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Newsome SD, Binns C, Kaunzner UW, Morgan S, Halper J. No Evidence of Disease Activity (NEDA) as a Clinical Assessment Tool for Multiple Sclerosis: Clinician and Patient Perspectives [Narrative Review]. Neurol Ther 2023; 12:1909-1935. [PMID: 37819598 PMCID: PMC10630288 DOI: 10.1007/s40120-023-00549-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023] Open
Abstract
The emergence of high-efficacy therapies for multiple sclerosis (MS), which target inflammation more effectively than traditional disease-modifying therapies, has led to a shift in MS management towards achieving the outcome assessment known as no evidence of disease activity (NEDA). The most common NEDA definition, termed NEDA-3, is a composite of three related measures of disease activity: no clinical relapses, no disability progression, and no radiological activity. NEDA has been frequently used as a composite endpoint in clinical trials, but there is growing interest in its use as an assessment tool to help patients and healthcare professionals navigate treatment decisions in the clinic. Raising awareness about NEDA may therefore help patients and clinicians make more informed decisions around MS management and improve overall MS care. This review aims to explore the potential utility of NEDA as a clinical decision-making tool and treatment target by summarizing the literature on its current use in the context of the expanding treatment landscape. We identify current challenges to the use of NEDA in clinical practice and detail the proposed amendments, such as the inclusion of alternative outcomes and biomarkers, to broaden the clinical information captured by NEDA. These themes are further illustrated with the real-life perspectives and experiences of our two patient authors with MS. This review is intended to be an educational resource to support discussions between clinicians and patients on this evolving approach to MS-specialized care.
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Affiliation(s)
- Scott D Newsome
- Johns Hopkins University School of Medicine, 600 North Wolfe Street, Pathology 627, Baltimore, MD, 21287, USA.
| | - Cherie Binns
- Multiple Sclerosis Foundation, 6520 N Andrews Avenue, Fort Lauderdale, FL, 33309, USA
| | | | - Seth Morgan
- National Multiple Sclerosis Society, 1 M Street SE, Suite 510, Washington, DC, 20003, USA
| | - June Halper
- Consortium of Multiple Sclerosis Centers, 3 University Plaza Drive Suite A, Hackensack, NJ, 07601, USA
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Adverse events and monitoring requirements associated with monoclonal antibody therapy in patients with multiple sclerosis. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00682-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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The evolution of "No Evidence of Disease Activity" in multiple sclerosis. Mult Scler Relat Disord 2017; 20:231-238. [PMID: 29579629 DOI: 10.1016/j.msard.2017.12.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 12/30/2022]
Abstract
The availability of effective therapies for patients with relapsing-remitting multiple sclerosis (RRMS) has prompted a re-evaluation of the most appropriate way to measure treatment response, both in clinical trials and clinical practice. Traditional parameters of treatment efficacy such as annualized relapse rate, magnetic resonance imaging (MRI) activity, and disability progression have an important place, but their relative merit is uncertain, and the role of other factors such as brain atrophy is still under study. More recently, composite measures such as "no evidence of disease activity" (NEDA) have emerged as new potential treatment targets, but NEDA itself has variable definitions, is not well validated, and may be hard to implement as a treatment goal in a clinical setting. We describe the development of NEDA as an outcome measure in MS, discuss definitions including NEDA-3 and NEDA-4, and review the strengths and limitations of NEDA, indicating where further research is needed.
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Nowinski CJ, Miller DM, Cella D. Evolution of Patient-Reported Outcomes and Their Role in Multiple Sclerosis Clinical Trials. Neurotherapeutics 2017; 14:934-944. [PMID: 28913785 PMCID: PMC5722775 DOI: 10.1007/s13311-017-0571-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Patient-reported outcomes (PROs) are playing an increasing role in multiple sclerosis (MS) research and practice, and are essential for understanding the effects that MS and MS treatments have on patients' lives. PROs are captured directly from patients and include symptoms, function, health status, and health-related quality of life. In this article, we review different categories (e.g., generic, targeted, preference-based) of PRO measures and considerations in selecting a measure. The PROs included in MS clinical research have evolved over time, as have the measures used to assess them. We describe findings from recent MS clinical trials that included PROs when evaluating Food and Drug Administration-approved disease-modifying therapies (e.g., daclizumab, teriflunomide). Variation in the measures used in these trials makes it difficult to draw any conclusions from the data. We therefore suggest a standardized approach to PRO assessment in MS research and describe 2 generic, National Institutes of Health-supported measurement systems [Neuro-QoL and the Patient-Reported Outcomes Measurement Information System (PROMIS)] that would facilitate such an approach. The use of PROs in MS care and research is expanding beyond clinical trials, as is demonstrated by examples from comparative effectiveness and other patient-centered research. The importance of PRO assessment is expected to continue to grow in the future.
