Department of Pharmacy, Hospital Universitari de Bellvitge–Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Antonio Martínez-Yélamos
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge–Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
- Departament de Ciències Clíniques, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Sergio Martínez-Yélamos
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge–Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
- Departament de Ciències Clíniques, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
25
|
Effectiveness and Safety of Early High-Efficacy Versus Escalation Therapy in Relapsing-Remitting Multiple Sclerosis in Argentina. Clin Neuropharmacol 2022; 45:45-51. [DOI: 10.1097/wnf.0000000000000503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
26
|
Luchesa Smith A, Sudarsan N, Hemingway C, Lim M. Diagnosis and management of multiple sclerosis and other relapsing demyelinating disease in childhood. Arch Dis Child 2022; 107:216-222. [PMID: 34230009 DOI: 10.1136/archdischild-2021-321911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/15/2021] [Indexed: 11/03/2022]
Abstract
There are several important relapsing demyelinating syndromes (RDS) that may present in childhood, of which paediatric-onset multiple sclerosis is the most common. These are rare conditions, so recognising presentations and referring early to specialist services is important to enable prompt diagnosis and effective treatment. Understanding of RDS is rapidly evolving, with many new and effective treatments that aim to reduce relapses and disability accumulation. A holistic and child-focused approach to management is key to supporting patients and families, with thought given to early detection of cognitive and psychological issues to provide appropriate support.
Collapse
Affiliation(s)
| | - Nikil Sudarsan
- Department of Paediatric Neurology, Royal Alexandra Children's Hospital, Brighton, UK
| | - Cheryl Hemingway
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| |
Collapse
|
27
|
Temmerman J, Van Der Veken F, Engelborghs S, Guldolf K, Nagels G, Smeets D, Allemeersch GJ, Costers L, D’hooghe MB, Vanbinst AM, Van Schependom J, Bjerke M, D’haeseleer M. Brain Volume Loss Can Occur at the Rate of Normal Aging in Patients with Multiple Sclerosis Who Are Free from Disease Activity. J Clin Med 2022; 11:jcm11030523. [PMID: 35159972 PMCID: PMC8836909 DOI: 10.3390/jcm11030523] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 02/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating and degenerative disorder of the central nervous system. Accelerated brain volume loss (BVL) has emerged as a promising magnetic resonance imaging marker (MRI) of neurodegeneration, correlating with present and future clinical disability. We have systematically selected MS patients fulfilling ‘no evidence of disease activity-3′ (NEDA-3) criteria under high-efficacy disease-modifying treatment (DMT) from the database of two Belgian MS centers. BVL between both MRI scans demarcating the NEDA-3 period was assessed and compared with a group of prospectively recruited healthy volunteers who were matched for age and gender. Annualized whole brain volume percentage change was similar between 29 MS patients achieving NEDA-3 and 24 healthy controls (−0.25 ± 0.49 versus −0.24 ± 0.20, p = 0.9992; median follow-up 21 versus 33 months; respectively). In contrast, we found a mean BVL increase of 72%, as compared with the former, in a second control group of MS patients (n = 21) whom had been excluded from the NEDA-3 group due to disease activity (p = 0.1371). Our results suggest that neurodegeneration in MS can slow down to the rate of normal aging once inflammatory disease activity has been extinguished and advocate for an early introduction of high-efficacy DMT to reduce the risk of future clinical disability.
Collapse
Affiliation(s)
- Joke Temmerman
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (J.T.); (F.V.D.V.); (S.E.); (K.G.); (G.N.); (M.B.D.)
- Center for Neurosciences (C4N), NEUR and AIMS, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussel, Belgium; (D.S.); (L.C.); (J.V.S.); (M.B.)
- Department of Biomedical Sciences, Institute Born-Bunge, Universiteit Antwerpen, Universiteitsplein 1, 2610 Antwerp, Belgium
| | - Floris Van Der Veken
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (J.T.); (F.V.D.V.); (S.E.); (K.G.); (G.N.); (M.B.D.)
| | - Sebastiaan Engelborghs
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (J.T.); (F.V.D.V.); (S.E.); (K.G.); (G.N.); (M.B.D.)
- Center for Neurosciences (C4N), NEUR and AIMS, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussel, Belgium; (D.S.); (L.C.); (J.V.S.); (M.B.)
