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Cahyadi M, Mesinovic J, Chim ST, Ebeling P, Zengin A, Grech L. Medication and bone health in multiple sclerosis: A systematic review and meta-analysis. J Manag Care Spec Pharm 2023; 29:1331-1353. [PMID: 38058136 PMCID: PMC10776270 DOI: 10.18553/jmcp.2023.29.12.1331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND People with multiple sclerosis (MS) are often prescribed medications associated with adverse effects on bone health. However, it is unclear whether these medications incur decreases in areal bone mineral density (aBMD) and higher fracture risk in this population. OBJECTIVE To investigate the effects of commonly used medications on aBMD and fracture risk among people with MS. METHODS MEDLINE, Embase, Scopus, CINAHL, and Web of Science were searched from their inception until February 5, 2023. We included randomized controlled trials as well as cross-sectional, retrospective, and prospective studies investigating whether glucocorticoids, immunomodulators, antidepressants, anticonvulsants, anxiolytics, opioids, or antipsychotics influenced aBMD or fracture risk in people with MS. Data were pooled using random effects meta-analyses to determine hazard ratios (HRs) and 95% CIs. RESULTS We included 22 studies (n = 18,193). Six studies were included in the meta-analyses of glucocorticoid use and aBMD, whereas 2 studies were included in the medication use and fracture risk meta-analyses. No studies assessed the effect of antidepressants, anxiolytics, anticonvulsants, opioids, and antipsychotics on aBMD, and no studies assessed the effect of immunomodulators on fracture risk. Glucocorticoid use was significantly negatively associated with femoral neck aBMD (correlation = -0.21 [95% CI = -0.29 to -0.13]), but not with lumbar spine aBMD (correlation = -0.21 [95% CI = -0.50 to 0.12]). There were no differences in fracture risk between users of glucocorticoids (HR = 1.71 [95% CI = 0.04 to 76.47]), antidepressants (HR = 1.84 [95% CI = 0.09 to 38.49]), or anxiolytics (HR = 2.01 [95% CI = 0.06 to 64.22]), compared with nonusers. CONCLUSIONS The available evidence is insufficient to support a relationship between greater fracture risk for people with MS taking glucocorticoid, antidepressant, or anxiolytic medication, compared with nonusers, and it is unclear whether these medications are associated with bone loss in people with MS, beyond that in the general population. Additional high-quality studies with homogenous methodology exploring how medications influence aBMD and fracture risk in people with MS are required.
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Affiliation(s)
- Michael Cahyadi
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Jakub Mesinovic
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Sher Ting Chim
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Peter Ebeling
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Ayse Zengin
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Lisa Grech
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
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Superoxide dismutase (SOD), advanced oxidation protein products (AOPP), and disease-modifying treatment are related to better relapse recovery after corticosteroid treatment in multiple sclerosis. Neurol Sci 2020; 42:3241-3247. [PMID: 33241537 DOI: 10.1007/s10072-020-04928-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The aim of our study was to analyze oxidative stress (OS) markers in multiple sclerosis (MS) patients during relapse and remission and to evaluate the effects of corticosteroid relapse treatment on oxidative status, and also to determine possible relationship between OS markers and relapse disability recovery after corticosteroid treatment. METHODS Our study included 118 MS patients, (59 relapse/59 remission) 70 females and 48 males, mean age 40.2 ± 9.4 years, and 88 matched healthy controls. Undergoing disease-modifying therapy (DMT) was present in 30.5% of relapse and 88% of remission MS patients. We analyzed in plasma/serum the following: pro-oxidative-antioxidative balance (PAB), nitrates and nitrites (NO3 + NO2), malondialdehyde (MDA), advanced oxidation protein products (AOPP) superoxide dismutase (SOD), catalase (CAT), uric acid, bilirubin, albumin, and transferrin in all patients and additionally after corticosteroid relapse treatment. Neurological disability was measured using the Extended Disability Status Scale (EDSS). RESULTS Better clinical recovery after relapse treatment was associated with increased baseline SOD, decreased AOPP, and ongoing DMT (all p < 0.05). There was no difference between OS markers in relapse and remission. MS patients had higher MDA, NO3 + NO2, PAB, SOD, CAT, lower AOPP, uric acid, albumin, bilirubin, and transferrin compared to controls (all p < 0.05). Corticosteroids caused significant decrease of all OS markers (all p < 0.05). CONCLUSION Increased baseline antioxidative activity of SOD and decreased baseline levels of pro-oxidant AOPP along with ongoing DMT were related to better clinical recovery after corticosteroid relapse treatment. Increase of pro-oxidants and antioxidant enzyme activity in relapse and remission confirms ongoing oxidative injury irrelevant of MS clinical presentation.
