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Gross RH, Corboy J. De-escalation and Discontinuation of Disease-Modifying Therapies in Multiple Sclerosis. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01355-w. [PMID: 38995483 DOI: 10.1007/s11910-024-01355-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE OF REVIEW Long-term use of multiple sclerosis (MS) disease-modifying therapies (DMTs) is standard practice to prevent accumulation of disability. Immunosenescence and other age-related changes lead to an altered risk-benefit ratio for older patients on DMTs. This article reviews recent research on the topic of de-escalation and discontinuation of MS DMTs. RECENT FINDINGS Observational and interventional studies have shed light on what happens to patients who de-escalate or discontinue DMTs and the factors, such as age, treatment type, and presence of recent disease activity, that influence outcomes. Though many questions remain, recent findings have been valuable for the development of an evidence-based approach to making de-escalation and discontinuation decisions in MS.
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Affiliation(s)
- Robert H Gross
- Department of Neurology, University of Colorado School of Medicine, 12631 East 17thAvenue, Mail Stop F727, Aurora, CO, 80045, USA.
- Department of Neurology, Rocky Mountain Regional Veterans Administration Medical Center, Aurora, CO, USA.
| | - John Corboy
- Department of Neurology, University of Colorado School of Medicine, 12631 East 17thAvenue, Mail Stop F727, Aurora, CO, 80045, USA
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Tallantyre EC, Dobson R, Froud JLJ, St John FA, Anderson VM, Arun T, Buckley L, Evangelou N, Ford HL, Galea I, George S, Gray OM, Hibbert AM, Hu M, Hughes SE, Ingram G, Kalra S, Lim CHE, Mathews JTM, McDonnell GV, Mescall N, Norris S, Ramsay SJ, Rice CM, Russell MJ, Shawe-Taylor MJ, Williams TE, Harding KE, Robertson NP. Real-world persistence of multiple sclerosis disease-modifying therapies. Eur J Neurol 2024:e16289. [PMID: 38567516 DOI: 10.1111/ene.16289] [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: 11/26/2023] [Revised: 02/26/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND PURPOSE Treatment persistence is the continuation of therapy over time. It reflects a combination of treatment efficacy and tolerability. We aimed to describe real-world rates of persistence on disease-modifying therapies (DMTs) for people with multiple sclerosis (pwMS) and reasons for DMT discontinuation. METHODS Treatment data on 4366 consecutive people with relapse-onset multiple sclerosis (MS) were pooled from 13 UK specialist centres during 2021. Inclusion criteria were exposure to at least one MS DMT and a complete history of DMT prescribing. PwMS in blinded clinical trials were excluded. Data collected included sex, age at MS onset, age at DMT initiation, DMT treatment dates, and reasons for stopping or switching DMT. For pwMS who had received immune reconstituting therapies (cladribine/alemtuzumab), discontinuation date was defined as starting an alternative DMT. Kaplan-Meier survival analyses were used to express DMT persistence. RESULTS In 6997 treatment events (1.6 per person with MS), median time spent on any single maintenance DMT was 4.3 years (95% confidence interval = 4.1-4.5 years). The commonest overall reasons for DMT discontinuation were adverse events (35.0%) and lack of efficacy (30.3%). After 10 years, 20% of people treated with alemtuzumab had received another subsequent DMT, compared to 82% of people treated with interferon or glatiramer acetate. CONCLUSIONS Immune reconstituting DMTs may have the highest potential to offer a single treatment for relapsing MS. Comparative data on DMT persistence and reasons for discontinuation are valuable to inform treatment decisions and in personalizing treatment in MS.
