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Hoeflich A, Fitzner B, Walz C, Hecker M, Tuchscherer A, Bastian M, Brenmoehl J, Schröder I, Willenberg HS, Reincke M, Zettl UK. Systemic Effects by Intrathecal Administration of Triamcinolone Acetonide in Patients With Multiple Sclerosis. Front Endocrinol (Lausanne) 2020; 11:574. [PMID: 32982971 PMCID: PMC7481359 DOI: 10.3389/fendo.2020.00574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
In patients suffering from multiple sclerosis (MS), intrathecal injection of triamcinolone acetonide (TCA) has been shown to improve symptoms of spasticity. Although repeated intrathecal injection of TCA has been used in a number of studies in late-stage MS patients with spinal cord involvement, no clinical-chemical data are available on the distribution of TCA in cerebrospinal fluid (CSF) or serum. Moreover, the effects of intrathecal TCA administration on the concentrations of endogenous steroids remain poorly understood. Therefore, we have quantified TCA and selected endogenous steroids in CSF and serum of TCA-treated MS patients suffering from spasticity. Concentrations of steroids were quantified by LC-MS, ELISA, or ECLIA and compared with the blood-brain barrier status, diagnosed with the Reibergram. The concentration of TCA in CSF significantly increased during each treatment cycle up to >5 μg/ml both in male and female patients (p < 0.001). Repeated TCA administration also evoked serum concentrations of TCA up to >30 ng/ml (p < 0.001) and severely depressed serum levels of cortisol and corticosterone (p < 0.001). In addition, concentrations of circulating estrogen were significantly suppressed (p < 0.001). Due to the potent suppressive effects of TCA on steroid hormone concentrations both in the brain and in the periphery, we recommend careful surveillance of adrenal function following repeated intrathecal TCA injections in MS patients.
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Affiliation(s)
- Andreas Hoeflich
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
- *Correspondence: Andreas Hoeflich
| | - Brit Fitzner
- Neuroimmunological Section, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Christina Walz
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Michael Hecker
- Neuroimmunological Section, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Armin Tuchscherer
- Institute of Genetics and Biometry, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Manuela Bastian
- Institute for Clinical Chemistry and Laboratory Medicine, Rostock University Medical Center, Rostock, Germany
| | - Julia Brenmoehl
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Ina Schröder
- Neuroimmunological Section, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Holger S. Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Uwe Klaus Zettl
- Neuroimmunological Section, Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Uwe Klaus Zettl
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Vohl K, Duscha A, Gisevius B, Kaisler J, Gold R, Haghikia A. Predictors for Therapy Response to Intrathecal Corticosteroid Therapy in Multiple Sclerosis. Front Neurol 2019; 10:132. [PMID: 30853935 PMCID: PMC6395388 DOI: 10.3389/fneur.2019.00132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 01/31/2019] [Indexed: 12/03/2022] Open
Abstract
Objective: The autoimmune disease Multiple Sclerosis (MS) represents a heterogeneous disease pattern with an individual course that may lead to permanent disability. In addition to immuno-modulating therapies patients benefit from symptomatic approaches like intrathecal corticosteroid therapy (ICT), which is frequently applied in a growing number of centers in Germany. ICT reduces spasticity, which elongates patient's walking distance and speed, thus improves quality of life. Methods: In our study we set out to investigate cerebrospinal fluid (CSF) parameters and clinical predictors for response to ICT. Therefore, we analyzed 811 CSF samples collected from 354 patients over a time period of 12 years. Patients who received ICT were divided in two groups (improving or active group) depending on their EDSS-progress. As control groups we analyzed data of ICT naïve patients, who were divided in the two groups as well. Additionally we observed the clinical progress after receiving ICT by comparison of patients in both groups. Results: The results showed clinical data had a significant influence on the probability to benefit from ICT. The probability (shown by Odds Ratio of 1.77–2.43) to belong to the improving group in contrast to the active group is significantly (p < 0.0001) higher at later stages of disease with early disease onset (< 35 years, OR = 2.43) and higher EDSS at timepoint of ICT-initiation (EDSS > 6, OR = 2.06). Additionally, we observed lower CSF cell counts (6.68 ± 1.37 μl) and lower total CSF protein (412 ± 18.25 mg/l) of patients who responded to ICT compared to patients who did not (p < 0.05). In the control group no significant differences were revealed. Furthermore analyses of our data revealed patients belonging to the improving group reach an EDSS of 6 after ICT-initiation less often than patients of the active group (after 13 years 39.8% in the improving group, 67.8% in the active group). Conclusion: Our study implies two relevant messages: (i) although the study was not designed to prospectively assess clinical data, in this cohort no severe side effects were observed under ICT; (ii) disease onset, EDSS, CSF cell count, and total protein may serve as predictive markers for therapy response.