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Benedict RHB, Amato MP, DeLuca J, Geurts JJG. Cognitive impairment in multiple sclerosis: clinical management, MRI, and therapeutic avenues. Lancet Neurol 2020; 19:860-871. [PMID: 32949546 PMCID: PMC10011205 DOI: 10.1016/s1474-4422(20)30277-5] [Citation(s) in RCA: 289] [Impact Index Per Article: 72.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/14/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022]
Abstract
Multiple sclerosis is a chronic, demyelinating disease of the CNS. Cognitive impairment is a sometimes neglected, yet common, sign and symptom with a profound effect on instrumental activities of daily living. The prevalence of cognitive impairment in multiple sclerosis varies across the lifespan and might be difficult to distinguish from other causes in older age. MRI studies show that widespread changes to brain networks contribute to cognitive dysfunction, and grey matter atrophy is an early sign of potential future cognitive decline. Neuropsychological research suggests that cognitive processing speed and episodic memory are the most frequently affected cognitive domains. Narrowing evaluation to these core areas permits brief, routine assessment in the clinical setting. Owing to its brevity, reliability, and sensitivity, the Symbol Digit Modalities Test, or its computer-based analogues, can be used to monitor episodes of acute disease activity. The Symbol Digit Modalities Test can also be used in clinical trials, and data increasingly show that cognitive processing speed and memory are amenable to cognitive training interventions.
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Affiliation(s)
- Ralph H B Benedict
- Department of Neurology and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.
| | - Maria Pia Amato
- Department of Neurology, University of Florence, IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | | | - Jeroen J G Geurts
- Department of Anatomy and Neurosciences, Section Clinical Neuroscience, Amsterdam UMC, Location VUmc, Vrije Universiteit, Amsterdam, Netherlands
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Benedict RH, Pol J, Yasin F, Hojnacki D, Kolb C, Eckert S, Tacca B, Drake A, Wojcik C, Morrow SA, Jakimovski D, Fuchs TA, Dwyer MG, Zivadinov R, Weinstock-Guttman B. Recovery of cognitive function after relapse in multiple sclerosis. Mult Scler 2020; 27:71-78. [PMID: 31971066 DOI: 10.1177/1352458519898108] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cognitive impairment is common in multiple sclerosis (MS) but its manifestation as acute disease activity is underappreciated. OBJECTIVE The aim of this study is to examine recovery after MS relapse on multiple tests of cognitive and motor function and explore correlates of change with Expanded Disability Status Scale (EDSS), magnetic resonance imaging (MRI), and cognitive reserve. METHODS Fifty relapsing group (RG) and matched stable participants were examined at baseline, during relapse, and at 3-month follow-up. Tests of cognitive processing speed (Symbol Digit Modalities Test (SDMT)) and consensus opinion measures of memory, ambulation, and manual dexterity were administered. All RG patients were treated with a 5-day course of Acthar Gel (5 mL/80 IU). RESULTS In RG patients, SDMT declined from 55.2 to 44.6 at relapse and recovered to 51.7, a slope differing from stable controls (p = 0.001). A statistical trend (p = 0.07) for the same effect was observed for verbal memory and was significant for ambulation (p = 0.03). The Cerebral Function Score from the EDSS also changed in the RG and recovered incompletely relative to controls (p = 0.006). CONCLUSION These results replicate earlier reports of cognitive worsening during relapse in MS. Clinically meaningful improvements followed relapse on SDMT and ambulation. Cognitive decline during relapse can be appreciated on neurological exam but not patient-reported outcomes.
