Management of diabetes and hypertension in people with multiple sclerosis

The risk of type 2 diabetes mellitus in multiple sclerosis and neuromyelitis optica spectrum disorder: A nationwide cohort study

BACKGROUND AND OBJECTIVES

An association has been suggested between premorbid type 2 diabetes mellitus (T2DM) and the risk of multiple sclerosis (MS). However, little is known about the risk of developing T2DM in MS and neuromyelitis optica spectrum disorder (NMOSD). This study aimed to determine the T2DM risk in patients with MS and NMSOD.

METHODS

The Korean National Health Insurance Service database was analyzed, and 1,801 and 1,721 adults with MS and NMOSD, respectively, who were free of T2DM between January 2010 and December 2017, were included. Matched controls were selected based on age, sex, and the presence of hypertension and dyslipidemia.

RESULTS

The risk of developing T2DM was 1.54 times higher in NMOSD than in the controls (adjusted hazard ratio [aHR], 95 % confidence interval [CI] = 1.20-1.96). However, increased T2DM risk was not observed in MS (aHR = 1.13, 95 % CI = 0.91-1.42). The T2DM risk in patients with NMOSD was higher in those who received steroid treatment (aHR = 1.77, 95 % CI = 1.36-2.30) but not in those who did not (aHR = 0.59, 95 % CI = 0.24-1.43, p for interaction = 0.02).

DISCUSSION

T2DM risk was increased in NMOSD but not in MS. Administering steroid treatment to patients with NMOSD may increase their T2DM risk.

Health, Wellness, and the Effect of Comorbidities on the Multiple Sclerosis Disease Course: Tackling the Modifiable

Multiple sclerosis (MS) is a disease of the central nervous system characterized by inflammatory demyelination and neurodegeneration. Numerous disease-modifying therapies for MS exist but are only partially effective, making it essential to optimize all factors that may influence the course of the disease. This includes conscientious management of both mental and physical comorbidities, as well as a comprehensive strategy for promoting wellness in patients with MS. Thoughtful engagement of those living with MS through shared decision making and involvement of a multidisciplinary team that includes primary care, relevant specialists, psychology, and rehabilitation is likely to lead to better outcomes.

The Importance of Managing Modifiable Comorbidities in People with Multiple Sclerosis: A Narrative Review

Multiple sclerosis (MS) is a chronic, inflammatory, degenerative demyelinating disease of the central nervous system (CNS) of unknown etiology that affects individuals in their early adulthood. In the last decade, life expectancy for people with MS (PwMS) has almost equaled that of the general population. This demographic shift necessitates a heightened awareness of comorbidities, especially the ones that can be prevented and modified, that can significantly impact disease progression and management. Vascular comorbidities are of particular interest as they are mostly modifiable health states, along with voluntary behaviors, such as smoking and alcohol consumption, commonly observed among individuals with MS. Vascular risk factors have also been implicated in the etiology of cerebral small vessel disease. Furthermore, differentiating between vascular and MS lesion load poses a significant challenge due to overlapping clinical and radiological features. This review describes the current evidence regarding the range of preventable and modifiable comorbidities and risk factors and their implications for PwMS.

The Barancik lecture: Comorbidity in multiple sclerosis-Looking backward, looking forward

Comorbidity is highly prevalent in people with multiple sclerosis (MS) throughout their disease course. In the last 15 years, our understanding of the association between comorbidity and outcomes such as relapses, disability progressive, health-related quality of life, health care use, and mortality has grown substantially. The broad adverse impacts of comorbidity on these outcomes point to the need to prevent and treat comorbidity effectively in people with MS. This requires having the necessary tools to evaluate comorbidity, an understanding of how MS affects management of comorbidity now, testing of interventions tailored to people with MS, and determining the best models of care to optimize comorbidity management.

The Prevalence of Diabetes Mellitus Type II (DMII) in the Multiple Sclerosis Population: A Systematic Review and Meta-Analysis

Introduction: The interactions between Diabetes Mellitus type II (DMII) and Multiple Sclerosis (MS) lead to higher levels of fatigue, higher risk of physical disability, faster cognitive decline, and in general a lower quality of life and a higher frequency of depression compared to the general population. All of the above accelerate the disability progression of patients with MS, reduce the patients' functional capacity, and further increase their psychological and economic burden. Methods: This systematic review and meta-analysis aims to calculate the prevalence of DMII in the MS population. Following PRISMA guidelines, a thorough search of the Medline Pubmed, Cochrane Library, and Scopus databases was performed, focusing on the frequency of DMII in the MS population. Results: A total of 19 studies were included in the synthesis. The results of the main meta-analysis of random effects using R studio 3.3.0 for Windows and the Meta r package showed that the prevalence of DMII in the MS population is 5% (95% CI [0.03, 0.07], 19 studies, I2 = 95%, pQ < 0.001). Additional subgroup analysis based on region showed a difference of 4.4% (I2 = 95.2%, pQ < 0.001), psubgroupdifference = 0.003) between European and non-European participants, while demographic- and MS-specific characteristic (EDSS, Disease Duration) did not seem to affect the prevalence of DMII in the MS population (p = 0.30, p = 0.539, p = 0.19, p = 0.838). No publication bias was discovered (Egger's p test value: 0.896). Conclusions: Even though the prevalence of DMII in the MS population is lower than 10% (the reported prevalence of DMII in the general population) the interactions between the two conditions create significant challenges for MS patients, their caregivers, and physicians. DΜΙΙ should be systematically recorded in the case of MS patients to clearly delineate any potential relationship between the two conditions. Additionally, more structured studies investigating the interactions of MS and DMΙΙ as well as the direction of the causation between those two conditions are necessary in order to gain a deeper insight into the nature of the interaction between MS and DMII.

