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Selmaj K, Hartung HP, Mycko MP, Selmaj I, Cross AH. MS treatment de-escalation: review and commentary. J Neurol 2024:10.1007/s00415-024-12584-x. [PMID: 39093335 DOI: 10.1007/s00415-024-12584-x] [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: 06/03/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 08/04/2024]
Abstract
Almost all currently licensed disease-modifying therapies (DMTs) for MS treatment require prolonged if not lifelong administration. Yet, as people age, the immune system has increasingly reduced responsiveness, known as immunosenescence. Many MS DMTs reduce the responsiveness of the immune system, increasing the risks for infections and possibly cancers. As people with MS (pwMS) age, it is recognized that inflammatory MS activity declines. Several studies have addressed de-escalation of DMTs for relapsing MS under special circumstances. Here, we review evidence for de-escalating DMTs as a strategy that is particularly relevant to pwMS of older age. Treatment de-escalation can involve various strategies, such as extended or reduced dosing, switching from high-efficacy DMTs having higher risks to moderately effective DMTs with lesser risks, or treatment discontinuation. Studies have suggested that for natalizumab extended dosing maintained clinical efficacy while reducing the risk of PML. Extended interval dosing of ocrelizumab mitigated the decline of Ig levels. Retrospective and observational discontinuation studies demonstrate that age is an essential modifier of drug efficacy. Discontinuation of MS treatment in older patients has been associated with a stable disease course, while younger patients who discontinued treatment were more likely to experience new clinical activity. A recently completed 2-year randomized-controlled discontinuation study in 260 stable pwMS > 55 years found stable clinical multiple sclerosis with only a small increased risk of new MRI activity upon discontinuation. DMT de-escalation or discontinuation in MS patients older than 55 years may be non-inferior to continued treatment with immunosuppressive agents having higher health risks. However, despite several small studies, a definite conclusion about treatment de-escalation in older pwMS will require larger and longer studies. Ideally, comparison of de-escalation versus continuation versus discontinuation of DMTs should be done by prospective randomized-controlled trials enrolling sufficient numbers of subjects to allow comparisons for MS patients of both sexes within age groups, such as 55-59, 60-65, 66-69, etc. Optimally, such studies should be 3 years or longer and should incorporate testing for specific markers of immunosenescence (such as T-cell receptor excision circles) to account for differential aging of individuals.
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Affiliation(s)
- Krzysztof Selmaj
- Department of Neurology, University of Warmia & Mazury, Olsztyn, Poland.
- Center of Neurology, Lodz, Poland.
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Palacky University, Olomouc, Czech Republic
- Brain and Mind Center, University of Sydney, Sydney, Australia
| | - Marcin P Mycko
- Department of Neurology, University of Warmia & Mazury, Olsztyn, Poland
| | | | - Anne H Cross
- Washington University School of Medicine, St. Louis, MO, USA
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Gudesblatt M, Bumstead B, Buhse M, Zarif M, Morrow SA, Nicholas JA, Hancock LM, Wilken J, Weller J, Scott N, Gocke A, Lewin JB, Kaczmarek O, Mendoza JP, Golan D. De-escalation of Disease-Modifying Therapy for People with Multiple Sclerosis Due to Safety Considerations: Characterizing 1-Year Outcomes in 25 People Who Switched from Ocrelizumab to Diroximel Fumarate. Adv Ther 2024; 41:3059-3075. [PMID: 38861218 PMCID: PMC11263251 DOI: 10.1007/s12325-024-02902-0] [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: 11/13/2023] [Accepted: 05/14/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Switching disease-modifying therapy (DMT) may be considered for relapsing-remitting multiple sclerosis (RRMS) if a patient's current therapy is no longer optimal. This was particularly important during the recent COVID-19 pandemic because of considerations around immune deficiency and impaired vaccine response associated with B cell-depleting DMTs. This real-world, single-center study aimed to evaluate change or decline in functional ability and overall disease stability in people with RRMS who were switched from B cell-depleting ocrelizumab (OCRE) to diroximel fumarate (DRF) because of safety concern related to the COVID-19 pandemic. METHODS Adults with RRMS were included if they had been clinically stable for ≥ 1 year on OCRE. Data collected at baseline and 1 year post switch included relapse rate, magnetic resonance imaging (MRI), blood work for assessment of peripheral immune parameters, the Cognitive Assessment Battery (CAB), optical coherence tomography (OCT), and patient-reported outcomes (PROs). RESULTS Participants (N = 25) had a mean (SD) age of 52 (9) years, and a mean (SD) duration of 26 (8) months' treatment with OCRE before the switch to DRF. Median washout duration since the last OCRE infusion was 7 months (range 4-18 months). No participants relapsed on DRF during follow-up, and all remained persistent on DRF after 1 year. There were no significant changes in peripheral immune parameters, other than an increase in the percentage of CD19+ cells 1 year after switching (p < 0.05). Similarly, there were no significant changes in CAB, OCT, and PROs. CONCLUSION These preliminary findings suggest that transition to DRF from OCRE may be an effective treatment option for people with RRMS who are clinically stable but may need to switch for reasons unrelated to effectiveness. Longer follow-up times on larger samples are needed to confirm these observations.