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Affiliation(s)
- Katja Vohl
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Alexander Duscha
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Barbara Gisevius
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Johannes Kaisler
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Aiden Haghikia
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
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Kim H, Choi B, Lim H, Min H, Oh JH, Choi S, Cho JG, Park JS, Lee SJ. Polyamidoamine dendrimer-conjugated triamcinolone acetonide attenuates nerve injury-induced spinal cord microglia activation and mechanical allodynia. Mol Pain 2017; 13:1744806917697006. [PMID: 28326946 PMCID: PMC5407664 DOI: 10.1177/1744806917697006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Accumulating evidence on the causal role of spinal cord microglia activation in the development of neuropathic pain after peripheral nerve injury suggests that microglial activation inhibitors might be useful analgesics for neuropathic pain. Studies also have shown that polyamidoamine dendrimer may function as a drug delivery vehicle to microglia in the central nervous system. In this regard, we developed polyamidoamine dendrimer-conjugated triamcinolone acetonide, a previously identified microglial activation inhibitor, and tested its analgesic efficacy in a mouse peripheral nerve injury model. Result Polyamidoamine dendrimer was delivered selectively to spinal cord microglia upon intrathecal administration. Dendrimer-conjugated triamcinolone acetonide inhibited lipoteichoic acid-induced proinflammatory gene expression in primary glial cells. In addition, dendrimer-conjugated triamcinolone acetonide administration (intrathecal) inhibited peripheral nerve injury-induced spinal cord microglial activation and the expression of pain-related genes in the spinal cord, including Nox2, IL-1β, TNF-α, and IL-6. Dendrimer-conjugated triamcinolone acetonide administration right after nerve injury almost completely reversed peripheral nerve injury-induced mechanical allodynia for up to three days. Meanwhile, dendrimer-conjugated triamcinolone acetonide administration 1.5 days post injury significantly attenuated mechanical allodynia. Conclusion Our data demonstrate that dendrimer-conjugated triamcinolone acetonide inhibits spinal cord microglia activation and attenuates neuropathic pain after peripheral nerve injury, which has therapeutic implications for the treatment of neuropathic pain.
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Affiliation(s)
- Hwisung Kim
- 1 Department of Neuroscience and Physiology, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Boomin Choi
- 1 Department of Neuroscience and Physiology, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Hyoungsub Lim
- 1 Department of Neuroscience and Physiology, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Hyunjung Min
- 1 Department of Neuroscience and Physiology, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Jae Hoon Oh
- 2 School of Chemistry and Molecular Engineering, Seoul National University, Seoul, Republic of Korea
| | - Sunghyun Choi
- 2 School of Chemistry and Molecular Engineering, Seoul National University, Seoul, Republic of Korea
| | - Joung Goo Cho
- 3 Department of Anesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Ilsan, Republic of Korea
| | - Jong-Sang Park
- 2 School of Chemistry and Molecular Engineering, Seoul National University, Seoul, Republic of Korea
| | - Sung Joong Lee
- 1 Department of Neuroscience and Physiology, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
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Bisht B, Darling WG, White EC, White KA, Shivapour ET, Zimmerman MB, Wahls TL. Effects of a multimodal intervention on gait and balance of subjects with progressive multiple sclerosis: a prospective longitudinal pilot study. Degener Neurol Neuromuscul Dis 2017; 7:79-93. [PMID: 30050380 PMCID: PMC6053103 DOI: 10.2147/dnnd.s128872] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To investigate the effects of a multimodal intervention including a modified Paleolithic diet, nutritional supplements, stretching, strengthening exercises with electrical stimulation of trunk and lower limb muscles, meditation and massage on walking performance and balance of subjects with progressive multiple sclerosis (MS). MATERIALS AND METHODS Twenty subjects with mean (standard deviation) age of 51.7 (6.4) years and Expanded Disability Status Scale score of 6.2 (1) participated in a 12-month study. Assessments were completed at baseline, 3, 6, 9, and 12 months. RESULTS The entire cohort did not show significant changes in any of the assessments over 12 months except higher speed of walking toward the 10 feet mark during timed up and go (TUG) test at 6 months compared with baseline (mean change 7.9 cm/s [95% confidence interval {CI}]: 0.3, 15.2; p=0.041). Sub-group analysis revealed that 50% subjects (n=10) showed decrease in TUG time from baseline to at least 3 of 4 time-points post-intervention and were considered as responders (TUG-Res), the remaining 10 subjects were considered as nonresponders (TUG-NRes). Over 12 months, TUG-Res showed decreased mean TUG time by 31% (95% CI: -52%, -2%), increased median Berg Balance Scale scores (42 to 47), 30% increase in mean timed 25-foot walk speed (>20% considered clinically significant) and increased speed of walk toward 10 feet mark during TUG by 11.6 cm/s (95% CI: -3.0, 25.9) associated with increases in step lengths and decrease in step duration. TUG-NRes showed deterioration in walking ability over 12 months. Comparison of TUG-Res and TUG-NRes showed no significant differences in adherence to intervention but better stride duration and longer step length at baseline for TUG-Res than for TUG-NRes (p<0.05). CONCLUSION A multimodal lifestyle intervention may improve walking performance and balance in subjects with progressive MS who have mild-to-moderate gait impairment, whereas subjects with severe gait impairments may not respond to this intervention. Future trials should assess effects of this intervention in subjects with MS during early stages of the disease.