Etiology, effects and management of comorbidities in multiple sclerosis: recent advances

Comorbid conditions commonly affect people with multiple sclerosis (MS). Population-based studies indicate that people with MS have an increased incidence of ischemic heart disease, cerebrovascular disease, peripheral vascular disease, and psychiatric disorders as compared to people without MS. People with MS from underrepresented minority and immigrant groups have higher comorbidity burdens. Comorbidities exert effects throughout the disease course, from symptom onset through diagnosis to the end of life. At the individual level, comorbidity is associated with higher relapse rates, greater physical and cognitive impairments, lower health-related quality of life, and increased mortality. At the level of the health system and society, comorbidity is associated with increased health care utilization, costs and work impairment. A nascent literature suggests that MS affects outcomes from comorbidities. Comorbidity management needs to be integrated into MS care, and this would be facilitated by determining optimal models of care.

Hypertension and hypertension severity in Hispanics/Latinx with MS

BACKGROUND

Vascular comorbidities (VCs) including hypertension (HTN) are associated with worse multiple sclerosis (MS) outcomes. HTN is common in Latinx, but the prevalence and relationship with disability are unknown in Latinx with MS.

METHODS

Latinx (n = 451) from the Alliance for Research in Hispanic MS (ARHMS) seen between 2007 and 2019 were included. HTN, diabetes (DM), hyperlipidemia (HLD), ischemic events, and smoking were considered VC. Blood pressures (BPs) were classified using the American Heart Association (AHA) criteria. Logistic regression determined associations between VC and ambulatory disability accounting for age, sex, and disease duration.

RESULTS

Medical comorbidities were found in 41.9% and VC in 24.2%. Smoking (13.6%) and HTN (7.3%) were the most common. HTN was the most common over the age of 40 (12.6%). The odds of having severe disability were three times higher for those with HTN (odds ratio [OR], 3.12; 95% confidence interval (CI), 1.37-7.12). Stage II HTN according to AHA also tripled the odds (OR, 2.89; 95%CI, 1.11-7.55). AHA BP confirmed HTN in 27.5% (compared to 7.3% with established diagnosis).

CONCLUSION

HTN diagnosis and stage II HTN defined by AHA were independently associated with severe ambulatory disability in Latinx with MS. HTN was underdiagnosed. Future studies should assess whether HTN treatment control would prevent disability in MS.

Characterizing relapsing remitting multiple sclerosis patients burdened with hypertension, hyperlipidemia, and asthma

BACKGROUND

Hypertension, hyperlipidemia, and asthma are common in multiple sclerosis (MS) patients and adversely impact physical and mental health independent of sociodemographic and clinical attributes. Characterizing MS patients with these comorbidities is necessary for informing comorbidity screening and managed care in vulnerable patient subgroups; however, there is sparse data currently available.

METHODS

We conducted cross-sectional analyses of 2,012 relapsing remitting (RR) MS patients. Separate multivariable logistic regression models were conducted for the presence of hypertension, hyperlipidemia, and asthma. Independent variables included age, sex, race, MS duration, body mass index classification, insurance payer, smoking status, median income by residence ZIP code, disease modifying therapies, and the other comorbidities.

RESULTS

Hypertension was more common in RRMS patients who were older, obese/severely obese, had hyperlipidemia, were asthmatics, living in neighborhoods with the lowest income, and who were Black Americans. RRMS patients with hyperlipidemia were more likely to be male, older, overweight/obese/severely obese, hypertensive, asthmatics, and White American. Asthmatic RRMS patients were more likely to be female, obese, hypertensive, and living in neighborhood of medium/low income, and less likely to be on interferons or glatiramer acetate.

CONCLUSION

We identified factors independently associated with common comorbidity burden in RRMS patients, which will inform risk-stratification efforts aimed at mitigating the adverse impact of these conditions in MS patients. Our results are consistent with what is known about the determinants of hypertension, hyperlipidemia, and asthma in the non-MS patient population, and therefore disparities that exist in screening and management in the general U.S. population may likely exist in U.S. MS patients. It is also possible that there may be unique differences in specific MS patient subgroups, which warrants further investigation and detailed characterization.

