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Mallucci G, Ferraro OE, Trojano M, Amato MP, Scalfari A, Zaffaroni M, Colombo E, Rigoni E, Iaffaldano P, Portaccio E, Saraceno L, Paolicelli D, Razzolini L, Montomoli C, Bergamaschi R. Early prediction of unfavorable evolution after a first clinical episode suggestive of multiple sclerosis: the EUMUS score. J Neurol 2024; 271:3496-3505. [PMID: 38532143 DOI: 10.1007/s00415-024-12304-5] [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: 11/30/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Predicting disease progression in patients with the first clinical episode suggestive of multiple sclerosis (MS) is crucial for personalized therapeutic approaches. This study aimed to develop the EUMUS score for accurately estimating the risk of early evidence of disease activity and progression (EDA). METHODS Retrospective analysis was conducted on data from 221 patients with a first clinical MS episode collected from four Italian MS centers. Various variables including socio-demographics, clinical features, cerebrospinal fluid analysis, evoked potentials, and brain MRI were considered. A prognostic multivariate regression model was identified to develop the EUMUS score. The optimal cutoff for predicting the transition from no evidence of disease activity (NEDA3) to EDA was determined. The accuracy of the prognostic model and score were tested in a separate UK MS cohort. RESULTS After 12 months, 61.54% of patients experienced relapses and/or new MRI lesions. Younger age (OR 0.96, CI 0.93-0.99; p = 0.005), MRI infratentorial lesion(s) at baseline (OR 2.21, CI 1.27-3.87; p = 0.005), positive oligoclonal bands (OR 2.89, CI 1.47-5.69; p = 0.002), and abnormal lower limb somatosensory-evoked potentials (OR 2.77, CI 1.41-5.42; p = 0.003) were significantly associated with increased risk of EDA. The EUMUS score demonstrated good specificity (72%) and correctly classified 80% of patients with EDA in the independent UK cohort. CONCLUSIONS The EUMUS score is a simple and useful tool for predicting MS evolution within 12 months of the first clinical episode. It has the potential to guide personalized therapeutic approaches and aid in clinical decision-making.
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Affiliation(s)
- Giulia Mallucci
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland.
| | - Ottavia Eleonora Ferraro
- Department of Public Health, Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
| | - Maria Trojano
- Department of Translational Biomedicines and Neurosciences University of Bari, A. Moro, Bari, Italy
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Antonio Scalfari
- Centre of Neuroscience, Department of Medicine, Imperial College London, Charing Cross Hospital, London, UK
| | - Mauro Zaffaroni
- Neuroimmunology Unit and Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, VA, Italy
| | | | | | - Pietro Iaffaldano
- Department of Translational Biomedicines and Neurosciences University of Bari, A. Moro, Bari, Italy
| | | | - Lorenzo Saraceno
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Damiano Paolicelli
- Department of Translational Biomedicines and Neurosciences University of Bari, A. Moro, Bari, Italy
| | | | - Cristina Montomoli
- Department of Public Health, Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
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Chitnis T, Banwell B, Kappos L, Arnold DL, Gücüyener K, Deiva K, Saubadu S, Hu W, Benamor M, Le-Halpere A, Truffinet P, Tardieu M. Teriflunomide in pediatric patients with relapsing multiple sclerosis: Open-label extension of TERIKIDS. Mult Scler 2024; 30:833-842. [PMID: 38619037 PMCID: PMC11134969 DOI: 10.1177/13524585241242050] [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: 09/24/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The double-blind TERIKIDS study demonstrated the efficacy and safety of teriflunomide. OBJECTIVE To evaluate the efficacy, safety, and tolerability of continuous teriflunomide treatment in the TERIKIDS open-label extension. METHODS In the double-blind period, children with relapsing MS were randomized to placebo or teriflunomide (14 mg adult-equivalent dose) for ⩽ 96 weeks. Participants received teriflunomide for ⩽ 192 weeks post-randomization in the open-label extension. RESULTS The mean age at screening was 14.6 years. For teriflunomide/teriflunomide versus placebo/teriflunomide, estimated clinical relapse risk was reduced by 38% (hazard ratio (HR) 0.62; 95% confidence interval (CI) 0.39-0.98; p = 0.11) and numbers of gadolinium-enhancing T1 and new/enlarging T2 lesions were reduced by 43% (relative risk (RR) 0.570; 95% CI 0.33-0.98; p = 0.043) and 49% (RR 0.511; 95% CI 0.34-0.76; p = 0.001), respectively, in the combined double-blind and open-label periods. There was a trend toward reduced risk of 24-week sustained disability progression for teriflunomide/teriflunomide versus placebo/teriflunomide (HR 0.47; 95% CI 0.23-0.96). During the open-label extension, incidences of safety-related discontinuations were 4.0% (teriflunomide/teriflunomide) and 13.5% (placebo/teriflunomide), including two children who developed pancreatitis in the teriflunomide/teriflunomide group. CONCLUSION Teriflunomide reduced the long-term risk of focal inflammatory activity, with generally manageable tolerability and no new safety signals. Further evidence would strengthen clinical efficacy findings.ClinicalTrials.gov: NCT02201108.
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Affiliation(s)
- Tanuja Chitnis
- Massachusetts General Hospital for Children, Boston, MA, USA
| | - Brenda Banwell
- Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University of Basel, Basel, Switzerland/MS Center and Neurologic Clinic and Policlinic, Departments of Biomedicine and Clinical Research, University Hospital of Basel, Basel, Switzerland
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada
- NeuroRx Research, Montréal, QC, Canada
| | - Kivilcim Gücüyener
- Gazi Universitesi Tip Fakultesi Pediatrik Nöroloji Bilim Dali, Ankara, Turkey
| | - Kumaran Deiva
- Department of Pediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Paris, France
| | | | | | | | | | | | - Marc Tardieu
- Department of Pediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Paris, France
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3
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Preziosa P, Rocca MA, Filippi M. Radiologically isolated syndromes: to treat or not to treat? J Neurol 2024; 271:2370-2378. [PMID: 38502339 DOI: 10.1007/s00415-024-12294-4] [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: 02/08/2024] [Revised: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/21/2024]
Abstract
The widespread use of magnetic resonance imaging (MRI) has led to increased detection of individuals exhibiting asymptomatic brain and spinal cord lesions suggestive of multiple sclerosis (MS), defined as "radiologically isolated syndrome" (RIS). Specific criteria have been proposed and updated over time to identify individuals with RIS. Moreover, a younger age, the presence of infratentorial, spinal cord or gadolinium-enhancing lesions, as well as of cerebrospinal fluid-specific oligoclonal bands have been recognized as relevant risk factors for the occurrence of a first clinical event. Recent randomized controlled trials conducted in individuals with RIS have shown that dimethyl fumarate and teriflunomide significantly reduce the occurrence of clinical events in this population. These findings support the notion that early treatment initiation may positively influence the prognosis of these patients. However, several aspects should be taken into account before treating individuals with RIS in the real-world clinical setting, including an accurate identification of individuals with RIS to avoid misdiagnosis, a precise stratification of their risk of experiencing a first clinical event and further data supporting favorable balance between benefits and risks, even in the long term. This commentary provides an overview of the latest updates in RIS diagnosis, prognosis, and emerging treatment evidence.
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Affiliation(s)
- Paolo Preziosa
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
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4
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Guo J, Wu J, Wang L, Liu H, Wu X, Yang H, Li W, Wang H, Bu B, Yang C, Zhou H, Guo S, Zhao Y, Wang Z, Li C, Tian DC, Chen S, Xue H, Zhang Y, Xu Y, Liang H, Wu Z, Zhang Y, Dong Q, Wang J, Quan C. Treatment algorithms of relapsing multiple sclerosis: an exploration based on the available disease-modifying therapies in China. Ther Adv Neurol Disord 2024; 17:17562864241239117. [PMID: 38616782 PMCID: PMC11015775 DOI: 10.1177/17562864241239117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/14/2024] [Indexed: 04/16/2024] Open
Abstract
Multiple sclerosis (MS) was defined as a rare disease in China due to its low prevalence. For a long time, interferon β was the only approved disease-modifying therapy (DMT). Since the first oral DMT was approved in 2018, DMT approval accelerated, and seven DMTs were approved within 5 years. With an increasing number of DMTs being prescribed in clinical practice, it is necessary to discuss the standardized MS treatment algorithms depending on the disease activity and DMT availability. In this review paper, more than 20 Chinese experts in MS have reviewed the therapeutic progress of MS in China and worldwide and discussed algorithms for treating relapsing MS (RMS) based on the available DMTs in China, providing insights for establishing the standardized RMS treatment algorithms in this country.
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Affiliation(s)
- Jun Guo
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Jiayong Wu
- Department of Neurology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Hongbo Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaomu Wu
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Wenyu Li
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Honghao Wang
- Department of Neurology, Guangzhou First People’s Hospital, Guangzhou, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunsheng Yang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital, Shandong First Medical University, Jinan, China
| | - Yinan Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhanhang Wang
- Department of Neurology, Guangdong 999 Brain Hospital, Guangzhou, China
| | - Chunyang Li
- Department of Neurology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - De-Cai Tian
- Center for Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sheng Chen
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huiru Xue
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Yanlin Zhang
- Department of Neurology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yongfeng Xu
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hui Liang
- Department of Neurology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhe Wu
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | | | - Qiang Dong
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Quan
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, No. 12, Middle Wulumuqi Road, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai, China
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Fernández Ó, Sörensen PS, Comi G, Vermersch P, Hartung HP, Leocani L, Berger T, Van Wijmeersch B, Oreja-Guevara C. Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review. Front Immunol 2024; 15:1379538. [PMID: 38646534 PMCID: PMC11032020 DOI: 10.3389/fimmu.2024.1379538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.
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Affiliation(s)
- Óscar Fernández
- Departament of Pharmacology, Faculty of Medicine; Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, Malaga, Spain
- Department of Pharmacology and Pediatry, Faculty of Medicine, University of Malaga, Malaga, Spain
| | - Per Soelberg Sörensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Copenhagen and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Giancarlo Comi
- Department of Neurorehabilitation Sciences, Multiple Sclerosis Centre Casa di Cura Igea, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Palacky University Olomouc, Olomouc, Czechia
| | - Letizia Leocani
- Department of Neurorehabilitation Sciences, Multiple Sclerosis Centre Casa di Cura Igea, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Bart Van Wijmeersch
- University MS Centre, Hasselt-Pelt, Belgium
- Rehabilitation and Multiple Sclerosis (MS), Noorderhart Hospitals, Pelt, Belgium
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico Universitario San Carlos, IdISSC, Madrid, Spain
- Department of Medicine, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Zhao Y, Chen C, Xiao X, Fang L, Cheng X, Chang Y, Peng F, Wang J, Shen S, Wu S, Huang Y, Cai W, Zhou L, Qiu W. Teriflunomide Promotes Blood-Brain Barrier Integrity by Upregulating Claudin-1 via the Wnt/β-catenin Signaling Pathway in Multiple Sclerosis. Mol Neurobiol 2024; 61:1936-1952. [PMID: 37819429 DOI: 10.1007/s12035-023-03655-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/10/2023] [Indexed: 10/13/2023]
Abstract
The blood-brain barrier (BBB) and tight junction (TJ) proteins maintain the homeostasis of the central nervous system (CNS). The dysfunction of BBB allows peripheral T cells infiltration into CNS and contributes to the pathophysiology of multiple sclerosis (MS). Teriflunomide is an approved drug for the treatment of MS by suppressing lymphocytes proliferation. However, whether teriflunomide has a protective effect on BBB in MS is not understood. We found that teriflunomide restored the injured BBB in the EAE model. Furthermore, teriflunomide treatment over 6 months improved BBB permeability and reduced peripheral leakage of CNS proteins in MS patients. Teriflunomide increased human brain microvascular endothelial cell (HBMEC) viability and promoted BBB integrity in an in vitro cell model. The TJ protein claudin-1 was upregulated by teriflunomide and responsible for the protective effect on BBB. Furthermore, RNA sequencing revealed that the Wnt signaling pathway was affected by teriflunomide. The activation of Wnt signaling pathway increased claudin-1 expression and reduced BBB damage in cell model and EAE rats. Our study demonstrated that teriflunomide upregulated the expression of the tight junction protein claudin-1 in endothelial cells and promoted the integrity of BBB through Wnt signaling pathway.
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Affiliation(s)
- Yipeng Zhao
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
- The Center of Mental and Neurological Disorders Study, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Chen Chen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Xiuqing Xiao
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
- Shenzhen Key Laboratory of Cardiovascular Disease, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, 518057, China
| | - Ling Fang
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Xi Cheng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Yanyu Chang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Jingqi Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Shishi Shen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Shilin Wu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Yiying Huang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Wei Cai
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
- The Center of Mental and Neurological Disorders Study, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Linli Zhou
- The Center of Mental and Neurological Disorders Study, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China.
- The Center of Mental and Neurological Disorders Study, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510000, China.
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Butzkueven H, Kalincik T, Patti F, Slee M, Weinstock-Guttman B, Buzzard K, Skibina O, Alroughani R, Prat A, Girard M, Horakova D, Havrdova EK, Van der Walt A, Eichau S, Hyde R, Campbell N, Bodhinathan K, Spelman T. Long-term clinical outcomes in patients with multiple sclerosis who are initiating disease-modifying therapy with natalizumab compared with BRACETD first-line therapies. Ther Adv Neurol Disord 2024; 17:17562864231221331. [PMID: 38414723 PMCID: PMC10898303 DOI: 10.1177/17562864231221331] [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: 06/05/2023] [Accepted: 11/05/2023] [Indexed: 02/29/2024] Open
Abstract
Background Aggressive disease control soon after multiple sclerosis (MS) diagnosis may prevent irreversible neurological damage, and therefore early initiation of a high-efficacy disease-modifying therapy (DMT) is of clinical relevance. Objectives Evaluate long-term clinical outcomes in patients with MS who initiated treatment with either natalizumab or a BRACETD therapy (interferon beta, glatiramer acetate, teriflunomide, or dimethyl fumarate). Design This retrospective analysis utilized data from MSBase to create a matched population allowing comparison of first-line natalizumab to first-line BRACETD. Methods This study included patients who initiated treatment either with natalizumab or a BRACETD DMT within 1 year of MS diagnosis and continued treatment for ⩾6 months, after which patients could switch DMTs or discontinue treatment. Patients had a minimum follow-up time of ⩾60 months from initiation. A subgroup analysis compared the natalizumab group to patients in the BRACETD group who escalated therapy after 6 months. Outcomes included unadjusted annualized relapse rates (ARRs), time-to-first relapse, time-to-first confirmed disability improvement (CDI), and time-to-first confirmed disability worsening (CDW). Results After 1:1 propensity score matching, 355 BRACETD patients were matched to 355 natalizumab patients. Patients initiating natalizumab were less likely to experience a relapse over the duration of follow-up, with ARRs [95% confidence interval (CI)] of 0.080 (0.070-0.092) for natalizumab patients and 0.191 (0.178-0.205) for BRACETD patients (p < 0.0001). A Cox regression model of time-to-first relapse showed a reduced risk of relapse for natalizumab patients [hazard ratio (95% CI) of 0.52 (0.42-0.65); p < 0.001] and a more favorable time-to-first CDI. The risk of CDW was similar between groups. The subgroup analysis showed an increased relapse risk as well as a significantly higher risk of CDW for BRACETD patients. Conclusion Early initiation of natalizumab produced long-term benefits in relapse outcomes in comparison with BRACETD, regardless of a subsequent escalation in therapy.