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Affiliation(s)
- Mark Gudesblatt
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA.
| | - Barbara Bumstead
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | - Marijean Buhse
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | - Myassar Zarif
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | - Sarah A Morrow
- Department of Clinical Neurosciences, University of Calgary, Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Jacqueline A Nicholas
- OhioHealth Multiple Sclerosis Center, Riverside Methodist Hospital, Columbus, OH, USA
| | - Laura M Hancock
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey Wilken
- Washington Neuropsychology Research Group, Fairfax, VA, USA
- Department of Neurology, Georgetown University School of Medicine, Washington, DC, USA
| | - Joanna Weller
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | | | | | | | - Olivia Kaczmarek
- NYU Langone South Shore Neurologic Associates, PC, 77 Medford Ave, Patchogue, NY, 11772, USA
| | | | - Daniel Golan
- Multiple Sclerosis and Neuroimmunology Center, Lady Davis Carmel Medical Center, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Pfeuffer S, Wolff S, Aslan D, Rolfes L, Korsen M, Pawlitzki M, Albrecht P, Havla J, Huttner HB, Kleinschnitz C, Meuth SG, Pul R, Ruck T. Association of Clinical Relapses With Disease Outcomes in Multiple Sclerosis Patients Older Than 50 Years. Neurology 2024; 103:e209574. [PMID: 38870471 PMCID: PMC11244741 DOI: 10.1212/wnl.0000000000209574] [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: 06/15/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Relapse and MRI activity usually decline with aging but are replaced by progression independent of relapse activity (PIRA) in patients with multiple sclerosis (PwMS). However, several older PwMS continue to experience clinical relapses, and the impact on their disease remains undetermined. We aimed to determine the impact of an index relapse on disease outcomes in patients older than 50 years and to identify risk factors of disadvantageous outcomes. METHODS We performed a secondary analysis from 3 prospective cohorts in Germany. We evaluated all PwMS 50 years and older with a relapse ≤60 days before a baseline visit and at least 18 months of follow-up compared with a control cohort of PwMS without a relapse. Patients were stratified according to age ("50-54" vs "55-59" vs "60+") or disease outcomes ("stable" vs "active" vs "progressive," according to the Lublin criteria). We analyzed relapses, MRI activity, relapse-associated worsening, and PIRA. Regression analysis was performed to evaluate the association of specific baseline risk factors and treatment regimen changes with disease outcomes at month 18. RESULTS A total of 681 patients were included in the "relapse cohort" (50+: 361; 55+: 220; 60+: 100). The "control cohort" comprised 232 patients (50+: 117; 55+: 71; 60+: 44). Baseline epidemiologic parameters were balanced among cohorts and subgroups. We observed increased abundance of inflammatory activity and relapse-independent disability progression in the "relapse" vs "control" cohort. In the "relapse" cohort, we identified 273 patients as "stable" (59.7%), 114 patients as "active" (24.9%), and 70 patients as "progressive" (15.3%) during follow-up. Cardiovascular risk factors (CVRFs) and older age at baseline were identified as risk factors of progressive, whereas disease-modifying treatment (DMT) administration at baseline favored stable disease. DMT during follow-up was associated with stable over active, but not over progressive disease. DISCUSSION A relapse-suggesting underlying active disease-in PwMS older than 50 years was associated with continued disease activity and increased risk of PIRA. Presence of CVRF and absence of DMT at baseline appeared as risk factors of disadvantageous disease courses. An escalation of DMT switch was associated with stable over active but not progressive disease.
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Affiliation(s)
- Steffen Pfeuffer
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Stephanie Wolff
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Derya Aslan
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Leoni Rolfes
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Melanie Korsen
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Marc Pawlitzki
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Philipp Albrecht
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Joachim Havla
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Hagen B Huttner
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Christoph Kleinschnitz
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Sven G Meuth
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Refik Pul
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
| | - Tobias Ruck
- From the Department of Neurology (S.P., S.W., H.B.H.), University Hospital Giessen, Justus-Liebig-University Giessen; Department of Neurology (D.A., C.K., R.P.), University Hospital Essen, University Duisburg-Essen; Department of Neurology (L.R., M.K., M.P., S.G.M., T.R.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (P.A.), Medical Faculty, Heinrich Department of Neurology, Maria-Hilf-Clinic, Mönchengladbach; and Institute of Clinical Neuroimmunology (J.H.), LMU Hospital, Ludwig-Maximilians University Munich, Germany
