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Stavropoulou De Lorenzo S, Bakirtzis C, Konstantinidou N, Kesidou E, Parissis D, Evangelopoulos ME, Elsayed D, Hamdy E, Said S, Grigoriadis N. How Early Is Early Multiple Sclerosis? J Clin Med 2023; 13:214. [PMID: 38202221 PMCID: PMC10780129 DOI: 10.3390/jcm13010214] [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: 12/07/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
The development and further optimization of the diagnostic criteria for multiple sclerosis (MS) emphasize the establishment of an early and accurate diagnosis. So far, numerous studies have revealed the significance of early treatment administration for MS and its association with slower disease progression and better late outcomes of the disease with regards to disability accumulation. However, according to current research results, both neuroinflammatory and neurodegenerative processes may exist prior to symptom initiation. Despite the fact that a significant proportion of individuals with radiologically isolated syndrome (RIS) progress to MS, currently, there is no available treatment approved for RIS. Therefore, our idea of "early treatment administration" might be already late in some cases. In order to detect the individuals who will progress to MS, we need accurate biomarkers. In this review, we present notable research results regarding the underlying pathology of MS, as well as several potentially useful laboratory and neuroimaging biomarkers for the identification of high-risk individuals with RIS for developing MS. This review aims to raise clinicians' awareness regarding "subclinical" MS, enrich their understanding of MS pathology, and familiarize them with several potential biomarkers that are currently under investigation and might be used in clinical practice in the future for the identification of individuals with RIS at high risk for conversion to definite MS.
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Affiliation(s)
- Sotiria Stavropoulou De Lorenzo
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (N.K.); (E.K.); (D.P.); (N.G.)
| | - Christos Bakirtzis
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (N.K.); (E.K.); (D.P.); (N.G.)
| | - Natalia Konstantinidou
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (N.K.); (E.K.); (D.P.); (N.G.)
| | - Evangelia Kesidou
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (N.K.); (E.K.); (D.P.); (N.G.)
| | - Dimitrios Parissis
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (N.K.); (E.K.); (D.P.); (N.G.)
| | | | - Dina Elsayed
- Department of Neuropsychiatry, Faculty of Medicine, Alexandria University, Alexandria 21311, Egypt; (D.E.); (E.H.); (S.S.)
| | - Eman Hamdy
- Department of Neuropsychiatry, Faculty of Medicine, Alexandria University, Alexandria 21311, Egypt; (D.E.); (E.H.); (S.S.)
| | - Sameh Said
- Department of Neuropsychiatry, Faculty of Medicine, Alexandria University, Alexandria 21311, Egypt; (D.E.); (E.H.); (S.S.)
| | - Nikolaos Grigoriadis
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (N.K.); (E.K.); (D.P.); (N.G.)
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Regnault A, Loubert A. Does the Multiple Sclerosis Impact Scale-29 (MSIS-29) have the range to capture the experience of fully ambulatory multiple sclerosis patients? Learnings from the ASCLEPIOS studies. Mult Scler J Exp Transl Clin 2023; 9:20552173231201422. [PMID: 37780483 PMCID: PMC10540592 DOI: 10.1177/20552173231201422] [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: 02/21/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Background Trials of disease-modifying therapies (DMTs) for multiple sclerosis (MS) often include patients with minimal disability. Patient-reported outcome instruments used in these trials have often not captured physical and psychological treatment effects concomitant with observed clinical benefits. Objective To examine whether the Multiple Sclerosis Impact Scale-29 (MSIS-29) captures changes in the impact of MS in a sample of patients enrolled in the Phase 3 ASCLEPIOS studies (ofatumumab vs. teriflunomide). Methods Measurement properties (i.e. item fit, reliability, and targeting) of the MSIS-29 were analyzed using Rasch measurement theory (RMT) in data from two phase 3 ofatumumab clinical trials including patients with relapsing-remitting or secondary progressive MS (N = 1882). Targeting of the MSIS-29 items to the patient population was explored within groups categorized by Expanded Disability Status Scale (EDSS) scores. Results Under RMT analyses, both the Physical and Psychological Impact scales of the MSIS-29 were not appropriately targeted to the overall sample of patients. In particular, 49% and 30% of patients with an EDSS score ≤ 2.5 had fewer physical and psychological impacts, respectively, than would typically be captured by these MSIS-29 items compared to patients with EDSS scores of ≥ 3. Conclusion The MSIS-29 is commonly used to evaluate the patient-reported physical and psychological impact of MS. However, it may be limited in evaluating changes associated with DMTs in patients with minimal disability.
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Buron MD, Christensen JR, Pontieri L, Joensen H, Kant M, Rasmussen PV, Sellebjerg F, Sørensen PS, Bech D, Magyari M. Natalizumab treatment of multiple sclerosis - a Danish nationwide study with 13 years of follow-up. Mult Scler Relat Disord 2023; 74:104713. [PMID: 37058764 DOI: 10.1016/j.msard.2023.104713] [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: 01/11/2023] [Revised: 03/29/2023] [Accepted: 04/08/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Natalizumab is a widely used high-efficacy treatment in multiple sclerosis (MS). Real-world evidence regarding long-term effectiveness and safety is warranted. We performed a nationwide study evaluating prescription patterns, effectiveness, and adverse events. METHODS A nationwide cohort study using the Danish MS Registry. Patients initiating natalizumab between June 2006 and April 2020 were included. Patient characteristics, annualized relapse rates (ARRs), confirmed Expanded Disability Status Scale (EDSS) score worsening, MRI activity (new/enlarging T2- or gadolinium-enhancing lesions), and reported adverse events were evaluated. Further, prescription patterns and outcomes across different time periods ("epochs") were analysed. RESULTS In total, 2424 patients were enrolled, with a median follow-up time of 2.7 years (interquartile range (IQR) 1.2-5.1). In recent epochs, patients were younger, had lower EDSS scores, had fewer pre-treatment relapses and were more often treatment naïve. At 13 years of follow-up, 36% had a confirmed EDSS worsening. On-treatment ARR was 0.30, corresponding to a 72% reduction from pre-initiation. MRI activity was rare, 6.8% had activity within 2-14 months from treatment start, 3.4% within 14-26 months, and 2.7% within 26-38 months. Approximately 14% of patients reported adverse events, with cephalalgia constituting the majority. During the study, 62.3% discontinued treatment. Of these, the main cause (41%) was due to JCV antibodies, while discontinuations due to disease activity (9%) or adverse events (9%) were less frequent. CONCLUSION Natalizumab is increasingly used earlier in the disease course. Most patients treated with natalizumab are clinically stable with few adverse events. JCV antibodies constitute the main cause for discontinuation.