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Affiliation(s)
- Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Alfred Campus, Monash University, 6/99 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Neurology, Box Hill Hospital, Monash University, Box Hill, VIC, Australia
| | - Tomas Kalincik
- Neuroimmunology Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies 'GF Ingrassia', University of Catania, Catania, Italy
| | - Mark Slee
- Flinders University, Adelaide, SA, Australia
| | | | - Katherine Buzzard
- Department of Neurology, Box Hill Hospital, Melbourne, VIC, Australia
| | - Olga Skibina
- Department of Neurology, Box Hill Hospital, Melbourne, VIC, Australia
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | | | - Marc Girard
- CHUM and Universite de Montreal, Montreal, QC, Canada
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | | | - Sara Eichau
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Robert Hyde
- Biogen, Cambridge, MA, USA, at the time of this analysis
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8
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Bergeron E, Bouffard MA. Evidence-based management of optic neuritis. Curr Opin Ophthalmol 2024; 35:73-82. [PMID: 37846574 DOI: 10.1097/icu.0000000000001007] [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: 10/18/2023]
Abstract
PURPOSE OF REVIEW Optic neuritis can result from several distinct causes, including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein antibody disease (MOGAD), when not idiopathic. This review discusses evidence-based treatment approaches contingent upon each specific cause of optic neuritis. RECENT FINDINGS Current evidence highlights the need for prompt plasmapheresis as adjunct to intravenous methylprednisolone (IVMP) in patients with NMOSD-associated optic neuritis. Recent advances have included a proliferation of novel disease modifying therapies (DMTs) for long-term management of NMOSD and an understanding of how existing therapeutic options can be leveraged to optimally treat MOGAD. SUMMARY In acute idiopathic or MS-associated optic neuritis, IVMP hastens visual recovery, though it does not substantially affect final visual outcomes. IVMP and adjunctive plasmapheresis are beneficial in the treatment of NMOSD-associated optic neuritis, with a shorter time-to-treatment associated with a higher likelihood of recovery. The natural history of untreated MOGAD-associated optic neuritis is unclear but treatment with IVMP is near-universal given phenotypic similarities with NMOSD. Long-term immunosuppressive therapy is warranted in patients with NMOSD as well as in patients with MOGAD with poor visual recovery or recurrent attacks.
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Affiliation(s)
- Emilie Bergeron
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Département d'ophtalmologie et d'oto-rhino-laryngologie - chirurgie cervico-faciale, Faculté de médecine, Centre Universitaire d'Ophtalmologie, Hôpital du Saint-Sacrement, CHU de Québec-Université Laval, Quebec UO-Recherche-Clinique, Hôpital du Saint-Sacrement, Centre de recherche du CHU de Québec City, Québec City, Quebec, Canada
| | - Marc A Bouffard
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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Tramacere I, Virgili G, Perduca V, Lucenteforte E, Benedetti MD, Capobussi M, Castellini G, Frau S, Gonzalez-Lorenzo M, Featherstone R, Filippini G. Adverse effects of immunotherapies for multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2023; 11:CD012186. [PMID: 38032059 PMCID: PMC10687854 DOI: 10.1002/14651858.cd012186.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic disease of the central nervous system that affects mainly young adults (two to three times more frequently in women than in men) and causes significant disability after onset. Although it is accepted that immunotherapies for people with MS decrease disease activity, uncertainty regarding their relative safety remains. OBJECTIVES To compare adverse effects of immunotherapies for people with MS or clinically isolated syndrome (CIS), and to rank these treatments according to their relative risks of adverse effects through network meta-analyses (NMAs). SEARCH METHODS We searched CENTRAL, PubMed, Embase, two other databases and trials registers up to March 2022, together with reference checking and citation searching to identify additional studies. SELECTION CRITERIA We included participants 18 years of age or older with a diagnosis of MS or CIS, according to any accepted diagnostic criteria, who were included in randomized controlled trials (RCTs) that examined one or more of the agents used in MS or CIS, and compared them versus placebo or another active agent. We excluded RCTs in which a drug regimen was compared with a different regimen of the same drug without another active agent or placebo as a control arm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for data extraction and pairwise meta-analyses. For NMAs, we used the netmeta suite of commands in R to fit random-effects NMAs assuming a common between-study variance. We used the CINeMA platform to GRADE the certainty of the body of evidence in NMAs. We considered a relative risk (RR) of 1.5 as a non-inferiority safety threshold compared to placebo. We assessed the certainty of evidence for primary outcomes within the NMA according to GRADE, as very low, low, moderate or high. MAIN RESULTS This NMA included 123 trials with 57,682 participants. Serious adverse events (SAEs) Reporting of SAEs was available from 84 studies including 5696 (11%) events in 51,833 (89.9%) participants out of 57,682 participants in all studies. Based on the absolute frequency of SAEs, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 18 additional people would have a SAE compared to placebo. Low-certainty evidence suggested that three drugs may decrease SAEs compared to placebo (relative risk [RR], 95% confidence interval [CI]): interferon beta-1a (Avonex) (0.78, 0.66 to 0.94); dimethyl fumarate (0.79, 0.67 to 0.93), and glatiramer acetate (0.84, 0.72 to 0.98). Several drugs met our non-inferiority criterion versus placebo: moderate-certainty evidence for teriflunomide (1.08, 0.88 to 1.31); low-certainty evidence for ocrelizumab (0.85, 0.67 to 1.07), ozanimod (0.88, 0.59 to 1.33), interferon beta-1b (0.94, 0.78 to 1.12), interferon beta-1a (Rebif) (0.96, 0.80 to 1.15), natalizumab (0.97, 0.79 to 1.19), fingolimod (1.05, 0.92 to 1.20) and laquinimod (1.06, 0.83 to 1.34); very low-certainty evidence for daclizumab (0.83, 0.68 to 1.02). Non-inferiority with placebo was not met due to imprecision for the other drugs: low-certainty evidence for cladribine (1.10, 0.79 to 1.52), siponimod (1.20, 0.95 to 1.51), ofatumumab (1.26, 0.88 to 1.79) and rituximab (1.01, 0.67 to 1.52); very low-certainty evidence for immunoglobulins (1.05, 0.33 to 3.32), diroximel fumarate (1.05, 0.23 to 4.69), peg-interferon beta-1a (1.07, 0.66 to 1.74), alemtuzumab (1.16, 0.85 to 1.60), interferons (1.62, 0.21 to 12.72) and azathioprine (3.62, 0.76 to 17.19). Withdrawals due to adverse events Reporting of withdrawals due to AEs was available from 105 studies (85.4%) including 3537 (6.39%) events in 55,320 (95.9%) patients out of 57,682 patients in all studies. Based on the absolute frequency of withdrawals, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 31 additional people would withdraw compared to placebo. No drug reduced withdrawals due to adverse events when compared with placebo. There was very low-certainty evidence (meaning that estimates are not reliable) that two drugs met our non-inferiority criterion versus placebo, assuming an upper 95% CI RR limit of 1.5: diroximel fumarate (0.38, 0.11 to 1.27) and alemtuzumab (0.63, 0.33 to 1.19). Non-inferiority with placebo was not met due to imprecision for the following drugs: low-certainty evidence for ofatumumab (1.50, 0.87 to 2.59); very low-certainty evidence for methotrexate (0.94, 0.02 to 46.70), corticosteroids (1.05, 0.16 to 7.14), ozanimod (1.06, 0.58 to 1.93), natalizumab (1.20, 0.77 to 1.85), ocrelizumab (1.32, 0.81 to 2.14), dimethyl fumarate (1.34, 0.96 to 1.86), siponimod (1.63, 0.96 to 2.79), rituximab (1.63, 0.53 to 5.00), cladribine (1.80, 0.89 to 3.62), mitoxantrone (2.11, 0.50 to 8.87), interferons (3.47, 0.95 to 12.72), and cyclophosphamide (3.86, 0.45 to 33.50). Eleven drugs may have increased withdrawals due to adverse events compared with placebo: low-certainty evidence for teriflunomide (1.37, 1.01 to 1.85), glatiramer acetate (1.76, 1.36 to 2.26), fingolimod (1.79, 1.40 to 2.28), interferon beta-1a (Rebif) (2.15, 1.58 to 2.93), daclizumab (2.19, 1.31 to 3.65) and interferon beta-1b (2.59, 1.87 to 3.77); very low-certainty evidence for laquinimod (1.42, 1.01 to 2.00), interferon beta-1a (Avonex) (1.54, 1.13 to 2.10), immunoglobulins (1.87, 1.01 to 3.45), peg-interferon beta-1a (3.46, 1.44 to 8.33) and azathioprine (6.95, 2.57 to 18.78); however, very low-certainty evidence is unreliable. Sensitivity analyses including only studies with low attrition bias, drug dose above the group median, or only patients with relapsing remitting MS or CIS, and subgroup analyses by prior disease-modifying treatments did not change these figures. Rankings No drug yielded consistent P scores in the upper quartile of the probability of being better than others for primary and secondary outcomes. AUTHORS' CONCLUSIONS We found mostly low and very low-certainty evidence that drugs used to treat MS may not increase SAEs, but may increase withdrawals compared with placebo. The results suggest that there is no important difference in the occurrence of SAEs between first- and second-line drugs and between oral, injectable, or infused drugs, compared with placebo. Our review, along with other work in the literature, confirms poor-quality reporting of adverse events from RCTs of interventions. At the least, future studies should follow the CONSORT recommendations about reporting harm-related issues. To address adverse effects, future systematic reviews should also include non-randomized studies.
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Affiliation(s)
- Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Ophthalmology, IRCCS - Fondazione Bietti, Rome, Italy
| | - Vittorio Perduca
- Université Paris Cité, CNRS, MAP5, F-75006 Paris, France
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Ersilia Lucenteforte
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Maria Donata Benedetti
- UOC Neurologia B - Policlinico Borgo Roma, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Capobussi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Greta Castellini
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | | | - Marien Gonzalez-Lorenzo
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Department of Oncology, Laboratory of Clinical Research Methodology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
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Cruz Rivera S, Aiyegbusi OL, Piani Meier D, Dunne A, Harlow DE, Henke C, Kamudoni P, Calvert MJ. The effect of disease modifying therapies on fatigue in multiple sclerosis. Mult Scler Relat Disord 2023; 79:105065. [PMID: 37839365 DOI: 10.1016/j.msard.2023.105065] [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: 07/07/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Fatigue is one of the most common and debilitating symptoms in people with multiple sclerosis (PwMS). Disease-modifying therapies (DMTs) are currently the gold standard in the treatment of MS and their effectiveness has been assessed through randomized clinical trials (RCTs). However, there is limited evidence on the impact of DMTs on fatigue in (PwMS). We conducted a systematic review to 1) understand whether fatigue is included as an outcome in MS trials of DMTs; 2) determine the effects on fatigue of treating MS with DMTs and 3) assess the quality of MS trials including fatigue as an outcome. METHODS Two independent researchers systematically searched MEDLINE, EMBASE and ClinicalTrials.gov from 1993 to January 2023 for RCTs that measured fatigue as an outcome. Adherence to reporting standards was assessed with the Consolidated Standards of Reporting Trials (CONSORT)-Patient-Reported Outcomes (PRO), while the risk of bias (RoB) was assessed with the RoB 2 tool by the Cochrane Handbook for Systematic Reviews of Interventions. The systematic review protocol was registered in PROSPERO (CRD42022383321). RESULTS The search strategy identified 130 RCTs of DMTs of which 7 (5%) assessed fatigue as an outcome. Of the 7 trials, only two presented statistically significant results. In addition, the reporting of fatigue among RCTs was suboptimal with a mean adherence to the CONSORT-PRO Statement of 36% across all trials. Of the 7 trials included, four were assessed as 'high' RoB.. CONCLUSIONS Fatigue has a major impact on PwMS yet there is limited trial-based evidence on the impact of DMTs on fatigue. Assessment of fatigue as an outcome is underrepresented in trials of DMTs and the reporting of PRO trial data is suboptimal. Thus, it is imperative that MS researchers conduct RCTs that include fatigue as an outcome, to support clinicians and people with MS (PwMS) to consider the impact of the different DMTs on fatigue.
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Affiliation(s)
- Samantha Cruz Rivera
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK; Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK.
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK; Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK; National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK; NIHR Applied Research Collaboration (ARC) West Midlands, University of Birmingham, Birmingham, UK; NIHR Blood and Transplant Research Unit (BTRU) in Precision Transplant and Cellular Therapeutics, University of Birmingham, UK
| | | | | | | | | | | | - Melanie J Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK; Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK; National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK; NIHR Applied Research Collaboration (ARC) West Midlands, University of Birmingham, Birmingham, UK; NIHR Blood and Transplant Research Unit (BTRU) in Precision Transplant and Cellular Therapeutics, University of Birmingham, UK; UK SPINE, University of Birmingham, Birmingham, UK; Health Data Research, Birmingham, UK
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11
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Lebrun-Frénay C, Siva A, Sormani MP, Landes-Chateau C, Mondot L, Bovis F, Vermersch P, Papeix C, Thouvenot E, Labauge P, Durand-Dubief F, Efendi H, Le Page E, Terzi M, Derache N, Bourre B, Hoepner R, Karabudak R, De Seze J, Ciron J, Clavelou P, Wiertlewski S, Turan OF, Yucear N, Cohen M, Azevedo C, Kantarci OH, Okuda DT, Pelletier D. Teriflunomide and Time to Clinical Multiple Sclerosis in Patients With Radiologically Isolated Syndrome: The TERIS Randomized Clinical Trial. JAMA Neurol 2023; 80:1080-1088. [PMID: 37603328 PMCID: PMC10442780 DOI: 10.1001/jamaneurol.2023.2815] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/13/2023] [Indexed: 08/22/2023]
Abstract
Importance Radiologically isolated syndrome (RIS) represents the earliest detectable preclinical phase of multiple sclerosis (MS) punctuated by incidental magnetic resonance imaging (MRI) white matter anomalies within the central nervous system. Objective To determine the time to onset of symptoms consistent with MS. Design, Setting, and Participants From September 2017 to October 2022, this multicenter, double-blind, phase 3, randomized clinical trial investigated the efficacy of teriflunomide in delaying MS in individuals with RIS, with a 3-year follow-up. The setting included referral centers in France, Switzerland, and Turkey. Participants older than 18 years meeting 2009 RIS criteria were randomly assigned (1:1) to oral teriflunomide, 14 mg daily, or placebo up to week 96 or, optionally, to week 144. Interventions Clinical, MRI, and patient-reported outcomes (PROs) were collected at baseline and yearly until week 96, with an optional third year in the allocated arm if no symptoms have occurred. Main outcomes Primary analysis was performed in the intention-to-treat population, and safety was assessed accordingly. Secondary end points included MRI outcomes and PROs. Results Among 124 individuals assessed for eligibility, 35 were excluded for declining to participate, not meeting inclusion criteria, or loss of follow-up. Eighty-nine participants (mean [SD] age, 37.8 [12.1] years; 63 female [70.8%]) were enrolled (placebo, 45 [50.6%]; teriflunomide, 44 [49.4%]). Eighteen participants (placebo, 9 [50.0%]; teriflunomide, 9 [50.0%]) discontinued the study, resulting in a dropout rate of 20% for adverse events (3 [16.7%]), consent withdrawal (4 [22.2%]), loss to follow-up (5 [27.8%]), voluntary withdrawal (4 [22.2%]), pregnancy (1 [5.6%]), and study termination (1 [5.6%]). The time to the first clinical event was significantly extended in the teriflunomide arm compared with placebo, in both the unadjusted (hazard ratio [HR], 0.37; 95% CI, 0.16-0.84; P = .02) and adjusted (HR, 0.28; 95% CI, 0.11-0.71; P = .007) analysis. Secondary imaging end point outcomes including the comparison of the cumulative number of new or newly enlarging T2 lesions (rate ratio [RR], 0.57; 95% CI, 0.27-1.20; P = .14), new gadolinium-enhancing lesions (RR, 0.33; 95% CI, 0.09-1.17; P = .09), and the proportion of participants with new lesions (odds ratio, 0.72; 95% CI, 0.25-2.06; P = .54) were not significant. Conclusion and Relevance Treatment with teriflunomide resulted in an unadjusted risk reduction of 63% and an adjusted risk reduction of 72%, relative to placebo, in preventing a first clinical demyelinating event. These data suggest a benefit to early treatment in the MS disease spectrum. Trial Registration ClinicalTrials.gov Identifier: NCT03122652.