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Affiliation(s)
- Babita Bisht
- Department of Internal Medicine, Carver College of Medicine,
- Department of Health and Human Physiology, UI College of Liberal Arts and Sciences
| | - Warren G Darling
- Department of Health and Human Physiology, UI College of Liberal Arts and Sciences
| | - Emily C White
- Department of Health and Human Physiology, UI College of Liberal Arts and Sciences
| | - Kaitlin A White
- Department of Health and Human Physiology, UI College of Liberal Arts and Sciences
| | | | | | - Terry L Wahls
- Department of Internal Medicine, Carver College of Medicine,
- Department of Extended Care and Rehabilitation Service Line, Iowa City VA Health Care System, Iowa City, IA, USA,
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Rommer PS, Kamin F, Abu-Mugheisib M, Koehler W, Hoffmann F, Winkelmann A, Benecke R, Zettl UK. Long-Term Effects of Repeated Cycles of Intrathecal Triamcinolone Acetonide on Spasticity in MS Patients. CNS Neurosci Ther 2015; 22:74-9. [PMID: 26584946 DOI: 10.1111/cns.12474] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/28/2015] [Accepted: 10/05/2015] [Indexed: 11/26/2022] Open
Abstract
MAIN PROBLEM Spasticity is a common feature in patients with multiple sclerosis (MS). Although options have broadened over the last years, there are still patients with no response to common therapeutic agents. Intrathecal administered triamcinolone acetonide (TCA) has been tested for spasticity in patients with MS. However, the long run effects are not known so far. The aim of this study was to evaluate the effects of repeated cycles of intrathecal TCA instillations on clinical parameters. METHODS A total of 54 patients with clinically definite MS and no response to commonly utilized antispastic drugs were enrolled. TCA was administered every 3 months for a period of 9 months. Clinical assessments including spasticity, disability (EDSS), mobility (walking distance, and timed 25-foot walk), bladder function, and quality of life were carried out prior to and at the end of each treatment cycle. RESULTS Repeated TCA treatment led to repeated effects on spasticity (P < 0.01). Bladder function improved in every 10th patient. Quality of life improved during each cycle but did not reach significance at the end of study (P = 0.09). However, long-lasting improvement on spasticity or EDSS was not shown at end of the study. Effects diminished over 3 months. CONCLUSION Repeated TCA instillations led to replicable effects on spasticity; subgroup analyses suggest that higher spasticity, more frequent treatments, and higher EDSS may lead to pronounced effects on spasticity and EDSS. Intrathecal TCA treatment was safe and no severe side effects occurred. We hypothesize a significant time dependence of re-administration of TCA and that an interval of 3 months between the treatments might be too long.
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Affiliation(s)
- Paulus Stefan Rommer
- Department of Neurology, University of Rostock, Rostock, Germany.,Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Frank Kamin
- Department of Neurology, University of Rostock, Rostock, Germany.,Department of Pathology, MVZ Hochstraße, Brandenburg an der Havel, Germany
| | - Mazen Abu-Mugheisib
- Department of Neurology, University of Rostock, Rostock, Germany.,Department of Neurology, Klinikum Braunschweig, Braunschweig, Germany
| | | | | | | | - Reiner Benecke
- Department of Neurology, University of Rostock, Rostock, Germany
| | - Uwe Klaus Zettl
- Department of Neurology, University of Rostock, Rostock, Germany
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Ziemssen T, Rauer S, Stadelmann C, Henze T, Koehler J, Penner IK, Lang M, Poehlau D, Baier-Ebert M, Schieb H, Meuth S. Evaluation of Study and Patient Characteristics of Clinical Studies in Primary Progressive Multiple Sclerosis: A Systematic Review. PLoS One 2015; 10:e0138243. [PMID: 26393519 PMCID: PMC4578855 DOI: 10.1371/journal.pone.0138243] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/27/2015] [Indexed: 12/05/2022] Open
Abstract
Background So far, clinical studies in primary progressive MS (PPMS) have failed to meet their primary efficacy endpoints. To some extent this might be attributable to the choice of assessments or to the selection of the study population. Objective The aim of this study was to identify outcome influencing factors by analyzing the design and methods of previous randomized studies in PPMS patients without restriction to intervention or comparator. Methods A systematic literature search was conducted in MEDLINE, EMBASE, BIOSIS and the COCHRANE Central Register of Controlled Trials (inception to February 2015). Keywords included PPMS, primary progressive multiple sclerosis and chronic progressive multiple sclerosis. Randomized, controlled trials of at least one year’s duration were selected if they included only patients with PPMS or if they reported sufficient PPMS subgroup data. No restrictions with respect to intervention or comparator were applied. Study quality was assessed by a biometrics expert. Relevant baseline characteristics and outcomes were extracted and compared. Results Of 52 PPMS studies identified, four were selected. Inclusion criteria were notably different among studies with respect to both the definition of PPMS and the requirements for the presence of disability progression at enrolment. Differences between the study populations included the baseline lesion load, pretreatment status and disease duration. The rate of disease progression may also be an important factor, as all but one of the studies included a large proportion of patients with a low progression rate. In addition, the endpoints specified could not detect progression adequately. Conclusion Optimal PPMS study methods involve appropriate patient selection, especially regarding the PPMS phenotype and progression rate. Functional composite endpoints might be more sensitive than single endpoints in capturing progression.