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Affiliation(s)
- Emma C Tallantyre
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
- Department of Neurology, University Hospital of Wales, Cardiff, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Joseph L J Froud
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
- Postgraduate Department, St Thomas' Hospital, London, UK
| | - Frederika A St John
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Valerie M Anderson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Tarunya Arun
- Department of Neuroscience, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Lauren Buckley
- Department of Neurology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Nikos Evangelou
- Nottingham Centre for Multiple Sclerosis and Neuroinflammation, Queen's Medical Centre, University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham, Nottingham, UK
| | - Helen L Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sumi George
- Department of Neurology, Ulster Hospital, Dundonald, UK
| | - Orla M Gray
- Department of Neurology, Ulster Hospital, Dundonald, UK
| | - Aimee M Hibbert
- Nottingham Centre for Multiple Sclerosis and Neuroinflammation, Queen's Medical Centre, University Hospitals NHS Trust, Nottingham, UK
| | - Mo Hu
- Department of Neurology, Swansea University Health Board, Swansea, UK
| | | | - Gillian Ingram
- Department of Neurology, Swansea University Health Board, Swansea, UK
| | - Seema Kalra
- Neurology Department, University Hospital North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Chia-Hui E Lim
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Naomi Mescall
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, University College London, London, UK
| | - Sam Norris
- Aneurin Bevan University Health Board, Department of Neurology, Royal Gwent Hospital, Newport, UK
| | | | - Claire M Rice
- Department of Neurology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
- Transplantation Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Melanie J Russell
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
| | - Marianne J Shawe-Taylor
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, University College London, London, UK
| | - Thomas E Williams
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, University College London, London, UK
- Faculty of Brain Sciences, Queen Square Institute of Neurology, University College London, London, UK
| | - Katharine E Harding
- Aneurin Bevan University Health Board, Department of Neurology, Royal Gwent Hospital, Newport, UK
| | - Neil P Robertson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
- Department of Neurology, University Hospital of Wales, Cardiff, UK
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Jeng B, Huynh TLT, Motl RW. Comorbid Conditions and Physical Function in Adults With Multiple Sclerosis. Arch Phys Med Rehabil 2024; 105:251-257. [PMID: 37442217 DOI: 10.1016/j.apmr.2023.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/12/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE We examined the total number of comorbid conditions as a correlate of physical function in persons with multiple sclerosis (MS). We further identified the presence of common comorbid conditions and examined physical function outcomes based on presence or absence of the comorbid conditions in persons with MS. DESIGN Cross-sectional, comparative study. SETTING University-based laboratory. PARTICIPANTS Two hundred seven persons with MS (N=207) completed the study. MAIN OUTCOME MEASURES Participants provided demographic, clinical, and comorbidity information. Participants then completed the 6-minute walk (6MW), timed 25-foot walk (T25FW), timed Up and Go (TUG), and short physical performance battery (SPPB). INTERVENTIONS Not applicable. RESULTS The number of comorbid conditions was associated with 6MW, T25FW, TUG, and SPPB scores (all P≤.001). Persons with MS who had hypertension performed worse on the 6MW, T25FW, TUG, and SPPB than persons without hypertension. Persons who had osteoarthritis performed worse on the 6MW, T25FW, and SPPB than persons without osteoarthritis. CONCLUSIONS The results demonstrate that persons who report more comorbid conditions have worse physical function, and this may largely be associated with hypertension or osteoarthritis. There are opportunities for the design of behavioral interventions that target physical activity and/or diet for improving physical function via comorbid conditions in persons with MS.
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Affiliation(s)
- Brenda Jeng
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL; Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL.
| | - Trinh L T Huynh
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL
| | - Robert W Motl
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL; Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL
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Marrie RA, Fisk JD, Fitzgerald K, Kowalec K, Maxwell C, Rotstein D, Salter A, Tremlett H. Etiology, effects and management of comorbidities in multiple sclerosis: recent advances. Front Immunol 2023; 14:1197195. [PMID: 37325663 PMCID: PMC10266935 DOI: 10.3389/fimmu.2023.1197195] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/19/2023] [Indexed: 06/17/2023] Open
Abstract
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.
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Affiliation(s)
- Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - John D. Fisk
- Nova Scotia Health and the Departments of Psychiatry, Psychology & Neuroscience, and Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kathryn Fitzgerald
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Kaarina Kowalec
- College of Pharmacy, University of Manitoba, Winnipeg, MB, Canada
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Colleen Maxwell
- Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Dalia Rotstein
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- St. Michael’s Hospital, Toronto, ON, Canada
| | - Amber Salter
- Department of Neurology, UT Southwestern, Dallas, TX, United States
| | - Helen Tremlett
- Department of Medicine (Neurology) and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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