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Affiliation(s)
- Christine Lebrun-Frénay
- Centre de Ressources et de Compétences Sclerose En Plaques, Neurologie Pasteur 2, CHU de Nice, Université Cote d’Azur, UMR2CA-URRIS, Nice, France
| | - Aksel Siva
- Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkiye
| | - Maria Pia Sormani
- University of Genoa, Genoa, Italy
- Ospedale Policlinico San Martino Instituti di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Cassandre Landes-Chateau
- Centre de Ressources et de Compétences Sclerose En Plaques, Neurologie Pasteur 2, CHU de Nice, Université Cote d’Azur, UMR2CA-URRIS, Nice, France
| | - Lydiane Mondot
- Centre de Ressources et de Compétences Sclerose En Plaques, Neurologie Pasteur 2, CHU de Nice, Université Cote d’Azur, UMR2CA-URRIS, Nice, France
| | | | - Patrick Vermersch
- Université de Lille, Inserm, Unit 1172, LilNCog, Centre Hospitalier Universitaire de Lille, Fédération Hospitalo-Universitaire Precise, Lille, France
| | - Caroline Papeix
- Assistance Publique des Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Thouvenot
- Multiple Sclerosis Clinic, Nîmes University Hospital, Nîmes, France
| | - Pierre Labauge
- Multiple Sclerosis Clinic, Montpellier University Hospital, Montpellier, France
| | | | - Husnu Efendi
- Neurology, Kocaeli University Faculty of Medicine, Kocaeli, Turkiye
| | - Emmanuelle Le Page
- Multiple Sclerosis Clinic, Rennes University Hospital, Inserm, CIC1414, Rennes, France
| | - Murat Terzi
- School of Medicine, Neurology, Ondokuz Mayis University, Samsun, Turkiye
| | - Nathalie Derache
- Multiple Sclerosis Clinic, Caen University Hospital, Caen, France
| | - Bertrand Bourre
- Multiple Sclerosis Clinic, Rouen University Hospital, Rouen, France
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Rana Karabudak
- Hacettepe University Medical Faculty, School of Medicine, Ankara, Turkiye
| | - Jérôme De Seze
- Strasbourg University Hospital, Clinical Investigation Center, INBSRM 1434, Strasbourg, France
| | - Jonathan Ciron
- Toulouse University Hospital, Centre de Ressources et de Compétences Sclérose en Plaques, Department of Neurology, Université Toulouse III, Infinity, Inserm UMR1291, CNRS UMR5051, Toulouse, France
| | - Pierre Clavelou
- Multiple Sclerosis Clinic, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Sandrine Wiertlewski
- Centre de Ressources et de Compétences Sclérose en Plaques and Clinical Investigation Center, Inserm, Nantes University Hospital, France
- Transplantation and Immunology Transplantation Center, Inserm, Nantes, France
| | | | - Nur Yucear
- Ege University Medical Faculty, Bornova, Izmir, Turkiye
| | - Mikael Cohen
- Centre de Ressources et de Compétences Sclerose En Plaques, Neurologie Pasteur 2, CHU de Nice, Université Cote d’Azur, UMR2CA-URRIS, Nice, France
| | | | | | - Darin T. Okuda
- The University of Texas Southwestern Medical Center, Dallas
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12
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Domínguez-Mozo MI, González-Suárez I, Villar LM, Costa-Frossard L, Villarrubia N, Aladro Y, Pilo B, Montalbán X, Comabella M, Casanova-Peño I, Martínez-Ginés ML, García-Domínguez JM, García-Martínez MÁ, Arroyo R, Álvarez-Lafuente R. Teriflunomide and Epstein-Barr virus in a Spanish multiple sclerosis cohort: in vivo antiviral activity and clinical response. Front Immunol 2023; 14:1248182. [PMID: 37841253 PMCID: PMC10570817 DOI: 10.3389/fimmu.2023.1248182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
Background Epstein-Barr virus (EBV) and human herpesvirus 6 (HHV-6) have been associated with multiple sclerosis (MS). Teriflunomide is an oral disease-modifying therapy approved for treatment of relapsing forms of MS. In the preclinical Theiler's murine encephalitis virus model of MS, the drug demonstrated an increased rate of viral clearance versus the vehicle placebo. Furthermore, teriflunomide inhibits lytic EBV infection in vitro. Objective 1. To evaluate the humoral response against EBV and HHV-6 prior to teriflunomide treatment and 6 months later. 2. To correlate the variation in the humoral response against EBV and HHV-6 with the clinical and radiological response after 24 months of treatment with teriflunomide. 3. To analyze the utility of different demographic, clinical, radiological, and environmental data to identify early biomarkers of response to teriflunomide. Methods A total of 101 MS patients (62 women; mean age: 43.4 years) with one serum prior to teriflunomide onset and another serum sample 6 months later were recruited. A total of 80 had been treated for at least 24 months, 13 had stopped teriflunomide before 24 months, and 8 were currently under teriflunomide therapy but with less than 24 months of follow-up. We analyzed the levels of the viral antibodies titers abovementioned in serum samples with ELISA commercial kits, and the levels of serum neurofilament light chain (Nf-L). Results Antiviral antibody titers decreased for EBNA-1 IgG (74.3%), VCA IgG (69%), HHV-6 IgG (60.4%), and HHV-6 IgM (73.3%) after 6 months of teriflunomide. VCA IgG titers at baseline correlated with Nf-L levels measured at the same time (r = 0.221; p = 0.028) and 6 months later (r = 0.240; p = 0.017). We found that higher EBNA-1 titers (p = 0.001) and a higher age (p = 0.04) at baseline were associated with NEDA-3 conditions. Thus, 77.8% of patients with EBNA-1 >23.0 AU and >42.8 years (P50 values) were NEDA-3. Conclusion Treatment with teriflunomide was associated with a reduction of the levels of IgG antibody titers against EBV and HHV-6. Furthermore, higher EBNA-1 IgG titers prior to teriflunomide initiation were associated with a better clinical response.
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Affiliation(s)
- María Inmaculada Domínguez-Mozo
- Grupo de Investigación de Factores ambientales en enfermedades degenerativas, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Red de Enfermedades Inflamatorias (REI), Madrid, Spain
| | - Inés González-Suárez
- Unidad de Enfermedades Desmielinizantes, Hospital Álvaro Cunqueiro, Red de Enfermedades Inflamatorias (REI), Vigo, Spain
| | - Luisa María Villar
- Servicio de Inmunología, Hospital Universitario Ramón y Cajal, Red de Enfermedades Inflamatorias (REI), Madrid, Spain
| | - Lucienne Costa-Frossard
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Red de Enfermedades Inflamatorias (REI), Madrid, Spain
| | - Noelia Villarrubia
- Servicio de Inmunología, Hospital Universitario Ramón y Cajal, Red de Enfermedades Inflamatorias (REI), Madrid, Spain
| | - Yolanda Aladro
- Servicio de Neurología, Hospital Universitario de Getafe, Getafe, Spain
| | - Belén Pilo
- Servicio de Neurología, Hospital Universitario de Getafe, Getafe, Spain
| | - Xavier Montalbán
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d’Hebron (VHIR), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Comabella
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d’Hebron (VHIR), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ignacio Casanova-Peño
- Servicio de Neurología, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - María Luisa Martínez-Ginés
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón/Red de Enfermedades Inflamatorias (REI), Madrid, Spain
| | - Jose Manuel García-Domínguez
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón/Red de Enfermedades Inflamatorias (REI), Madrid, Spain
| | - María Ángel García-Martínez
- Grupo de Investigación de Factores ambientales en enfermedades degenerativas, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Red de Enfermedades Inflamatorias (REI), Madrid, Spain
| | - Rafael Arroyo
- Departamento de Neurología, Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | - Roberto Álvarez-Lafuente
- Grupo de Investigación de Factores ambientales en enfermedades degenerativas, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Red de Enfermedades Inflamatorias (REI), Madrid, Spain
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Cobo-Calvo A, Tur C, Otero-Romero S, Carbonell-Mirabent P, Ruiz M, Pappolla A, Villacieros Alvarez J, Vidal-Jordana A, Arrambide G, Castilló J, Galan I, Rodríguez Barranco M, Midaglia LS, Nos C, Rodriguez Acevedo B, Zabalza de Torres A, Mongay N, Rio J, Comabella M, Auger C, Sastre-Garriga J, Rovira A, Tintore M, Montalban X. Association of Very Early Treatment Initiation With the Risk of Long-term Disability in Patients With a First Demyelinating Event. Neurology 2023; 101:e1280-e1292. [PMID: 37468284 PMCID: PMC10558169 DOI: 10.1212/wnl.0000000000207664] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 06/02/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Early treatment is associated with better long-term outcomes in patients with a first demyelinating event and early multiple sclerosis (MS). However, magnetic resonance (MR) findings are not usually integrated to construct propensity scores (PSs) when evaluating outcomes. We assessed the association of receiving very early treatment with the risk of long-term disability including an MR score (MRS) in patients with a first demyelinating event. METHODS We included 580 patients with a first demyelinating event prospectively collected between 1994 and 2021, who received at least 1 disease-modifying drug (DMD). Patients were classified into tertiles according to the cohort's distribution of the time from the first demyelinating event to the first DMD: first tertile (FT) or very early treatment (6 months; n = 194), second tertile (6.1-16 months, n = 192), and third tertile (TT) (16.1 months, n = 194). A 5-point MRS was built according to the sum of the following indicators: ≥9 brain lesions (1 point); ≥1 infratentorial lesion (1 point); ≥1 spinal cord (SC) lesion (1 point); ≥1 contrast-enhancing (CE) brain lesion (1 point); and ≥1 CE SC lesion (1 point). PS based on covariates and the MRS was computed for each of the outcomes. Inverse PS-weighted Cox and linear regression models assessed the risk of different outcomes between tertile groups. Finally, to confirm the role of MR in treatment decision, we studied the time elapsed from the first demyelinating event to treatment initiation according to the MRS in all patients with radiologic available information, renamed as raw-MRS. RESULTS Very early treatment decreased the risk of reaching Expanded Disability Status Scale 3.0 (hazard ratio [HR] 0.55, 95% CI 0.32-0.97), secondary progressive MS (HR 0.40, 95% CI 0.19-0.85), and sustained disease progression at 12 months after treatment initiation (HR 0.50, 95% CI 0.29-0.84), when compared with patients from the TT group. Patients from the FT group had a lower disability progression rate (β estimate -0.009, 95% CI -0.016 to -0.002) and a lower severe disability measured by the Patient-Determined Disease Step (β estimate -0.52, 95% CI -0.91 to -0.13) than the TT group. Finally, there was a 62.4% reduction in the median time between the first demyelinating event and the first-ever treatment initiation from patients displaying a raw-MRS 1 to patients with a raw-MRS 5. DISCUSSION Using PS models with and without MRS, we showed that treatment initiation at very early stages is associated with a reduction in the risk of long-term disability accrual in patients with a first demyelinating event. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that earlier treatment of patients with MS presenting with a first demyelinating event is associated with improved clinical outcomes.
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Affiliation(s)
- Alvaro Cobo-Calvo
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain.
| | - Carmen Tur
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Susana Otero-Romero
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Pere Carbonell-Mirabent
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Mariano Ruiz
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Agustin Pappolla
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Javier Villacieros Alvarez
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Angela Vidal-Jordana
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Georgina Arrambide
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Joaquín Castilló
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Ingrid Galan
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Marta Rodríguez Barranco
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Luciana Soledad Midaglia
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Carlos Nos
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Breogan Rodriguez Acevedo
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Ana Zabalza de Torres
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Neus Mongay
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Jordi Rio
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Manuel Comabella
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Cristina Auger
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Jaume Sastre-Garriga
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Alex Rovira
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Mar Tintore
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Xavier Montalban
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (A.C.-C., C.T., S.O.-R., P.C.-M., A.P., J.V.A., A.V.-J., G.A., J.C., I.G., M.R.B., L.S.M., C.N., B.R.A., A.Z.d.T., N.M., J.R., M.C., J.S.-G., M.T., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Department of Neurology (M.R.), Hospital Universitario Doce de Octubre, Madrid; and Section of Neuroradiology (C.A., A.R.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
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Longbrake EE, Kalincik T. Early Treatment for Multiple Sclerosis: Time Is Brain. Neurology 2023; 101:549-550. [PMID: 37468283 DOI: 10.1212/wnl.0000000000207754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023] Open
Affiliation(s)
- Erin E Longbrake
- From the Department of Neurology (E.E.L., T.K.), Yale University, New Haven, CT; Neuroimmunology Centre (E.E.L., T.K.), Department of Neurology, Royal Melbourne Hospital; and CORe (E.E.L., T.K.), Department of Medicine, University of Melbourne, Australia.
| | - Tomas Kalincik
- From the Department of Neurology (E.E.L., T.K.), Yale University, New Haven, CT; Neuroimmunology Centre (E.E.L., T.K.), Department of Neurology, Royal Melbourne Hospital; and CORe (E.E.L., T.K.), Department of Medicine, University of Melbourne, Australia
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Hobart J, Chitnis T, Oh J, Burke L, King M, Vo P, Vandercappellen J, Lloyd A. Do clinical trials prepare to fail by failing to prepare? An examination of MS trials and recommendations for patient-reported outcome measure selection. Mult Scler Relat Disord 2023; 76:104788. [PMID: 37327599 DOI: 10.1016/j.msard.2023.104788] [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: 04/14/2023] [Revised: 05/24/2023] [Accepted: 06/01/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Many clinical trials use patient-reported outcome (PRO) measures, which can influence treatment decision-making, drug approval and label claims. Given that many PRO measure options exist, and there are conceptual and contextual complexities with PRO measurement, we aimed to evaluate how and why specific PRO measures have been selected for pivotal multiple sclerosis (MS) clinical trials. Specifically, we aimed to identify the reasons documented for PRO measure selection in contemporary phase III MS disease-modifying treatment (DMT) clinical trials. METHODS We searched for phase III clinical trials of MS DMTs published between 2015 and 2021 and evaluated trial protocols, or primary publications where available, for PRO measure selection information. Specifically, we examined study documents for their clarification of clinical concepts measured, definitions of concepts measured, explanations of which PRO measures were considered, why specific PRO measures were chosen, and trade-offs in PRO measure selection. RESULTS We identified 1705 abstracts containing 61 unique phase III MS DMT clinical trials. We obtained and examined 27/61 trial protocols. Six protocols were excluded: four contained no mention of PRO measures and two contained redacted sections preventing adequate assessment, leaving 21 protocols for assessment. For the remaining 34 trials (61-27), we retrieved 31 primary publications; 15 primary publications mentioned the use of a PRO measure. None of the 36 clinical trials that mentioned the use of PRO measures (21 protocols and 15 primary publications) documented clear PRO or clinical outcome assessment (COA) measurement strategies, provided clear justifications for PRO selection, or reasons why specific PRO measures were selected when alternatives existed. CONCLUSION PRO measure selection for clinical trials is not evidence-based or underpinned by structured systematic approaches. This represents a critical area for study design improvement as PRO measure results directly affect patient care, PRO measurement has conceptual and contextual complexities, and there is a wide range of options when selecting a PRO measure. We recommend trial designers use formal approaches for PRO measure selection to ensure PRO measurement-based decisions are optimised. We provide a simple, logical, five-stage approach for PRO measure selection in clinical trials.
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Affiliation(s)
- Jeremy Hobart
- Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jiwon Oh
- Division of Neurology, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | - Pamela Vo
- Novartis Pharma AG, Basel, Switzerland
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Bu B, Quan C, Li W, Zeng Q, Shi Z, Chen B, Zhou L, Jin L, Zhou H, Yang H. The effectiveness of teriflunomide in patients with multiple sclerosis in China: a real-world comparison to no DMT treatment in the first year after diagnosis. Ther Adv Neurol Disord 2023; 16:17562864231181170. [PMID: 37529720 PMCID: PMC10387708 DOI: 10.1177/17562864231181170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/23/2023] [Indexed: 08/03/2023] Open
Abstract
Background Teriflunomide is a first-line oral immunomodulatory agent approved in China for the treatment of relapsing multiple sclerosis. Objective To compare the treatment outcomes of teriflunomide and no disease-modifying therapy (DMT) treatment (in first year) in multi-center real-world Chinese multiple sclerosis patients. Design Retrospective study. Methods This study was conducted in five tertiary hospitals in different geographical regions of China. We collected clinical data of patients treated with teriflunomide and no DMT treatment (in first year) between 1 January 2017 and 31 August 2021. The effectiveness of teriflunomide was described. Potential factors influencing the effectiveness of teriflunomide were investigated. Results A total of 372 patients treated with teriflunomide and 148 no DMT treatment patients were included. A total of 292 patients were treated with teriflunomide for at least 6 months, described as a stable teriflunomide cohort. The annualized relapse rate was significantly lower in the stable teriflunomide cohort than in the no DMT treatment cohort (0.23 ± 0.47 versus 0.87 ± 0.67, p < 0.001). The mean Expanded Disability Status Scale (EDSS) score of the stable teriflunomide cohort (1.77 ± 1.62) was slightly different from that of the no DMT treatment cohort (2.09 ± 2.00). A previous annualized relapse rate of ⩾1, a previous EDSS score of ⩾2, and a long disease duration of ⩾5 years were associated with better clinical effectiveness. Conclusion Teriflunomide is associated with a lower relapse rate and less disability accumulation in Chinese patients with multiple sclerosis.