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Affiliation(s)
- T. Ziemssen
- University Clinic Carl Gustav Carus Dresden, Center of Clinical Neuroscience, Dresden, Germany
| | - S. Rauer
- Albert-Ludwigs-Universitaet Freiburg, Neurologische Klinik und Poliklinik, Freiburg, Germany
| | - C. Stadelmann
- Georg August University, University Medical Center Göttingen, Department of Neuropathology, Göttingen, Germany
| | - T. Henze
- PASSAUER WOLF Reha-Zentrum Nittenau, Rehabilitationsklinik für Neurologie-Geriatrie-Urologie, Nittenau, Germany
| | - J. Koehler
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen, Berg, Germany
| | - I.-K. Penner
- University of Basel, Department of Cognitive Psychology and Methodology, Basel, Switzerland
| | - M. Lang
- Neuropoint Patient Academy, Neurological Practice Center, Ulm, Germany
| | | | | | - H. Schieb
- Novartis Pharma GmbH, Nuremberg, Germany
| | - S. Meuth
- University of Muenster, Department of Neurology, Muenster, Germany
- * E-mail:
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Effects of repeated intrathecal triamcinolone-acetonide application on cerebrospinal fluid biomarkers of axonal damage and glial activity in multiple sclerosis patients. Mol Diagn Ther 2015; 18:631-7. [PMID: 24986188 PMCID: PMC4245486 DOI: 10.1007/s40291-014-0114-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background and Objectives Multiple sclerosis (MS) is the most common inflammatory disease of the central nervous system in young adults. Over time, the disease progresses and, with accumulating disability, symptoms such as spasticity may occur. Although several treatment options are available, some patients may not respond to first-line therapeutics. However, some of these patients may benefit from intrathecally administered triamcinolone-acetonide (TCA), a derivative of glucocorticosteroids (GCS). GCS may have neurotoxic effects, and cell apoptosis may occur. The aim of this study was to investigate the effects of TCA on biomarkers in the cerebrospinal fluid (CSF) suggestive of neurodegeneration. Methods In order to assess neurotoxic effects of TCA, neurofilament heavy-chain (NfH)SMI35, tau protein, and S-100B protein levels were determined before and during treatment with TCA in 54 patients with primary progressive MS, as well as relapsing MS (relapsing–remitting and secondary progressive MS). Results NfHSMI35 levels in the CSF of patients treated with TCA intrathecally did not increase significantly during the treatment cycle (p = 0.068). After application of TCA, tau protein levels were increased significantly at day 4 (p = 0.03) and at day 8 (p ≤ 0.001). S-100B protein levels decreased significantly (p ≤ 0.05) during treatment with TCA. Conclusion NfHSMI35 levels did not change significantly; however, tau protein levels did increase significantly within the reference range. Taking these findings together, the long-term effects of TCA on NfHSMI35 and tau protein levels need to be investigated further to understand whether levels of both biomarkers will change over repeated TCA applications. Interestingly, S-100B protein levels decreased significantly during the first applications, which may have represented reduced astrocytic activity during TCA treatment.
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Wittstock M, Rommer PS, Schiffmann F, Jügelt K, Stüwe S, Benecke R, Schiffmann D, Zettl UK. Effect of methylprednisolone on mammalian neuronal networks in vitro. Cell Mol Neurobiol 2015; 35:111-4. [PMID: 25283186 DOI: 10.1007/s10571-014-0117-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/21/2014] [Indexed: 10/24/2022]
Abstract
Glucocorticosteroids (GCS) are widely used for the treatment of neurological diseases, e.g. multiple sclerosis. High levels of GCS are toxic to the central nervous system and can produce adverse effects. The effect of methylprednisolone (MP) on mammalian neuronal networks was studied in vitro. We demonstrate a dose-dependent excitatory effect of MP on cultured neuronal networks, followed by a shut-down of electrical activity using the microelectrode array technique.