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Affiliation(s)
- Mathias Due Buron
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Jeppe Romme Christensen
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Luigi Pontieri
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Hanna Joensen
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Matthias Kant
- MS clinic Southern Denmark, Department of Neurology, University of Southern Denmark, Hospital of Southern Jutland, Denmark
| | | | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Danny Bech
- Department of Neurology, Viborg Regional Hospital, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Kotov SV, Yakushina TI, Novikova ES, Lizhdvoy VY, Belova YA. [The use of monoclonal antibodies in the treatment of patients with high-active multiple sclerosis in real clinical practice]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:77-83. [PMID: 37560838 DOI: 10.17116/jnevro202312307277] [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] [Indexed: 08/11/2023]
Abstract
OBJECTIVE To study the efficacy of ocrelizumab (OCR) and natalizumab (NAT) using indicators of activity and progression in patients with highly active multiple sclerosis (HAMS) during the first year of therapy in real clinical practice. MATERIAL AND METHODS The study included 110 patients with HAMS and 13 patients with rapidly progressive MS (RPMS), aged 19 to 60 years, who received monoclonal antibody (MAT) therapy for 12 months. Group 1 consisted of 77 patients receiving NAT therapy, group 2 of 46 patients receiving OCR therapy. To assess the efficacy of therapy, we used indicators of the average frequency of exacerbations per year, EDSS estimates, and MRI data. RESULTS EDSS score at the time of initiation of MAT therapy was 2.4±1.0 in group 1 and 2.8±1.2 in group 2 (p=0.047); 12 months after the start of MAT therapy, EDSS score in group 1 decreased slightly (p=0.001), in group 2 it has not changed. The frequency of exacerbations per year after the start of MAT therapy was 0.04±0.2 in group 1 and 0.07±0.2 in group 2 (p<0.0001 in both groups). The number of foci accumulating gadolinium detected during the year was 3 in group 1, one in group 2 (p=0.629 between groups). Subgroups of patients who received line 1 DMT (n=22) or NAT (n=21) before the start of OCR therapy were considered separately. In both subgroups, a stable assessment of EDSS was noted, the average annual number of exacerbations did not differ (p=0.117). In patients with RPMS after a year of MAT therapy, EDSS scores were stable, the average annual frequency of exacerbations was 0.08±0.3 per year. CONCLUSION The administration of MAT therapy led to a statistically significant decrease in the number of exacerbations and stabilization of neurological deficits during the first year of follow-up. After 12 months of therapy, both groups experienced a dramatic decrease in the average annual number of exacerbations, no increase in disability, and positive dynamics according to MRI results. A similar level of OCR efficacy was found in patients who switched from DMT 1 line therapy and NAT.
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Affiliation(s)
- S V Kotov
- Moscow Regional Research and Clinical Institute («MONIKI»), Moscow, Russia
| | - T I Yakushina
- Moscow Regional Research and Clinical Institute («MONIKI»), Moscow, Russia
| | - E S Novikova
- Moscow Regional Research and Clinical Institute («MONIKI»), Moscow, Russia
| | - V Yu Lizhdvoy
- Moscow Regional Research and Clinical Institute («MONIKI»), Moscow, Russia
| | - Yu A Belova
- Moscow Regional Research and Clinical Institute («MONIKI»), Moscow, Russia
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Correale J, Rush CA, Barboza A. Are highly active and aggressive multiple sclerosis the same entity? Front Neurol 2023; 14:1132170. [PMID: 36937521 PMCID: PMC10020517 DOI: 10.3389/fneur.2023.1132170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/10/2023] [Indexed: 03/06/2023] Open
Affiliation(s)
- Jorge Correale
- Departamento de Neurología, Fleni, Buenos Aires, Argentina
- Instituto de Química y Fisicoquímica Biológicas (IQUIFIB), Universidad de Buenos Aires-CONICET, Buenos Aires, Argentina
- *Correspondence: Jorge Correale ;
| | - Carolina A. Rush
- Department of Medicine-Neurosciences, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Andrés Barboza
- Departamento de Neurologia, Hospital Central de Mendoza, Mendoza, Argentina
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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] [MESH Headings] [Grants] [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.
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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
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Constantinescu V, Akgün K, Ziemssen T. Current status and new developments in sphingosine-1-phosphate receptor antagonism: fingolimod and more. Expert Opin Drug Metab Toxicol 2022; 18:675-693. [PMID: 36260948 DOI: 10.1080/17425255.2022.2138330] [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: 11/04/2022]
Abstract
INTRODUCTION Fingolimod was the first oral disease-modifying treatment approved for relapsing-remitting multiple sclerosis (MS) that serves as a sphingosine-1-phosphate receptor (S1PR) agonist. The efficacy is primarily mediated by S1PR subtype 1 activation, leading to agonist-induced down-modulation of receptor expression and further functional antagonism, blocking the egression of auto-aggressive lymphocytes from the lymph nodes in the peripheral compartment. The role of S1P signaling in the regulation of other pathways in human organisms through different S1PR subtypes has received much attention due to its immune-modulatory function and its significance for the regeneration of the central nervous system (CNS). The more selective second-generation S1PR modulators have improved safety and tolerability profiles. AREAS COVERED This review has been carried out based on current data on S1PR modulators, emphasizing the benefits of recent advances in this emergent class of immunomodulatory treatment for MS. EXPERT OPINION Ongoing clinical research suggests that S1PR modulators represent an alternative to first-line therapies in selected cases of MS. A better understanding of the relevance of selective S1PR pathways and the ambition to optimize selective modulation has improved the safety and tolerability of S1PR modulators in MS therapy and opened new perspectives for the treatment of other diseases.
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Affiliation(s)
- Victor Constantinescu
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Katja Akgün
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
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Lefort M, Vukusic S, Casey R, Edan G, Leray E. Disability Progression in Multiple Sclerosis Patients using Early First-line Treatments. Eur J Neurol 2022; 29:2761-2771. [PMID: 35617144 PMCID: PMC9544933 DOI: 10.1111/ene.15422] [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: 11/09/2021] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Therapeutic management of relapsing-remitting multiple sclerosis (RRMS) has evolved towards early treatment. The objective was to assess the impact of early treatment initiation on disability progression among RRMS first-line treated patients. METHODS This study included all incident RRMS cases starting interferon or glatiramer acetate for the first time from 1996/01/01 to 2012/31/12 (N=5,279) from ten MS expert OFSEP centers (Observatoire Français de la Sclérose en Plaques). The delay from treatment start to attain an irreversible Expanded Disability Status Scale score of 3.0 were compared between "Early" group (N= 1,882; treated within 12 months following MS clinical onset) and "Later" group using propensity score weighted Kaplan-Meier methods, overall and stratified by age. RESULTS Overall, the restricted mean time before reaching EDSS 3.0 (RMST) from treatment start was 11 years and two months for patients treated within the year following MS clinical onset and 10 years and seven months for patients treated later. Thus, early treated patients gained 7 months (95% CI: [4-11] months) in the time to reach EDSS 3.0 compared to patients treated later (treatment start delayed by 28 months). The difference in RMST was respectively six months (95% CI: [1-10] months) and 14 months (95% CI: [4-24] months) in the "≤40 years" age group and in the ">40 years" age group, in favour of early group. . CONCLUSIONS Early treatment initiation resulted in a significant reduction of disability progression among patients with RRMS, and also among older patients.
