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Ghezzi A. Old and New Strategies in the Treatment of Pediatric Multiple Sclerosis: A Personal View for a New Treatment Approach. Neurol Ther 2024; 13:949-963. [PMID: 38822947 PMCID: PMC11263277 DOI: 10.1007/s40120-024-00633-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/14/2024] [Indexed: 06/03/2024] Open
Abstract
Up to 10 years ago the most common approach to the treatment of pediatric MS (ped-MS) was to start with IFNB or GA (so-called first-line therapies or moderate-efficacy disease-modifying therapies [ME-DMTs]) and to switch to more aggressive treatments (or high-efficacy disease-modifying therapies [HE-DMTs]) in non-responder patients. The use of HE-DMTs as first choice was recommended in selected cases with an active, aggressive form of MS. Indications for the treatment of ped-MS were essentially derived from data of observational studies. Recently, results of three randomized clinical trials have been published as well as data from many observational studies evaluating the effect of new and more active DMTs, with clear evidence that HE-DMTs are more effective than ME-DMTs. Therefore, the paradigm of treatment for patients with MS onset before 18 years of age should be changed, offering treatment with HE-DMTs as first option, because of their superior effectiveness to prevent relapses and disease progression. HE-DMTs present an overall reassuring safety profile and obtain better adherence to treatment.
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Affiliation(s)
- Angelo Ghezzi
- Dipartimento di Scienze della Salute, Università Piemonte Orientale A. Avogadro, Via Solaroli 17, 28100, Novara, Italy.
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Breu M, Sandesjö F, Milos R, Svoboda J, Salzer J, Schneider L, Reichelt JB, Bertolini A, Blaschek A, Fink K, Höftberger R, Lycke J, Rostásy K, Seidl R, Siegert S, Wickström R, Kornek B. Rituximab treatment in pediatric-onset multiple sclerosis. Eur J Neurol 2024; 31:e16228. [PMID: 38375947 PMCID: PMC11235651 DOI: 10.1111/ene.16228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/05/2023] [Accepted: 01/15/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND PURPOSE Rituximab (RTX) is frequently used off-label in multiple sclerosis. However, studies on the risk-benefit profile of RTX in pediatric-onset multiple sclerosis are scarce. METHODS In this multicenter retrospective cohort study, patients with pediatric-onset multiple sclerosis from Sweden, Austria and Germany, who received RTX treatment were identified by chart review. Annualized relapse rates, Expanded Disability Status Scale scores and magnetic resonance imaging parameters (new T2 lesions and contrast-enhancing lesions) were assessed before and during RTX treatment. The proportion of patients who remained free from clinical and disease activity (NEDA-3) during RTX treatment was calculated. Side effects such as infusion-related reactions, infections and laboratory abnormalities were assessed. RESULTS Sixty-one patients received RTX during a median (interquartile range) follow-up period of 20.9 (35.6) months. The annualized relapse rate decreased from 0.6 (95% confidence interval [CI] 0.38-0.92) to 0.03 (95% CI 0.02-0.14). The annual rate of new T2 lesions decreased from 1.25 (95% CI 0.70-2.48) to 0.08 (95% CI 0.03-0.25) and annual rates of new contrast-enhancing lesions decreased from 0.86 (95% CI 0.30-3.96) to 0. Overall, 70% of patients displayed no evidence of disease activity (NEDA-3). Adverse events were observed in 67% of patients. Six patients discontinued treatment due to ongoing disease activity or adverse events. CONCLUSION Our study provides class IV evidence that RTX reduces clinical and radiological activity in pediatric-onset multiple sclerosis.