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Affiliation(s)
- Matthias Wittstock
- Department of Neurology, University of Rostock, Gehlsheimer Str. 20, 18147, Rostock, Germany,
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Effects of intrathecal triamincinolone-acetonide treatment in MS patients with therapy-resistant spasticity. Spinal Cord 2014; 53:109-13. [PMID: 25224601 DOI: 10.1038/sc.2014.155] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 07/10/2014] [Accepted: 08/01/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Multiple sclerosis (MS) is an autoimmune disease affecting young people and is a major cause of disability. In the course of time, disability progresses and symptoms like spasticity may occur. Spasticity is a major cost factor in MS patients. Various agents are approved for the treatment of spasticity, but each of those agents may have several side effects. Intrathecally administered steroids (triamcinolone-acetonide (TCA)) may be efficient in treating spasticity in patients with lesions in the spinal cord and no response to first-line therapeutics. The aim of this study is to show effects of TCA treatment on clinical parameters in patients with MS. METHODS This multicentre open label study included 54 patients with MS. The clinical outcome parameters were spasticity, disability, maximum walking distance, bladder function and quality of life. All patients received physiotherapy in addition to TCA treatment to obtain optimal effects on clinical parameters. RESULTS Spasticity, maximum walking distance as well as disability improved significantly (P ⩽ 0.001) during TCA applications. Bladder function improved in every seventh patient. CONCLUSION We observed the effects of intrathecally administered TCA on different clinical parameters including bladder function. TCA administration is a safe method to treat different symptoms in MS patients. Longitudinal trials with repeated TCA cycles are needed to show long-term effects. Besides TCA treatment, physiotherapy contributes to the improvement of clinical parameters.
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Decreased levels of repulsive guidance molecule A in association with beneficial effects of repeated intrathecal triamcinolone acetonide application in progressive multiple sclerosis patients. J Neural Transm (Vienna) 2014; 122:841-8. [PMID: 25209051 DOI: 10.1007/s00702-014-1308-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 09/02/2014] [Indexed: 12/23/2022]
Abstract
Repeated intrathecal application of the sustained release steroid triamcinolone acetonide is beneficial in progressive multiple sclerosis patients. Its putative regenerative effect may involve regulation of the repulsive guidance molecule A synthesis. This protein inhibits axonal regeneration and functional recovery. Objectives were to demonstrate the efficacy of four triamcinolone applications every other day in association with repulsive guidance molecule A levels in cerebrospinal fluid. Clinical evaluation was performed at baseline and on each day after a triamcinolone administration in 25 progressive multiple sclerosis patients. Repulsive guidance molecule A concentrations were determined before each triamcinolone application by western blot analysis with quantification. Clinical scores for multiple sclerosis improved, and the maximum walking distance and speed ameliorated in 17 patients. Repulsive guidance molecule A levels declined in these responders. The remaining patients showed no prompt clinical benefit and no decrease of repulsive guidance molecule A concentrations. Decline of repulsive guidance molecule A may reflect regeneration and functional recovery by triamcinolone in progressive multiple sclerosis patients.
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de Sa JCC, Airas L, Bartholome E, Grigoriadis N, Mattle H, Oreja-Guevara C, O'Riordan J, Sellebjerg F, Stankoff B, Vass K, Walczak A, Wiendl H, Kieseier BC. Symptomatic therapy in multiple sclerosis: a review for a multimodal approach in clinical practice. Ther Adv Neurol Disord 2011; 4:139-68. [PMID: 21694816 DOI: 10.1177/1756285611403646] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As more investigations into factors affecting the quality of life of patients with multiple sclerosis (MS) are undertaken, it is becoming increasingly apparent that certain comorbidities and associated symptoms commonly found in these patients differ in incidence, pathophysiology and other factors compared with the general population. Many of these MS-related symptoms are frequently ignored in assessments of disease status and are often not considered to be associated with the disease. Research into how such comorbidities and symptoms can be diagnosed and treated within the MS population is lacking. This information gap adds further complexity to disease management and represents an unmet need in MS, particularly as early recognition and treatment of these conditions can improve patient outcomes. In this manuscript, we sought to review the literature on the comorbidities and symptoms of MS and to summarize the evidence for treatments that have been or may be used to alleviate them.
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Lukas C, Bellenberg B, Hahn HK, Rexilius J, Drescher R, Hellwig K, Köster O, Schimrigk S. Benefit of repetitive intrathecal triamcinolone acetonide therapy in predominantly spinal multiple sclerosis: prediction by upper spinal cord atrophy. Ther Adv Neurol Disord 2011; 2:42-9. [PMID: 21180629 DOI: 10.1177/1756285609343480] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Intrathecal injection of triamcinolone acetonide (TCA) has been shown to provide substantial benefit in a subset of progressive multiple sclerosis (MS) patients with predominant spinal symptoms. We examined whether atrophy of the upper spinal cord (USC) as measured by MRI can serve as a predictive marker for response to repetitive intrathecal TCA application. Repetitive administration of 40 mg TCA was performed in 31 chronic progressive MS patients up to six times within 3 weeks. Expanded Disability Status Scale (EDSS) and maximum walking distance (WD) were assessed before and after the treatment cycle. Cervical 3D T1-weighted images were acquired on a 1.5T scanner at baseline. Mean cross-sectional area of the USC was determined using a semi-automated volumetry method. Results were compared with a group of 29 healthy controls to group patients into those with and without atrophy. Results show a negative correlation between the degree of USC atrophy and treatment benefit. A higher treatment benefit in patients with little USC atrophy but short initial maximum WD was observed. Absence of USC atrophy as measured on MRI is a predictive marker for intrathecal TCA therapy outcome in progressive MS. Patients with initial poor walking abilities, but only little or no atrophy, benefited most from TCA therapy.