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Foong YC, Merlo D, Gresle M, Buzzard K, Zhong M, Yeh WZ, Jokubaitis V, Monif M, Skibina O, Ozakbas S, Patti F, Grammond P, Amato MP, Kalincik T, Horakova D, Kubala Havrdova E, Weinstock-Guttman B, Lechner Scott J, Boz C, Sa MJ, Butzkueven H, van der Walt A, Zhu C. Comparing ocrelizumab to interferon/glatiramer acetate in people with multiple sclerosis over age 60. J Neurol Neurosurg Psychiatry 2024; 95:767-774. [PMID: 38453478 DOI: 10.1136/jnnp-2023-332883] [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] [Received: 10/27/2023] [Accepted: 02/11/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Ongoing controversy exists regarding optimal management of disease modifying therapy (DMT) in older people with multiple sclerosis (pwMS). There is concern that the lower relapse rate, combined with a higher risk of DMT-related infections and side effects, may alter the risk-benefit balance in older pwMS. Given the lack of pwMS above age 60 in randomised controlled trials, the comparative efficacy of high-efficacy DMTs such as ocrelizumab has not been shown in older pwMS. We aimed to evaluate the comparative effectiveness of ocrelizumab, a high-efficacy DMT, versus interferon/glatiramer acetate (IFN/GA) in pwMS over the age of 60. METHODS Using data from MSBase registry, this multicentre cohort study included pwMS above 60 who switched to or started on ocrelizumab or IFN/GA. We analysed relapse and disability outcomes after balancing covariates using an inverse probability treatment weighting (IPTW) method. Propensity scores were obtained based on age, country, disease duration, sex, baseline Expanded Disability Status Scale, prior relapses (all-time, 12 months and 24 months) and prior DMT exposure (overall number and high-efficacy DMTs). After weighting, all covariates were balanced. Primary outcomes were time to first relapse and annualised relapse rate (ARR). Secondary outcomes were 6-month confirmed disability progression (CDP) and confirmed disability improvement (CDI). RESULTS A total of 248 participants received ocrelizumab, while 427 received IFN/GA. The IPTW-weighted ARR for ocrelizumab was 0.01 and 0.08 for IFN/GA. The IPTW-weighted ARR ratio was 0.15 (95% CI 0.06 to 0.33, p<0.001) for ocrelizumab compared with IFN/GA. On IPTW-weighted Cox regression models, HR for time to first relapse was 0.13 (95% CI 0.05 to 0.26, p<0.001). The hazard of first relapse was significantly reduced in ocrelizumab users after 5 months compared with IFN/GA users. However, the two groups did not differ in CDP or CDI over 3.57 years. CONCLUSION In older pwMS, ocrelizumab effectively reduced relapses compared with IFN/GA. Overall relapse activity was low. This study adds valuable real-world data for informed DMT decision making with older pwMS. Our study also confirms that there is a treatment benefit in older people with MS, given the existence of a clear differential treatment effect between ocrelizumab and IFN/GA in the over 60 age group.
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Affiliation(s)
- Yi Chao Foong
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
- Department of Neurology, Tasmanian Health Service, Hobart, Tasmania, Australia
| | - Daniel Merlo
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Eastern Health, Box Hill, Victoria, Australia
| | - Melissa Gresle
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
- Melbourne Health, Melbourne, Victoria, Australia
| | - Katherine Buzzard
- Eastern Health, Box Hill, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael Zhong
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Wei Zhen Yeh
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Olga Skibina
- Alfred Health, Melbourne, Victoria, Australia
- Eastern Health, Box Hill, Victoria, Australia
| | | | - Francesco Patti
- Neuroscience, University of Catania Department of Surgical and Medical Sciences and Advanced Technologies 'G.F. Ingrassia', Catania, Italy
- University of Catania, Catania, Italy
| | | | - Maria Pia Amato
- Department of Neurological Siences, University of Florence, Florence, Italy
| | - Tomas Kalincik
- Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | | | - Jeanette Lechner Scott
- Hunter New England Health, New Lambton, New South Wales, Australia
- The University of Newcastle, Newcastle, New South Wales, Australia
| | - Cavit Boz
- Karadeniz Technical University, Trabzon, Turkey
| | - Maria Jose Sa
- Neurology, Centro Hospitalar de São João, Porto, Portugal
- Faculty of Health Sciences University Fernando Pessoa, Porto, Portugal
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Chao Zhu
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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5
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Gross RH, Corboy J. De-escalation and Discontinuation of Disease-Modifying Therapies in Multiple Sclerosis. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01355-w. [PMID: 38995483 DOI: 10.1007/s11910-024-01355-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE OF REVIEW Long-term use of multiple sclerosis (MS) disease-modifying therapies (DMTs) is standard practice to prevent accumulation of disability. Immunosenescence and other age-related changes lead to an altered risk-benefit ratio for older patients on DMTs. This article reviews recent research on the topic of de-escalation and discontinuation of MS DMTs. RECENT FINDINGS Observational and interventional studies have shed light on what happens to patients who de-escalate or discontinue DMTs and the factors, such as age, treatment type, and presence of recent disease activity, that influence outcomes. Though many questions remain, recent findings have been valuable for the development of an evidence-based approach to making de-escalation and discontinuation decisions in MS.
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Affiliation(s)
- Robert H Gross
- Department of Neurology, University of Colorado School of Medicine, 12631 East 17thAvenue, Mail Stop F727, Aurora, CO, 80045, USA.