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Affiliation(s)
| | | | | | | | | | - Bo Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Zhou
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Luya Jin
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China
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Okuda DT, Kantarci O, Lebrun-Frénay C, Sormani MP, Azevedo CJ, Bovis F, Hua LH, Amezcua L, Mowry EM, Hotermans C, Mendoza J, Walsh JS, von Hehn C, Vargas WS, Donlon S, Naismith RT, Okai A, Pardo G, Repovic P, Stüve O, Siva A, Pelletier D. Dimethyl Fumarate Delays Multiple Sclerosis in Radiologically Isolated Syndrome. Ann Neurol 2023; 93:604-614. [PMID: 36401339 DOI: 10.1002/ana.26555] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The radiologically isolated syndrome (RIS) represents the earliest detectable pre-clinical phase of multiple sclerosis (MS). This study evaluated the impact of therapeutic intervention in preventing first symptom manifestation at this stage in the disease spectrum. METHODS We conducted a multi-center, randomized, double-blinded, placebo-controlled study involving people with RIS. Individuals without clinical symptoms typical of MS but with incidental brain MRI anomalies consistent with central nervous system (CNS) demyelination were included. Within 12 MS centers in the United States, participants were randomly assigned 1:1 to oral dimethyl fumarate (DMF) 240 mg twice daily or placebo. The primary endpoint was the time to onset of clinical symptoms attributable to a CNS demyelinating event within a follow-up period of 96 weeks. An intention-to-treat analysis was applied to all participating individuals in the primary and safety investigations. The study is registered at ClinicalTrials.gov, NCT02739542 (ARISE). RESULTS Participants from 12 centers were recruited from March 9, 2016, to October 31, 2019, with 44 people randomized to dimethyl fumarate and 43 to placebo. Following DMF treatment, the risk of a first clinical demyelinating event during the 96-week study period was highly reduced in the unadjusted Cox proportional-hazards regression model (hazard ratio [HR] = 0.18, 95% confidence interval [CI] = 0.05-0.63, p = 0.007). More moderate adverse reactions were present in the DMF (34 [32%]) than placebo groups (19 [21%]) but severe events were similar (DMF, 3 [5%]; placebo, 4 [9%]). INTERPRETATION This is the first randomized clinical trial demonstrating the benefit of a disease-modifying therapy in preventing a first acute clinical event in people with RIS. ANN NEUROL 2023;93:604-614.
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Affiliation(s)
- Darin T Okuda
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Department of Health Sciences, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Francesca Bovis
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Le H Hua
- Department of Neurology, Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV
| | - Lilyana Amezcua
- Department of Neurology, University of Southern California, Los Angeles, CA
| | - Ellen M Mowry
- Department of Neurology-Neuroimmunology and Neurological Infections, Johns Hopkins University, Baltimore, MD
| | | | | | | | | | - Wendy S Vargas
- Department of Neurology, Columbia University Medical Center, New York, NY
| | - Stacy Donlon
- Department of Neuroimmunology, Multicare Auburn Medical Center, Tacoma, WA
| | | | - Annette Okai
- Department of Neurology, Baylor University Medical Center, Dallas, TX
| | - Gabriel Pardo
- Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Pavle Repovic
- Department of Neurology, Swedish Medical Center, Seattle, WA
| | - Olaf Stüve
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX.,Neurology Section, Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Aksel Siva
- Department of Neurology, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Daniel Pelletier
- Department of Neurology, University of Southern California, Los Angeles, CA
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18
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Bridge F, Brotherton JML, Foong Y, Butzkueven H, Jokubaitis VG, Van der Walt A. Risk of cervical pre-cancer and cancer in women with multiple sclerosis exposed to high efficacy disease modifying therapies. Front Neurol 2023; 14:1119660. [PMID: 36846149 PMCID: PMC9950275 DOI: 10.3389/fneur.2023.1119660] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/24/2023] [Indexed: 02/12/2023] Open
Abstract
There is a growing need to better understand the risk of malignancy in the multiple sclerosis (MS) population, particularly given the relatively recent and widespread introduction of immunomodulating disease modifying therapies (DMTs). Multiple sclerosis disproportionately affects women, and the risk of gynecological malignancies, specifically cervical pre-cancer and cancer, are of particular concern. The causal relationship between persistent human papillomavirus (HPV) infection and cervical cancer has been definitively established. To date, there is limited data on the effect of MS DMTs on the risk of persistent HPV infection and subsequent progression to cervical pre-cancer and cancer. This review evaluates the risk of cervical pre-cancer and cancer in women with MS, including the risk conferred by DMTs. We examine additional factors, specific to the MS population, that alter the risk of developing cervical cancer including participation in HPV vaccination and cervical screening programs.
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Affiliation(s)
- Francesca Bridge
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia,*Correspondence: Francesca Bridge ✉
| | - Julia M. L. Brotherton
- Australian Centre for the Prevention of Cervical Cancer (Formerly Victorian Cytology Service), Carlton South, VIC, Australia,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Yi Foong
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia,Department of Neurosciences, Eastern Health, Melbourne, VIC, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Vilija G. Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Anneke Van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
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Abstract
The multiple sclerosis (MS) neurotherapeutic landscape is rapidly evolving. New disease-modifying therapies (DMTs) with improved efficacy and safety, in addition to an expanding pipeline of agents with novel mechanisms, provide more options for patients with MS. While treatment of MS neuroinflammation is well tailored in the existing DMT armamentarium, concerted efforts are currently underway for identifying neuropathological targets and drug discovery for progressive MS. There is also ongoing research to develop agents for remyelination and neuroprotection. Further insights are needed to guide DMT initiation and sequencing as well as to determine the role of autologous stem cell transplantation in relapsing and progressive MS. This review provides a summary of these updates.
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Affiliation(s)
- Moein Amin
- Cleveland Clinic, Department of Neurology, Cleveland, OH 44195, USA
| | - Carrie M Hersh
- Cleveland Clinic, Lou Ruvo Center for Brain Health, Las Vegas, NV 89106, USA
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20
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Berkovich R, Negroski D, Wynn D, Sellers D, Bzdek KG, Lublin AL, Rawlings AM, Quach C, Wells DP, Dumlao M, Bora A, Ranno AE, Luo KL, Chavin J, Hua LH, Becker D. Effectiveness and safety of switching to teriflunomide in older patients with relapsing multiple sclerosis: A real-world retrospective multicenter analysis. Mult Scler Relat Disord 2023; 70:104472. [PMID: 36566698 DOI: 10.1016/j.msard.2022.104472] [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: 09/20/2022] [Revised: 12/05/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The prevalence of multiple sclerosis (MS) in older people is increasing due to population aging and availability of effective disease-modifying therapies (DMTs). Treating older people with MS is complicated by age-related and MS-related comorbidities, immunologic effects of prior DMTs, and immunosenescence. Teriflunomide is a once-daily oral immunomodulator that has demonstrated efficacy and acceptable safety in clinical trials of adults with relapsing forms of MS (RMS). However, there are limited clinical trial and real-world data regarding teriflunomide use in people with MS aged >55 years. We analyzed real-world data to assess the effectiveness and safety of teriflunomide in older people with RMS who had switched to this agent from other DMTs. METHODS People with RMS (relapsing remitting and active secondary progressive MS) aged ≥55 years who had switched from other DMTs to teriflunomide (7 mg or 14 mg) for ≥1 year were identified retrospectively by chart review at four sites in the United States. Data were extracted from medical records from 1 year pre-index to 2 years post-index (index defined as the teriflunomide start date). Assessments of effectiveness included annualized relapse rate (ARR), Expanded Disability Status Scale (EDSS) score, and magnetic resonance imaging (MRI) outcomes. Assessments of safety included lymphocyte counts, infections, and malignancies. We examined the effectiveness outcomes and lymphocyte counts within sub-groups defined by age (55-64, ≥65 years), sex, MS type, and prior route of DMT administration (oral, injectable, infusible). RESULTS In total, 182 patients with RMS aged ≥55 years who switched from other DMTs to teriflunomide were identified (mean [SD] age: 62.5 [5.4] years). Mean ARR decreased from the start of teriflunomide treatment (mean [SD]: 0.43 [0.61]) to year 1 post-index (0.13 [0.65]) and year 2 post-index (0.05 [0.28]). Mean EDSS score remained unchanged from index (mean [SD]: 4.5 [1.8]) to 1 year post-treatment (4.5 [1.8]) and increased slightly at 2 years post-treatment (4.7 [1.7]). MRI scans from index and years 1 and 2 post-index compared with scans from the previous year indicated that most patients had stable or improved MRI outcomes at index (87.7%) and remained stable or improved at years 1 (96.0%) and 2 (93.6%). Lymphopenia decreased at years 1 (21.4%) and 2 post-index (14.8%, compared to index (23.5%). By 1 year post-index, fewer patients had grade 3 or 4 lymphopenia, and at 2 years post-index, there were no patients with grade 3 or 4 lymphopenia. Infection incidence was low (n = 40, 22.0%) and none were related to teriflunomide. The decreases in lymphopenia were driven by decreases among people who switched from a prior oral DMT; there were no notable differences in lymphopenia across the other sub-groups examined. ARR, EDSS score, and MRI outcomes across all sub-groups were similar to the results of the overall population. CONCLUSION Our multicenter, longitudinal, retrospective study demonstrated that patients with RMS aged 55 or older switching to teriflunomide from other DMTs had significantly improved ARR, stable disability, and stable or improved MRI over up to 2 years' follow up. Safety results were acceptable with fewer patients exhibiting lymphopenia at years 1 and 2 post-index.
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Affiliation(s)
- Regina Berkovich
- Regina Berkovich MD PhD Inc MS Neurology, West Hollywood, CA, United States; USC-LAC Neurology, Los Angeles, CA, United States
| | | | - Daniel Wynn
- Consultants in Neurology MS Center, Northbrook, IL, United States
| | | | - Kristen G Bzdek
- Sanofi, Cambridge, MA, United States; Worldwide Clinical Trials, Research Triangle Park, NC, United States
| | | | | | - Cuc Quach
- Sanofi, Cambridge, MA, United States
| | | | | | | | | | | | | | - Le H Hua
- Lou Ruvo Center for Brain Health, Las Vegas, NV, United States
| | - Daniel Becker
- International Neurorehabilitation Institute, Baltimore, MD, USA; Johns Hopkins Hospital, Baltimore, MD, United States.
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21
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Pennington P, Weinstock-Guttman B, Kolb C, Jakimovski D, Sacca K, Benedict RHB, Eckert S, Stecker M, Lizarraga A, Dwyer MG, Schumacher CB, Bergsland N, Picco P, Bernitsas E, Zabad R, Pardo G, Negroski D, Belkin M, Hojnacki D, Zivadinov R. Communicating the relevance of neurodegeneration and brain atrophy to multiple sclerosis patients: patient, provider and researcher perspectives. J Neurol 2023; 270:1095-1119. [PMID: 36376729 DOI: 10.1007/s00415-022-11405-3] [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: 06/22/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022]
Abstract
Central nervous system (CNS) atrophy provides valuable additional evidence of an ongoing neurodegeneration independent of lesion accrual in persons with multiple sclerosis (PwMS). However, there are limitations for interpretation of CNS volume changes at individual patient-level. Patients are receiving information on the topic of atrophy through various sources, including media, patient support groups and conferences, and discussions with their providers. Whether or not the topic of CNS atrophy should be proactively discussed with PwMS during office appointments is currently controversial. This commentary/perspective article represents perspectives of PwMS, providers and researchers with recommendations for minimizing confusion and anxiety, and facilitating proactive discussion about brain atrophy, as an upcoming routine measure in evaluating disease progression and treatment response monitoring. The following recommendations were created based on application of patient's and provider's surveys, and various workshops held over a period of 2 years: (1) PwMS should receive basic information on understanding of brain functional anatomy, and explanation of inflammation and neurodegeneration; (2) the expertise for atrophy measurements should be characterized as evolving; (3) quality patient education materials on these topics should be provided; (4) the need for standardization of MRI exams has to be explained and communicated; (5) providers should discuss background on volumetric changes, including references to normal aging; (6) the limitations of brain volume assessments at an individual-level should be explained; (7) the timing and language used to convey this information should be individualized based on the patient's background and disease status; (8) a discussion guide may be a very helpful resource for use by providers/staff to support these discussions; (9) understanding the role of brain atrophy and other MRI metrics may elicit greater patient satisfaction and acceptance of the value of therapies that have proven efficacy around these outcomes; (10) the areas that represent possibilities for positive self-management of MS symptoms that foster hope for improvement should be emphasized, and in particular regarding use of physical and mental exercise that build or maintain brain reserve through increased network efficiency, and (11) an additional time during clinical visits should be allotted to discuss these topics, including creation of specific educational programs.
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Affiliation(s)
- Penny Pennington
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Channa Kolb
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Dejan Jakimovski
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 14203, USA
| | - Katherine Sacca
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | - Ralph H B Benedict
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Svetlana Eckert
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Marc Stecker
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | - Alexis Lizarraga
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Michael G Dwyer
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 14203, USA.,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Carol B Schumacher
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | - Niels Bergsland
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 14203, USA.,IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Patricia Picco
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | | | - Rana Zabad
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Gabriel Pardo
- Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | | | - Martin Belkin
- Michigan Institute for Neurological Disorders (MIND), Farmington Hills, MI, USA
| | - David Hojnacki
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Robert Zivadinov
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 14203, USA. .,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA.
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22
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Teriflunomide Concentrations in Cerebrospinal Fluid and Plasma in Patients with Multiple Sclerosis: A Pharmacokinetic Study. CNS Drugs 2023; 37:181-188. [PMID: 36729276 PMCID: PMC9911485 DOI: 10.1007/s40263-023-00985-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Teriflunomide is a disease modifying treatment (DMT) approved for relapsing-remitting multiple sclerosis (RRMS) in adults and children. It reduces lymphocyte proliferation by inhibiting the mitochondrial enzyme dihydroorotate dehydrogenase (DHODH) and thereby the pyrimidine synthesis. Although most DMTs in multiple sclerosis (MS) modulate or inhibit the immune system in the periphery, the efficacy may improve if the agent also targets immune activity within the central nervous system (CNS), acts as a neuro-protective and enhances neuro-regeneration. The objective of this study was to determine the passage of teriflunomide over the blood-cerebrospinal fluid barrier (BCSFB). METHODS Plasma and cerebrospinal fluid (CSF) teriflunomide concentrations were determined at steady state in 12 patients with RRMS, treated with oral teriflunomide 14 mg once daily. Included patients were all clinically stable without relapse or disability worsening within 6 months prior from baseline and were on no other immune modulating or immunosuppressive drugs. RESULTS The mean teriflunomide concentrations in plasma and CSF were 38775 (SEM ± 7256) ng/mL and 68 (SEM ± 15) ng/mL, respectively. The passage over the BCSFB was 0.17 % (SEM ± 0.01). While no correlation was found between the function of the BCSFB assessed with the albumin ratio and the CSF teriflunomide concentration, the CSF and plasma teriflunomide concentrations were highly correlated (rs = 0.90, < 0.0001). CONCLUSIONS Further studies are warranted to determine if the obtained CSF teriflunomide concentration reflects that in the CNS and is able to influence inflammatory and degenerative processes within the CNS.