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Affiliation(s)
- Carsten Lukas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, St Josef Hospital, Ruhr-University of Bochum, Bochum, Germany
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Repeated intrathecal triamcinolone acetonide administration in progressive multiple sclerosis: a review. Mult Scler Int 2011; 2011:219049. [PMID: 22096630 PMCID: PMC3196978 DOI: 10.1155/2011/219049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 03/09/2011] [Accepted: 04/27/2011] [Indexed: 11/18/2022] Open
Abstract
At the present time, anti-inflammatory, immunomodulatory, or immunosuppressive treatments of multiple sclerosis (MS) are mainly effective in the early phases of the disease but are of less advantage in progressive phases. Current therapeutic strategies of both primary and secondary progressive MS are rare. One alternative may be intrathecal application of triamcinolone acetonide (TCA). Number of papers deal with advantages and disadvantages of intrathecal administration in MS. Former trials lacked detailed selection of MS patients, with small sample sizes, low steroid dosages, and only a small number of intrathecal administration of short acting steroids. The present paper summarizes recent trials performed following a different treatment regime. They were conducted in patients with progressive MS suffering mainly from spinal symptoms and documented a significant improvement of EDSS and walking distance (WD). Intrathecal TCA administration is a proposal to take into account as one therapy option in patients with a progressive clinical course and predominantly spinal symptoms.
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Adjuvant dexamethasone with bupivacaine prolongs the duration of interscalene block: a prospective randomized trial. J Anesth 2011; 25:704-9. [DOI: 10.1007/s00540-011-1180-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Accepted: 05/23/2011] [Indexed: 10/18/2022]
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Goericke SL, Engelhorn T, Forsting M, Speck U, Maderwald S, Ladd ME, Doerfler A. Intrathecal corticoids in permanent focal cerebral ischemia in rats. Part I: a new therapeutic approach in the acute phase. J Cereb Blood Flow Metab 2010; 30:801-7. [PMID: 19904284 PMCID: PMC2949163 DOI: 10.1038/jcbfm.2009.243] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Intrathecally, triamcinolone acetonide (TCA) was suggested to have neuroprotective efficacy on infarction volume in acute focal cerebral ischemia in rats. In the first dose-finding study, TCA in five different doses or saline was administered into the cisterna magna of 12 rats, each 30 mins after endovascular occlusion of the middle cerebral artery (MCAO). In the second magnet resonance controlled confirmation study, the most neuroprotective dose was compared with controls in each of the 15 rats. Infarction volume was calculated at 24 h by 2.3.5 triphenyl-tetrazolium-chloride staining. Compared with controls (18.2%), infarction volume was significantly reduced using TCA at a dose of 0.012 mg/kg body weight (BW) (13.4%, P=0.04). TCA at doses of 0.03 (17.7%, P=0.84), 0.006 (15.9%, P=0.24), and 0.003 mg/kg BW (14.5%, P=0.11) did not significantly reduce infarction size. TCA 0.3 mg/kg BW resulted in bilateral infarction with increased infarction volume (19.8%, P=0.49). Magnetic resonance imaging confirmed successful MCAO and intrathecal administration. In experiment 2 compared with controls (20.0%), infarction volume was significantly reduced using TCA 0.012 mg/kg (13.4%, P=0.02). Intrathecally, TCA may significantly reduce infarction volume in acute focal cerebral ischemia in rats. Further studies are necessary to define the value of this therapy.
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Affiliation(s)
- Sophia L Goericke
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, Essen 45122, Germany.
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Müller T. Role of intraspinal steroid application in patients with multiple sclerosis. Expert Rev Neurother 2009; 9:1279-87. [PMID: 19769444 DOI: 10.1586/ern.09.60] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Clinical trials on patients with progressive multiple sclerosis (MS) have shown no clear evidence of an effective symptomatic treatment with improving disability. Immunomodulatory compounds efficaciously reduce the relapse rate. Numerous earlier papers exist on the pros and cons and/or on the efficacy of intrathecal administration of differing dosages of various conventional released steroids. Furthermore, this treatment approach was nearly abondoned owing to a debate on side effects and a missing proven superiority over intravenous systemic high dosage steroid administration. However, recent open-label studies in progressive MS patients with predominant spinal symptomatology investigated the repeated intraspinal application of the sustained-release compound triamcinolone acetonide (TCA). A distinct improvement of walking distance and MS scores in the short term and stabilization of this beneficial effect after repeat TCA application every 6-12 weeks was found. Moreover, patients with a relapse with acute onset of painful sensations showed a marked pain improvement after repeated TCA application following prior unsuccessful treatment with intravenous steroids. The available data from open studies ask for the performance of a randomized clinical trial, comparing intravenous with intrathecal steroid administration, to confirm the higher efficacy of the more invasive therapy with repeated lumbar puncture.