- Department of Biomedical Sciences, Institute Born-Bunge, Universiteit Antwerpen, Universiteitsplein 1, 2610 Antwerp, Belgium
| | - Kaat Guldolf
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (J.T.); (F.V.D.V.); (S.E.); (K.G.); (G.N.); (M.B.D.)
- Department of Neurology, Onze-Lieve-Vrouw Ziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium
| | - Guy Nagels
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (J.T.); (F.V.D.V.); (S.E.); (K.G.); (G.N.); (M.B.D.)
- Center for Neurosciences (C4N), NEUR and AIMS, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussel, Belgium; (D.S.); (L.C.); (J.V.S.); (M.B.)
- Icometrix, Kolonel Begaultlaan 1b, 3012 Leuven, Belgium
| | - Dirk Smeets
- Center for Neurosciences (C4N), NEUR and AIMS, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussel, Belgium; (D.S.); (L.C.); (J.V.S.); (M.B.)
- Icometrix, Kolonel Begaultlaan 1b, 3012 Leuven, Belgium
| | - Gert-Jan Allemeersch
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (G.-J.A.); (A.-M.V.)
| | - Lars Costers
- Center for Neurosciences (C4N), NEUR and AIMS, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussel, Belgium; (D.S.); (L.C.); (J.V.S.); (M.B.)
- Icometrix, Kolonel Begaultlaan 1b, 3012 Leuven, Belgium
| | - Marie B. D’hooghe
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (J.T.); (F.V.D.V.); (S.E.); (K.G.); (G.N.); (M.B.D.)
- Center for Neurosciences (C4N), NEUR and AIMS, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussel, Belgium; (D.S.); (L.C.); (J.V.S.); (M.B.)
- Nationaal Multiple Sclerose Centrum (NMSC), Vanheylenstraat 16, 1820 Melsbroek, Belgium
| | - Anne-Marie Vanbinst
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (G.-J.A.); (A.-M.V.)
| | - Jeroen Van Schependom
- Center for Neurosciences (C4N), NEUR and AIMS, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussel, Belgium; (D.S.); (L.C.); (J.V.S.); (M.B.)
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), Pleinlaan 2, 1050 Brussels, Belgium
| | - Maria Bjerke
- Center for Neurosciences (C4N), NEUR and AIMS, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussel, Belgium; (D.S.); (L.C.); (J.V.S.); (M.B.)
- Department of Biomedical Sciences, Institute Born-Bunge, Universiteit Antwerpen, Universiteitsplein 1, 2610 Antwerp, Belgium
- Laboratory of Clinical Neurochemistry, Department of Clinical Biology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Miguel D’haeseleer
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (J.T.); (F.V.D.V.); (S.E.); (K.G.); (G.N.); (M.B.D.)
- Center for Neurosciences (C4N), NEUR and AIMS, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussel, Belgium; (D.S.); (L.C.); (J.V.S.); (M.B.)
- Nationaal Multiple Sclerose Centrum (NMSC), Vanheylenstraat 16, 1820 Melsbroek, Belgium
- Correspondence:
| |
Collapse
|
28
|
Casanova B, Quintanilla-Bordás C, Gascón F. Escalation vs. Early Intense Therapy in Multiple Sclerosis. J Pers Med 2022; 12:jpm12010119. [PMID: 35055434 PMCID: PMC8778390 DOI: 10.3390/jpm12010119] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/28/2021] [Accepted: 01/01/2022] [Indexed: 02/01/2023] Open
Abstract
The treatment strategy of multiple sclerosis (MS) is a highly controversial debate. Currently, there are up to 19 drugs approved. However, there is no clear evidence to guide fundamental decisions such as what treatment should be chosen in first place, when treatment failure or suboptimal response should be considered, or what treatment should be considered in these cases. The “escalation strategy” consists of starting treatment with drugs of low side-effect profile and low efficacy, and “escalating” to drugs of higher efficacy—with more potential side-effects—if necessary. This strategy has prevailed over the years. However, the evidence supporting this strategy is based on short-term studies, in hope that the benefits will stand in the long term. These studies usually do not consider the heterogeneity of the disease and the limited effect that relapses have on the long-term. On the other hand, “early intense therapy” strategy refers to starting treatment with drugs of higher efficacy from the beginning, despite having a less favorable side-effect profile. This approach takes advantage of the so-called “window of opportunity” in hope to maximize the clinical benefits in the long-term. At present, the debate remains open. In this review, we will critically review both strategies. We provide a summary of the current evidence for each strategy without aiming to reach a definite conclusion.