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Affiliation(s)
- Mathilde Lefort
- Univ Rennes; EHESP, CNRS, Inserm, Arènes—UMR 6051RSMS (Recherche sur les Services et Management en Santé)—U 1309RennesFrance
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes)RennesFrance
| | - Sandra Vukusic
- Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro‐inflammationBronFrance
- Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de LyonINSERM 1028 et CNRS UMR 5292LyonFrance
- Université de LyonUniversité Claude Bernard Lyon 1LyonFrance
- Eugène Devic EDMUS Foundation against Multiple Sclerosis (a government approved foundation)BronFrance
| | - Romain Casey
- Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro‐inflammationBronFrance
- Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de LyonINSERM 1028 et CNRS UMR 5292LyonFrance
- Université de LyonUniversité Claude Bernard Lyon 1LyonFrance
- Eugène Devic EDMUS Foundation against Multiple Sclerosis (a government approved foundation)BronFrance
| | - Gilles Edan
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes)RennesFrance
- Department of NeurologyCHU PontchaillouRennesFrance
| | - Emmanuelle Leray
- Univ Rennes; EHESP, CNRS, Inserm, Arènes—UMR 6051RSMS (Recherche sur les Services et Management en Santé)—U 1309RennesFrance
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes)RennesFrance
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An Innovative Approach to Modelling the Optimal Treatment Sequence for Patients with Relapsing-Remitting Multiple Sclerosis: Implementation, Validation, and Impact of the Decision-Making Approach. Adv Ther 2022; 39:892-908. [PMID: 34796464 PMCID: PMC8866358 DOI: 10.1007/s12325-021-01975-5] [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: 05/06/2021] [Accepted: 10/26/2021] [Indexed: 10/24/2022]
Abstract
INTRODUCTION An innovative computational model was developed to address challenges regarding the evaluation of treatment sequences in patients with relapsing-remitting multiple sclerosis (RRMS) through the concept of a 'virtual' physician who observes and assesses patients over time. We describe the implementation and validation of the model, then apply this framework as a case study to determine the impact of different decision-making approaches on the optimal sequence of disease-modifying therapies (DMTs) and associated outcomes. METHODS A patient-level discrete event simulation (DES) was used to model heterogeneity in disease trajectories and outcomes. The evaluation of DMT options was implemented through a Markov model representing the patient's disease; outcomes included lifetime costs and quality of life. The DES and Markov models underwent internal and external validation. Analyses of the optimal treatment sequence for each patient were based on several decision-making criteria. These treatment sequences were compared to current treatment guidelines. RESULTS Internal validation indicated that model outcomes for natural history were consistent with the input parameters used to inform the model. Costs and quality of life outcomes were successfully validated against published reference models. Whereas each decision-making criterion generated a different optimal treatment sequence, cladribine tablets were the only DMT common to all treatment sequences. By choosing treatments on the basis of minimising disease progression or number of relapses, it was possible to improve on current treatment guidelines; however, these treatment sequences were more costly. Maximising cost-effectiveness resulted in the lowest costs but was also associated with the worst outcomes. CONCLUSIONS The model was robust in generating outcomes consistent with published models and studies. It was also able to identify optimal treatment sequences based on different decision criteria. This innovative modelling framework has the potential to simulate individual patient trajectories in the current treatment landscape and may be useful for treatment switching and treatment positioning decisions in RRMS.
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Monreal E, Sainz de la Maza S, Costa-Frossard L, Walo-Delgado P, Zamora J, Fernández-Velasco JI, Villarrubia N, Espiño M, Lourido D, Lapuente P, Toboso I, Álvarez-Cermeño JC, Masjuan J, Villar LM. Predicting Aggressive Multiple Sclerosis With Intrathecal IgM Synthesis Among Patients With a Clinically Isolated Syndrome. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/5/e1047. [PMID: 34301819 PMCID: PMC8299514 DOI: 10.1212/nxi.0000000000001047] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/14/2021] [Indexed: 01/14/2023]
Abstract
Objective To determine the best method to measure intrathecal immunoglobulin (Ig) M synthesis (ITMS), a biomarker of worse prognosis in multiple sclerosis (MS). We compared the ability for predicting a poor evolution of 4 methods assessing ITMS (IgM oligoclonal bands [OCMBs], lipid-specific OCMBs [LS-OCMBs], Reibergram, and IgM index) in patients with a clinically isolated syndrome (CIS). Methods Prospective study with consecutive patients performed at a referral MS center. We used unadjusted and multivariate Cox regressions for predicting a second relapse, Expanded Disability Status Scale (EDSS) scores of 4 and 6, and development of secondary progressive MS (SPMS). Results A total of 193 patients were included, with a median (interquartile range) age of 31 (25–38) years and a median follow-up of 12.9 years. Among all methods, only OCMB, LS-OCMB, and Reibergram significantly identified patients at risk of some of the pre-established outcomes, being LS-OCMB the technique with the strongest associations. Adjusted hazard ratio (aHR) of LS-OCMB for predicting a second relapse was 2.50 (95% CI 1.72–3.64, p < 0.001). The risk of reaching EDSS scores of 4 and 6 and SPMS was significantly higher among patients with LS-OCMB (aHR 2.96, 95% CI 1.54–5.71, p = 0.001; aHR 4.96, 95% CI 2.22–11.07, p < 0.001; and aHR 2.31, 95% CI 1.08–4.93, p = 0.03, respectively). Conclusions ITMS predicts an aggressive MS at disease onset, especially when detected as LS-OCMB. Classification of Evidence This study provides Class II evidence that lipid-specific IgM oligoclonal bands can predict progression from CIS to MS and a worse disease course over a follow-up of at least 2 years.
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Affiliation(s)
- Enric Monreal
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - Susana Sainz de la Maza
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Lucienne Costa-Frossard
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Paulette Walo-Delgado
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Javier Zamora
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - José Ignacio Fernández-Velasco
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Noelia Villarrubia
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Mercedes Espiño
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Daniel Lourido
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Paloma Lapuente
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Inmaculada Toboso
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - José Carlos Álvarez-Cermeño
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Jaime Masjuan
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Luisa María Villar
- From the Department of Neurology (E.M., S.S.d.l.M., L.C.-F., J.C.Á.-C., J.M.), and Department of Immunology (P.W.-D., J.I.F.-V., N.V., M.E., P.L., I.T., L.M.V.), Hospital Universitario Ramón y Cajal, REEM, IRYCIS; Clinical Biostatistics Unit (J.Z.), Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain; Institute of Metabolism and System Research (J.Z.), University of Birmingham, United Kingdom; and Department of Radiology (D.L.), Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
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11
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Kim KH, Kim SH, Park NY, Hyun JW, Kim HJ. Real-World Effectiveness of Natalizumab in Korean Patients With Multiple Sclerosis. Front Neurol 2021; 12:714941. [PMID: 34305808 PMCID: PMC8299833 DOI: 10.3389/fneur.2021.714941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Natalizumab is a highly efficacious disease-modifying therapy for relapsing-remitting multiple sclerosis (MS). Data on the efficacy and safety profile of natalizumab in Asian patients with MS are limited. This study assessed the efficacy and safety of natalizumab in Korean patients with MS in a real-world setting. Methods: This study enrolled consecutive Korean patients with active relapsing-remitting MS who were treated with natalizumab for at least 6 months between 2015 and 2021. To evaluate the therapeutic outcome of natalizumab, we used the Expanded Disability Status Scale (EDSS) scores and brain magnetic resonance imaging; adverse events were assessed at regular intervals. No evidence of disease activity (NEDA) was defined as no clinical relapse, no worsening of EDSS score, and no radiological activities. Results: Fourteen subjects with MS were included in the study. The mean age at initiation of natalizumab therapy was 32 years. All patients were positive for anti-John Cunningham virus antibodies before natalizumab administration. The mean annual relapse rate was markedly reduced from 2.7 ± 3.2 before natalizumab therapy to 0.1 ± 0.4 during natalizumab therapy (p = 0.001). Disability was either improved or stabilized after natalizumab treatment in 13 patients (93%). During the 1st year and 2 years after initiating natalizumab, NEDA-3 was achieved in 11/12 (92%) and 9/11 (82%) patients, respectively. No progressive multifocal leukoencephalopathy or other serious adverse events leading to the discontinuation of natalizumab were observed. Conclusions: Natalizumab therapy showed high efficacy in treating Korean patients with active MS, without unexpected safety problems.
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Affiliation(s)
- Ki Hoon Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Su-Hyun Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Na Young Park
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Jae-Won Hyun
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
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12
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Changing Paradigms and Unmet Needs in Multiple Sclerosis: The Role of Clinical Neurophysiology. J Clin Neurophysiol 2021; 38:162-165. [PMID: 33958565 DOI: 10.1097/wnp.0000000000000749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
SUMMARY Our increasing understanding of the immunopathogenesis of multiple sclerosis has led to the development of many disease-modifying therapies that have revolutionized the care of patients with relapsing forms of the disease. Our understanding of the pathophysiologic basis of progressive forms of the disease is much more limited but has dramatically changed over the past several decades. We are now on the verge of developing therapies that promote remyelination, reduce axonal loss, and restore axonal function. This progress is challenged by inadequate animal models of progressive disease and incomplete biomarkers of progression. In measuring central nervous system function, evoked potentials may have an advantage over biomarkers, which measure only pathologic change. Monitoring multifocal visual evoked potential amplitude may be one possible means of monitoring disease progression in multiple sclerosis. Additional clinical studies are required to document whether evoked potentials can adequately serve as effective biomarkers of progression.