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Affiliation(s)
- Cindy J Nowinski
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | | | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Smith AL, Cohen JA, Hua LH. Therapeutic Targets for Multiple Sclerosis: Current Treatment Goals and Future Directions. Neurotherapeutics 2017; 14:952-960. [PMID: 28653282 PMCID: PMC5722758 DOI: 10.1007/s13311-017-0548-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system, and the most common cause of nontraumatic disability in young adults. Most patients have a relapsing-remitting course, and roughly half of them will eventually enter a degenerative progressive phase, marked by gradual accrual of disability over time in the absence of relapses. Early initiation of treatment has delayed the onset of disability progression. Thus, there is increased interest in treating to target in MS, particularly targeting no evidence of disease activity. This review will describe the most common treatment goals in MS: the Rio scores, disease-free survival, and no evidence of disease activity. We will also cover how well current disease-modifying therapies achieve no evidence of disease activity, and discuss future options for improving MS treatment targets.
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Affiliation(s)
- Andrew L Smith
- Mellen Center for MS Treatment and Research, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Le H Hua
- Lou Ruvo Center for Brain Health, Cleveland Clinic, 888 W. Bonneville, Las Vegas, NV, USA
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Fragoso YD, Willie PR, Goncalves MVM, Brooks JBB. Critical analysis on the present methods for brain volume measurements in multiple sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:464-469. [PMID: 28746434 DOI: 10.1590/0004-282x20170072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/30/2017] [Indexed: 11/22/2022]
Abstract
Objective The treatment of multiple sclerosis (MS) has quickly evolved from a time when controlling clinical relapses would suffice, to the present day, when complete disease control is expected. Measurement of brain volume is still at an early stage to be indicative of therapeutic decisions in MS. Methods This paper provides a critical review of potential biases and artifacts in brain measurement in the follow-up of patients with MS. Results Clinical conditions (such as hydration or ovulation), time of the day, type of magnetic resonance machine (manufacturer and potency), brain volume artifacts and different platforms for volumetric assessment of the brain can induce variations that exceed the acceptable physiological rate of annual loss of brain volume. Conclusion Although potentially extremely valuable, brain volume measurement still has to be regarded with caution in MS.
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Affiliation(s)
- Yara Dadalti Fragoso
- Universidade Metropolitana de Santos, Centro de Referência de Esclerose Múltipla, Departamento de Neurologia, Santos SP, Brasil
| | - Paulo Roberto Willie
- Universidade da Região de Joinville, Departamento de Neuroradiologia, Joinville SC, Brasil
| | | | - Joseph Bruno Bidin Brooks
- Universidade Metropolitana de Santos, Centro de Referência de Esclerose Múltipla, Departamento de Neurologia, Santos SP, Brasil
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Londoño AC, Mora CA. Evidence of disease control: a realistic concept beyond NEDA in the treatment of multiple sclerosis. F1000Res 2017; 6:566. [PMID: 28588765 PMCID: PMC5446020 DOI: 10.12688/f1000research.11349.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 12/21/2022] Open
Abstract
Although no evidence of disease activity (NEDA) permits evaluation of response to treatment in the systematic follow-up of patients with multiple sclerosis (MS), its ability to accomplish detection of surreptitious activity of disease is limited, thus being unable to prevent patients from falling into a non-reversible progressive phase of disease. A protocol of evaluation based on the use of validated biomarkers that is conducted at an early stage of disease would permit the capture of abnormal neuroimmunological phenomena and lead towards intervention with modifying therapy before tissue damage has been reached.