Collapse
Affiliation(s)
- Bonaventura Casanova
- Unitat de Neuroimmunologia, Hospital Universitari i Politècnic La Fe. València, la Universitat de València, 46026 Valencia, Spain;
- Correspondence:
| | - Carlos Quintanilla-Bordás
- Unitat de Neuroimmunologia, Hospital Universitari i Politècnic La Fe. València, la Universitat de València, 46026 Valencia, Spain;
| | - Francisco Gascón
- Unitat de Neuroimmunologia, Hospital Clínic Universitari de València, 46010 Valencia, Spain;
| |
Collapse
|
29
|
Freeman L, Longbrake EE, Coyle PK, Hendin B, Vollmer T. High-Efficacy Therapies for Treatment-Naïve Individuals with Relapsing-Remitting Multiple Sclerosis. CNS Drugs 2022; 36:1285-1299. [PMID: 36350491 PMCID: PMC9645316 DOI: 10.1007/s40263-022-00965-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/11/2022]
Abstract
There are > 18 distinct disease-modifying therapy (DMT) options covering 10 mechanisms of action currently approved by the US Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis (RRMS). Given the multitude of available treatment options, and recent international consensus guidelines offering differing recommendations, there is broad heterogeneity in how the DMTs are used in clinical practice. Choosing a DMT for newly diagnosed patients with MS is currently a topic of significant debate in MS care. Historically, an escalation approach to DMT was used for newly diagnosed patients with RRMS. However, the evidence for clinical benefits of early treatment with high-efficacy therapies (HETs) in this population is emerging. In this review, we provide an overview of the DMT options and MS treatment strategies, and discuss the clinical benefits of HETs (including ofatumumab, ocrelizumab, natalizumab, alemtuzumab, and cladribine) in the early stages of MS, along with safety concerns associated with these DMTs. By minimizing the accumulation of neurological damage early in the disease course, early treatment with HETs may enhance long-term clinical outcomes over the lifetime of the patient.
Collapse
Affiliation(s)
- Léorah Freeman
- Department of Neurology, Dell Medical School, The University of Texas at Austin, 1601 Trinity St, Austin, TX, 78701, USA.
| | | | - Patricia K. Coyle
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Barry Hendin
- Banner, University Medicine Neurosciences Clinic, Phoenix, AZ USA
| | - Timothy Vollmer
- Department of Neurology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| |
Collapse
|
30
|
Smith JA, Nicaise AM, Ionescu RB, Hamel R, Peruzzotti-Jametti L, Pluchino S. Stem Cell Therapies for Progressive Multiple Sclerosis. Front Cell Dev Biol 2021; 9:696434. [PMID: 34307372 PMCID: PMC8299560 DOI: 10.3389/fcell.2021.696434] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/10/2021] [Indexed: 12/19/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system characterized by demyelination and axonal degeneration. MS patients typically present with a relapsing-remitting (RR) disease course, manifesting as sporadic attacks of neurological symptoms including ataxia, fatigue, and sensory impairment. While there are several effective disease-modifying therapies able to address the inflammatory relapses associated with RRMS, most patients will inevitably advance to a progressive disease course marked by a gradual and irreversible accrual of disabilities. Therapeutic intervention in progressive MS (PMS) suffers from a lack of well-characterized biological targets and, hence, a dearth of successful drugs. The few medications approved for the treatment of PMS are typically limited in their efficacy to active forms of the disease, have little impact on slowing degeneration, and fail to promote repair. In looking to address these unmet needs, the multifactorial therapeutic benefits of stem cell therapies are particularly compelling. Ostensibly providing neurotrophic support, immunomodulation and cell replacement, stem cell transplantation holds substantial promise in combatting the complex pathology of chronic neuroinflammation. Herein, we explore the current state of preclinical and clinical evidence supporting the use of stem cells in treating PMS and we discuss prospective hurdles impeding their translation into revolutionary regenerative medicines.