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13
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Meca-Lallana J, García-Merino JA, Martínez-Yélamos S, Vidal-Jordana A, Costa L, Eichau S, Rovira À, Brieva L, Agüera E, Zarranz ARA. Identification of patients with relapsing multiple sclerosis eligible for high-efficacy therapies. Neurodegener Dis Manag 2021; 11:251-261. [PMID: 33966475 DOI: 10.2217/nmt-2020-0049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Relapsing multiple sclerosis (RMS) presents a highly variable clinical evolution among patients, and its management should be personalized. Although there is no cure at present, effective disease-modifying therapies (DMTs) are available. Selection of the most appropriate DMT for each patient is influenced by several clinical, radiological and demographic aspects as well as personal preferences that, at times, are not covered in the regulatory criteria. This may be a source of difficulty, especially in certain situations where so-called 'high-efficacy DMTs' (usually considered second-line) could be of greater benefit to the patient. In this narrative review, we discuss evidence and experience, and propose a pragmatic guidance on decision-making with respect to the indication and management of high-efficacy DMT in adult patients with RMS based on expert opinion.
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Affiliation(s)
- José Meca-Lallana
- Multiple Sclerosis CSUR, Neurology Department, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, 30120, Spain
| | | | - Sergio Martínez-Yélamos
- Neurology Department, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, 08907, Spain
| | - Angela Vidal-Jordana
- Neurology-Neuroimmunology Department, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitario Vall d'Hebron, Barcelona, 08035, Spain
| | - Lucienne Costa
- CSUR de Esclerosis Múltiple, Neurology Department, Fundación para la Investigación Biomédica IRyCIS, Hospital Universitario Ramón y Cajal, Madrid, 28034, Spain
| | - Sara Eichau
- EM Unit, Neurology Department, Hospital Universitario Virgen de la Macarena, Seville, 41009, Spain
| | - Àlex Rovira
- Neuroradiology Section, Radiology Department, Hospital Universitario Vall d'Hebron, Barcelona, 08035, Spain
| | - Luis Brieva
- Neurology Section, Hospital Universitario Arnau de Vilanova, IRB Lleida, Lleida, 25198, Spain
| | - Eduardo Agüera
- Neurology department, Hospital Universitario Reina Sofía, Cordoba, 14004, Spain
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14
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Vermersch P, Galazka A, Dangond F, Damian D, Wong SL, Jack D, Harty G. Efficacy of cladribine tablets in high disease activity patients with relapsing multiple sclerosis: post hoc analysis of subgroups with and without prior disease-modifying drug treatment. Curr Med Res Opin 2021; 37:459-464. [PMID: 33331183 DOI: 10.1080/03007995.2020.1865888] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Relapsing-remitting multiple sclerosis (RRMS) patients with high disease activity (HDA) experience more severe disease than those without HDA. This analysis describes the efficacy of cladribine tablets 3.5 mg/kg in HDA patient subgroups that were either treated with disease-modifying drugs (DMDs) prior to study entry or were treatment naïve. METHODS Post hoc analysis of the 96 week Cladribine Tablets Treating Multiple Sclerosis Orally (CLARITY) study compared cladribine tablets 3.5 mg/kg to placebo in subgroups of patients meeting the high relapse activity plus disease activity on treatment definition of HDA. Patients were categorized into either prior DMD treatment or DMD treatment-naïve subgroups. Endpoints included annualized relapse rate (ARR), time to first relapse, time to disability progression and magnetic resonance imaging (MRI) outcomes. No inferential statistical analyses were conducted between subgroups. RESULTS The DMD-naïve cohort (n = 187) was larger than the prior-DMD cohort (n = 102). In both the DMD-naïve and prior-DMD cohorts, cladribine tablets were associated with a reduction in ARR (rate ratio [RR]: 0.26; 95% confidence interval [CI]: 0.16-0.42; p < .0001 and RR: 0.55; 95% CI: 0.32-0.95; p = .0324, respectively). In both subgroups, cladribine tablets increased the time to relapse versus placebo (hazard ratio [HR]: 0.36; 95% CI: 0.21-0.62; p = .0002 for DMD-naïve cohort and HR: 0.50; 95% CI: 0.24-1.02; p = .0557 for prior-DMD cohort). Significant differences were observed for all assessed disability and MRI outcomes independently of previous treatment. CONCLUSION Post hoc evidence suggests consistent treatment benefits of cladribine tablets 3.5 mg/kg during the 96 week CLARITY study among HDA-RRMS patients who were either previously treated with DMDs or were treatment naïve.
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Affiliation(s)
- Patrick Vermersch
- Inserm U1172, CHU Lille, FHU Imminent, University of Lille, Lille, France
| | - Andrew Galazka
- Ares Trading S.A., Eysins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Fernando Dangond
- EMD Serono Research & Development Institute Inc., Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
| | - Doris Damian
- EMD Serono Research & Development Institute Inc., Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
| | - Schiffon L Wong
- EMD Serono Research & Development Institute Inc., Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
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15
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Eliseeva DD, Vasiliev AV, Abramova AA, Kochergin IA, Zakharova MN. [Monoclonal antibody therapies for rapidly progressive and highly active multiple sclerosis in the era of the COVID-19 pandemic]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:31-36. [PMID: 34387443 DOI: 10.17116/jnevro202112107231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As the COVID-19 pandemic continues, reducing the risk of infection for immunocompromised patients remains an important issue. Patients with aggressive multiple sclerosis (MS) require immunosuppressive therapy in order to control the overactive autoimmune response. Preliminary international and national trials demonstrate that older age, higher disability status and progressive MS are generally associated with a more severe clinical course of COVID-19. However, uncertainty remains about the effect of disease-modifying therapies on the COVID-19 clinical presentation. In this article, we pay special attention to monoclonal antibodies used for immune reconstitution therapy, which results in significant changes to the T-cell and/or B-cell repertoire. Based on the published data from registries in different countries, we attempted to estimate the benefits and risks of these therapies in a complicated epidemiological setting.
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Affiliation(s)
| | - A V Vasiliev
- «Neuroclinic» (Yusupov Hospital), Moscow, Russia
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16
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Abstract
Alemtuzumab (Lemtrada®) is an anti-CD52 monoclonal antibody approved in the EU for the treatment of highly active relapsing-remitting multiple sclerosis (RRMS). In phase 3 trials in patients with active RRMS, intravenous alemtuzumab was more effective than subcutaneous interferon β-1a in terms of decreasing relapse rates (in treatment-naïve or -experienced patients) and disability progression (treatment-experienced patients). Treatment benefits were maintained over up to 9 years of follow-up, with ≈ 50% of patients not requiring retreatment. The efficacy of alemtuzumab in patients with highly active disease was generally similar to that in the overall population. Alemtuzumab has an acceptable tolerability profile, with infusion-associated reactions, infections and autoimmunity being the main safety and tolerability issues. Current evidence indicates that alemtuzumab is an effective treatment option for adults with highly active RRMS, with an acceptable safety and tolerability profile and convenient treatment regimen.