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23
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Finkener S, Achtnichts L, Cervenakova M, Nedeltchev K, Findling O. Oral disease modifying therapies - A game changer for treatment decision in untreated patients with RRMS and CIS? - A swiss single center cross-sectional study. Mult Scler Relat Disord 2022; 68:104396. [PMID: 36544325 DOI: 10.1016/j.msard.2022.104396] [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: 07/31/2022] [Revised: 09/19/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Several disease-modifying therapies (DMTs) show efficacy in relapsing-remitting multiple sclerosis (RRMS) and clinically isolated syndrome (CIS). However, there is still a relevant proportion of patients who remain untreated. We provide real-world data on untreated and treated patients and we report whether and how the introduction of oral DMTs changed the treatment decision. Furthermore, we discuss possible reasons for not receiving DMTs. METHODS We conducted a retrospective cross-sectional study and analysed demographic and clinical data of patients with RRMS and CIS at our MS center. Comparison was made between untreated and treated patients in 2010 (before the introduction of oral DMTs) and in 2014 (after the introduction of oral DMTs). Furthermore, we analysed reasons for the decision against DMTs in patients who never received DMTs and patients who discontinued DMTs. RESULTS We analysed datasets of 344 MS patients in 2010 and 253 in 2014. There were more untreated patients in CIS than in RRMS. In RRMS, the proportion of untreated patients decreased significantly between 2010 and 2014 from 23.6% to 11.1%, while the use of oral medications increased significantly from <1% to more than 50% in 2014. In CIS, there was no significant change in untreated patients between 2010 and 2014 (61.1% in 2010 to 52.6% in 2014). Untreated patients with RRMS were significantly older and had lower ARR than treated patients. Patients who never received DMT had lower EDSS compared to patients that had been treated before. The main reasons for the decision against DMT were "belief in a benign course" and "fear of adverse effects". Treatment discontinuation was caused mainly by the adverse effects. DISCUSSION In our data a relevant proportion of patients with RRMS and CIS did not receive any DMT. We hypothesize that in patients with RRMS the introduction of oral DMTs translated to a higher rate of treatment, whereas in CIS there no change was observed. This could be due to limited therapeutic options in CIS. There is more information needed regarding the treatment recommendation for older patients and patients with mild course of the disease.
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Affiliation(s)
| | - Lutz Achtnichts
- Department of Neurology, Aarau Cantonal Hospital, Aarau, Switzerland
| | | | - Krassen Nedeltchev
- Department of Neurology, Aarau Cantonal Hospital, Aarau, Switzerland; University of Bern, Bern, Switzerland
| | - Oliver Findling
- Department of Neurology, Aarau Cantonal Hospital, Aarau, Switzerland; MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel(RC2NB),Head, Spine and Neuromedicine, Clinical Research and Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
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24
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Controversies in neuroimmunology: multiple sclerosis, vaccination, SARS-CoV-2 and other dilemas. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2022; 42:78-99. [PMID: 36322548 PMCID: PMC9714524 DOI: 10.7705/biomedica.6366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Indexed: 12/04/2022]
Abstract
Neuroimmunology is a discipline that increasingly broadens its horizons in the understanding of neurological diseases. At the same time, and in front of the pathophysiological links of neurological diseases and immunology, specific diagnostic and therapeutic approaches have been proposed. Despite the important advances in this discipline, there are multiple dilemmas that concern and filter into clinical practice. This article presents 15 controversies and a discussion about them, which are built with the most up-to-date evidence available. The topics included in this review are: steroid decline in relapses of multiple sclerosis; therapeutic recommendations in MS in light of the SARS-CoV-2 pandemic; evidence of vaccination in multiple sclerosis and other demyelinating diseases; overview current situation of isolated clinical and radiological syndrome; therapeutic failure in multiple sclerosis, as well as criteria for suspension of disease-modifying therapies; evidence of the management of mild relapses in multiple sclerosis; recommendations for prophylaxis against Strongyloides stercolaris; usefulness of a second course of immunoglobulin in the Guillain-Barré syndrome; criteria to differentiate an acute-onset inflammatory demyelinating chronic polyneuropathy versus Guillain-Barré syndrome; and, the utility of angiotensin-converting enzyme in neurosarcoidosis. In each of the controversies, the general problem is presented, and specific recommendations are offered that can be adopted in daily clinical practice.
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25
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Štrosová D, Tužil J, Turková BV, Pilnáčková BF, de Souza LL, Doležalová H, Rašková M, Dufek M, Doležal T. Relationship between Patient Preferences, Attitudes to Treatment, Adherence, and Quality of Life in New Users of Teriflunomide. Pharmaceuticals (Basel) 2022; 15:1248. [PMID: 36297360 PMCID: PMC9609230 DOI: 10.3390/ph15101248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/27/2022] [Accepted: 10/02/2022] [Indexed: 03/08/2024] Open
Abstract
Background: A poor patient adherence often limits the real-world effectiveness of an oral disease-modifying therapy (DMT) for multiple sclerosis (MS). In the present study, we aimed to map patient preferences, attitudes toward treatment, and quality of life to identify the predictors of non-adherence to teriflunomide. Methods: This was a single-arm, non-interventional, multicenter study (Czech Act 378/2007 Coll.) consisting of three visits: the first at treatment initiation (teriflunomide 14 mg), and then after 3 and 9 months of therapy. We enrolled both DMT-naïve and patients who had undergone a DMT diagnosed with a clinically isolated syndrome (CIS) or relapsing-remitting multiple sclerosis (RRMS). The functional status and MS activity were estimated using the Expanded Disability Status Scale (EDSS) and annualized relapse rate (ARR); the quality of life via the Multiple Sclerosis Impact Scale (MSIS-29); the medication adherence with the Morisky Medication Adherence Scale (MMAS-8); the confidence in the ability to take medications by the Self-Efficacy for Appropriate Medication Score (SEAMS); and the attitude to the therapy via the Beliefs about Medicines Questionnaire (BMQ). After nine months of therapy, we predicted the adherence to teriflunomide (MMAS-8) by fitting a multivariate ordinal logistic model with EDSS changes, gender, previous DMT, MSIS-29, BMQ, and SEAMS as the explanatory variables. Results: Between 2018 and 2019, 114 patients were enrolled at 10 sites in the Czech Republic. The mean age was 41.2 years, 64.8% were diagnosed with a CIS, 52.4% were DMT-naïve, and 98.1% of patients preferred an oral administration at the baseline. The mean EDSS baseline was 1.97 and remained constant during the 9 months of therapy. The ARR baseline was 0.72 and dropped to 0.19 and 0.15 after 3 and 9 months, respectively. Despite a more than 4-fold higher ARR baseline, the treatment-naïve patients achieved an ARR at 9 months comparable with those previously treated. There were ten non-serious adverse reactions. After nine months of teriflunomide therapy, 63.3%, 21.2%, and 15.4% of patients had a high, medium, and low adherence, respectively, as per the MMAS-8; 100% of patients preferred an oral administration. The SEAMS score (odds ratio (OR) = 0.91; p = 0.013) and previous DMT (OR = 4.28; p = 0.005) were the only significant predictors of non-adherence. The disability, the quality of life, and beliefs about medicines had no measurable effect on adherence. Conclusion: After nine months of teriflunomide therapy, both the disability and quality of life remained stable; the relapse rate significantly decreased, 63.3% of patients had a high adherence, and 100% of patients preferred an oral administration. A low adherence was associated with previous DMT experiences and a low self-efficacy for the appropriate medication (i.e., the confidence in one's ability to take medication correctly).
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Affiliation(s)
- Daniela Štrosová
- Value Outcomes Ltd., Vaclavska 316/12, 12000 Prague, Czech Republic
| | - Jan Tužil
- Value Outcomes Ltd., Vaclavska 316/12, 12000 Prague, Czech Republic
- Medical Informatics, First Medical Faculty, Charles University, Kateřinská 1660/32, 12000 Prague, Czech Republic
| | | | | | | | | | | | - Michal Dufek
- 1st Department of Neurology, St. Anne’s University Hospital, Pekařská 664/53, 60200 Brno, Czech Republic
| | - Tomáš Doležal
- Value Outcomes Ltd., Vaclavska 316/12, 12000 Prague, Czech Republic
- Pharmacology Department, Faculty of Medicine, Masaryk University, Kamenice 753/5, 62500 Brno, Czech Republic
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26
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Treatment and Relapse Prevention of Typical and Atypical Optic Neuritis. Int J Mol Sci 2022; 23:ijms23179769. [PMID: 36077167 PMCID: PMC9456305 DOI: 10.3390/ijms23179769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 12/02/2022] Open
Abstract
Optic neuritis (ON) is an inflammatory condition involving the optic nerve. Several important typical and atypical ON variants are now recognized. Typical ON has a more favorable prognosis; it can be idiopathic or represent an early manifestation of demyelinating diseases, mostly multiple sclerosis (MS). The atypical spectrum includes entities such as antibody-driven ON associated with neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD), chronic/relapsing inflammatory optic neuropathy (CRION), and sarcoidosis-associated ON. Appropriate and timely diagnosis is essential to rapidly decide on the appropriate treatment, maximize visual recovery, and minimize recurrences. This review paper aims at presenting the currently available state-of-the-art treatment strategies for typical and atypical ON, both in the acute phase and in the long-term. Moreover, emerging therapeutic approaches and novel steps in the direction of achieving remyelination are discussed.
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Lazzaro C, Bergamaschi R, Zaffaroni M, Totaro R, Paolicelli D. Cost-utility analysis of teriflunomide in naïve vs. previously treated patients with relapsing–remitting multiple sclerosis in Italy. Neurol Sci 2022; 43:4933-4944. [PMID: 35420360 PMCID: PMC9349140 DOI: 10.1007/s10072-022-06022-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 03/16/2022] [Indexed: 12/03/2022]
Abstract
Background Multiple sclerosis (MS) accounts for 176 cases per 100,000 inhabitants (female/male ratio = 2:1) in Italy. For most of the patients (67%), the disease course is relapsing–remitting MS (RRMS). Objective To compare the costs and quality-adjusted life years (QALYs) of teriflunomide in RRMS naïve patients vs. RRMS patients previously treated (experienced) with other disease-modifying therapies in Italy. Methods A four health states Markov model-supported cost-utility analysis (CUA) covering a 7-year timespan through annual cycles was developed, following the healthcare sector and the societal viewpoints. Part of the parameters that populated the Markov model was obtained from a questionnaire administered to four primary Italian MS centres. Costs of healthcare and non-healthcare resources, expressed in euro (€) 2019, and QALYs were discounted at 3% real social discount rate. One-way, scenario and probabilistic sensitivity analyses tested the uncertainty of the baseline findings. Results Baseline CUA shows that teriflunomide in RRMS naïve patients is strongly dominant vs. experienced patients (healthcare sector perspective: − €1042.68 and + 0.480 QALYs; societal perspective: − €6782.81 and + 0.480 QALYs). Sensitivity analyses confirmed the robustness of the baseline results. Conclusion Teriflunomide in RRMS naïve vs. experienced patients is cost-effective and possibly strongly dominant from both the healthcare sector and the society viewpoints in Italy. Our findings need further confirmation from real-world studies. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-022-06022-x.
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Affiliation(s)
- Carlo Lazzaro
- Studio di Economia Sanitaria, Via Stefanardo da Vimercate, 19, 20128, Milan, Italy.
| | | | - Mauro Zaffaroni
- Multiple Sclerosis Centre, Hospital of Gallarate, ASST Della Valle Olona, Gallarate, Italy
| | - Rocco Totaro
- Centro Malattie Demielinizzanti, Ospedale San Salvatore, L'Aquila, Italy
| | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
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Bierhansl L, Hartung HP, Aktas O, Ruck T, Roden M, Meuth SG. Thinking outside the box: non-canonical targets in multiple sclerosis. Nat Rev Drug Discov 2022; 21:578-600. [PMID: 35668103 PMCID: PMC9169033 DOI: 10.1038/s41573-022-00477-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 12/11/2022]
Abstract
Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system that causes demyelination, axonal degeneration and astrogliosis, resulting in progressive neurological disability. Fuelled by an evolving understanding of MS immunopathogenesis, the range of available immunotherapies for clinical use has expanded over the past two decades. However, MS remains an incurable disease and even targeted immunotherapies often fail to control insidious disease progression, indicating the need for new and exceptional therapeutic options beyond the established immunological landscape. In this Review, we highlight such non-canonical targets in preclinical MS research with a focus on five highly promising areas: oligodendrocytes; the blood-brain barrier; metabolites and cellular metabolism; the coagulation system; and tolerance induction. Recent findings in these areas may guide the field towards novel targets for future therapeutic approaches in MS.
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Affiliation(s)
- Laura Bierhansl
- Department of Neurology, Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Michael Roden
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
- German Center of Diabetes Research, Partner Düsseldorf, Neuherberg, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
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Hardy TA, Parratt J, Beadnall H, Blum S, Macdonell R, Beran RG, Shuey N, Lee A, Carroll W, Shaw C, Worrell R, Moody J, Sedhom M, Barnett M, Vucic S. Treatment satisfaction in patients with relapsing-remitting multiple sclerosis initiated on teriflunomide in routine clinical practice: Australian observational data. BMJ Neurol Open 2022; 4:e000315. [PMID: 35865788 PMCID: PMC9255404 DOI: 10.1136/bmjno-2022-000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background Adherence and persistence are critical to optimising therapeutic benefit from disease-modifying therapies (DMTs) in relapsing-remitting multiple sclerosis (RRMS). This prospective, open-label, multicentre, observational study (AubPRO), conducted in 13 hospital-based neurology clinics around Australia, describes treatment satisfaction in patients newly initiated on teriflunomide (Aubagio) and evaluates the use of an electronic patient-reported outcome (PRO) tool. Methods Patients (≥18 years) newly initiated on teriflunomide (14 mg/day) were followed up at 24 and 48 weeks. Patients completed questionnaires and pill counts electronically using MObile Data in Multiple Sclerosis. The primary endpoint was treatment satisfaction, measured by the Treatment Satisfaction Questionnaire for Medication (TSQM, V.1.4), at week 48. Secondary endpoints included treatment satisfaction at week 24, other PRO scales, clinical outcomes, medication adherence and safety. Results Patients (n=103; 54 (52.4%) treatment naive) were mostly female (n=82 (79.6%)), aged 49.5 (11.8) years, with MS duration since symptom onset of 9.1 (11.8) years and a median Expanded Disability Status Scale score of 1.0. Mean treatment satisfaction scores were high (≥60%) across all domains of the TSQM V.1.4 at week 24 and at week 48. Compared with week 24, week 48 treatment satisfaction increased for patients who were treatment naïve and for those previously on another oral or injectable DMT. Over 48 weeks, PROs remained stable across a range of measures including disability, physical health, emotional health and mobility, and there were improvements in work capacity and daily life activity. Adherence was high throughout the study with mean compliance (pill counts) of 93.2%±6.26%, and 98 of 103 (95.1%) patients remained relapse-free. Conclusion This cohort of Australian patients with RRMS, newly initiated on teriflunomide, and treated in a real-world clinical practice setting, reported high treatment satisfaction and adherence at 24 and 48 weeks. Patient-reported measures of disability remained stably low, work capacity and daily life activity improved, and most patients remained relapse-free.
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Affiliation(s)
- Todd A Hardy
- Department of Neurology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - John Parratt
- Department of Neurology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Heidi Beadnall
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Stefan Blum
- Department of Neurology, Princess Alexandra Hospital Health Service District, Woolloongabba, Queensland, Australia
| | - Richard Macdonell
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Roy G Beran
- Department of Medicine, South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Legal Medicine, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
| | - Neil Shuey
- Department of Neurology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Andrew Lee
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Department of Neurology, Calvary Adelaide Hospital, Adelaide, South Australia, Australia
| | - William Carroll
- Perron Institute for Neurological and Translational Research, Nedlands, Western Australia, Australia
| | - Cameron Shaw
- Geelong Clinical School, Deakin University, Geelong, Victoria, Australia
| | - Richard Worrell
- Sanofi Australia, Macquarie Park, New South Wales, Australia
| | - Jana Moody
- Sanofi Australia, Macquarie Park, New South Wales, Australia
| | - Mamdouh Sedhom
- Sanofi Australia, Macquarie Park, New South Wales, Australia
| | - Michael Barnett
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, Concord Clinical School, Concord, New South Wales, Australia
- Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia
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Collongues N, Becker G, Jolivel V, Ayme-Dietrich E, de Seze J, Binamé F, Patte-Mensah C, Monassier L, Mensah-Nyagan AG. A Narrative Review on Axonal Neuroprotection in Multiple Sclerosis. Neurol Ther 2022; 11:981-1042. [PMID: 35610531 PMCID: PMC9338208 DOI: 10.1007/s40120-022-00363-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/03/2022] [Indexed: 01/08/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) resulting in demyelination and neurodegeneration. The therapeutic strategy is now largely based on reducing inflammation with immunosuppressive drugs. Unfortunately, when disease progression is observed, no drug offers neuroprotection apart from its anti-inflammatory effect. In this review, we explore current knowledge on the assessment of neurodegeneration in MS and look at putative targets that might prove useful in protecting the axon from degeneration. Among them, Bruton's tyrosine kinase inhibitors, anti-apoptotic and antioxidant agents, sex hormones, statins, channel blockers, growth factors, and molecules preventing glutamate excitotoxicity have already been studied. Some of them have reached phase III clinical trials and carry a great message of hope for our patients with MS.
