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Iaffaldano P, Lucisano G, Guerra T, Paolicelli D, Portaccio E, Inglese M, Foschi M, Patti F, Granella F, Romano S, Cavalla P, De Luca G, Gallo P, Bellantonio P, Gallo A, Montepietra S, Di Sapio A, Vianello M, Quatrale R, Spitaleri D, Clerici R, Torri Clerici V, Cocco E, Brescia Morra V, Marfia GA, Boccia VD, Filippi M, Amato MP, Trojano M. A comparison of natalizumab and ocrelizumab on disease progression in multiple sclerosis. Ann Clin Transl Neurol 2024. [PMID: 38970214 DOI: 10.1002/acn3.52118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/17/2024] [Accepted: 05/23/2024] [Indexed: 07/08/2024] Open
Abstract
OBJECTIVE No direct comparisons of the effect of natalizumab and ocrelizumab on progression independent of relapse activity (PIRA) and relapse-associated worsening (RAW) events are currently available. We aimed to compare the risk of achieving first 6 months confirmed PIRA and RAW events and irreversible Expanded Disability Status Scale (EDSS) 4.0 and 6.0 in a cohort of naïve patients treated with natalizumab or ocrelizumab from the Italian Multiple Sclerosis Register. METHODS Patients with a first visit within 1 year from onset, treated with natalizumab or ocrelizumab, and ≥3 visits were extracted. Pairwise propensity score-matched analyses were performed. Risk of reaching the first PIRA, RAW, and EDSS 4.0 and 6.0 events were estimated using multivariable Cox proportional hazards models. Kaplan-Meier curves were used to show cumulative probabilities of reaching outcomes. RESULTS In total, 770 subjects were included (natalizumab = 568; ocrelizumab = 212) and the propensity score-matching retrieved 195 pairs. No RAW events were found in natalizumab group and only 1 was reported in ocrelizumab group. A first PIRA event was reached by 23 natalizumab and 25 ocrelizumab exposed patients; 7 natalizumab- and 10 ocrelizumab-treated patients obtained an irreversible EDSS 4.0, while 13 natalizumab- and 15 ocrelizumab-treated patients reached an irreversible EDSS 6.0. No differences between the two groups were found in the risk (HR, 95%CI) of reaching a first PIRA (1.04, 0.59-1.84; p = 0.88) event, an irreversible EDSS 4.0 (1.23, 0.57-2.66; p = 0.60) and 6.0 (0.93, 0.32-2.68; p = 0.89). INTERPRETATION Both medications strongly suppress RAW events and, in the short term, the risk of achieving PIRA events, EDSS 4.0 and 6.0 milestones is not significantly different.
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Affiliation(s)
- Pietro Iaffaldano
- Department of Translational Biomedicines and Neurosciences, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Lucisano
- CORESEARCH - Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Tommaso Guerra
- Department of Translational Biomedicines and Neurosciences, University of Bari Aldo Moro, Bari, Italy
| | - Damiano Paolicelli
- Department of Translational Biomedicines and Neurosciences, University of Bari Aldo Moro, Bari, Italy
| | - Emilio Portaccio
- Department of Neurofarba, University of Florence, Florence, Italy
| | - Matilde Inglese
- Dipartimento Di Neuroscienze, Riabilitazione, Oftalmologia, Genetica E Scienze Materno - Infantili (DINOGMI), Università di Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Foschi
- Department of Neuroscience, Multiple Sclerosis Center-Neurology Unit, S. Maria delle Croci Hospital of Ravenna, AUSL Romagna, Ravenna, 48121, Italy
| | - Francesco Patti
- Dipartimento di Scienze Mediche e Chirurgiche e Tecnologie Avanzate, GF Ingrassia, Sez. Neuroscienze, Centro Sclerosi Multipla, Università di Catania, Catania, Italy
| | - Franco Granella
- Unit of Neurosciences, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Silvia Romano
- Department of Neurosciences, Mental Health and Sensory Organs, Centre for Experimental Neurological Therapies (CENTERS), Sapienza University of Rome, Rome, Italy
| | - Paola Cavalla
- Multiple Sclerosis Center and 1 Neurology Unit, Department of Neurosciences and Mental Health, AOU Città della Salute e della Scienza di Torino via Cherasco 15, Torino, 10126, Italy
| | - Giovanna De Luca
- Centro Sclerosi Multipla, Clinica Neurologica, Policlinico SS. Annunziata, Chieti, Italy
| | - Paolo Gallo
- Department of Neurosciences, Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy
| | - Paolo Bellantonio
- Unit of Neurology and Neurorehabilitation, IRCCS Neuromed, Pozzilli, Italy
| | - Antonio Gallo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Sara Montepietra
- Neurology Unit, Neuromotor and Rehabilitation Department, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Alessia Di Sapio
- Regional Referral MS Center, Neurological Unit, Univ. Hospital San Luigi, Orbassano, Italy
| | | | - Rocco Quatrale
- Ambulatorio Sclerosi Multipla - Divisione di Neurologia, Ospedale dell'Angelo, Mestre, Italy
| | - Daniele Spitaleri
- Department of Neurology, AORN San G. Moscati di Avellino, Avellino, Italy
| | - Raffaella Clerici
- Centro ad Alta Specializzazione per la diagnosi e la cura della sclerosi multipla, Ospedale Generale di zona Valduce, Como, Italy