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Affiliation(s)
- Yahiya Y Syed
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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17
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Fernández O, Izquierdo G, Aguera E, Ramo C, Hernandez M, Silva D, Walker R, Butzkueven H, Wang C, Barnett M. Comparison of first-line and second-line use of fingolimod in relapsing MS: The open-label EARLIMS study. Mult Scler J Exp Transl Clin 2020; 6:2055217320957358. [PMID: 32974041 PMCID: PMC7493256 DOI: 10.1177/2055217320957358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/30/2020] [Accepted: 08/18/2020] [Indexed: 12/03/2022] Open
Abstract
Background Treatment of MS often begins with low-efficacy injectable disease-modifying therapy (iDMT). Objectives To compare the effect of fingolimod 0.5 mg/day on clinical, MRI, patient-reported, and safety outcomes, in treatment-naïve and previously treated (≥1 iDMT) patients with early MS. Methods EARLIMS was a multicentre, open-label, non-randomized, parallel-group phase 3 b/4 study in Australia and Spain. Patients with relapsing–remitting MS, Expanded Disability Status Scale (EDSS) score <4.0, and ≥1–5 years since diagnosis, received daily fingolimod for 48 weeks. The primary endpoint was annualized relapse rate (ARR). Results Of 347 patients enrolled at 51 sites (treatment-naïve, 200 [57.6%]; previously treated, 147 [42.4%]), 320 completed the study (treatment-naïve, 184 [92.0%]; previously treated, 136 [92.5%]), but the study remained underpowered (planned enrolment, n = 432). Fingolimod reduced ARR to similar levels in both treatment-naïve (mean ARR [95% confidence interval], 0.21 [0.14, 0.29]) and previously treated groups (0.30 [0.20, 0.41]; p = 0.1668). There were no new safety signals. Conclusions Fingolimod appeared equally effective as first- or second-line therapy in relapsing MS. There was a trend for better outcomes with fingolimod in treatment-naïve patients than in those previously treated with >1 iDMT.
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Affiliation(s)
- Oscar Fernández
- Department of Neurology, Instituto de Investigación Biomédica de Málaga, Hospital Regional Universitario, Málaga, Spain.,Department of Pharmacology, Faculty of Medicine, University of Malaga, Malaga, Spain
| | - Guillermo Izquierdo
- Unidad de Esclerosis Múltiple, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Eduardo Aguera
- Neurología, Hospital Universitario Reina Sofía - IMIBIC, Córdoba, Spain
| | - Cristina Ramo
- Departamento de Neurociencias, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Miguel Hernandez
- Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | | | - Rob Walker
- Novartis Pharmaceuticals Australia, NSW, Australia
| | - Helmut Butzkueven
- MS and Neuroimmunology Unit, Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Chenyu Wang
- Brain and Mind Centre, University of Sydney, Camperdown, NSW, Australia.,Sydney Neuroimaging Analysis Centre, Camperdown, NSW, Australia
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney, Camperdown, NSW, Australia.,Sydney Neuroimaging Analysis Centre, Camperdown, NSW, Australia
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18
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Sørensen PS, Centonze D, Giovannoni G, Montalban X, Selchen D, Vermersch P, Wiendl H, Yamout B, Salloukh H, Rieckmann P. Expert opinion on the use of cladribine tablets in clinical practice. Ther Adv Neurol Disord 2020; 13:1756286420935019. [PMID: 32636933 PMCID: PMC7318823 DOI: 10.1177/1756286420935019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/12/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Gaps in current product labels and a lack of detailed clinical guidelines leaves clinicians' questions on the practical management of patients receiving cladribine tablets for the treatment of relapsing multiple sclerosis (MS) unanswered. We describe a consensus-based programme led by international MS experts with the aim of providing recommendations to support the use of cladribine tablets in clinical practice. METHODS A steering committee (SC) of nine international MS experts led the programme and developed 11 clinical questions concerning the practical use of cladribine tablets. Statements to address each question were drafted using available evidence, expert experiences and perspectives from the SC and an extended faculty of 33 MS experts, representing 19 countries. Consensus on recommendations was achieved when ⩾75% of respondents expressed an agreement score of 7-9, on a 9-point scale. RESULTS Consensus was achieved on 46 out of 47 recommendations. Expert-agreed practical recommendations are provided on topics including: the definition of highly active disease; patterns of treatment response and suboptimal response with cladribine tablets; management of pregnancy planning and malignancy risk, infection risk and immune function, and switching to and from cladribine tablets. CONCLUSION These expert recommendations provide up-to-date relevant guidance on the use of cladribine tablets in clinical practice.
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Affiliation(s)
- Per Soelberg Sørensen
- Department of Neurology, Danish Multiple Sclerosis Center, University of Copenhagen, 2082, Rigshospitalet, 9, Blegdamsvej, Copenhagen, 2100, Denmark
| | - Diego Centonze
- Unit of Neurology and Neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Xavier Montalban
- Department of Neurology, Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniel Selchen
- Division of Neurology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Bassem Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut, Beirut, Lebanon
| | - Hashem Salloukh
- Ares Trading S.A., and affiliate of Merck Serono S.A., Eysins, Switzerland
| | - Peter Rieckmann
- Department of Neurology, Center for Clinical Neuroplasticity, Medical Park Loipl, Bischofswiesen, University of Erlangen, Germany
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19
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Inshasi JS, Almadani A, Fahad SA, Noori SI, Alsaadi T, Shakra M, Shatila AO, Zein TM, Boshra A. High-efficacy therapies for relapsing-remitting multiple sclerosis: implications for adherence. An expert opinion from the United Arab Emirates. Neurodegener Dis Manag 2020; 10:257-266. [PMID: 32438857 DOI: 10.2217/nmt-2020-0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The number of disease-modifying treatments (DMDs) for relapsing-remitting multiple sclerosis has increased. DMDs differ not only in their efficacy and safety/tolerability, but also in the treatment burden of, associated with their initiation, route/frequency of administration, maintenance treatment and monitoring. High-efficacy DMDs bring the prospect of improved suppression of relapses and progression of disability, but may have serious safety issues, and burdensome long-term monitoring. Studies of patient preferences in this area have focused on side effects, efficacy and route of administration. Adherence to DMDs is often suboptimal in relapsing-remitting multiple sclerosis and there is a need to understand more about how the complex therapeutic and administration profiles of newer DMDs interact with these barriers to support optimal adherence to therapy.