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Affiliation(s)
- Thomas Müller
- Department of Neurology, St Joseph Hospital, Berlin-Weissensee, Gartenstrasse 1, 13088 Berlin, Germany.
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Patejdl R, Winkelmann A, Benecke R, Zettl UK. Muscle rupture caused by exacerbated spasticity in a patient with multiple sclerosis. J Neurol 2008; 255 Suppl 6:115-8. [DOI: 10.1007/s00415-008-6021-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
While pain is a common problem in patients with multiple sclerosis (MS), it is not frequently mentioned by patients and a more direct approach is required in order to obtain information about pain from patients. Many patients with MS experience more than one pain syndrome; combinations of dysaesthesia, headaches and/or back or muscle and joint pain are frequent. For each pain syndrome a clear diagnosis and therapeutic concept needs to be established. Pain in MS can be classified into four diagnostically and therapeutically relevant categories: (i) neuropathic pain due to MS (pain directly related to MS); (ii) pain indirectly related to MS; (iii) MS treatment-related pain; and (iv) pain unrelated to MS. Painful paroxysmal symptoms such as trigeminal neuralgia (TN), or painful tonic spasms are treated with antiepileptics as first choice, e.g. carbamazepine, oxcarbazepine, lamotrigine, gabapentin, pregabalin, etc. Painful 'burning' dysaesthesias, the most frequent chronic pain syndrome, are treated with TCAs such as amitriptyline, or antiepileptics such as gabapentin, pregabalin, lamotrigine, etc. Combinations of drugs with different modes of action can be particularly useful for reducing adverse effects. While escalation therapy may require opioids, there are encouraging results from studies regarding cannabinoids, but their future role in the treatment of MS-related pain has still to be determined. Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents such as baclofen or tizanidine and in patients with phasic spasticity, gabapentin or levetiracetam are administered. In patients with severe spasticity, botulinum toxin injections or intrathecal baclofen merit consideration. While physiotherapy may ameliorate malposition-induced joint and muscle pain, additional drug treatment with paracetamol (acetaminophen) or NSAIDs may be useful. Moreover, painful pressure lesions should be avoided by using optimally adjusted aids. Treatment-related pain associated with MS can occur with subcutaneous injections of interferon-beta or glatiramer acetate, and may be reduced by optimizing the injection technique and by local cooling. Systemic (particularly 'flu-like') adverse effects of interferons, e.g. myalgias, can be reduced by administering paracetamol, ibuprofen or naproxen. A potential increase in the frequency of pre-existing headaches after starting treatment with interferons may require optimization of headache attack therapy or even prophylactic treatment. Pain unrelated to MS, such as back pain or headache, is common in patients with MS and may deteriorate as a result of the disease. In summary, a careful analysis of each pain syndrome will allow the design of the appropriate treatment plan using various medical and nonmedical options (multimodal therapy), and will thus help to improve the quality of life (QOL) of the patients.
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Hellwig K, Schimrigk S, Lukas C, Hoffmann V, Brune N, Przuntek H, Müller T. Efficacy of mitoxantrone and intrathecal triamcinolone acetonide treatment in chronic progressive multiple sclerosis patients. Clin Neuropharmacol 2006; 29:286-91. [PMID: 16960474 DOI: 10.1097/01.wnf.0000229545.81245.a4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Treatment approaches are rare for chronic progressive patients with multiple sclerosis (MS). Objective was to evaluate the clinical benefit of repeated intrathecal application of the sustained release steroid triamcinolone acetonide or the administration of mitoxantrone (MIX) in 2 similar cohorts of chronic progressive patients with MS in an open-label fashion. Expanded Disability Status Scale scores significantly decreased after the first 6 intraspinal triamcinolone acetonide injections, which were performed every third day, and then remained stable. Walking distance significantly increased and did not reduce until the end of the 1-year-long trial period. Mitoxantrone treatment did not improve the Expanded Disability Status Scale score; however, no further significant deterioration appeared. Walking distance did not significantly decrease. Both treatment regimens were safe; the patients experienced nearly no adverse effects. Triamcinolone acetonide application provided a clinical benefit, whereas MIX administration prevented further worsening of MS symptoms. We stress that only specialists with a broad experience in intraspinal triamcinolone acetonide application and MIX administration should perform both kinds of therapy only after a careful information and risk-benefit evaluation in cooperation with the patient. Future trials will show the efficacy of combination of both treatment approaches in chronic progressive patients with MS.