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Affiliation(s)
- Nicolas Collongues
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France. .,Center for Clinical Investigation, INSERM U1434, Strasbourg, France. .,Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France. .,University Department of Pharmacology, Addictology, Toxicology and Therapeutic, Strasbourg University, Strasbourg, France.
| | - Guillaume Becker
- University Department of Pharmacology, Addictology, Toxicology and Therapeutic, Strasbourg University, Strasbourg, France.,NeuroCardiovascular Pharmacology and Toxicology Laboratory, UR7296, University Hospital of Strasbourg, Strasbourg, France
| | - Valérie Jolivel
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Estelle Ayme-Dietrich
- University Department of Pharmacology, Addictology, Toxicology and Therapeutic, Strasbourg University, Strasbourg, France.,NeuroCardiovascular Pharmacology and Toxicology Laboratory, UR7296, University Hospital of Strasbourg, Strasbourg, France
| | - Jérôme de Seze
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France.,Center for Clinical Investigation, INSERM U1434, Strasbourg, France.,Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Fabien Binamé
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Christine Patte-Mensah
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Laurent Monassier
- University Department of Pharmacology, Addictology, Toxicology and Therapeutic, Strasbourg University, Strasbourg, France.,NeuroCardiovascular Pharmacology and Toxicology Laboratory, UR7296, University Hospital of Strasbourg, Strasbourg, France
| | - Ayikoé Guy Mensah-Nyagan
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
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Okuda DT, Burgess KW, Cook K, McCreary M, Winkler MD, Moog TM. Hiding in Plain Sight: The Magnitude of Unused Disease Modifying Therapies in Multiple Sclerosis and Strategies for Reducing the Economic Burden of Care. Mult Scler Relat Disord 2022; 63:103920. [DOI: 10.1016/j.msard.2022.103920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/06/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022]
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Talanki Manjunatha R, Habib S, Sangaraju SL, Yepez D, Grandes XA. Multiple Sclerosis: Therapeutic Strategies on the Horizon. Cureus 2022; 14:e24895. [PMID: 35706718 PMCID: PMC9187186 DOI: 10.7759/cureus.24895] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 12/24/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic disease affecting the brain and the spinal cord. It is a chronic inflammatory demyelinating disease of the central nervous system. It is the leading cause of non-traumatic disability in young adults. The clinical course of the disease is quite variable, ranging from stable chronic disease to rapidly evolving debilitating disease. The pathogenesis of MS is not fully understood. Still, there has been a rapid shift in understanding the immune pathology of MS away from pure T cell-mediated disease to B cells and microglia/astrocytes having a vital role in the pathogenesis of MS. This has helped in the emergence of new therapies for management. Effective treatment of MS requires a multidisciplinary approach to manage acute attacks, prevent relapses and disease progression and treat the disabling symptoms associated with the disease. In this review, we discuss the pathogenesis of MS, management of acute relapses, disease-modifying therapies in MS, new drugs and drugs currently in trial for MS and the symptomatic treatment of MS. All language search was conducted on Google Scholar, PubMed, MEDLINE, and Embase till February 2022. The following search strings and medical subheadings (MeSH) were used: "Multiple Sclerosis", "Pathogenesis of MS", and "Disease-modifying therapies in MS". We explored literature on the pathogenic mechanisms behind MS, management of acute relapses, disease-modifying therapies in MS and symptomatic management.
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Affiliation(s)
| | - Salma Habib
- Medicine and Surgery, Institute of Applied Health Science, Chittagong, BGD
| | | | - Daniela Yepez
- Faculty of Medicine, Universidad Catolica de Santiago de Guayaquil, Guayaquil, ECU
| | - Xavier A Grandes
- General Physician, Universidad Catolica Santiago de Guayaquil, Guayaquil, ECU
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Hestvik ALK, Frederiksen JL, Nielsen HH, Torkildsen Ø, Eek C, Huang-Link Y, Haghighi S, Tsai JA, Kant M. Real-World Study of Relapsing-Remitting Multiple Sclerosis Patients Treated with Teriflunomide in Nordic Countries: Quality-Of-Life, Efficacy, Safety and Adherence Outcomes. Mult Scler Relat Disord 2022; 63:103892. [DOI: 10.1016/j.msard.2022.103892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/13/2022] [Accepted: 05/15/2022] [Indexed: 10/18/2022]
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Kutskaya AM, Serkov SA, Voronin VV, Ledovskaya MS, Polynski MV. Negligible Substituent Effect as Key to Synthetic Versatility: a Computational‐Experimental Study of Vinyl Ethers Addition to Nitrile Oxides. ChemistrySelect 2022. [DOI: 10.1002/slct.202200174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Anastasia M. Kutskaya
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
| | - Semyon A. Serkov
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
| | - Vladimir V. Voronin
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
| | - Maria S. Ledovskaya
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
| | - Mikhail V. Polynski
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
- Zelinsky Institute of Organic Chemistry Russian Academy of Sciences Leninsky Prospect 47 Moscow 119991 Russia
- MSU Faculty of Chemistry Leninskiye Gory 1–3 Moscow 119991 Russia
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Bebo BF, Allegretta M, Landsman D, Zackowski KM, Brabazon F, Kostich WA, Coetzee T, Ng AV, Marrie RA, Monk KR, Bar-Or A, Whitacre CC. Pathways to cures for multiple sclerosis: A research roadmap. Mult Scler 2022; 28:331-345. [PMID: 35236198 PMCID: PMC8948371 DOI: 10.1177/13524585221075990] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Multiple Sclerosis (MS) is a growing global health challenge affecting nearly 3 million people. Progress has been made in the understanding and treatment of MS over the last several decades, but cures remain elusive. The National MS Society is focused on achieving cures for MS. Objectives: Cures for MS will be hastened by having a roadmap that describes knowledge gaps, milestones, and research priorities. In this report, we share the Pathways to Cures Research Roadmap and recommendations for strategies to accelerate the development of MS cures. Methods: The Roadmap was developed through engagement of scientific thought leaders and people affected by MS from North America and the United Kingdom. It also included the perspectives of over 300 people living with MS and was endorsed by many leading MS organizations. Results: The Roadmap consist of three distinct but overlapping cure pathways: (1) stopping the MS disease process, (2) restoring lost function by reversing damage and symptoms, and (3) ending MS through prevention. Better alignment and focus of global resources on high priority research questions are also recommended. Conclusions: We hope the Roadmap will inspire greater collaboration and alignment of global resources that accelerate scientific breakthroughs leading to cures for MS.
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Affiliation(s)
- Bruce F Bebo
- National Multiple Sclerosis Society 733 3rd Ave New York, NY 10017 USA
| | - Mark Allegretta
- National Multiple Sclerosis Society 733 3rd Ave New York, NY 10017 USA
| | - Douglas Landsman
- National Multiple Sclerosis Society 733 3rd Ave New York, NY 10017 USA
| | - Kathy M Zackowski
- National Multiple Sclerosis Society 733 3rd Ave New York, NY 10017 USA
| | - Fiona Brabazon
- National Multiple Sclerosis Society 733 3rd Ave New York, NY 10017 USA
| | - Walter A Kostich
- National Multiple Sclerosis Society 733 3rd Ave New York, NY 10017 USA
| | - Timothy Coetzee
- National Multiple Sclerosis Society 733 3rd Ave New York, NY 10017 USA
| | | | - Ruth Ann Marrie
- Department of Internal Medicine (Neurology), University of Manitoba, Winnipeg, MB, Canada
| | - Kelly R Monk
- Vollum Institute, Oregon Health & Science University, Portland, OR, USA
| | - Amit Bar-Or
- Center for Neuroinflammation and Neurotherapeutics, Multiple Sclerosis Division, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Liu Y, Rang X, Zou X, Wang X, Zhang X, Wang Y, Xu C, Fu J. Identification of common susceptibility genes and drug target genes in multiple sclerosis, systemic lupus erythematosus, and rheumatoid arthritis and its value to guide clinical treatment. Mult Scler Relat Disord 2022; 58:103504. [PMID: 35030369 DOI: 10.1016/j.msard.2022.103504] [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: 07/16/2021] [Revised: 12/11/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an autoimmune-mediated demyelinating disease of the white matter in the central nervous system (CNS). In clinical practice, it was found that MS is associated with a variety of autoimmune diseases, such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA). The aim of this study was to identify common susceptibility genes and drug target genes in MS, SLE, and RA and to provide new insights into treatment. METHODS The common susceptibility genes of MS, SLE, and RA were obtained by searching the GWAS database and using microarray data to validate. The Genome Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were performed, and the common KEGG pathways were selected. All the genes enriched in the common pathways were obtained and intersected with the susceptibility genes of MS, SLE, and RA to obtain the pathway genes of them respectively, and found the common pathogenesis-related genes of the three diseases. By reviewing the literature and the DrugBank database, the drugs and drug target genes that have been approved for the treatment of the three diseases were obtained. Finally, the DGIdb database was searched to predict potential drugs or molecular compounds that interact with susceptibility genes common to MS, SLE, and RA. RESULTS In MS, SLE, and RA, there were 46 common susceptibility genes, of which 23 were significantly differentially expressed in the microarray expression profile. Then, 2117 genes were obtained in the 42 common pathways, among which 17 pathogenesis-related genes were common in MS, SLE, and RA. The Drugbank database was used to obtain 29 drug target genes for MS, 43 drug target genes for RA, and 20 drug target genes for SLE. DHODH is a common drug target gene for MS, SLE, and RA, and its corresponding drugs are Leflunomide and Teriflunomide. A total of 13 genes and 366 potential drugs or molecular compounds were predicted to have interaction relationships after searching the DGIdb database. CONCLUSION The common susceptibility genes and drug target genes among MS, SLE, and RA provide a theoretical basis for the co-morbidity phenomenon of the three diseases in clinical practice and may guide the clinical treatment.
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Affiliation(s)
- Yang Liu
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Xinming Rang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Xiaowei Zou
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Xin Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Xuemei Zhang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yifei Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Chaohan Xu
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Heilongjiang Province, China.
| | - Jin Fu
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China.
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Guarnaccia JB, Cabot A, Garten LL, Napoli S, Hasbani MJ. Teriflunomide levels in women whose male sexual partner is on teriflunomide for relapsing multiple sclerosis. Mult Scler Relat Disord 2022; 57:103347. [PMID: 35158456 DOI: 10.1016/j.msard.2021.103347] [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: 06/29/2021] [Revised: 10/05/2021] [Accepted: 10/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND For small molecules such as teriflunomide, used to treat relapsing multiple sclerosis (MS), that are potentially embryotoxic, there is a theoretical risk of transmission of the medication from males on the drug to female sexual partners. However, that risk has been undefined up to now. METHODS Teriflunomide concentrations were assayed concomitantly in ten sexually active couples, not using barrier methods of contraception, in whom the male partner with MS was on treatment with teriflunomide 14 mg daily for at least two months. These results were compared by male and female age, teriflunomide concentrations and reported average number of incidences of sexual intercourse per month. The threshold level of detection of teriflunomide was 0.020 µg/ml in females. RESULTS The average age of the cohort was 46.70 for males and 47.10 for females. Four of ten females had detectible teriflunomide concentrations (mean 0.046 µg/ml (range 0.22-0.077, standard deviation 0.025). Male age and both female teriflunomide positive threshold and female teriflunomide concentration were inversely correlated (r = 0.67, R2=0.45, p = 0.034) for the former and (r = 0.62, R2=0.39, p = 0.05, ns) for the latter. No significant correlations were observed for female age, male teriflunomide concentrations, or reported mean monthly episodes of sexual intercourse. CONCLUSION This limited study suggests that the small risk that low levels of teriflunomide can be transmitted from male to female partners via sexual intercourse is related to male age. This supports the recommendations found in the United States Product Insert (USPI) stating that men taking teriflunomide who do not wish to father a child, and their female partners, should use reliable contraception. Men wishing to father a child should discontinue use of teriflunomide and undergo an accelerated elimination procedure to reduce the plasma concentrations of the medication to less than 0.02 mg/L (0.02 µg/ml1.
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Affiliation(s)
| | - Ann Cabot
- MS Specialty Care Program, Concord Hospital, NH, United States
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Alroughani R, Inshasi J, Al Khawajah M, Ahmed SF, Al Malik Y, Alkhabouri J, Shatila A, Aljarallah S, Cupler EJ, Qureshi SA, Thakre M, Elhasin H, Ezzat A, Roushdy S. Real-world effectiveness and safety profile of teriflunomide in the management of multiple sclerosis in the Gulf Cooperation Council countries: An expert consensus narrative review. Mult Scler J Exp Transl Clin 2022; 8:20552173221077185. [PMID: 35284088 PMCID: PMC8915209 DOI: 10.1177/20552173221077185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/06/2022] [Accepted: 01/13/2022] [Indexed: 12/21/2022] Open
Abstract
Background The prevalence of multiple sclerosis (MS) is increasing in Gulf Cooperation Council (GCC) countries. Multiple sclerosis contributes to significant burden on patients and caregivers. The pharmacological treatment in MS involves treating acute exacerbations and preventing relapses and disability progression using disease-modifying therapies. Clinical evidence suggests that teriflunomide is one of the therapeutic choices for patients with relapsing–remitting MS (RRMS). However, genetic and cultural differences across different regions may contribute to variations in drug use. Therefore, it is necessary to consider real-world evidence for teriflunomide usage in GCC countries. Methods An expert group for MS gathered from GCC countries in December 2020. The consensus highlighting role of teriflunomide in MS management has been developed using clinical experiences and evidence-based approach. Results The expert-recommended patient profile for teriflunomide usage includes individuals aged 18 years and above, both men and women (on effective contraceptives) with clinically isolated syndrome or RRMS. The factors considered were cost-effectiveness of the drug, patient preference, adherence, monitoring, established safety profile, and coronavirus disease 2019 status. Conclusion Expert recommendations based on their clinical experience will be more helpful to clinicians in clinical settings regarding the usage of teriflunomide and provide valuable insights applicable in day-to-day practice.
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Affiliation(s)
- Raed Alroughani
- Division of Neurology, Department of Medicine, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Jihad Inshasi
- Neurology Department, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, UAE
| | | | | | - Yaser Al Malik
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | | | | | - Edward J Cupler
- King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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Zhou R, Li H, Yang H, Jiang F, Cai H, Li J, Chen S, Fang L, Yin J, Zeng Q. Serological markers exploration and real-world effectiveness and safety of teriflunomide in south Chinese patients with multiple sclerosis. Mult Scler Relat Disord 2021; 58:103446. [PMID: 34929454 DOI: 10.1016/j.msard.2021.103446] [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: 07/01/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Since September 2012, when teriflunomide was approved as a disease-modifying treatment for relapsing multiple sclerosis, real-world observational studies on teriflunomide in Chinese patients are limited. METHODS We collected demographic characteristics and peripheral blood samples at different time points. Clinical symptoms, magnetic resonance imaging data, and concentrations of neurofilament light chains and multiple cytokines at different time points were compared to assess the efficacy. Moreover, the safety was assessed by blood routine, liver and kidney function, and a questionnaire to report adverse reactions. RESULTS Teriflunomide significantly reduced serum levels of neurofilament light chains and several inflammatory cytokines. After accepting teriflunomide treatment, many clinical symptoms improved, scores of the expanded disability status scale decreased from 2.0 to 1.75, and annualized relapse rates decreased from 1.45 to 0.31. 29 (80.56%) and 15 (78.95%) patients achieved the no evidence of disease activity-3 status after 6 months and 12 months treatment, respectively. Teriflunomide was associated with mild or moderate discomfort, and discontinuation rates due to adverse events were low. CONCLUSION Serum neurofilament light chain protein is sensitive to teriflunomide treatment, suggesting that it has the potential to be used as an indicator to assess the efficacy of teriflunomide. Teriflunomide can significantly reduce the concentrations of inflammatory cytokines, indicating that teriflunomide may regulate neuroinflammation through the inhibitory effect on a variety of immune cells and their cytokines. Teriflunomide can improve clinical symptoms and disease severity in MS patients in southern China, and patients have good compliance.