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Affiliation(s)
- Jihad Said Inshasi
- MS Section, Rashid Hospital & Dubai Medical College, Dubai Health Authority (DHA), Dubai, UAE
| | - Abubaker Almadani
- Rashid Hospital & Dubai Medical College, Dubai health Authority (DHA), Dubai, UAE
| | - Sarmad Al Fahad
- Neurology Department, Neurospinal Hospital, Baghdad Medical College, Dubai, UAE
| | | | - Taoufik Alsaadi
- Neurology Department, American Center for Psychiatry & Neurology, Dubai, UAE
| | - Mustafa Shakra
- Department of Neurology, Sheikh Khalifa Medical City, Abu Dhabi, UAE
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20
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Malpas CB, Manouchehrinia A, Sharmin S, Roos I, Horakova D, Havrdova EK, Trojano M, Izquierdo G, Eichau S, Bergamaschi R, Sola P, Ferraro D, Lugaresi A, Prat A, Girard M, Duquette P, Grammond P, Grand’Maison F, Ozakbas S, Van Pesch V, Granella F, Hupperts R, Pucci E, Boz C, Sidhom Y, Gouider R, Spitaleri D, Soysal A, Petersen T, Verheul F, Karabudak R, Turkoglu R, Ramo-Tello C, Terzi M, Cristiano E, Slee M, McCombe P, Macdonell R, Fragoso Y, Olascoaga J, Altintas A, Olsson T, Butzkueven H, Hillert J, Kalincik T. Early clinical markers of aggressive multiple sclerosis. Brain 2020; 143:1400-1413. [DOI: 10.1093/brain/awaa081] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/21/2020] [Accepted: 02/05/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Patients with the ‘aggressive’ form of multiple sclerosis accrue disability at an accelerated rate, typically reaching Expanded Disability Status Score (EDSS) ≥ 6 within 10 years of symptom onset. Several clinicodemographic factors have been associated with aggressive multiple sclerosis, but less research has focused on clinical markers that are present in the first year of disease. The development of early predictive models of aggressive multiple sclerosis is essential to optimize treatment in this multiple sclerosis subtype. We evaluated whether patients who will develop aggressive multiple sclerosis can be identified based on early clinical markers. We then replicated this analysis in an independent cohort. Patient data were obtained from the MSBase observational study. Inclusion criteria were (i) first recorded disability score (EDSS) within 12 months of symptom onset; (ii) at least two recorded EDSS scores; and (iii) at least 10 years of observation time, based on time of last recorded EDSS score. Patients were classified as having ‘aggressive multiple sclerosis’ if all of the following criteria were met: (i) EDSS ≥ 6 reached within 10 years of symptom onset; (ii) EDSS ≥ 6 confirmed and sustained over ≥6 months; and (iii) EDSS ≥ 6 sustained until the end of follow-up. Clinical predictors included patient variables (sex, age at onset, baseline EDSS, disease duration at first visit) and recorded relapses in the first 12 months since disease onset (count, pyramidal signs, bowel-bladder symptoms, cerebellar signs, incomplete relapse recovery, steroid administration, hospitalization). Predictors were evaluated using Bayesian model averaging. Independent validation was performed using data from the Swedish Multiple Sclerosis Registry. Of the 2403 patients identified, 145 were classified as having aggressive multiple sclerosis (6%). Bayesian model averaging identified three statistical predictors: age > 35 at symptom onset, EDSS ≥ 3 in the first year, and the presence of pyramidal signs in the first year. This model significantly predicted aggressive multiple sclerosis [area under the curve (AUC) = 0.80, 95% confidence intervals (CIs): 0.75, 0.84, positive predictive value = 0.15, negative predictive value = 0.98]. The presence of all three signs was strongly predictive, with 32% of such patients meeting aggressive disease criteria. The absence of all three signs was associated with a 1.4% risk. Of the 556 eligible patients in the Swedish Multiple Sclerosis Registry cohort, 34 (6%) met criteria for aggressive multiple sclerosis. The combination of all three signs was also predictive in this cohort (AUC = 0.75, 95% CIs: 0.66, 0.84, positive predictive value = 0.15, negative predictive value = 0.97). Taken together, these findings suggest that older age at symptom onset, greater disability during the first year, and pyramidal signs in the first year are early indicators of aggressive multiple sclerosis.
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Affiliation(s)
- Charles B Malpas
- CORe Unit, Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Ali Manouchehrinia
- Centre for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Sifat Sharmin
- CORe Unit, Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Izanne Roos
- CORe Unit, Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | - Patrizia Sola
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Diana Ferraro
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra Lugaresi
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Marc Girard
- CHUM and Universite de Montreal, Montreal, Canada
| | | | | | | | | | - Vincent Van Pesch
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Université Catholique de Louvain, Brussels, Belgium
| | - Franco Granella
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Eugenio Pucci
- UOC Neurologia, Azienda Sanitaria Unica Regionale Marche - AV3, Macerata, Italy
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | - Youssef Sidhom
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Riadh Gouider
- Department of Neurology, Razi Hospital, LR 18SP03, Clinical Investigation Center Neurosciences and Mental Health, Faculty of Medicine University Tunis El Manar, Tunis, Tunisia
| | - Daniele Spitaleri
- Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy
| | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | | | | | | | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | | | - Murat Terzi
- Medical Faculty, 19 Mayis University, Samsun, Turkey
| | | | - Mark Slee
- Flinders University, Adelaide, Australia
| | - Pamela McCombe
- University of Queensland, Brisbane, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | | | - Yara Fragoso
- Universidade Metropolitana de Santos, Santos, Brazil
| | - Javier Olascoaga
- Instituto de Investigación Sanitaria Biodonostia, Hospital Universitario Donostia, San Sebastián, Spain
| | - Ayse Altintas
- Koc University, School of Medicine, Department of Neurology, Istanbul, Turkey
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Helmut Butzkueven
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, The Alfred Hospital, Melbourne, Australia
- Department of Neurology, Box Hill Hospital, Monash University, Melbourne, Australia
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Tomas Kalincik
- CORe Unit, Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
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21
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Siddiqui MK, Singh B, Attri S, Veraart C, Harty G, Wong SL. Use of rituximab in adults with relapsing-remitting multiple sclerosis: a systematic literature review. Curr Med Res Opin 2020; 36:809-826. [PMID: 32129684 DOI: 10.1080/03007995.2020.1739009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Rituximab is used as an off-label treatment for relapsing-remitting multiple sclerosis (RRMS); however, the comparative efficacy and safety of rituximab versus currently licensed disease-modifying drugs (DMDs) for RRMS is unknown. A systematic literature review was conducted to evaluate the available data pertaining to efficacy and safety of rituximab in adult patients with RRMS and highly active relapsing multiple sclerosis (HA-RMS); data quality was critically assessed via risk of bias (RoB) assessment.Methods: Biomedical literature databases were searched until mid-2018 and key proceedings were searched from 2016 to 2018. Critical appraisal of non-randomized studies was conducted using the Cochrane RoB assessment tool; randomized controlled trials (RCTs) were appraised using comprehensive assessment criteria based on the NICE guidelines.Results: Thirty-eight unique studies based on 49 publications were identified: 25 RRMS studies (one RCT) and 13 HA-RMS studies (no RCTs). The evidence among patients with RRMS generally favored rituximab in comparison to placebo (relapse rate) and interferons/glatiramer acetate (relapse rate and disability progression), although much of the non-randomized data were descriptive and/or not statistically significant. In comparison to placebo, rituximab was associated with a greater risk of adverse events. Two-thirds of the non-randomized RRMS studies were associated with critical/serious RoB; the single RCT was associated with low RoB. Furthermore, all of the non-randomized HA-RMS studies were associated with critical/serious RoB.Conclusions: Available evidence of off-label rituximab use for the treatment of patients with RRMS suggests generally favorable efficacy versus placebo and interferons/glatiramer acetate; however, the poor quality of the included studies limits any robust conclusions.
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Ohlmeier C, Gothe H, Haas J, Osowski U, Weinhold C, Blauwitz S, Schmedt N, Galetzka W, Berkemeier F, Tackenberg B, Stangel M. Epidemiology, characteristics and treatment of patients with relapsing remitting multiple sclerosis and incidence of high disease activity: Real world evidence based on German claims data. PLoS One 2020; 15:e0231846. [PMID: 32357176 PMCID: PMC7194363 DOI: 10.1371/journal.pone.0231846] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/01/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Multiple Sclerosis (MS) is a chronic inflammatory, immune mediated disease of the central nervous system, with Relapsing Remitting MS (RRMS) being the most common type. Within the last years, the status of high disease activity (HDA) has become increasingly important for clinical decisions. Nevertheless, little is known about the incidence, the characteristics, and the current treatment of patients with RRMS and HDA in Germany. Therefore, this study aims to estimate the incidence of HDA in a German RRMS patient population, to characterize this population and to describe current drug treatment routines and further healthcare utilization of these patients. METHODS A claims data analyses has been conducted, using a sample of the InGef Research Database that comprises data of approximately four million insured persons from around 70 German statutory health insurances (SHI). The study was conducted in a retrospective cohort design, including the years 2012-2016. Identification of RRMS population based on ICD-10 code (ICD-10-GM: G35.1). For identification of HDA, criteria from other studies as well as expert opinions have been used. Information on incidence, characteristics and current treatment of patients with RRMS and HDA was considered. RESULTS The overall HDA incidence within the RRMS population was 8.5% for 2016. It was highest for the age group of 0-19 years (29.4% women, 33.3% men) and lowest for the age group of ≥ 50 years (4.3% women, 5.6% men). Mean age of patients with RRMS and incident HDA was 38.4 years (SD: 11.8) and women accounted for 67.8%. Analyses of drug utilization showed that 82.4% received at least one disease-modifying drug (DMD) in 2016. A percentage of 49.8% of patients received drugs for relapse therapy. A share of 55% of RRMS patients with HDA had at least one hospitalization with a mean length of stay of 13.9 days (SD: 18.3 days) in 2016. The average number of outpatient physician contacts was 28.1 (SD: 14.0). CONCLUSIONS This study based on representative Germany-wide claims data from the SHI showed a high incidence of HDA especially within the young RRMS population. Future research should consider HDA as an important criterion for the quality of care for MS patients.