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Affiliation(s)
- Ralph Hb Benedict
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Jeta Pol
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Faizan Yasin
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - David Hojnacki
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Channa Kolb
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Svetlana Eckert
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Beth Tacca
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Allison Drake
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Curtis Wojcik
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | | | - Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Tom A Fuchs
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA/Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Michael G Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA/Center for Biomedical Imaging, Clinical and Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA/Center for Biomedical Imaging, Clinical and Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
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Horta-Hernández AM, Esaclera-Izquierdo B, Yusta-Izquierdo A, Martín-Alcalde E, Blanco-Crespo M, Álvarez-Nonay A, Torralba M. High-dose oral methylprednisolone for the treatment of multiple sclerosis relapses: cost-minimisation analysis and patient's satisfaction. Eur J Hosp Pharm 2018; 26:280-284. [PMID: 31656616 DOI: 10.1136/ejhpharm-2018-001499] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/13/2018] [Accepted: 04/10/2018] [Indexed: 11/04/2022] Open
Abstract
Objective To study the use of high-dose oral methylprednisolone compounded formulation and intravenous methylprednisolone for the treatment of multiple sclerosis relapses. To compare both routes of methylprednisolone administration related to cost and patient's satisfaction with the treatment. Methods A retrospective cohort observational study was performed from January 2012 to December 2016. All multiple sclerosis relapses treated with high-dose oral methylprednisolone compounded formulation or intravenous methylprednisolone were studied. Patient's acceptance grade of the treatment was analysed with a survey based on the Treatment Satisfaction Questionnaire for Medication. A cost-minimisation analysis using real world data from our hospital was performed to compare the high-dose oral methylprednisolone formulation and intravenous administration. Results 92 patients were included (88% had recurrent remitting multiple sclerosis). Median Expanded Disability Status Scale score was 2 (IRC: 1-3.5). 162 relapses were treated: 77 with intravenous methylprednisolone and 85 with high-dose oral methylprednisolone formulation. The most frequent prescriptions were 1000 mg intravenous methylprednisolone and 1250 mg oral methylprednisolone during 4 days. Recovery from relapse was achieved in 91% of patients in the intravenous group and 93% in the oral group. The survey revealed that 79% of patients preferred the oral route because of convenience (P<0.001) and global satisfaction (P<0.04). Real world data demonstrated savings of €61 708 (91%) using the high-dose oral methylprednisolone formulation during the study period. Conclusions High-dose oral methylprednisolone compounded formulation was a cost-effective alternative compared with methylprednisolone intravenous administration. Moreover, patients with multiple sclerosis preferred the oral compounded formulation for the treatment of relapses.
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Affiliation(s)
| | - Begoña Esaclera-Izquierdo
- Ciencias Biomédicas, Universidad de Alcala de Henares Facultad de Farmacia, Alcala de Henares, Spain
| | | | - Eva Martín-Alcalde
- Department of Pharmacy, Hospital General Universitario de Guadalajara, Guadalajara, Spain
| | - María Blanco-Crespo
- Department of Pharmacy, Hospital General Universitario de Guadalajara, Guadalajara, Spain
| | - Adriana Álvarez-Nonay
- Department of Pharmacy, Hospital General Universitario de Guadalajara, Guadalajara, Spain
| | - Miguel Torralba
- Research Unit, Hospital General Universitario de Guadalajara, Guadalajara, Spain
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Smets I, Van Deun L, Bohyn C, van Pesch V, Vanopdenbosch L, Dive D, Bissay V, Dubois B. Corticosteroids in the management of acute multiple sclerosis exacerbations. Acta Neurol Belg 2017; 117:623-633. [PMID: 28391390 DOI: 10.1007/s13760-017-0772-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/12/2017] [Indexed: 11/29/2022]
Abstract
Multiple sclerosis (MS) is an autoimmune, inflammatory demyelinating disease of the central nervous system characterized in the majority of the patients by a relapsing-remitting disease course. For decades high-dosage corticosteroids (CS) are considered the cornerstone in the management of acute MS relapses. However, many unanswered questions remain when it comes to the exact modalities of CS administration. In this review on behalf of the Belgian Study Group for MS we define the efficacy of CS in reducing MS-related morbidity and examine whether the effect is different according to type of CS, route of administration, cumulative dosage, timing of initiation and disease course. We also review the use of CS in combination with other MS treatments and during pregnancy and lactation. Furthermore, we delineate the relevant adverse events due to a pulse CS regimen and present a decision tree that can be used when treating MS relapses in clinical practice.
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Affiliation(s)
- I Smets
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium.
| | - L Van Deun
- Department of Neurology, University Hospitals Brussels, Laarbeeklaan 101, Jette, Belgium
| | - C Bohyn
- Department of Radiology, University Hospitals Leuven, Herestraat 49, Louvain, Belgium
| | - V van Pesch
- Department of Neurology, Cliniques Universitaires Saint-Luc, Hippokrateslaan 10, Sint-Lambrechts-Woluwe, Belgium
| | - L Vanopdenbosch
- Department of Neurology, Hospital AZ Sint-Jan, Ruddershove 10, Brugge, Belgium
| | - D Dive
- Neuroimmunological and Rehabilitation Unit, University Hospitals Liège, Avenue de L'Hòpital 1, Liège, Belgium
| | - V Bissay
- Department of Neurology, University Hospitals Brussels, Laarbeeklaan 101, Jette, Belgium
| | - B Dubois
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium
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