| | | | - Eleonora Cocco
- Department of Medical Science and Public Health, Centro Sclerosi Multipla, University of Cagliari, Cagliari, Italy
| | - Vincenzo Brescia Morra
- Department of Neuroscience (NSRO), Multiple Sclerosis Clinical Care and Research Center, Federico II University, Naples, Italy
| | | | - Vincenzo Daniele Boccia
- Dipartimento Di Neuroscienze, Riabilitazione, Oftalmologia, Genetica E Scienze Materno - Infantili (DINOGMI), Università di Genova, Genoa, Italy
| | - Massimo Filippi
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Pia Amato
- Department of Neurofarba, University of Florence, Florence, Italy
| | - Maria Trojano
- Department of Translational Biomedicines and Neurosciences, University of Bari Aldo Moro, Bari, Italy
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Zapf A, Wiessner C, König IR. Regression Analyses and Their Particularities in Observational Studies. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:128-134. [PMID: 38231741 PMCID: PMC11019761 DOI: 10.3238/arztebl.m2023.0278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Regression analysis is a standard method in medical research. It is often not clear, however, how the individual components of regression models are to be understood and interpreted. In this article, we provide an overview of this type of analysis and discuss its special features when used in observational studies. METHODS Based on a selective literature review, the individual components of a regression model for differently scaled outcome variables (metric: linear regression; binary: logistic regression; time to event: Cox regression; count variable: Poisson or negative binomial regression) are explained, and their interpretation is illustrated with respect to a study on multiple sclerosis. The prerequisites for the use of each of these models, their applications, and their limitations are described in detail. RESULTS Regression analyses are used to quantify the relation between several variables and the outcome variable. In randomized clinical trials, this flexible statistical analysis method is usually lean and prespecified. In observational studies, where there is a need to control for potential confounders, researchers with knowledge of the topic in question must collaborate with experts in statistical modeling to ensure high model quality and avoid errors. Causal diagrams are an increasingly important basis for evaluation. They should be constructed in collaboration and should differentiate between confounders, mediators, and colliders. CONCLUSION Researchers need a basic understanding of regression models so that these models will be well defined and their findings will be fully reported and correctly interpreted.
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Affiliation(s)
- Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Christian Wiessner
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Inke Regina König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
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Mizell R. The Impact of Insurance Restrictions in Newly Diagnosed Individuals With Multiple Sclerosis. Int J MS Care 2024; 26:17-21. [PMID: 38213675 PMCID: PMC10779716 DOI: 10.7224/1537-2073.2022-069] [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: 01/13/2024]
Abstract
BACKGROUND The medical system in the United States has been riddled with insurance restrictions used by insurance companies to limit health care costs. The effects of insurance restrictions on patients receiving disease-modifying therapies for multiple sclerosis (MS) have not been specifically studied. METHODS A retrospective cross-sectional study of 52 individuals recently diagnosed with MS at a tertiary neurology clinic was conducted to measure the association between prior authorization (PA) duration and other variables of interest. The Cox proportional hazards model was used to determine likelihood of approval. Further analysis included multivariable logistic regression to assess the influence of variables of interest on the initial decision from the insurance company and the effect of the PA on disease activity. RESULTS Of 52 PAs, 50% were initially denied. An initial denial decreased the likelihood of approval by 98% (HR, 0.02; 95% CI, <0.01-0.09; P < .001). The odds of denial for oral medications (odds ratio [OR], 4.91; 95% CI, 1.33-21.52; P = .02) and infusions (OR, 8.35; 95% CI, 1.10-88.77; P = .05) were significantly higher than for injections. Medicaid had higher odds of denial compared with commercial insurance (OR, 4.51; 95% CI, 1.13-22.01; P = .04). An initial denial by insurance significantly increased the likelihood of disease activity (OR, 6.18; 95% CI, 1.33-44.86; P = .03). CONCLUSIONS Insurance restrictions delay necessary treatments, increase the likelihood of disease activity, and rarely change the approved disease-modifying therapy. Reducing PAs may lead to improved outcomes for patients with MS.