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Affiliation(s)
- Christoph Ohlmeier
- Department Health Services Research, IGES Institut GmbH, Berlin, Germany
- * E-mail:
| | - Holger Gothe
- Department Health Services Research, IGES Institut GmbH, Berlin, Germany
- Chair for Health Sciences / Public Health, Medical Faculty “Carl Gustav Carus”, Technical University Dresden, Dresden, Germany
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Judith Haas
- Center for Multiple Sclerosis, Jewish Hospital Berlin, Berlin, Germany
| | - Ulrike Osowski
- Merck Serono GmbH, Darmstadt, Germany, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Carina Weinhold
- Merck Serono GmbH, Darmstadt, Germany, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Sarah Blauwitz
- Department Health Services Research, IGES Institut GmbH, Berlin, Germany
| | - Niklas Schmedt
- InGef - Institute for Applied Health Research Berlin GmbH, Berlin, Germany
| | - Wolfgang Galetzka
- InGef - Institute for Applied Health Research Berlin GmbH, Berlin, Germany
| | - Fabian Berkemeier
- Department Health Services Research, IGES Institut GmbH, Berlin, Germany
| | - Björn Tackenberg
- Center of Neuroimmunology, Philipps-University, Marburg, Germany
| | - Martin Stangel
- Clinical Neuroimmunology and Neurochemistry, Dept. of Neurology, Hannover Medical School, Hannover, Germany
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Ghezzi A, Chitnis T, K-Laflamme A, Meinert R, Häring DA, Pohl D. Long-Term Effect of Immediate Versus Delayed Fingolimod Treatment in Young Adult Patients with Relapsing-Remitting Multiple Sclerosis: Pooled Analysis from the FREEDOMS/FREEDOMS II Trials. Neurol Ther 2019; 8:461-475. [PMID: 31325110 PMCID: PMC6858894 DOI: 10.1007/s40120-019-0146-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Fingolimod has demonstrated clinical and MRI benefits versus placebo/interferon β-1a in young adults with multiple sclerosis (MS). Here we report the long-term effects of fingolimod 0.5 mg on clinical and MRI outcomes in young adults with MS aged ≤ 30 years followed up for up to 8 years (96 months). METHODS This post hoc analysis of pooled FREEDOMS/FREEDOMS II studies included patients who either received fingolimod 0.5 mg from randomization (immediate; N = 163) or switched from placebo to fingolimod at month (M) 24 (delayed; N = 147). The 6-month confirmed disability improvement [6m-CDI: based on Expanded Disability Status Scale (EDSS)], 6m-CDI-plus (6m-CDI+; EDSS, 9-Hole Peg Test, Timed 25-Foot Walk Test), 6-month confirmed disability progression (6m-CDP), time to EDSS score ≥ 4, annualized relapse rates (ARRs), new/newly enlarging T2 (neT2) lesions, and annual rate of brain volume loss (BVL) were analyzed from baseline to M24, M48, and M96. Cox regression and negative binomial regression models were used to analyze measured outcomes. RESULTS At baseline, more than two-thirds of young adult patients were treatment naïve, had more than two relapses in the previous 2 years, and EDSS score < 2. From M0 to M96, a significantly higher proportion of young adult patients in the immediate group (vs. delayed group) achieved 6m-CDI (58.2% vs. 30.5%, p = 0.0206) and 6m-CDI+ (70.6% vs. 42.3%, p = 0.0149); significantly fewer patients reached 6m-CDP (20.1% vs. 34.7%, p = 0.0058) and EDSS ≥ 4 (24.1% vs. 34.1%, p = 0.0041). Up to M96, young adults in the immediate versus delayed group had lower ARRs (0.16 vs. 0.38, p < 0.0001) and a higher proportion of patients were free of neT2 lesions at M48 (31.0% vs. 5.0%, p = 0.0011). CONCLUSION In young adult patients with MS, immediate versus delayed fingolimod treatment was associated with improved disease outcomes and greater long-term benefits in both disease activity and disability progression. FUNDING Novartis Pharma AG.
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Affiliation(s)
| | - Tanuja Chitnis
- Partners Pediatric Multiple Sclerosis Centre, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Daniela Pohl
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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Switching from fingolimod to alemtuzumab in patients with highly active relapsing-remitting multiple sclerosis: Α case series. Mult Scler Relat Disord 2019; 38:101517. [PMID: 31751858 DOI: 10.1016/j.msard.2019.101517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/02/2019] [Accepted: 11/10/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The management of "aggressive" and "highly-active" relapsing-remitting multiple sclerosis remains problematic. Although a number of highly efficacious agents are currently available, the optimal timing of their use and the balancing between efficacy and immediate and long-term consequences are still a matter of conjecture. METHODS We describe the clinical, radiological and immunological profile of three multiple sclerosis patients with persistent clinical and radiological disease activity under fingolimod treatment. After fingolimod cessation patients demonstrated severe disease exacerbation and were successfully treated with alemtuzumab. RESULTS All patients experienced significant improvement after the administration of alemtuzumab and achieved no evidence of disease activity status that persisted after a median of 19 months of follow-up (range: 17-25 months). Confirmed disability improvement was achieved in all cases. Quantitative MRI data demonstrated a reduction of the T2 lesion load in 2 out of 3 patients and complete abrogation of inflammatory activity in all patients after the administration of alemtuzumab. Α patient presented a previously unreported, persistent lymphocytosis after alemtuzumab administration, that was not associated with infectious, lymphoproliferative or autoimmune diseases and had no apparent clinical implications. CONCLUSIONS Alemtuzumab appears to be an effective and safe short-term therapeutic option both as a rescue therapy for the disease flare-up associated with fingolimod withdrawal, as well as for the reversal of the deteriorating course observed in patients who fail treatment with fingolimod.
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D'Amico E, Zanghì A, Romano A, Sciandra M, Palumbo GAM, Patti F. The Neutrophil-to-Lymphocyte Ratio is Related to Disease Activity in Relapsing Remitting Multiple Sclerosis. Cells 2019; 8:cells8101114. [PMID: 31547008 PMCID: PMC6830321 DOI: 10.3390/cells8101114] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 12/29/2022] Open
Abstract
Background: The role of the neutrophil-to-lymphocyte ratio (NLR) of peripheral blood has been investigated in relation to several autoimmune diseases. Limited studies have addressed the significance of the NLR in terms of being a marker of disease activity in multiple sclerosis (MS). Methods: This is a retrospective study in relapsing–remitting MS patients (RRMS) admitted to the tertiary MS center of Catania, Italy during the period of 1 January to 31 December 2018. The aim of the present study was to investigate the significance of the NLR in reflecting the disease activity in a cohort of early diagnosed RRMS patients. Results: Among a total sample of 132 patients diagnosed with RRMS, 84 were enrolled in the present study. In the association analysis, a relation between the NLR value and disease activity at onset was found (V-Cramer 0.271, p = 0.013). In the logistic regression model, the variable NLR (p = 0.03 ExpB 3.5, CI 95% 1.089–11.4) was related to disease activity at onset. Conclusion: An elevated NLR is associated with disease activity at onset in RRMS patients. More large-scale studies with a longer follow-up are needed.