- Department of Neurology, Rocky Mountain Regional Veterans Administration Medical Center, Aurora, CO, USA.
| | - John Corboy
- Department of Neurology, University of Colorado School of Medicine, 12631 East 17thAvenue, Mail Stop F727, Aurora, CO, 80045, USA
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6
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Hu Y, Frisell T, Alping P, Song H, Pawitan Y, Fang F, Piehl F. Hospital-Treated Infections and Risk of Disability Worsening in Multiple Sclerosis. Ann Neurol 2024. [PMID: 38984615 DOI: 10.1002/ana.27026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 06/08/2024] [Accepted: 06/13/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE To investigate the association between infections and disability worsening in people with multiple sclerosis (MS) treated with either B-cell depleting therapy (rituximab) or interferon-beta/glatiramer acetate (IFN/GA). METHODS This cohort study spanned from 2000 to 2021, using data from the Swedish MS Registry linked to national health care registries, comprising 8,759 rituximab and 7,561 IFN/GA treatment episodes. The risk of hospital-treated infection was estimated using multivariable Cox models. The association between infections and increase in Expanded Disability Status Scale (EDSS) scores was assessed using a doubly robust generalized estimating equations model. Additionally, a piece-wise exponential model analyzed events of increased disability beyond defined cut-off values, controlling for relapses, and MRI activity. RESULTS Compared with IFN/GA, rituximab displayed increased risk of both inpatient- and outpatient-treated infections (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.50-2.90 and HR, 1.37; 95% CI, 1.13-1.67, respectively). An inpatient-treated infection was associated with a 0.19-unit increase in EDSS (95% CI, 0.12-0.26). Degree of worsening was greatest for progressive MS, and under IFN/GA treatment, which unlike rituximab, was more commonly associated with MRI activity. After controlling for relapses and MRI activity, inpatient-treated infections were associated with disability worsening in people with relapsing-remitting MS treated with IFN/GA (HR, 2.01; 95% CI, 1.59-2.53), but not in those treated with rituximab. INTERPRETATION Compared to IFN/GA, rituximab doubled the infection risk, but reduced the risk of subsequent disability worsening. Further, the risk of worsening after hospital-treated infection was greater with progressive MS than with relapsing-remitting MS. Infection risk should be considered to improve long term outcomes. ANN NEUROL 2024.
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Affiliation(s)
- Yihan Hu
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Peter Alping
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Huan Song
- Med-X Center for Informatics, Sichuan University, Chengdu, China
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yudi Pawitan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Fang Fang
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Center for Neurology, Academic Specialist Center, Stockholm, Sweden
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DiMauro KA, Swetlik C, Cohen JA. Management of multiple sclerosis in older adults: review of current evidence and future perspectives. J Neurol 2024; 271:3794-3805. [PMID: 38689068 PMCID: PMC11233312 DOI: 10.1007/s00415-024-12384-3] [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: 12/20/2023] [Revised: 04/02/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
IMPORTANCE The prevalence of multiple sclerosis (MS) and aging MS patients is increasing worldwide. There is a need to better understand this MS sub-population, which historically is underrepresented in the literature. This narrative review examines the evolving demographics, disease course, and treatments for older adults with MS (OAMS) to address current knowledge gaps and highlight areas critical for future research. OBSERVATIONS OAMS populations require special consideration by clinicians. Older individuals have different care needs than individuals with adult onset MS who are mid-life or younger. Comorbidities, an aging immune system, increasing neurodegeneration, decreasing neurologic reserve, changing benefit/risk relationship for disease modifying therapies (DMTs), and wellness require special attention to provide holistic comprehensive care. Active areas of research include potential cessation of DMTs and novel disease targets. CONCLUSIONS AND RELEVANCE This review highlights both the current knowledge and information gaps in the literature that are critical to understanding and properly managing OAMS. The aims are to inform MS clinicians in their current practice, as well as inspire future studies which are critical to providing quality and evidence-based care for OAMS.
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Affiliation(s)
- Kimberly A DiMauro
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Carol Swetlik
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA.
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8
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Gelibter S, Saraceno L, Pirro F, Susani EL, Protti A. As time goes by: Treatment challenges in elderly people with multiple sclerosis. J Neuroimmunol 2024; 391:578368. [PMID: 38761652 DOI: 10.1016/j.jneuroim.2024.578368] [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: 12/20/2023] [Revised: 03/11/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024]
Abstract
A demographic shift in multiple sclerosis (MS) is leading to an increased number of elderly people with MS (pwMS) and a rise in late-onset MS (LOMS) cases. This shift adds complexity to the treatment management of these patients, due to enhanced treatment-associated risks and the possible interplay between immunosenescence and disease-modifying therapies (DMTs). In the present paper, we performed a systematic review of the current evidence concerning the relationship between aging and treatment management in elderly pwMS. Our literature search identified 35 original studies relevant to this topic. The gathered evidence consistently indicates a diminished efficacy of DMTs in older pwMS, particularly in preventing disability accrual. Against this background, high-efficacy therapies (HETs) appear to show less benefit over moderate-low-efficacy DMTs in older patients. These data mainly derive from observational retrospective studies or meta-analyses conducted on randomized clinical trials (RCTs). RCTs, however, exclude pwMS older than 55 years, limiting our ability to acquire robust evidence regarding this patient group. Regarding treatment discontinuation in elderly pwMS with stable disease, the available data, which mainly focuses on older injectable DMTs, suggests that their suspension appears to be relatively safe in terms of disease activity. Nevertheless, the first RCT specifically targeting treatment discontinuation recently failed to demonstrate the non-inferiority of treatment discontinuation over continuation, in terms of MRI activity. On the other hand, the evidence on the impact of discontinuation on disease progression is more conflicting and less robust. Furthermore, there is an important lack of studies concerning sequestering DMTs and virtually no data on the discontinuation of anti-CD20 monoclonal antibodies. De-escalation strategy is gaining attention as a de-risking approach alternative to complete treatment discontinuation. It may be defined as the decision to shift from HETs to less potent DMTs in elderly pwMS who have a stable disease. This strategy could reduce treatment-related risks, while minimizing the risk of disease activity and progression potentially associated with treatment discontinuation. This approach, however, remains unexplored due to a lack of studies. Given these findings, the present scenario underlines the urgent need for more comprehensive and robust studies to develop optimized, data-driven treatment strategies for elderly pwMS and LOMS, addressing the unique challenges of MS treatment and aging.