Collapse
Affiliation(s)
- Jayden A. Smith
- Cambridge Innovation Technologies Consulting (CITC) Limited, Cambridge, United Kingdom
| | - Alexandra M. Nicaise
- Department of Clinical Neurosciences and National Institute for Health Research (NIHR) Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Rosana-Bristena Ionescu
- Department of Clinical Neurosciences and National Institute for Health Research (NIHR) Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Regan Hamel
- Department of Clinical Neurosciences and National Institute for Health Research (NIHR) Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Luca Peruzzotti-Jametti
- Department of Clinical Neurosciences and National Institute for Health Research (NIHR) Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Stefano Pluchino
- Department of Clinical Neurosciences and National Institute for Health Research (NIHR) Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
31
|
Iaffaldano P, Lucisano G, Caputo F, Paolicelli D, Patti F, Zaffaroni M, Brescia Morra V, Pozzilli C, De Luca G, Inglese M, Salemi G, Maniscalco GT, Cocco E, Sola P, Lus G, Conte A, Amato MP, Granella F, Gasperini C, Bellantonio P, Totaro R, Rovaris M, Salvetti M, Torri Clerici VLA, Bergamaschi R, Maimone D, Scarpini E, Capobianco M, Comi G, Filippi M, Trojano M. Long-term disability trajectories in relapsing multiple sclerosis patients treated with early intensive or escalation treatment strategies. Ther Adv Neurol Disord 2021; 14:17562864211019574. [PMID: 34104220 PMCID: PMC8170278 DOI: 10.1177/17562864211019574] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background and aims: No consensus exists on how aggressively to treat relapsing–remitting multiple
sclerosis (RRMS) nor on the timing of the treatment. The objective of this
study was to evaluate disability trajectories in RRMS patients treated with
an early intensive treatment (EIT) or with a moderate-efficacy treatment
followed by escalation to higher-efficacy disease modifying therapy
(ESC). Methods: RRMS patients with ⩾5-year follow-up and ⩾3 visits after disease modifying
therapy (DMT) start were selected from the Italian MS Registry. EIT group
included patients who received as first DMT fingolimod, natalizumab,
mitoxantrone, alemtuzumab, ocrelizumab, cladribine. ESC group patients
received the high efficacy DMT after ⩾1 year of glatiramer acetate,
interferons, azathioprine, teriflunomide or dimethylfumarate treatment.
Patients were 1:1 propensity score (PS) matched for characteristics at the
first DMT. The disability trajectories were evaluated by applying a
longitudinal model for repeated measures. The effect of early
versus late start of high-efficacy DMT was assessed by
the mean annual Expanded Disability Status Scale (EDSS) changes compared
with baseline values (delta-EDSS) in EIT and ESC groups. Results: The study cohort included 2702 RRMS patients. The PS matching procedure
produced 363 pairs, followed for a median (interquartile range) of 8.5
(6.5–11.7) years. Mean annual delta-EDSS values were all significantly
(p < 0.02) higher in the ESC group compared with the
EIT group. In particular, the mean delta-EDSS differences between the two
groups tended to increase from 0.1 (0.01–0.19, p = 0.03) at
1 year to 0.30 (0.07–0.53, p = 0.009) at 5 years and to
0.67 (0.31–1.03, p = 0.0003) at 10 years. Conclusion: Our results indicate that EIT strategy is more effective than ESC strategy in
controlling disability progression over time.
Collapse
Affiliation(s)
- Pietro Iaffaldano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Lucisano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Francesca Caputo
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Francesco Patti
- Dipartimento di Scienze Mediche e Chirurgiche e Tecnologie Avanzate, GF Ingrassia, Sez. Neuroscienze, Centro Sclerosi Multipla, Università di Catania, Catania, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, Hospital of Gallarate, ASST della Valle Olona, Gallarate (Varese), Italy
| | - Vincenzo Brescia Morra
- Department of Neuroscience (NSRO), Multiple Sclerosis Clinical Care and Research Center, Federico II University, Naples, Italy
| | - Carlo Pozzilli
- Department of Human Neuroscience, Multiple Sclerosis Center, S. Andrea Hospital, Rome, Italy
| | - Giovanna De Luca
- Centro Sclerosi Multipla, Clinica Neurologica, Policlinico SS. Annunziata, Abruzzo, Chieti, Italy
| | - Matilde Inglese
- Dipartimento Di Neuroscienze, Riabilitazione, Oftalmologia, Genetica E Scienze Materno - Infantili (DINOGMI), Universita' di Genova, Genova, Liguria, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Sicilia, Italy
| | | | - Eleonora Cocco
- Department of Medical Science and Public health, Centro Sclerosi Multipla, University of Cagliari, Italy
| | - Patrizia Sola