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Affiliation(s)
- Emanuele D'Amico
- Department "G.F. Ingrassia", MS Center, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy.
| | - Aurora Zanghì
- Department "G.F. Ingrassia", MS Center, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy.
| | - Alessandra Romano
- Department of Surgery and Medical Specialties, Division of Hematology-A.O.U. Policlinico-OVE, Catania, Via Santa Sofia 78, 95123 Catania, Italy.
| | - Mariangela Sciandra
- Department of Economics, Business and Statistics, University of Palermo, 90128 Palermo, Italy.
| | - Giuseppe Alberto Maria Palumbo
- Department "G.F. Ingrassia", Division of Hematology-A.O.U. Policlinico-OVE, Catania, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy. giuseppealberto.palumbo@gmail
| | - Francesco Patti
- Department "G.F. Ingrassia", MS Center, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy.
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Berardi A, Siddiqui MK, Treharne C, Harty G, Wong SL. Estimating the comparative efficacy of cladribine tablets versus alternative disease modifying treatments in active relapsing-remitting multiple sclerosis: adjusting for patient characteristics using meta-regression and matching-adjusted indirect treatment comparison approaches. Curr Med Res Opin 2019; 35:1371-1378. [PMID: 30786783 DOI: 10.1080/03007995.2019.1585779] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: To estimate the comparative efficacy of cladribine tablets versus alternative disease modifying therapies (DMTs) - fingolimod, natalizumab, alemtuzumab and ocrelizumab - in adults with active relapsing-remitting multiple sclerosis (RRMS), using meta-regression to provide subpopulation-specific estimates of drug effect. Additionally, to determine the feasibility of conducting a matching-adjusted indirect comparison (MAIC) to validate the meta-regression results. Methods: A published systematic literature review (SLR) identified studies evaluating the efficacy of cladribine tablets and alternative DMTs in the management of active RRMS. A series of meta-regression models were run with adjustment for baseline risk, fitted to data from the intention-to-treat cohorts of trials identified in the SLR. A non-parametric MAIC analysis adjusted for differences between studies by reweighting patient-level data from the index trial to match the mean baseline characteristics reported for trials with only aggregate data. Results: The meta-regression analysis showed significant overlap in credible intervals for the hazard ratios of 6 month confirmed disability progression (CDP-6M) and annualized relapse rate (ARR), with no therapy statistically dominating in terms of efficacy and all therapies estimated to reduce the ARR compared to placebo in all subpopulations. In the MAIC analysis, cladribine tablets showed a reduction in CDP-6M and ARR comparable to alemtuzumab before and after matching. Conclusion: This analysis has demonstrated that cladribine tablets have comparable relative efficacy to other highly efficacious DMTs in active RRMS across all subpopulations, thus validating the comparative effectiveness results from previous network meta-analysis. The MAIC analysis showed that cladribine tablets are comparable in efficacy to alemtuzumab in the treatment of patients with RRMS.
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Affiliation(s)
| | | | | | - Gerard Harty
- c EMD Serono Research and Development , Billerica , USA
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Abstract
PURPOSE OF REVIEW Newly introduced disease-modifying therapies offer greater efficacy than previous therapies but also have serious side effects. This article reviews factors useful in identifying those at risk of developing aggressive relapsing multiple sclerosis (MS) and therapies available for treatment. RECENT FINDINGS Several factors predict aggressive MS, including demographic factors, relapses, symptom characteristics, MRI activity, and other biomarkers. These can be used to select patients for more aggressive therapies, including natalizumab, alemtuzumab, fingolimod, and ocrelizumab. Additional off-label treatments are available for patients with severe disease. The benefits and side effects of these treatments must be considered when making therapeutic decisions. SUMMARY Selecting patients who are most appropriate for aggressive therapy involves considering risk factors for poor outcomes, early recognition of treatment failure, balancing treatment efficacy and side effects, and sharing the decision with patients to assist them in making optimal treatment choices. Vigilance for signs of treatment failure and early switching to more aggressive therapy are important components in optimal care.
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Arroyo R, Bury DP, Guo JD, Margolin DH, Melanson M, Daizadeh N, Cella D. Impact of alemtuzumab on health-related quality of life over 6 years in CARE-MS II trial extension patients with relapsing-remitting multiple sclerosis. Mult Scler 2019; 26:955-963. [PMID: 31144568 PMCID: PMC7350196 DOI: 10.1177/1352458519849796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: In CARE-MS II (Comparison of Alemtuzumab and Rebif® Efficacy in Multiple Sclerosis; NCT00548405), alemtuzumab (12 mg/day; baseline: 5 days; 12 months later: 3 days) significantly improved health-related quality of life (HRQL) outcomes versus subcutaneous interferon beta-1a (SC IFNB-1a) in relapsing-remitting multiple sclerosis (RRMS) patients over 2 years. Patients completing CARE-MS II could enter a 4-year extension study (NCT00930553). Objective: The aim of this study is to assess 6-year HRQL outcomes in alemtuzumab-treated CARE-MS II patients, including those with highly active disease (HAD). Methods: During extension, patients could receive additional alemtuzumab for clinical/magnetic resonance imaging (MRI) activity or other disease-modifying therapies per investigator’s discretion. Assessments include Functional Assessment of Multiple Sclerosis (FAMS), 36-Item Short-Form Health Survey (SF-36), and EQ-5D visual analog scale (EQ-VAS). Results: Alemtuzumab-treated patients improved or stabilized all HRQL measures over 6 years with significant improvements from baseline at all time points on EQ-VAS and for up to 5 years on FAMS, SF-36 MCS, and SF-36 PCS. Alemtuzumab-treated patients with HAD showed significant improvements versus baseline at Year 2 on all HRQL measures, and significant improvements versus SC IFNB-1a on SF-36 PCS and EQ-VAS; however, the improvements did not reach the threshold for clinical relevance. Conclusion: Alemtuzumab-treated CARE-MS II patients improved or stabilized HRQL versus baseline over 6 years. This is the first study to show long-term HRQL benefits in patients with HAD.
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Affiliation(s)
- Rafael Arroyo
- Department of Neurology, Hospital Universitario Quirónsalud, Madrid, Spain
| | | | - Jennifer D Guo
- Sanofi, Cambridge, MA, USA; Bristol-Myers Squibb, Lawrence Township, NJ, USA
| | | | | | | | - David Cella
- Department of Medical Social Sciences, Center for Patient-Centered Outcomes, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Cladribine for multiple sclerosis. Drug Ther Bull 2018; 56:21-24. [PMID: 29449328 DOI: 10.1136/dtb.2018.2.0590] [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: 06/08/2023]
Abstract
In the UK, there are twelve disease-modifying drugs licensed for various forms of multiple sclerosis (MS), of which three are oral therapies. An oral formulation of cladribine (Mavenclad - Merck Serono Europe Limited) was recently licensed by the European Medicines Agency (EMA) for the treatment of adult patients with highly active relapsing MS.1,2 It is claimed to be "an innovatively simple approach" for treating this form of MS and "the only disease modifying therapy that can deliver and sustain 4 years of disease control with a maximum of 20 days oral treatment in the first 2 years."3 Here, we consider the evidence for its use in the treatment of highly active relapsing MS.
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