Teriflunomide in relapsing-remitting multiple sclerosis: outcomes by age and pre-treatment status

Background and aims:

To investigate effectiveness and safety of teriflunomide (14 mg once daily) in association with age and pre-treatment in unselected MS patients.

Methods:

Prespecified analysis of a non-interventional, prospective, real-world study in Germany.

Results:

A total of 558 (49.5%) patients were above 45 years old, and 593 patients (52.6%) had been pre-treated within 6 months prior to teriflunomide. Baseline Expanded Disability Status Scale (EDSS) was higher with older age, with lower number of relapses. Relapse rate decreased in all age groups, and in both treatment-naïve (0.82 ± 0.73 at baseline; 0.25 ± 0.55 under teriflunomide) and pre-treated (from 0.48 ± 0.76; 0.22 ± 0.50) patients after 12 months compared with the year before teriflunomide initiation. EDSS remained stable in patients of all age groups as well as in therapy-naïve and pre-treated patients over 24 months. The percentage of patients with adverse events (AEs) ranged between 29.2% (age group >25–35) and 38.9% (age group >55–65), with an increased discontinuation rate (most commonly due to diarrhoea, alopecia and nausea) in the higher age groups. AE rates were lower in pre-treated compared with treatment-naïve patients.

Conclusion:

Overall, patients of all age groups including older patients, and irrespective of pre-treatment, benefit from teriflunomide treatment in routine clinical practice.

Registration:

BfArM public study database number 2075.

Risk factors for deterioration of renal function after percutaneous nephrolithotomy in solitary kidney patients with staghorn calculi

Background

Nowadays, it has not been reported in detail which factors have adverse effects on renal function after PNCL surgery in solitary kidney patients with staghorn calculi. To evaluate the risk factors that deteriorate the renal function in solitary kidney patients with staghorn calculi after percutaneous nephrolithotomy (PCNL).

Methods

A retrospective study was performed on solitary kidney patients with staghorn calculi between March 2014 and Jun 2019. Renal function-related indexes were collected pre-operatively, and at 1 and 6 months post-operatively. These pre- and post-operative indexes were compared to study the risk factors on renal function.

Results

Totally 71 solitary kidney patients with staghorn calculi were included with a male-to-female ratio of 53:18 and mean age of 54.3±10.2 years old. The mean pre-operative estimated glomerular filtration rate (eGFR) and serum creatinine were 55.1±18.9 mL/min/1.73 m² and 130.9±41.0 µmol/L, respectively. The mean diameter of largest stones was 5.0±1.7 cm, and the stone-free rate was 71.8%. Univariate analysis showed urinary tract infection (UTI) was a significant risk factor for deteriorating renal function after PCNL. At 1 to 6 months after surgery, renal function deteriorated by both UTI and combined diseases. The surgical side at the right kidney, mild hydronephrosis, and surgical time without 20 min or beyond 40 min can deteriorate renal function. Multivariate analysis demonstrated UTI was the main factor leading to deteriorated renal function with increasing serum creatinine and declining eGFR.

Conclusions

Preoperative UTI can deteriorate the renal function at 1 month after PCNL, and diabetes can deteriorate the postoperative renal function at 6 months after PCNL. Controlled perioperative UTI, diabetes and factors play a crucial role in protecting renal function after PCNL for solitary kidney patients with staghorn calculi.

The prevalence of comorbidities in patients with multiple sclerosis: population-based registry data

BACKGROUND

Comorbidities occur frequently in persons with multiple sclerosis (MS). The aim of the present study was to determine the prevalence of the most common comorbidities in the population of MS patients in Belgrade, Serbia.

MATERIAL AND METHODS

Data on diagnosed and fully documented comorbidities were taken from the Belgrade MS population registry. The list of explored comorbidities included cardiovascular, malignant, and autoimmune diseases; psychiatric disorders; epilepsy; and type 2 diabetes. In the data analysis, crude, age- and gender-specific, and age-adjusted prevalence was calculated. Additionally, comorbidities were analyzed in patients with various MS phenotypes.

RESULTS

The most prevalent group of comorbidities were psychiatric (prevalence (Prev) = 20.59%, 95% CI 19.10-22.17) and cardiovascular comorbidities (Prev = 15.23%, 95% CI 13.93-16.63). The most prevalent single comorbidities were depression (Prev = 11.82%, 95% CI 10.64-13.11) and hypertension (Prev = 11.41%, 95% CI 10.25-12.68). Type 2 diabetes was significantly more prevalent in patients with primary progressive MS compared with the patients with relapsing-remitting and secondary progressive MS (p < 0.001). We found statistically significant positive correlation between number of comorbidities and progression index (p < 0.001). Patients treated with disease-modifying therapies (DMTs) had significantly higher risk of developing comorbidity, after treatment initiation, compared with those who were untreated (p = 0.001).

CONCLUSIONS

Our study demonstrated high prevalence of comorbidities in persons with MS, with psychiatric and cardiovascular diseases being the most common. Furthermore, our findings confirmed the association of comorbidities with progression of disability and emphasized their role in treatment decision-making in MS.