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Affiliation(s)
- Ryan Mizell
- From AdventHealth Neurology, Orlando, FL, USA
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Eliasdottir O, Kjartansson Ó, Olafsson E. Mortality of multiple sclerosis in Iceland population-based mortality of MS in incidence and prevalence cohorts. Mult Scler J Exp Transl Clin 2023; 9:20552173231169467. [PMID: 37125266 PMCID: PMC10134140 DOI: 10.1177/20552173231169467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Mortality is an important feature of the natural history of multiple sclerosis (MS). We report the mortality of all individuals with MS in Iceland, identified in a nationwide population-based study. Patients and Methods The results are based on a prevalence cohort and an incidence cohort. The prevalence cohort consisted of all patients with MS (n = 526) living in Iceland on the 31 December 2007. The incidence cohort consisted of all residents of Iceland (n = 222) diagnosed with MS during 2002 to 2007. Mortality was determined by following both the incidence cohort (from diagnosis) and the prevalence cohort (from the prevalence day) until death or 31 December 2020. The mortality, associated with MS, was compared with that expected in the Icelandic population (standardized mortality ratio (SMR)). Results (a) Prevalence cohort (n = 526). The mean follow up was 12.0 years (range 0.3-13.0). The SMR was 1.6 (95% confidence interval (CI) 1.3-2.0). (b) Incidence cohort (n = 222). The mean follow up was 15.4 years (range 3.7-18.5). The SMR was 1.2 (95% CI 0.6-2.2). Conclusion During the follow-up period, there was a substantial increase in mortality among the patients with MS, compared with the general population. There was no increase in mortality among the incidence cohort, when followed for up to 18.5 years following diagnosis.
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Affiliation(s)
- Olöf Eliasdottir
- Olöf Eliasdottir, Department of Neurology,
Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Ólafur Kjartansson
- Department of Radiology, Landspítali-The
National University Hospital of Iceland, Reykjavik, Iceland
| | - Elias Olafsson
- Faculty of Medicine, University of Iceland,
Reykjavik, Iceland
- Department of Neurology, Landspítali-The
National University Hospital of Iceland, Reykjavik, Iceland
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Lublin FD, Häring DA, Ganjgahi H, Ocampo A, Hatami F, Čuklina J, Aarden P, Dahlke F, Arnold DL, Wiendl H, Chitnis T, Nichols TE, Kieseier BC, Bermel RA. OUP accepted manuscript. Brain 2022; 145:3147-3161. [PMID: 35104840 PMCID: PMC9536294 DOI: 10.1093/brain/awac016] [Citation(s) in RCA: 130] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/01/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with multiple sclerosis acquire disability either through relapse-associated worsening (RAW) or progression independent of relapse activity (PIRA). This study addresses the relative contribution of relapses to disability worsening over the course of the disease, how early progression begins and the extent to which multiple sclerosis therapies delay disability accumulation. Using the Novartis-Oxford multiple sclerosis (NO.MS) data pool spanning all multiple sclerosis phenotypes and paediatric multiple sclerosis, we evaluated ∼200 000 Expanded Disability Status Scale (EDSS) transitions from >27 000 patients with ≤15 years follow-up. We analysed three datasets: (i) A full analysis dataset containing all observational and randomized controlled clinical trials in which disability and relapses were assessed (n = 27 328); (ii) all phase 3 clinical trials (n = 8346); and (iii) all placebo-controlled phase 3 clinical trials (n = 4970). We determined the relative importance of RAW and PIRA, investigated the role of relapses on all-cause disability worsening using Andersen-Gill models and observed the impact of the mechanism of worsening and disease-modifying therapies on the time to reach milestone disability levels using time continuous Markov models. PIRA started early in the disease process, occurred in all phenotypes and became the principal driver of disability accumulation in the progressive phase of the disease. Relapses significantly increased the hazard of all-cause disability worsening events; following a year in which relapses occurred (versus a year without relapses), the hazard increased by 31–48% (all P < 0.001). Pre-existing disability and older age were the principal risk factors for incomplete relapse recovery. For placebo-treated patients with minimal disability (EDSS 1), it took 8.95 years until increased limitation in walking ability (EDSS 4) and 18.48 years to require walking assistance (EDSS 6). Treating patients with disease-modifying therapies delayed these times significantly by 3.51 years (95% confidence limit: 3.19, 3.96) and 3.09 years (2.60, 3.72), respectively. In patients with relapsing-remitting multiple sclerosis, those who worsened exclusively due to RAW events took a similar length of time to reach milestone EDSS values compared with those with PIRA events; the fastest transitions were observed in patients with PIRA and superimposed relapses. Our data confirm that relapses contribute to the accumulation of disability, primarily early in multiple sclerosis. PIRA begins in relapsing-remitting multiple sclerosis and becomes the dominant driver of disability accumulation as the disease evolves. Pre-existing disability and older age are the principal risk factors for further disability accumulation. The use of disease-modifying therapies delays disability accrual by years, with the potential to gain time being highest in the earliest stages of multiple sclerosis.
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Affiliation(s)
- Fred D Lublin
- Correspondence to: Professor Fred D. Lublin The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Icahn School of Medicine at Mount Sinai 5 East 98th Street, Box 1138 New York, NY 10029-6574, USA E-mail:
| | | | - Habib Ganjgahi
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Farhad Hatami
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | | | | | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Thomas E Nichols
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Robert A Bermel
- Department of Neurology, Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
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