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Affiliation(s)
- Markus Breu
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | - Fredrik Sandesjö
- Neuropediatric Unit, Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Ruxandra‐Iulia Milos
- Department of Biomedical Imaging and Image‐guided TherapyMedical University of ViennaViennaAustria
| | - Jan Svoboda
- Department of NeuroradiologyKarolinska University HospitalStockholmSweden
| | - Jonatan Salzer
- Department of Clinical Science, NeurosciencesUmeå UniversityUmeåSweden
| | - Lisa Schneider
- Division of Infectious Diseases, Department of Internal Medicine IMedical University of ViennaViennaAustria
| | - Julian Benedikt Reichelt
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
- Department of NeurologyMedical University of ViennaViennaAustria
| | - Annikki Bertolini
- Department of Pediatric NeurologyUniversity Witten/Herdecke, Children's Hospital DattelnDattelnGermany
| | - Astrid Blaschek
- Paediatric Neurology and Developmental MedicineLudwig Maximilian University of Munich, Dr. von Hauner Children's HospitalMunichGermany
| | - Katharina Fink
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of NeurologyMedical University of ViennaViennaAustria
- Comprehensive Center for Clinical Neurosciences and Mental HealthMedical University of ViennaViennaAustria
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Kevin Rostásy
- Department of Pediatric NeurologyUniversity Witten/Herdecke, Children's Hospital DattelnDattelnGermany
| | - Rainer Seidl
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | - Sandy Siegert
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | - Ronny Wickström
- Neuropediatric Unit, Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Barbara Kornek
- Department of NeurologyMedical University of ViennaViennaAustria
- Comprehensive Center for Clinical Neurosciences and Mental HealthMedical University of ViennaViennaAustria
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Meltzer E, Charron O, Wozny J, Onuorah H, Montague A, Kline AC, Largent A, Krause TM, Freeman L. Indirect impact of the COVID-19 pandemic on the care and outcomes of people with MS: A combined survey and insurance claims study. Mult Scler Relat Disord 2023; 80:105085. [PMID: 37931487 DOI: 10.1016/j.msard.2023.105085] [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] [Received: 03/28/2023] [Revised: 09/08/2023] [Accepted: 10/15/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND In the context of the COVID-19 pandemic, people with multiple sclerosis (pwMS) have been particularly vulnerable to adverse outcomes due to increased risk of severe infection and/or widespread disruptions in care. The CopeMS study led by The University of Texas at Austin and the MS Association of America investigates the long-term impact of the COVID-19 pandemic on healthcare access, disease modifying therapy (DMT) utilization and outcomes of pwMS. METHODS This retrospective cohort analysis used Optum's de-identified Clinformatics® Data Mart Database (CDM), a large de-identified administrative healthcare claims database to identify pwMS who were continuously enrolled from 01/01/2019 to 12/31/2020 and assessed changes in the utilization of DMTs and healthcare services during the COVID-19 pandemic compared to the year prior. Additionally, a national survey of pwMS and healthcare providers (HCPs) was conducted to further understand the indirect impact of the pandemic on healthcare resource utilization (HCRU), outcomes and prescription patterns. RESULTS Out of 529 pwMS in our national survey, over 47 % reported that their overall health and neurologic symptoms had deteriorated during the COVID-19 pandemic, with increased anxiety, and inability to maintain exercise habits as leading perceived causes for worsening. Survey respondents reported widespread disruption of MS-related services during the pandemic. In the Optum database, we identified 39,209 pwMS validating inclusion criteria. We observed a decrease in the utilization of MS-related services in 2020 compared to 2019. Significantly fewer pwMS had visits with their neurologist, primary care provider, physical or occupational therapist despite an increased utilization of telemedicine services. Fewer pwMS had magnetic resonance imaging (MRI) studies of the brain or spinal cord during the pandemic. Only 22.2 % of HCPs surveyed agreed that the perceived risk of more severe COVID-19 infection on a specific DMT influenced their therapeutic decisions. In the Optum database, individuals with an established diagnosis of MS prior to 2019 saw decreases in utilization of platform and moderate efficacy DMTs. In this group, those over the age of 55 saw a decrease in utilization of B-cell therapies (rate ratio 0.79, CI 0.75-0.83), whereas individuals under the age of 55 saw an increase in utilization of B-cell therapies (rate ratio 1.10, CI 1.03-1.17). We did not see any difference in rates of starting DMTs in persons diagnosed in 2019 prior to the pandemic and those diagnosed in 2020. Compared to 2019, B-cell therapies were prescribed more frequently in pwMS diagnosed in 2020 who were younger than 55 or commercially insured (rate ratio 1.35, CI 1.11-1.63). CONCLUSION The COVID-19 pandemic was associated with perceived worsening of neurological symptoms in pwMS. Despite the expansion of telemedicine, we observed decreased access to healthcare services important to the comprehensive care of pwMS. Additionally, we observed changes in DMT utilization in pwMS during the pandemic, particularly in older adults with an established diagnosis of MS.
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Affiliation(s)
- Ethan Meltzer
- Department of Neurology, Dell Medical School, The University of Texas at Austin, 1601 Trinity St, Austin, TX 78701, USA
| | - Odelin Charron
- Department of Neurology, Dell Medical School, The University of Texas at Austin, 1601 Trinity St, Austin, TX 78701, USA
| | - Joe Wozny
- Center for Healthcare Data, School of Public Health, The University of Texas Health Science Center at Houston, USA
| | - Helen Onuorah
- University of Texas Medical Branch, Galveston, TX, USA
| | | | | | - Avery Largent
- Department of Neurology, Dell Medical School, The University of Texas at Austin, 1601 Trinity St, Austin, TX 78701, USA
| | - Trudy Millard Krause
- Center for Healthcare Data, School of Public Health, The University of Texas Health Science Center at Houston, USA
| | - Leorah Freeman
- Department of Neurology, Dell Medical School, The University of Texas at Austin, 1601 Trinity St, Austin, TX 78701, USA.