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Affiliation(s)
- Stefano Gelibter
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Lorenzo Saraceno
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fiammetta Pirro
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Emanuela Laura Susani
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandra Protti
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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9
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Collongues N, Durand-Dubief F, Lebrun-Frenay C, Audoin B, Ayrignac X, Bensa C, Bigaut K, Bourre B, Carra-Dallière C, Ciron J, Defer G, Kwiatkowski A, Leray E, Maillart E, Marignier R, Mathey G, Morel N, Thouvenot E, Zéphir H, Boucher J, Boutière C, Branger P, Da Silva A, Demortière S, Guillaume M, Hebant B, Januel E, Kerbrat A, Manchon E, Moisset X, Montcuquet A, Pierret C, Pique J, Poupart J, Prunis C, Roux T, Schmitt P, Androdias G, Cohen M. Cancer and multiple sclerosis: 2023 recommendations from the French Multiple Sclerosis Society. Mult Scler 2024; 30:899-924. [PMID: 38357870 DOI: 10.1177/13524585231223880] [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] [Indexed: 02/16/2024]
Abstract
BACKGROUND Epidemiological data reveal that 45% of persons with multiple sclerosis (PwMS) in France are more than 50 years. This population more than 50 is more susceptible to cancer, and this risk may be increased by frequent use of immunosuppressive drugs. Consequently, concerns have arisen about the potential increased risk of cancer in PwMS and how patients should be screened and managed in terms of cancer risk. OBJECTIVE To develop evidence-based recommendations to manage the coexistence of cancer and multiple sclerosis (MS). METHODS The French Group for Recommendations in MS collected articles from PubMed and university databases covering the period January 1975 through June 2022. The RAND/UCLA method was employed to achieve formal consensus. MS experts comprehensively reviewed the full-text articles and developed the initial recommendations. A group of multidisciplinary health care specialists then validated the final proposal. RESULTS Five key questions were addressed, encompassing various topics such as cancer screening before or after initiating a disease-modifying therapy (DMT), appropriate management of MS in the context of cancer, recommended follow-up for cancer in patients receiving a DMT, and the potential reintroduction of a DMT after initial cancer treatment. A strong consensus was reached for all 31 recommendations. CONCLUSION These recommendations propose a strategic approach to managing cancer risk in PwMS.
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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
- Department of Pharmacology, Addictology, Toxicology, and Therapeutics, Strasbourg University, Strasbourg, France
| | - Françoise Durand-Dubief
- Service de Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Christine Lebrun-Frenay
- Department of Neurology, CHU Nice, Nice, France
- Université Côte d'Azur, UMR2CA-URRIS, Nice, France
| | - Bertrand Audoin
- Department of Neurology, CRMBM, APHM, Aix-Marseille University, Marseille, France
| | - Xavier Ayrignac
- Department of Neurology, Montpellier University Hospital, Montpellier, France
- University of Montpellier, Montpellier, France
- INM, INSERM, Montpellier, France
| | - Caroline Bensa
- Department of Neurology, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Kévin Bigaut
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | | | | | - Jonathan Ciron
- CHU de Toulouse, CRC-SEP, Department of Neurology, Toulouse, France
- Université Toulouse III, Infinity, INSERM UMR1291-CNRS UMR5051, Toulouse, France
| | - Gilles Defer
- Department of Neurology, Caen University Hospital, Caen, France
| | - Arnaud Kwiatkowski
- Department of Neurology, Lille Catholic University, Lille Catholic Hospitals, Lille, France
| | - Emmanuelle Leray
- Université de Rennes, EHESP, CNRS, INSERM, ARENES-UMR 6051, RSMS-U1309, Rennes, France
| | | | - Romain Marignier
- Service de Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Guillaume Mathey
- Department of Neurology, Nancy University Hospital, Nancy, France
| | - Nathalie Morel
- Service de Neurologie, Centre Hospitalier Annecy Genevois, Epagny-Metz-Tessy, France
| | - Eric Thouvenot
- Service de Neurologie, CHU de Nîmes, Nîmes, France
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - Hélène Zéphir
- University of Lille, INSERM U1172, CHU de Lille, Lille, France
| | - Julie Boucher
- Department of Neurology, CHU de Lille, Lille, France
| | - Clémence Boutière
- Department of Neurology, University Hospital of Marseille, Marseille, France
| | - Pierre Branger
- Service de Neurologie, CHU de Caen Normandie, Caen, France
| | - Angélique Da Silva
- Breast Cancer Unit, Centre François Baclesse, Institut Normand du Sein, Caen, France
| | - Sarah Demortière
- Department of Neurology, CRMBM, APHM, Aix-Marseille University, Marseille, France
| | | | | | - Edouard Januel
- Sorbonne Université, Paris, France/Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
- Département de Neurologie, Hôpital Pitié Salpêtrière, AP-HP, Paris, France
| | - Anne Kerbrat
- Service de Neurologie, CHU de Rennes, France
- EMPENN U1228, INSERM-INRIA, Rennes, France
| | - Eric Manchon
- Service de Neurologie, Centre Hospitalier de Gonesse, Gonesse, France
| | - Xavier Moisset
- Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM, Neuro-Dol, Clermont-Ferrand, France
| | | | - Chloé Pierret
- Université de Rennes, EHESP, CNRS, INSERM, ARENES-UMR 6051, RSMS U-1309, Rennes, France
| | - Julie Pique
- Service de Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Julien Poupart
- Department of Neurology and U995-LIRIC-Lille Inflammation Research International Center, INSERM, University of Lille, CHU Lille, Lille, France
| | - Chloé Prunis
- Department of Neurology, Nancy University Hospital, Nancy, France
| | - Thomas Roux
- Hôpital La Pitié-Salpêtrière, Service de Neurologie, Paris, France
- CRC-SEP Paris. Centre des maladies inflammatoires rares du cerveau et de la moelle de l'enfant et de l'adulte (Mircem)
| | | | - Géraldine Androdias
- Service de Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Bron, France
- Clinique de la Sauvegarde-Ramsay Santé, Lyon, France
| | - Mikael Cohen
- Department of Neurology, CHU Nice, Nice, France/Université Côte d'Azur, UMR2CA-URRIS, Nice, France
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10
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de Seze J, Dive D, Ayrignac X, Castelnovo G, Payet M, Rayah A, Gobbi C, Vermersch P, Zecca C. Narrative Review on the Use of Cladribine Tablets as Exit Therapy for Stable Elderly Patients with Multiple Sclerosis. Neurol Ther 2024; 13:519-533. [PMID: 38587749 PMCID: PMC11136913 DOI: 10.1007/s40120-024-00603-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
The number of ageing people with relapsing multiple sclerosis (RMS) is increasing. The efficacy of disease-modifying therapies (DMTs) for RMS declines with age. Also, older persons with MS may be more susceptible to infections, hospitalisations and malignancy. Aging people with MS have higher rates of comorbidities versus aged-matched controls, increasing the individual risk of disability. We review the therapeutic properties of cladribine tablets (CladT) in ageing people with RMS, with regard to their utility for allowing these individuals to cease continuous administration of a DMT (i.e. to act as an "exit therapy"). CladT is thought to be an immune reconstitution therapy, in that two short courses of oral treatment 1 year apart provide suppression of MS disease activity in responders that far outlasts the duration of treatment and post-treatment reductions in lymphocyte counts. Post hoc analyses, long-term follow-up of populations with RMS in randomised trials, and real-world evidence suggest that the efficacy of CladT is probably independent of age, although more data in the elderly are still needed. No clear adverse signals for lymphopenia or other adverse safety signals have emerged with increasing age, although immunosenescence in the setting of age-related "inflammaging" may predispose elderly patients to a higher risk of infections. Updating vaccination status is recommended, especially against pneumococci and herpes zoster for older patients, to minimise the risk of these infections. CladT may be a useful alternative treatment for ageing people with MS who often bear a burden of multiple comorbidities and polypharmacy and who are more exposed to the adverse effects of continuous immunosuppressive therapy.
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Affiliation(s)
- Jerome de Seze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France.
| | - Dominique Dive
- Department of Neurology, Liège University Hospital, Liège, Belgium
| | - Xavier Ayrignac
- Department of Neurology, University of Montpellier, INM, INSERM, Montpellier University Hospital, Montpellier, France
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Marianne Payet
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Amel Rayah
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Claudio Gobbi
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Patrick Vermersch
- University of Lille, INSERM U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Chiara Zecca
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
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11
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Zhu W, Xia Z. Treatment discontinuation in older people with multiple sclerosis. Curr Opin Neurol 2024; 37:220-227. [PMID: 38567633 PMCID: PMC11058008 DOI: 10.1097/wco.0000000000001272] [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] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW The aim of this review was to examine the evidence for disease-modifying therapies (DMTs) discontinuation in older people with multiple sclerosis (MS). We first summarized aging-associated biological changes that influence MS progression and DMT effectiveness, and then summarized recent evidence in evaluating clinical outcomes of discontinuing DMTs in older people with MS. RECENT FINDINGS Recent findings provide mixed evidence regarding the outcomes of DMT discontinuation in older people with MS. Retrospective observational studies suggested older age and longer stable duration on DMT before DMT discontinuation were associated with lower risk of relapse in people with MS. However, one randomized clinical trial did not demonstrate the noninferiority of DMT discontinuation. SUMMARY The available clinical evidence examining DMT discontinuation in older people with MS remains inconclusive. More robust evidence from clinical trials and real-world data will be necessary to guide clinical decisions regarding DMT discontinuation in older people with MS.