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Affiliation(s)
- Ran Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Hongliang Li
- The First Affiliated Hospital, Hunan University of Chinese Medicine, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Fei Jiang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Haobing Cai
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Jing Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Si Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Liangjuan Fang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Jun Yin
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qiuming Zeng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
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Dobson R, Craner M, Waddingham E, Miller A, Cavey A, Webb S, Hemingway C, Hobart J, Evangelou N, Scolding N, Rog D, Nicholas R, Marta M, Blain C, Young CA, Ford HL, Matthews PM. OPTIMISE: MS study protocol: a pragmatic, prospective observational study to address the need for, and challenges with, real world pharmacovigilance in multiple sclerosis. BMJ Open 2021; 11:e050176. [PMID: 34824113 PMCID: PMC8627413 DOI: 10.1136/bmjopen-2021-050176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 10/25/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The power of 'real world' data to improve our understanding of the clinical aspects of multiple sclerosis (MS) is starting to be realised. Disease modifying therapy (DMT) use across the UK is driven by national prescribing guidelines. As such, the UK provides an ideal country in which to gather MS outcomes data. A rigorously conducted observational study with a focus on pharmacovigilance has the potential to provide important data to inform clinicians and patients while testing the reliability of estimates from pivotal trials when applied to patients in the UK. METHODS AND ANALYSIS The primary aim of this study is to characterise the incidence and compare the risk of serious adverse events in people with MS treated with DMTs. The OPTIMISE:MS database enables electronic data capture and secure data transfer. Selected clinical data, clinical histories and patient-reported outcomes are collected in a harmonised fashion across sites at the time of routine clinical visits. The first patient was recruited to the study on 24 May 2019. As of January 2021, 1615 individuals have baseline data recorded; follow-up data are being captured and will be reported in due course. ETHICS AND DISSEMINATION This study has ethical permission (London City and East; Ref 19/LO/0064). Potential concerns around data storage and sharing are mitigated by the separation of identifiable data from all other clinical data, and limiting access to any identifiable data. The results of this study will be disseminated via publication. Participants provide consent for anonymised data to be shared for further research use, further enhancing the value of the study.
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Affiliation(s)
- Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Matthew Craner
- Department of Neurology, John Radcliffe Hospital NHS Trust, Oxford, UK
- Department of Neurology, Frimley Park Health Foundation NHS Trust, Frimley, UK
| | - Ed Waddingham
- Department of Brain Sciences, Imperial College London and UK Dementia Research Institute, Imperial College London, London, UK
| | - Aleisha Miller
- Department of Brain Sciences, Imperial College London and UK Dementia Research Institute, Imperial College London, London, UK
| | - Ana Cavey
- Department of Neurology, John Radcliffe Hospital NHS Trust, Oxford, UK
| | - Stewart Webb
- Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Department of Neurology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Neil Scolding
- Department of Neurology, Southmead Hospital NHS Trust, Bristol, UK
- Department of Neurosciences, University of Bristol, Bristol, UK
| | - David Rog
- Department of Neurology, Greater Manchester Neurosciences Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - Richard Nicholas
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Monica Marta
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
- Department of Neurology, Southend Hospital, Westcliff-on-Sea, UK
| | - Camilla Blain
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Helen L Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul M Matthews
- Department of Brain Sciences, Imperial College London and UK Dementia Research Institute, Imperial College London, London, UK
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Chitnis T, Banwell B, Kappos L, Arnold DL, Gücüyener K, Deiva K, Skripchenko N, Cui LY, Saubadu S, Hu W, Benamor M, Le-Halpere A, Truffinet P, Tardieu M. Safety and efficacy of teriflunomide in paediatric multiple sclerosis (TERIKIDS): a multicentre, double-blind, phase 3, randomised, placebo-controlled trial. Lancet Neurol 2021; 20:1001-1011. [PMID: 34800398 DOI: 10.1016/s1474-4422(21)00364-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 09/17/2021] [Accepted: 10/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Therapeutic options for children with multiple sclerosis are scarce. Teriflunomide is approved in more than 80 countries for the treatment of adults with relapsing multiple sclerosis. The TERIKIDS study examined the safety and efficacy of teriflunomide in children with relapsing multiple sclerosis. METHODS The TERIKIDS trial was a multicentre, phase 3, double-blind, parallel-group, randomised, placebo-controlled study conducted at 57 clinical centres in 22 countries in Asia, Europe, the Middle East, North Africa, and North America. The trial enrolled patients aged 10-17 years, diagnosed with relapsing multiple sclerosis and with at least one relapse in the year preceding screening or at least two relapses in the 2 years preceding screening. Patients were randomly assigned (2:1) to oral teriflunomide (dosage equivalent to 14 mg in adults) or matching placebo, using an interactive web and voice response system, for up to 96 weeks. Personnel in all sites and all patients were masked to study treatment in the double-blind period. Early entry into a subsequent 96-week open-label extension phase was possible before the end of the double-blind period for patients with confirmed clinical relapse or high MRI activity (at least five new or enlarged T2 lesions at week 24, followed by at least nine new or enlarged T2 lesions at week 36, or at least five new or enlarged T2 lesions at weeks 36 and 48, or at weeks 48 and 72). The primary endpoint was time to first confirmed clinical relapse by the end of the double-blind period. Key secondary imaging endpoints were number of new or enlarged T2 lesions and number of gadolinium-enhancing lesions per MRI scan. Efficacy endpoints were analysed in the intention-to-treat population, and safety was assessed in all patients randomly assigned to treatment and exposed to the double-blind study medication. This study is registered with ClinicalTrials.gov (trial number NCT02201108) and is closed to recruitment, but an additional optional open-label extension is ongoing. FINDINGS Between July 24, 2014, and the date of last patient visit on Oct 25, 2019, 185 patients were screened for eligibility, 166 (90%) were enrolled, and 109 were randomly assigned teriflunomide and 57 were randomly assigned placebo. 102 (94%) of 109 and 53 (93%) of 57 completed the double-blind period. Switch to the ongoing open-label extension because of high MRI activity was more frequent than anticipated in the placebo group (14 [13%] of 109 patients in the teriflunomide group vs 15 [26%] of 57 in the placebo group), decreasing the power of the study. After 96 weeks, there was no difference in time to first confirmed clinical relapse with teriflunomide compared with placebo (hazard ratio 0·66, 95% CI 0·39-1·11; p=0·29). Teriflunomide reduced the number of new or enlarged T2 lesions versus placebo by 55% (relative risk 0·45, 95% CI 0·29-0·71; p=0·00061), and the number of gadolinium-enhancing lesions by 75% (relative risk 0·25, 0·13-0·51; p<0·0001). Adverse events occurred in 96 (88%) patients in the teriflunomide group and 47 (82%) patients in the placebo group; serious adverse events occurred in 12 (11%) patients in the teriflunomide group and 6 (11%) patients in the placebo group. Nasopharyngitis, upper-respiratory-tract infection, alopecia, paraesthesia, abdominal pain, and increased blood creatine phosphokinase were more frequent with teriflunomide than with placebo. During the double-blind phase, four patients in the teriflunomide group had pancreatic adverse events (two with acute pancreatitis and two with pancreatic enzyme elevation), of which three events led to treatment discontinuation. INTERPRETATION No significant difference in time to first confirmed clinical relapse was found, possibly because more patients than expected switched from the double-blind to the open-label treatment period because of high MRI activity. Key secondary imaging analyses and a prespecified sensitivity analysis of probability of relapse or high MRI activity suggest that teriflunomide might have beneficial effects in children with relapsing multiple sclerosis by reducing the risk of focal inflammatory activity. FUNDING Sanofi.
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Affiliation(s)
- Tanuja Chitnis
- Massachusetts General Hospital for Children, Boston, MA, USA.
| | - Brenda Banwell
- Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ludwig Kappos
- Research Centre for Clinical Neuroimmunology and Neuroscience Basel, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | - Douglas L Arnold
- NeuroRx Research, Montréal, QC, Canada; Montréal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Kivilcim Gücüyener
- Gazi Universitesi Tip Fakültesi Pediatrik Nöroloji Bilim Dali, Ankara, Turkey
| | | | - Natalia Skripchenko
- FSBI Research Institute for Paediatric Infectious Diseases FMBA Russia, St Petersburg, Russia
| | - Li-Ying Cui
- Peking Union Medical College Hospital, Beijing, China
| | | | | | | | | | | | - Marc Tardieu
- Hôpitaux Universitaires Paris-Sud, Paris, France
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Gebhardt M, Kropp P, Hoffmann F, Zettl UK. Headache in multiple sclerosis - pharmacological aspects. Curr Pharm Des 2021; 28:445-453. [PMID: 34551691 DOI: 10.2174/1381612827666210922114100] [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: 02/22/2021] [Accepted: 07/19/2021] [Indexed: 12/11/2022]
Abstract
For decades, headache was not considered a typical symptom of multiple sclerosis (MS) and was construed as a "red flag" for important differential diagnoses such as cerebral vasculitis. Meanwhile, several studies have demonstrated an increased prevalence of headache in MS compared to the general population. This is due to the heterogeneity of headache genesis with frequent occurrence of both primary and secondary headaches in MS. On the one hand, MS and migraine are often comorbid. On the other hand, secondary headaches occur frequently, especially in the course of MS relapses. These are often migraine-like headaches caused by inflammation, which can improve as a result of MS-specific therapy. Headaches are particularly common in the early stages of chronic inflammatory CNS disease, where inflammatory activity is greatest. In addition, headache can also occur as a side effect of disease-modifying drugs (DMDs). Headache can occur with most DMDs and is most frequently described with interferon-beta therapy. The aim of this work is to present the prevalence of headache and describe the heterogeneity of possible causes of headache in MS. In addition, important therapeutic aspects in the treatment of MS patients in general will be presented as well as different approaches to the treatment of headache in MS depending on the etiological classification.
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Affiliation(s)
- Marcel Gebhardt
- Krankenhaus Martha-Maria Halle-Dölau, Klinik für Neurologie, Röntgenstraße 1, 06120 Halle. Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, Medical Faculty, University of Rostock, Gehlsheimer Straße 20, 18147, Rostock. Germany
| | | | - Uwe K Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock. Germany
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Miller AE. An updated review of teriflunomide's use in multiple sclerosis. Neurodegener Dis Manag 2021; 11:387-409. [PMID: 34486382 DOI: 10.2217/nmt-2021-0014] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Teriflunomide, a once daily, oral disease-modifying therapy, has demonstrated consistent efficacy, safety and tolerability in patients with relapsing forms of multiple sclerosis (MS) and with a first clinical episode suggestive of MS treated up to 12 years. This review is an update to a previous version that examined data from the teriflunomide core clinical development program and extension studies. Data have since become available from active comparator trials with other disease-modifying therapies, treatment-related changes in brain volume (analyzed using structural image evaluation using normalization of atrophy) and real-world evidence including patient-reported outcomes. Initial data on the potential antiviral effects of teriflunomide in patients with MS, including case reports of patients infected with the 2019 novel coronavirus (SARS-CoV-2), are also presented.
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA
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Marin CE, Callegaro D, Lana-Peixoto MA, Fernández O, Gomes Neto AP, Vasconcelos CCF, d'Almeida JAC, Gonçalves MVM, Mendes MF, Parolin MKF, Nascimento O, Gama PDD, Dias-Carneiro RPC, Dias RM, Damasceno A, Becker J. Evaluation of diagnosis and treatment practices of Brazilian neurologists among patients with multiple sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:598-606. [PMID: 34468497 DOI: 10.1590/0004-282x-anp-2020-0362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/29/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Recent changes to the diagnostic criteria for multiple sclerosis (MS) and new medications have had a major impact on the way in which specialists manage the disease. OBJECTIVE To investigate factors considered by Brazilian neurologists in managing MS, and to identify how these contribute to diagnosis and treatment. METHODS Potential participants were selected by a steering committee (MS experts who developed this survey). Only MS specialists were included in the study (neurologists who had completed a neuroimmunology fellowship or who were treating more than 30 MS patients). Links to the online questionnaire were distributed between March 2019 and January 2020. This questionnaire was composed of sections with hypothetical MS scenarios. RESULTS Neurologists from 13 Brazilian states responded to the survey (n = 94). In the clinically isolated syndrome (CIS) scenario, the respondents agreed to treat patients with a high risk of MS diagnosis, whereas in the radiologically isolated syndrome (RIS) half of the respondents opted not to treat, even among high-risk patients. In cases of low-activity relapsing-remitting MS (RRMS), the choice of treatment was distributed among interferon beta, glatiramer acetate and teriflunomide, which were changed to fingolimod and natalizumab, as RRMS severity increased. The topics in which disagreement was found included practices regarding use of disease-modifying therapy (DMT) for pregnant patients and the washout period required for some DMTs. CONCLUSIONS This study enabled identification of areas of agreement and disagreement about MS treatment among Brazilian neurologists, which can be used to update future protocols and improve patient management.
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Affiliation(s)
- Cássia Elisa Marin
- Pontifícia Universidade Católica do Rio Grande do Sul, Hospital São Lucas, Porto Alegre RS, Brazil
| | - Dagoberto Callegaro
- Universidade de São Paulo, Faculdade de Medicina de São Paulo, Hospital das Clínicas, São Paulo SP, Brazil
| | - Marco Aurélio Lana-Peixoto
- Universidade Federal de Minas Gerais, Faculdade de Medicina de Minas Gerais Hospital das Clínicas, Belo Horizonte MG, Brazil
| | - Oscar Fernández
- University of Malaga, Hospital Universitário Regional de Málaga, Malaga, Spain
| | | | | | | | | | | | | | | | | | | | | | | | - Jefferson Becker
- Pontifícia Universidade Católica do Rio Grande do Sul, Hospital São Lucas, Porto Alegre RS, Brazil.,Universidade Federal Fluminense, Rio de Janeiro RJ, Brazil
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Linker RA, Gold R. [Immunotherapy and personalized treatment of multiple sclerosis]. DER NERVENARZT 2021; 92:986-995. [PMID: 34427718 DOI: 10.1007/s00115-021-01176-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 11/29/2022]
Abstract
Personalized medicine requires a patient-oriented approach with the exact classification of the disease being determined by the underlying pathophysiological processes. In particular, the optimal treatment of multiple sclerosis (MS) requires personalized treatment that goes beyond the pure concept of precision medicine; however, due to the lack of robust biomarkers beyond cranial magnetic resonance imaging and a lacking detailed understanding of some aspects of MS pathogenesis, this approach is not yet fully implemented. Important questions for a better therapeutic stratification of MS patients are: (1) when does MS start? (2) Does the spectrum of MS really span multiple diseases? (3) When does the progressive phase of the disease begin? (4) In which phase of the disease is there a therapeutic window for immunotherapy? Recent findings indicate that MS represents a spectrum of diseases and that there is a therapeutic delay of several years, on which the optimal treatment effect of a disease-modifying treatment depends. For a personalized treatment of MS it is important to determine the exact disease stage of the patient and to react to the development or increase of focal inflammatory activity in a timely manner.