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Affiliation(s)
- Kerstin Hellwig
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
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Henze T, Rieckmann P, Toyka KV. Symptomatic treatment of multiple sclerosis. Multiple Sclerosis Therapy Consensus Group (MSTCG) of the German Multiple Sclerosis Society. Eur Neurol 2006; 56:78-105. [PMID: 16966832 DOI: 10.1159/000095699] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Accepted: 07/12/2006] [Indexed: 01/13/2023]
Abstract
Besides immunomodulation and immunosuppression, the specific treatment of symptoms is an essential component of the overall management of multiple sclerosis (MS). Symptomatic treatment is aimed at the elimination or reduction of symptoms impairing the functional abilities and quality of life of the affected patients. Moreover, with symptomatic treatment the development of a secondary physical impairment due to an existing one may be avoided. Many therapeutic techniques as well as different drugs are used for the treatment of MS symptoms, but only a few of them have been investigated, especially in MS patients, and are approved by the national health authorities. Despite an overwhelming number of publications, only a few evidence-based studies exist and consensus reports are very rare, too. Therefore, it seemed necessary to develop a consensus statement on symptomatic treatment of MS comprising existing evidence-based literature as well as therapeutic experience of neurologists who have dealt with these problems over a long time. This consensus paper contains proposals for the treatment of the most common MS symptoms: disorders of motor function and coordination, of cranial nerve function, of autonomic, cognitive, and psychological functions as well as MS-related pain syndromes and epileptic seizures.
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Affiliation(s)
- T Henze
- Reha-Zentrum Nittenau, Rehabilitationszentrum fur Neurologie, Nittenau, Germany.
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Hoffmann V, Kuhn W, Schimrigk S, Islamova S, Hellwig K, Lukas C, Brune N, Pöhlau D, Przuntek H, Müller T. Repeat intrathecal triamcinolone acetonide application is beneficial in progressive MS patients. Eur J Neurol 2006; 13:72-6. [PMID: 16420395 DOI: 10.1111/j.1468-1331.2006.01145.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Available immunomodulatory and conventional steroid treatment regimens provide a limited symptomatic benefit for patients with progressive multiple sclerosis (MS). We performed an open trial on the short-term efficacy of repeated intrathecal application of the sustained release steroid triamcinolone acetonide (TCA) in 27 progressive MS patients. Six TCA administrations, performed every third day, reduced the Expanded Disability Status Scale (EDSS) score [initial: 5.4+/-1.3, 3-7.5 (mean+/-SD, range); end: 4.9+/-1.1; 2.5-6.5; P<0.001] and significantly increased the walking distance and speed in particular after the fourth TCA injection. Concomitantly serially determined cerebrospinal fluid (CSF) markers of cell injury, neuron-specific enolase, total tau-protein, S-100, and beta-amyloid did not significantly change within the interval of TCA treatment. No serious side effects appeared. We conclude that repeat intrathecal injection of 40 mg TCA provides a substantial benefit in progressive MS patients with predominant spinal symptoms and does not alter CSF markers of neuronal cell injury.
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Affiliation(s)
- V Hoffmann
- Department of Neurology, Kamillus-Klinik, Asbach, and Department of Neurology, St Josef-Hospital, Ruhr-University, Bochum, Germany
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Efficacy of repeated intrathecal triamcinolone acetonide application in progressive multiple sclerosis patients with spinal symptoms. BMC Neurol 2004; 4:18. [PMID: 15530171 PMCID: PMC535343 DOI: 10.1186/1471-2377-4-18] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Accepted: 11/07/2004] [Indexed: 11/10/2022] Open
Abstract
Background There are controversial results on the efficacy of the abandoned, intrathecal predominant methylprednisolone application in multiple sclerosis (MS) in contrast to the proven effectiveness in intractable postherpetic neuralgia. Methods We performed an analysis of the efficacy of the application of 40 mg of the sustained release steroid triamcinolone acetonide (TCA). We intrathecally injected in sterile saline dissolved TCA six times within three weeks on a regular basis every third day in 161 hospitalized primary and predominant secondary progressive MS patients with spinal symptoms. The MS patients did not experience an acute onset of exacerbation or recent distinct increased progression of symptoms. We simultaneously scored the MS patients with the EDSS and the Barthel index, estimated the walking distance and measured somatosensory evoked potentials. Additionally the MS patients received a standardized rehabilitation treatment. Results EDSS score and Barthel index improved, walking distance increased, latencies of somatosensory evoked potentials of the median and tibial nerves shortened in all MS patients with serial evaluation (p < 0.0001 for all variables). Side effects were rare, five patients stopped TCA application due to onset of a post lumbar puncture syndrome. Conclusions Repeated intrathecal TCA application improves spinal symptoms, walking distance and SSEP latencies in progressive MS patients in this uncontrolled study. Future trials should evaluate the long-term benefit of this invasive treatment.
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