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Gombolay G, Hallman-Cooper J. COVID-19 and the Pandemic-Related Aspects in Pediatric Demyelinating Disorders. Semin Pediatr Neurol 2023; 46:101055. [PMID: 37451752 PMCID: PMC10169322 DOI: 10.1016/j.spen.2023.101055] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 07/05/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as Coronavirus-19 (COVID-19) infection, has been associated with several neurological symptoms, including acute demyelinating syndromes (ADS). There is a growing body of literature discussing COVID-19 and demyelinating conditions in adults; however, there is less published about COVID-19 demyelinating conditions in the pediatric population. This review aims to discuss the impact of COVID-19 in pediatric patients with central nervous system ADS (cADS) and chronic demyelinating conditions. We reviewed PubMed, Google Scholar, and Medline for articles published between December 1, 2019 and October 25, 2022 related to COVID-19 and pediatric demyelinating conditions. Of 56 articles reviewed, 20 cases of initial presentation of ADS associated with COVID-19 were described. The most commonly described cADS associated with COVID-19 infection in children was Acute Disseminated Encephalomyelitis followed by Transverse Myelitis. Cases of Myelin Oligodendrocyte Glycoprotein Antibody Disease, Neuromyelitis Optica Spectrum Disorder, and Multiple Sclerosis are also described. The risk of severe COVID-19 in pediatric patients with demyelinating conditions appears low, including in patients on disease modifying therapies, but studies are limited. The pandemic did affect disease modifying therapies in ADS, whether related to changes in prescriber practice or access to medications. COVID-19 is associated with ADS in children and the COVID-19 pandemic has impacted pediatric patients with demyelinating conditions in various ways.
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Affiliation(s)
- Grace Gombolay
- Department of Pediatrics, Division of Pediatric Neurology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA.
| | - Jamika Hallman-Cooper
- Department of Pediatrics, Division of Pediatric Neurology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
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Jakimovski D, Awan S, Eckert SP, Farooq O, Weinstock-Guttman B. Multiple Sclerosis in Children: Differential Diagnosis, Prognosis, and Disease-Modifying Treatment. CNS Drugs 2022; 36:45-59. [PMID: 34940954 PMCID: PMC8697541 DOI: 10.1007/s40263-021-00887-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 12/19/2022]
Abstract
Pediatric-onset multiple sclerosis (POMS) is a rare neuroinflammatory and neurodegenerative disease that has a significant impact on long-term physical and cognitive patient outcomes. A small percentage of multiple sclerosis (MS) diagnoses occur before the age of 18 years. Before treatment initiation, a careful differential diagnosis and exclusion of other similar acquired demyelinating syndromes such as anti-aquaporin-4-associated neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody spectrum disorder (MOGSD) is warranted. The recent 2017 changes to the McDonald criteria can successfully predict up to 71% of MS diagnoses and have good specificity of 95% and sensitivity of 71%. Additional measures such as the presence of T1-weighted hypointense lesions and/or contrast-enhancing lesions significantly increase the accuracy of diagnosis. In adults, early use of disease-modifying therapies (DMTs) is instrumental to a better long-term prognosis, including lower rates of relapse and disability worsening, and numerous FDA-approved therapies for adult-onset MS are available. However, unlike their adult counterparts, the development, testing, and regulatory approval of POMS treatments have been significantly slower and hindered by logistic and/or ethical considerations. Currently, only two MS DMTs (fingolimod and teriflunomide) have been tested in large phase III trials and approved by regulatory agencies for use in POMS. First-line therapies not approved by the FDA for use in children (interferon-β and glatiramer acetate) are also commonly used and result in a significant reduction in inflammatory activity when compared with non-treated POMS patients. An increasing number of POMS patients are now treated with moderate efficacy therapies such as dimethyl fumarate and high-efficacy therapies such as natalizumab, anti-CD20 monoclonal antibodies, anti-CD52 monoclonal antibodies, and/or autologous hematopoietic stem cell transplantation. These high-efficacy DMTs generally provide additional reduction in inflammatory activity when compared with the first-line medications (up to 62% of relapse-rate reduction). Therefore, a number of phase II and III trials are currently investigating their efficacy and safety in POMS patients. In this review, we discuss potential changes in the regulatory approval process for POMS patients that are recommended for DMTs already approved for the adult MS population, including smaller sample size for pharmacokinetic/pharmacodynamic studies, MRI-centered primary outcomes, and/or inclusion of teenagers in the adult trials.
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Affiliation(s)
- Dejan Jakimovski
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA ,Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY USA
| | - Samreen Awan
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA
| | - Svetlana P. Eckert
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA
| | - Osman Farooq
- Division of Pediatric Neurology, Oishei Children’s Hospital of Buffalo, Buffalo, NY USA ,Department of Neurology, Jacobs School of Medicine, State University of New York at Buffalo, Buffalo, NY USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY, 14202, USA.
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