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Affiliation(s)
- Ana C Londoño
- Instituto Neurológico de Colombia (INDEC), Medellín, Colombia
| | - Carlos A Mora
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
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Londoño AC, Mora CA. Evidence of disease control: a realistic concept beyond NEDA in the treatment of multiple sclerosis. F1000Res 2017; 6:566. [PMID: 28588765 PMCID: PMC5446020 DOI: 10.12688/f1000research.11349.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 10/13/2023] Open
Abstract
Although no evidence of disease activity (NEDA) permits evaluation of response to treatment in the systematic follow-up of patients with multiple sclerosis (MS), its ability to accomplish detection of surreptitious activity of disease is limited, thus being unable to prevent patients from falling into a non-reversible progressive phase of disease. A protocol of evaluation based on the use of validated biomarkers that is conducted at an early stage of disease would permit the capture of abnormal neuroimmunological phenomena and lead towards intervention with modifying therapy before tissue damage has been reached.
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Affiliation(s)
- Ana C. Londoño
- Instituto Neurológico de Colombia (INDEC), Medellín, Colombia
| | - Carlos A. Mora
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
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Conway DS, Thompson NR, Cohen JA. Lack of magnetic resonance imaging lesion activity as a treatment target in multiple sclerosis: An evaluation using electronically collected outcomes. Mult Scler Relat Disord 2016; 9:129-34. [PMID: 27645360 DOI: 10.1016/j.msard.2016.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 07/21/2016] [Accepted: 07/26/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The appropriate treatment target in multiple sclerosis (MS) is unclear. Lack of magnetic resonance imaging (MRI) lesion activity, a component of the no evidence of disease activity concept, has been proposed as a treatment target in MS. We used our MS database to investigate whether aggressively pursuing MRI stability by changing disease modifying therapy (DMT) when MRI activity is observed leads to better clinical and imaging outcomes. METHODS The Knowledge Program (KP) is a database linked to our electronic medical record allowing capture of patient and clinician reported outcomes. Through KP query and chart review, we identified all relapsing-remitting MS patients visiting between 1 January 2008 and 31 December 2014 with active MRIs despite DMT. Propensity modeling based on demographic and disease characteristics was used to match DMT switchers to non-switchers. KP and MRI outcomes were compared 18 months after the active MRI using mixed-effects linear regression models. RESULTS We identified 417 patients who met criteria for our analysis. After propensity matching, 78 switchers and 91 non-switchers were analyzed. There was no difference in clinical or radiologic outcomes between these groups at 18 months. CONCLUSIONS We did not find a short-term benefit of changing DMT to pursue MRI stability.
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Affiliation(s)
- Devon S Conway
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundatio, 9500 Euclid Avenue/U10, Cleveland, OH, 44195 USA.
| | - Nicolas R Thompson
- Department of Quantitative Health Sciences, Neurological Institute Center for Outcomes Research and Evaluation, Cleveland Clinic Foundation, 9500 Euclid Avenue/JJ3, Cleveland, OH, 44195 USA
| | - Jeffrey A Cohen
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundatio, 9500 Euclid Avenue/U10, Cleveland, OH, 44195 USA
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Coles A. Newer therapies for multiple sclerosis. Ann Indian Acad Neurol 2015; 18:S30-4. [PMID: 26538846 PMCID: PMC4604695 DOI: 10.4103/0972-2327.164824] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 11/04/2022] Open
Abstract
The newer immunotherapies for multiple sclerosis (fingolimod, natalizumab, dimethyl fumarate, teriflunomide, alemtuzumab) offer advantages of efficacy or tolerability over the injectable therapies of the 1990s. But they also have greater risks. As further treatments emerge (daclizumab and ocrelizumab are likely to be licensed in the next two years), the physician needs to be able to place them within a complex landscape of drugs and a specific treatment strategy, which may be an "escalation" or "induction" approach. Whilst on treatment, neurologist and patient need to be vigilant to signs of disease breakthrough or adverse effects.
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Affiliation(s)
- Alasdair Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Banwell B, Giovannoni G, Hawkes C, Lublin F. Editors' Welcome. Mult Scler Relat Disord 2015. [PMID: 26195063 DOI: 10.1016/j.msard.2015.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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