- Azienda Ospedaliera Universitaria di Modena/OCB, UO Neurologia, Italy
| | - Giacomo Lus
- Multiple Sclerosis Center, II Division of Neurology, Department of Clinical and Experimental Medicine, Second University of Naples, Caserta, Campania, Italy
| | - Antonella Conte
- Department of Human Neurosciences, Sapienza University of Rome, Italy
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Firenze, Italy
| | - Franco Granella
- Unit of Neurosciences, Department of Medicine and Surgery, University of Parma, Parma, Emilia-Romagna, Italy
| | - Claudio Gasperini
- Centro Sclerosi Multipla - Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | | | - Rocco Totaro
- Centro Malattie Demielinizzanti - Clinica Neurologica, Ospedale San Salvatore, L'Aquila, Abruzzo, Italy
| | - Marco Rovaris
- Multiple Sclerosis Center, IRCCS Fondazione don Carlo Gnocchi ONLUS, Milan, Italy
| | - Marco Salvetti
- IRCCS Istituto Neurologico Mediterraneo (INM) Neuromed, Pozzilli, Italy
| | | | | | - Davide Maimone
- Centro Sclerosi Multipla - UOC di Neurologia - ARNAS Garibaldi, Catania, Sicilia, Italy
| | - Elio Scarpini
- Centro Sclerosi Multipla - UOSD Malattie Neurodegenerative - IRCCS Ospedale Maggiore Policlinico, Università Milano, Milano, Lombardia, Italy
| | - Marco Capobianco
- Struttura Complessa Ospedaliera Neurologia & CRESM (Centro di Riferimento Regionale per la SM) - AOU San Luigi, Orbassano (Torino), Italy
| | - Giancarlo Comi
- Institute of Experimental Neurology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Massimo Filippi
- Dipartimento di Neurologia, Neurofisiologia e Neuroriabilitazione, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro" Bari, Piazza G. Cesare, 11, Bari, 70124, Italy
| | | |
Collapse
|
32
|
Simpson A, Mowry EM, Newsome SD. Early Aggressive Treatment Approaches for Multiple Sclerosis. Curr Treat Options Neurol 2021; 23:19. [PMID: 34025110 PMCID: PMC8121641 DOI: 10.1007/s11940-021-00677-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 12/19/2022]
Abstract
Purpose of review This review presents a comprehensive analysis of the current high-efficacy disease-modifying therapies (DMTs) available for treatment of multiple sclerosis (MS). We discuss the existing approved and emerging therapeutics in patients with relapsing and progressive forms of MS using data from clinical trials and observational studies. Treatment considerations in pediatric and pregnant populations are also reviewed. Finally, we discuss the treatment paradigms of the escalation and early aggressive approaches to treatment of MS, with review of ongoing clinical trials to compare these approaches. Recent findings Natalizumab has shown promising data on efficacy in not only randomized trials but also observational studies when compared with placebo, the injectable DMTs, and fingolimod. The anti-CD20 B cell depleting therapies (rituximab, ocrelizumab, and ofatumumab) have also demonstrated superiority in randomized clinical trials compared to their comparator group (placebo, interferon, and teriflunomide, respectively) and rituximab has shown in observational studies to be more effective than older injectable therapies and some of the oral therapies. Alemtuzumab has shown good efficacy in randomized controlled trials and observational studies yet has several potentially severe side effects limiting its use. Mitoxantrone has similarly demonstrated significant reduction in new disease activity compared to placebo but is rarely used due to its severe side effects. Cladribine is an oral DMT often grouped in discussion with other higher efficacy DMTs but may be slightly less effective than the other therapies described in this review. Many emerging targets for therapeutic intervention are currently under investigation that may prove to be beneficial in early aggressive MS, including autologous hematopoietic stem cell transplantation. Summary Traditionally, MS has been treated with an escalation approach, starting patients on a modestly effective DMT and subsequently escalating to a higher efficacy DMT when there is evidence of clinical and/or radiologic breakthrough activity. With the development of higher efficacy therapies and emerging data showing the potential positive long-term impact of these therapies when started earlier in the disease course, many clinicians have shifted to an early aggressive treatment approach in which patients are initially started on a higher efficacy DMT. Two clinical trials, the TRaditional versus Early Aggressive Therapy for MS (TREAT-MS) trial and the Determining the Effectiveness of earLy Intensive Versus Escalation approaches for the treatment of Relapsing-remitting MS (DELIVER-MS) trial, aim to directly compare these treatment strategies and their impact on clinical and radiologic outcomes.