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Affiliation(s)
- Wen Zhu
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA
| | - Zongqi Xia
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA
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12
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Goereci Y, Ellenberger D, Rommer P, Dunkl V, Golla H, Zettl U, Stahmann A, Warnke C. Persons with multiple sclerosis older than 55 years: an analysis from the German MS registry. J Neurol 2024; 271:3409-3416. [PMID: 38517521 PMCID: PMC11136707 DOI: 10.1007/s00415-024-12286-4] [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: 02/13/2024] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Persons with MS (PwMS) ≥ 55 years are underrepresented in therapy studies leading to a lack of evidence. OBJECTIVE AND METHODS To study the subgroup of PwMS ≥ 55 years in the German MS registry in comparison with PwMS < 55 years. Endpoints of interest were the grade of disability, leading symptoms, clinical and magnetic resonance imaging activity, and use of disease modifying therapy. RESULTS At the time of analysis, data from 40,428 PwMS were available for analysis. In PwMS aged ≥ 65 and PwMS aged ≥ 55 to 64 years, compared with PwMS aged < 55 years, the mean Expanded Disability Status Scale Scores were higher (5.3, 4.2 and 2.7, respectively), while the proportion of individuals with current use of disease modifying therapy was lower (42.6%, 60.9% and 76.7%, respectively). The older patient groups were more likely to be labeled with progressive MS and the frequency of occupational invalidity was high (38.8% in PwMS aged ≥ 55 to 64 years). Gait disorder, fatigue, bladder dysfunction, and spasticity were among the leading symptoms in PwMS aged ≥ 55 years. CONCLUSION PwMS ≥ 55 years have a high degree of disability, but a large proportion do not receive disease modifying therapy, exposing an unmet need.
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Affiliation(s)
- Yasemin Goereci
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - David Ellenberger
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hannover, Germany
| | - Paulus Rommer
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Veronika Dunkl
- Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Uwe Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
| | - Alexander Stahmann
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hannover, Germany
| | - Clemens Warnke
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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13
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Jouvenot G, Courbon G, Lefort M, Rollot F, Casey R, Le Page E, Michel L, Edan G, de Seze J, Kremer L, Bigaut K, Vukusic S, Mathey G, Ciron J, Ruet A, Maillart E, Labauge P, Zephir H, Papeix C, Defer G, Lebrun-Frenay C, Moreau T, Laplaud DA, Berger E, Stankoff B, Clavelou P, Thouvenot E, Heinzlef O, Pelletier J, Al-Khedr A, Casez O, Bourre B, Cabre P, Wahab A, Magy L, Camdessanché JP, Doghri I, Moulin S, Ben-Nasr H, Labeyrie C, Hankiewicz K, Neau JP, Pottier C, Nifle C, Collongues N, Kerbrat A. High-Efficacy Therapy Discontinuation vs Continuation in Patients 50 Years and Older With Nonactive MS. JAMA Neurol 2024; 81:490-498. [PMID: 38526462 PMCID: PMC10964164 DOI: 10.1001/jamaneurol.2024.0395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/05/2024] [Indexed: 03/26/2024]
Abstract
Importance A recent randomized clinical trial concluded that discontinuing medium-efficacy therapy might be a reasonable option for older patients with nonactive multiple sclerosis (MS), but there is a lack of data on discontinuing high-efficacy therapy (HET). In younger patients, the discontinuation of natalizumab and fingolimod is associated with a risk of rebound of disease activity. Objective To determine whether discontinuing HET in patients 50 years and older with nonactive MS is associated with an increased risk of relapse compared with continuing HET. Design, Setting, and Participants This observational cohort study used data from 38 referral centers from the French MS registry (Observatoire Français de la Sclérose en Plaques [OFSEP] database). Among 84704 patients in the database, data were extracted for 1857 patients 50 years and older with relapsing-remitting MS treated by HET and with no relapse or magnetic resonance imaging activity for at least 2 years. After verification of the medical records, 1620 patients were classified as having discontinued HET or having remained taking treatment and were matched 1:1 using a dynamic propensity score (including age, sex, disease phenotype, disability, treatment of interest, and time since last inflammatory activity). Patients were included from February 2008 to November 2021, with a mean (SD) follow-up of 5.1 (2.9) years. Data were extracted in June 2022. Exposures Natalizumab, fingolimod, rituximab, and ocrelizumab. Main Outcomes and Measures Time to first relapse. Results Of 1620 included patients, 1175 (72.5%) were female, and the mean (SD) age was 54.7 (4.8) years. Among the 1452 in the HET continuation group and 168 in the HET discontinuation group, 154 patients in each group were matched using propensity scores (mean [SD] age, 57.7 [5.5] years; mean [SD] delay since the last inflammatory activity, 5.6 [3.8] years; mean [SD] follow-up duration after propensity score matching, 2.5 [2.1] years). Time to first relapse was significantly reduced in the HET discontinuation group compared with the HET continuation group (hazard ratio, 4.1; 95% CI, 2.0-8.5; P < .001) but differed between HETs, with a hazard ratio of 7.2 (95% CI, 2.1-24.5; P = .001) for natalizumab, 4.5 (95% CI, 1.3-15.5; P = .02) for fingolimod, and 1.1 (95% CI, 0.3-4.8; P = .85) for anti-CD20 therapy. Conclusion and Relevance As in younger patients, in patients 50 years and older with nonactive MS, the risk of relapse increased significantly after stopping HETs that impact immune cell trafficking (natalizumab and fingolimod). There was no significant increase in risk after stopping HETs that deplete B-cells (anti-CD20 therapy). This result may inform decisions about stopping HETs in clinical practice.