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Affiliation(s)
- Ralf A Linker
- Neurologische Klinik, Universitätsklinik Regensburg, Universität Regensburg, Universitätsstraße 84, 93053, Regensburg, Deutschland.
| | - Ralf Gold
- Neurologische Klinik, St. Josef-Hospital, Ruhr-Universität-Bochum, Bochum, Deutschland
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Wiendl H, Gold R, Berger T, Derfuss T, Linker R, Mäurer M, Aktas O, Baum K, Berghoff M, Bittner S, Chan A, Czaplinski A, Deisenhammer F, Di Pauli F, Du Pasquier R, Enzinger C, Fertl E, Gass A, Gehring K, Gobbi C, Goebels N, Guger M, Haghikia A, Hartung HP, Heidenreich F, Hoffmann O, Kallmann B, Kleinschnitz C, Klotz L, Leussink VI, Leutmezer F, Limmroth V, Lünemann JD, Lutterotti A, Meuth SG, Meyding-Lamadé U, Platten M, Rieckmann P, Schmidt S, Tumani H, Weber F, Weber MS, Zettl UK, Ziemssen T, Zipp F. Multiple Sclerosis Therapy Consensus Group (MSTCG): position statement on disease-modifying therapies for multiple sclerosis (white paper). Ther Adv Neurol Disord 2021; 14:17562864211039648. [PMID: 34422112 PMCID: PMC8377320 DOI: 10.1177/17562864211039648] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/28/2021] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis is a complex, autoimmune-mediated disease of the central nervous system characterized by inflammatory demyelination and axonal/neuronal damage. The approval of various disease-modifying therapies and our increased understanding of disease mechanisms and evolution in recent years have significantly changed the prognosis and course of the disease. This update of the Multiple Sclerosis Therapy Consensus Group treatment recommendation focuses on the most important recommendations for disease-modifying therapies of multiple sclerosis in 2021. Our recommendations are based on current scientific evidence and apply to those medications approved in wide parts of Europe, particularly German-speaking countries (Germany, Austria, and Switzerland).
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Affiliation(s)
- Heinz Wiendl
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster
| | - Ralf Gold
- Neurologie, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Gudrunstraße 56, 44791 Bochum, Germany
| | - Thomas Berger
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Wien, Austria
| | - Tobias Derfuss
- Neurologische Klinik und Poliklinik, Universitätsspital Basel, Basel, Switzerland
| | - Ralf Linker
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Mathias Mäurer
- Neurologie und Neurologische Frührehabilitation, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, Würzburg, Germany
| | - Orhan Aktas
- Neurologische Klinik, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Karl Baum
- Neurologie, Klinik Hennigsdorf, Hennigsdorf, Germany
| | | | - Stefan Bittner
- Klinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew Chan
- Neurologie, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | | | | | | | | | - Christian Enzinger
- Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz, Austria
| | - Elisabeth Fertl
- Wiener Gesundheitsverbund, Neurologische Abteilung, Wien, Austria
| | - Achim Gass
- Neurologische Klinik, Universitätsmedizin Mannheim/Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Klaus Gehring
- Berufsverband Deutscher Nervenärzte (BVDN), Neurozentrum am Klosterforst, Itzehoe, Germany
| | | | - Norbert Goebels
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Guger
- Klinik für Neurologie 2, Kepler Universitätsklinikum, Linz, Austria
| | | | - Hans-Peter Hartung
- Klinik für Neurologie, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany; Klinik für Neurologie, Medizinische Universität Wien, Wien, Austria
| | - Fedor Heidenreich
- Diakovere Krankenhaus, Henriettenstift, Klinik für Neurologie und klinische Neurophysiologie, Hannover, Germany
| | - Olaf Hoffmann
- Klinik für Neurologie, Alexianer St. Josefs-Krankenhaus Potsdam, Potsdam, Germany; NeuroCure, Charité-Universitätsmedizin Berlin, Berlin, Germany; Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Germany
| | - Boris Kallmann
- Kallmann Neurologie, Multiple Sklerose Zentrum Bamberg, Bamberg, Germany
| | | | - Luisa Klotz
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Münster, Germany
| | | | - Fritz Leutmezer
- Neurologie, Universitäts-Klinik für Neurologie Wien, Wien, Austria
| | - Volker Limmroth
- Klinik für Neurologie, Krankenhaus Köln-Merheim, Köln, Germany
| | - Jan D Lünemann
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Münster, Germany
| | | | - Sven G Meuth
- Neurologische Klinik, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Michael Platten
- Neurologische Klinik, Universitätsmedizin Mannheim/Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Peter Rieckmann
- Medical Park, Fachklinik für Neurologie, Zentrum für Klinische Neuroplastizität, Bischofswiesen, Germany
| | - Stephan Schmidt
- Neurologie, Gesundheitszentrum St. Johannes Hospital, Bonn, Germany
| | - Hayrettin Tumani
- Fachklinik für Neurologie Dietenbronn, Akademisches Krankenhaus der Universität Ulm, Ulm, Germany
| | - Frank Weber
- Neurologie, Sana Kliniken, Cham, Switzerland
| | - Martin S Weber
- Institut für Neuropathologie, Neurologische Klinik, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Uwe K Zettl
- Klinik und Poliklinik für Neurologie, Zentrum für Nervenheilkunde, Universitätsmedizin Rostock, Rostock, Germany
| | - Tjalf Ziemssen
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Frauke Zipp
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
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47
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Oh J, Vukusic S, Tiel-Wilck K, Inshasi JS, Rog D, Baker DP, Pyatkevich Y, Poole EM, Vermersch P. Efficacy and Safety of Teriflunomide in Multiple Sclerosis across Age Groups: Analysis from Pooled Pivotal and Real-world Studies. J Cent Nerv Syst Dis 2021; 13:11795735211028781. [PMID: 34377047 PMCID: PMC8330455 DOI: 10.1177/11795735211028781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/10/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Evidence suggests that efficacy and safety of disease-modifying treatments for multiple sclerosis may differ with age. We evaluate efficacy and safety of teriflunomide across age subgroups of patients from pooled clinical trials and real-world studies. Methods: Post hoc analyses of patients who received teriflunomide 14 mg in the pooled phase II and III TEMSO, TOWER, TENERE, and TOPIC core and extension studies (n = 1978), and the real-world Teri-PRO (n = 928) and TAURUS-MS I (n = 1126) studies were conducted. Data were stratified by age at study entry: ⩽25, >25 to ⩽35, >35 to ⩽45, and >45 years. In Teri-PRO and TAURUS-MS I, an additional group, >55 years, was assessed. Results: In the pooled core studies, teriflunomide reduced annualized relapse rate (ARR) versus placebo across all ages. Unadjusted ARRs remained low across age groups in pooled extensions (0.18-0.30), Teri-PRO (0.10-0.35), and TAURUS-MS I (0.14-0.35). Baseline Expanded Disability Status Scale scores were higher with age, but stable through core and extension studies (mean increases over 7 years: ⩽25 years, +0.59; >25 to ⩽35 years, +0.46; >35 to ⩽45 years, +0.35; >45 years, +0.81). Across age groups, adverse event (AE) incidences were 78.4% to 90.7% in pooled core and extension studies and Teri-PRO, and 29.2% to 37.7% in TAURUS-MS I; serious AE incidences were ⩽21.3% in all studies. In pooled phase III and Teri-PRO studies, lymphocyte count decreases over 1 year after initiating teriflunomide, and proportions of patients developing lymphopenia, were small across age groups. Conclusions: Teriflunomide efficacy was demonstrated regardless of age. Safety was generally consistent across age groups.
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Affiliation(s)
- Jiwon Oh
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sandra Vukusic
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation et Fondation Eugène Devic EDMUS Pour la Sclérose en Plaques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon-Bron, France.,Centre des Neurosciences de Lyon, INSERM 1028 et CNRS UMR5292, Observatoire Français de la Sclérose en Plaques, Lyon, France.,Université Claude Bernard Lyon 1, Villeurbanne, France
| | | | | | - David Rog
- Manchester Centre for Clinical Neurosciences, Salford, UK
| | | | - Yelena Pyatkevich
- Sanofi, Cambridge, MA, USA.,Takeda Pharmaceutical, Cambridge, MA, USA
| | | | - Patrick Vermersch
- Universite de Lille, Inserm U1172, CHU Lille, FHU Precise, Lille, France
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48
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Wiendl H, Gold R, Berger T, Derfuss T, Linker R, Mäurer M, Stangel M, Aktas O, Baum K, Berghoff M, Bittner S, Chan A, Czaplinski A, Deisenhammer F, Di Pauli F, Du Pasquier R, Enzinger C, Fertl E, Gass A, Gehring K, Gobbi C, Goebels N, Guger M, Haghikia A, Hartung HP, Heidenreich F, Hoffmann O, Hunter ZR, Kallmann B, Kleinschnitz C, Klotz L, Leussink V, Leutmezer F, Limmroth V, Lünemann JD, Lutterotti A, Meuth SG, Meyding-Lamadé U, Platten M, Rieckmann P, Schmidt S, Tumani H, Weber MS, Weber F, Zettl UK, Ziemssen T, Zipp F. [Multiple sclerosis treatment consensus group (MSTCG): position paper on disease-modifying treatment of multiple sclerosis 2021 (white paper)]. DER NERVENARZT 2021; 92:773-801. [PMID: 34297142 PMCID: PMC8300076 DOI: 10.1007/s00115-021-01157-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 12/16/2022]
Abstract
Die Multiple Sklerose ist eine komplexe, autoimmun vermittelte Erkrankung des zentralen Nervensystems, charakterisiert durch inflammatorische Demyelinisierung sowie axonalen/neuronalen Schaden. Die Zulassung verschiedener verlaufsmodifizierender Therapien und unser verbessertes Verständnis der Krankheitsmechanismen und -entwicklung in den letzten Jahren haben die Prognose und den Verlauf der Erkrankung deutlich verändert. Diese Aktualisierung der Behandlungsempfehlung der Multiple Sklerose Therapie Konsensus Gruppe konzentriert sich auf die wichtigsten Empfehlungen für verlaufsmodifizierende Therapien der Multiplen Sklerose im Jahr 2021. Unsere Empfehlungen basieren auf aktuellen wissenschaftlichen Erkenntnissen und gelten für diejenigen Medikamente, die in weiten Teilen Europas, insbesondere in den deutschsprachigen Ländern (Deutschland, Österreich, Schweiz), zugelassen sind.
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Affiliation(s)
- Heinz Wiendl
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Westfälische Wilhelms-Universität Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland. .,Steuerungsgruppe der MSTKG, Münster, Deutschland. .,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.
| | - Ralf Gold
- Steuerungsgruppe der MSTKG, Münster, Deutschland. .,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland. .,Neurologie, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland.
| | - Thomas Berger
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Universitätsklinik für Neurologie, Medizinische Universität Wien, Wien, Österreich
| | - Tobias Derfuss
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Neurologische Klinik und Poliklinik, Universitätsspital Basel, Basel, Schweiz
| | - Ralf Linker
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Klinik und Poliklinik für Neurologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Mathias Mäurer
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Neurologie und Neurologische Frührehabilitation, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, Würzburg, Deutschland
| | - Martin Stangel
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Klinische Neuroimmunologie und Neurochemie, Klinik für Neurologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Orhan Aktas
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Karl Baum
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Martin Berghoff
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Stefan Bittner
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Andrew Chan
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Adam Czaplinski
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | | | - Franziska Di Pauli
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Renaud Du Pasquier
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Christian Enzinger
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Elisabeth Fertl
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Achim Gass
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Klaus Gehring
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Claudio Gobbi
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Norbert Goebels
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Michael Guger
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Aiden Haghikia
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Hans-Peter Hartung
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Fedor Heidenreich
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Olaf Hoffmann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Zoë R Hunter
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Boris Kallmann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | | | - Luisa Klotz
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Verena Leussink
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Fritz Leutmezer
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Volker Limmroth
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Jan D Lünemann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Andreas Lutterotti
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Sven G Meuth
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Uta Meyding-Lamadé
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Michael Platten
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Peter Rieckmann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Stephan Schmidt
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Hayrettin Tumani
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Martin S Weber
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Frank Weber
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Uwe K Zettl
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Tjalf Ziemssen
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Frauke Zipp
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
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49
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Papeix C, Donze C, Lebrun-Frénay C. Infections and multiple sclerosis: Recommendations from the French Multiple Sclerosis Society. Rev Neurol (Paris) 2021; 177:980-994. [PMID: 34303537 DOI: 10.1016/j.neurol.2021.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/29/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Viral, bacterial, or fungal infections are suspected of triggering multiple sclerosis (MS) and promoting relapses of the disease and are likely to be promoted by immune-active treatments. This raises questions about the infectious workup and preventive treatment of these infections prior to their initiation. OBJECTIVES To establish recommendations on infections and MS. Provide information to patients and healthcare professionals on the minimal infectious workup to be performed in an MS patient at diagnosis and prior to initiation of immuno-active therapy in MS. METHODS The recommendation attempts to answer four main questions about infections and MS. The French Group for Recommendations in Multiple Sclerosis (France4MS) did a systematic review of articles from PubMed and universities databases (from January 1975 to June 2020), using the RAND/UCLA formalized consensus method. The RAND/UCLA method has been developed to synthesize the scientific literature and expert opinions on health care topics and was used for reaching a formal agreement. Twenty-three experts contributed to the detailed review and a group of 63 multidisciplinary health professionals validated the final version of 36 recommendations. RESULTS It is recommended that MS patients undergo a minimal infectious workup, check their vaccination status at diagnosis, and repeat it during follow-up and before starting immunotherapy. Screening and preventive treatment of viral (group Herpes virus, HPV, JCV, HCV, HBV), bacterial (mycobacteria) and fungal (Cryptococcus) infections is recommended prior to the initiation of certain immuno-active MS therapies. DISCUSSION AND CONCLUSIONS At diagnosis of MS and prior to the choice of therapeutic strategy, it is recommended to update the vaccination schedule of MS patients in reference to the HCSP vaccination schedule and the SFSEP recommendations. Before starting immunosuppressive treatment, it is recommended to inform patients of the risks of infections and to look for a constitutive or acquired immune deficiency. Health professionals and patients should be informed of the updated recommendations on infections and MS.
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Affiliation(s)
- C Papeix
- Département de neurologie, CRCSEP-Paris, Sorbonne Université, Hôpital de la Pitié salpêtrière, AP-HP 6, Paris 75013, France.
| | - C Donze
- Faculté de médecine et de maïeutique de Lille, hôpital Saint-Philibert, groupement des hôpitaux de l'institut catholique de Lille, Lomme, France
| | - C Lebrun-Frénay
- URC2A, Cote d'Azur University, CRCSEP-Côte d'Azur, neurologie, Hôpital Pasteur2, CHU Nice, France
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50
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Chaloulos-Iakovidis P, Wagner F, Weber L, Diem L, Chan A, Salmen A, Friedli C, Hoepner R. Predicting conversion to multiple sclerosis in patients with radiologically isolated syndrome: a retrospective study. Ther Adv Neurol Disord 2021; 14:17562864211030664. [PMID: 34349838 PMCID: PMC8287642 DOI: 10.1177/17562864211030664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 06/09/2021] [Indexed: 11/17/2022] Open
Abstract
Aims To retrospectively analyse the Bernese radiologically isolated syndrome (RIS) cohort with the goal of developing a prediction score for conversion to multiple sclerosis (MS). Methods A total of 31 patients with RIS were identified by screening medical records of neurological patients seen at the University Hospital of Bern between 2004 and 2017 for the diagnoses 'radiologically isolated syndrome' and 'RIS' adhering to 2009 Okuda recommendations. We analysed clinical, paraclinical and magnetic resonance imaging data during a maximum follow-up period of 3 years and identified significant predictors of conversion to MS. Results Data were available for 31 patients meeting 2009 Okuda RIS criteria. During the 3 years of follow up, 5/31 RIS patients converted to relapsing-remitting (RR) MS. In our univariate analysis, gadolinium (Gd) enhancement, brainstem and cerebellar hemisphere lesions, immune cell count and albumin concentration in cerebrospinal fluid (CSF), and anti-nuclear antibody (ANA) positivity in serum were identified as significant predictors of conversion to MS. Integrating these factors into our 'RIS-MS prediction score' enabled us to calculate a cut-off for prediction of conversion to MS within 3 years with high specificity [1.0, 95% confidence interval (CI) 0.84-1.00) and acceptable sensitivity (0.6, 95% CI 0.17-0.93)]. Conclusion Our RIS-MS prediction score, if validated in an independent cohort, integrating radiological (Gd enhancement, brainstem and cerebellar hemisphere lesions) and paraclinical factors (ANA in serum, cell count and albumin in CSF) could be a useful prognostic tool for early recognition of RIS patients with a high risk of clinical progression to MS.
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Affiliation(s)
- Panagiotis Chaloulos-Iakovidis
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Freiburgstrasse, Bern, CH-3010, Switzerland
| | - Franca Wagner
- Department of Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Lea Weber
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Lara Diem
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christoph Friedli
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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