Collapse
Affiliation(s)
- Alexandra Simpson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA.,Division of Neuroimmunology and Neurological Infections, Johns Hopkins Hospital, 600 North Wolfe St., Pathology 627, Baltimore, MD 21287 USA
| |
Collapse
|
33
|
Wang J, Lou Y, Lu J, Luo Y, Lu A, Chen A, Fu J, Liu J, Zhou X, Yang J. A Deep Look into the Program of Rapid Tumor Growth of Hepatocellular Carcinoma. J Clin Transl Hepatol 2021; 9:22-31. [PMID: 33604252 PMCID: PMC7868698 DOI: 10.14218/jcth.2020.00084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/12/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND AIMS Great efforts have been made towards increasing our understanding of the pathogenesis involved in hepatocellular carcinoma (HCC), but the rapid growth inherent to such tumor development remains to be explored. METHODS We identified distinct gene coexpression modes upon liver tumor growth using weighted gene coexpression network analysis. Modeling of tumor growth as signaling activity was employed to understand the main cascades responsible for the growth. Hub genes in the modules were determined, examined in vitro, and further assembled into the growth signature. RESULTS We revealed modules related to the different growth states in HCC, especially the fastest growth module, which is preserved among different HCC cohorts. Moreover, signaling flux in the cell cycle pathway was found to act as a driving force for rapid growth. Twenty hub genes in the module were identified and assembled into the growth signature, and two genes (NCAPH, and RAD54L) were tested for their growth potential in vitro. Genetic alteration of the growth signature affected the global gene expression. The activity of the signature was associated with tumor metabolism and immunity in HCC. Finally, the prognosis effect of the growth signature was reproduced in nine cancers. CONCLUSIONS These results collectively demonstrate the molecule organization of rapid tumor growth in HCC, which is a highly synergistic process, with implications for the future management of patients.
Collapse
Affiliation(s)
- Jie Wang
- Department of Translational Medicine, Affiliated Hospital of Hangzhou Normal University, Institute of Hepatology and Metabolic Diseases of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
- Department of Liver Disease, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Yi Lou
- Department of Occupational Medicine, Hangzhou Red Cross Hospital, Zhejiang Provincial Integrated Chinese and Western Medicine Hospital, Hangzhou, Zhejiang, China
| | - Jianmin Lu
- Department of Orthopedics, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Yuxiao Luo
- Department of Orthopedics, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Anqian Lu
- Department of Translational Medicine, Affiliated Hospital of Hangzhou Normal University, Institute of Hepatology and Metabolic Diseases of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Anna Chen
- Department of Translational Medicine, Affiliated Hospital of Hangzhou Normal University, Institute of Hepatology and Metabolic Diseases of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Jiantao Fu
- Department of Translational Medicine, Affiliated Hospital of Hangzhou Normal University, Institute of Hepatology and Metabolic Diseases of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Jing Liu
- Department of Translational Medicine, Affiliated Hospital of Hangzhou Normal University, Institute of Hepatology and Metabolic Diseases of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
- Department of Liver Disease, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Xiang Zhou
- Department of Translational Medicine, Affiliated Hospital of Hangzhou Normal University, Institute of Hepatology and Metabolic Diseases of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
- Department of Liver Disease, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
- Correspondence to: Jin Yang, Department of Translational Medicine, Affiliated Hospital of Hangzhou Normal University, Institute of Hepatology and Metabolic Diseases of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang 310015, China. Tel: +86-571-88358062, E-mail: ; Xiang Zhou, Department of Liver Disease, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang 310015, China. Tel: +86-571-88303403, E-mail:
| | - Jin Yang
- Department of Translational Medicine, Affiliated Hospital of Hangzhou Normal University, Institute of Hepatology and Metabolic Diseases of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
- Department of Liver Disease, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
- Correspondence to: Jin Yang, Department of Translational Medicine, Affiliated Hospital of Hangzhou Normal University, Institute of Hepatology and Metabolic Diseases of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang 310015, China. Tel: +86-571-88358062, E-mail: ; Xiang Zhou, Department of Liver Disease, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang 310015, China. Tel: +86-571-88303403, E-mail:
| |
Collapse
|
34
|
Coyle PK. Commentary: The Multiple Sclerosis Controversy: Is It Escalation or Induction High Efficacy? Neurotherapeutics 2020; 17:971-972. [PMID: 32488481 PMCID: PMC7609745 DOI: 10.1007/s13311-020-00869-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, 11794, USA.
| |
Collapse
|