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Affiliation(s)
- Guillaume Jouvenot
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Guilhem Courbon
- Department of Neurology, University Hospital of Rennes, Rennes, France
| | - Mathilde Lefort
- University of Rennes, EHESP, CNRS, INSERM, Arènes—UMR 6051, RSMS (Recherche sur les Services et Management en Santé)—U 1309, Rennes, France
| | - Fabien Rollot
- Université de Lyon, Université Claude Bernard, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 and CNRS UMR 5292, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Romain Casey
- Université de Lyon, Université Claude Bernard, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 and CNRS UMR 5292, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Emmanuelle Le Page
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
| | - Laure Michel
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
| | - Gilles Edan
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
| | - Jérome de Seze
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Laurent Kremer
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Kevin Bigaut
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
| | - Sandra Vukusic
- Université de Lyon, Université Claude Bernard, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 and CNRS UMR 5292, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Guillaume Mathey
- Department of Neurology, Nancy University Hospital, Nancy, France
- Université de Lorraine, APEMAC, Nancy, France
| | - Jonathan Ciron
- CRC-SEP, Department of Neurology, CHU de Toulouse, Toulouse, France
| | - Aurélie Ruet
- Department of Neurology, CHU de Bordeaux, CIC Bordeaux CIC1401, Bordeaux, France
| | - Elisabeth Maillart
- Département de Neurologie, Hôpital Pitié-Salpêtrière, APHP, Centre de Ressources et de Compétences SEP, Paris, France
| | | | | | - Caroline Papeix
- Department of Neurology, Fondation Rothschild, Paris, France
| | - Gilles Defer
- Department of Neurology, MS Expert Centre, CHU de Caen, Caen, France
| | - Christine Lebrun-Frenay
- Neurology, UR2CA-URRIS, Centre Hospitalier Universitaire Pasteur2, Université Nice Côte d’Azur, Nice, France
| | | | - David Axel Laplaud
- Department of Neurology, CHU de Nantes, Nantes, France
- Nantes Université, CHU Nantes, INSERM, CIC 14131413, Center for Research in Translational Immunology, UMR 1064, Nantes, France
| | - Eric Berger
- Service de Neurologie, CHU de Besançon, Besançon, France
| | - Bruno Stankoff
- Department of Neurology, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Pierre Clavelou
- Department of Neurology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Eric Thouvenot
- Department of Neurology, Nimes University Hospital, Nimes, France
| | | | - Jean Pelletier
- Service de Neurologie, APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille, France
| | | | - Olivier Casez
- CHU Grenoble Alpes, Department of Neurology, Neurology MS Clinic Grenoble, Grenoble Alpes University Hospital, Grenoble, France
| | | | - Philippe Cabre
- Department of Neurology, CHU de la Martinique, Fort-de-France, France
| | - Abir Wahab
- Department of Neurology, APHP, Hôpital Henri Mondor, Créteil, France
| | - Laurent Magy
- Department of Neurology, CHU de Limoges, Hôpital Dupuytren, Limoges, France
| | | | - Ines Doghri
- Department of Neurology, CHU de Tours, Hôpital Bretonneau, Tours, France
| | - Solène Moulin
- Department of Neurology, CHU de Reims, CRC-SEP, Reims, France
| | - Haifa Ben-Nasr
- Hôpital Sud Francilien, Department of Neurology, Corbeil-Essonnes, France
| | - Céline Labeyrie
- Department of Neurology, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Karolina Hankiewicz
- Department of Neurology, Hôpital Pierre Delafontaine, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Jean-Philippe Neau
- Department of Neurology, CHU La Milétrie, Hôpital Jean Bernard, Poitiers, France
| | - Corinne Pottier
- Department of Neurology, CH de Pontoise, Hôpital René Dubos, Pontoise, France
| | - Chantal Nifle
- Departement of Neurology, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Nicolas Collongues
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
- Department of Pharmacology, Addictology, Toxicology and Therapeutics, Strasbourg University, Strasbourg, France
| | - Anne Kerbrat
- Department of Neurology, University Hospital of Rennes, Rennes, France
- CIC-P 1414 INSERM, University Hospital of Rennes, Rennes, France
- Empenn U1228, University of Rennes, Inria, CNRS, INSERM, IRISA UMR 6074, Rennes, France
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14
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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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15
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Goyne CE, Fair AE, Sumowski PE, Graves JS. The Impact of Aging on Multiple Sclerosis. Curr Neurol Neurosci Rep 2024; 24:83-93. [PMID: 38416310 DOI: 10.1007/s11910-024-01333-2] [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] [Accepted: 01/17/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE OF REVIEW Multiple sclerosis (MS) is a chronic, immune-mediated demyelinating disorder of the central nervous system. Age is one of the most important factors in determining MS phenotype. This review provides an overview of how age influences MS clinical characteristics, pathology, and treatment. RECENT FINDINGS New methods for measuring aging have improved our understanding of the aging process in MS. New studies have characterized the molecular and cellular composition of chronic active or smoldering plaques in MS. These lesions are important contributors to disability progression in MS. These studies highlight the important role of immunosenescence and the innate immune system in sustaining chronic inflammation. Given these changes in immune function, several studies have assessed optimal treatment strategies in aging individuals with MS. MS phenotype is intimately linked with chronologic age and immunosenescence. While there are many unanswered questions, there has been much progress in understanding this relationship which may lead to more effective treatments for progressive disease.
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Affiliation(s)
- Christopher E Goyne
- Department of Neurosciences, University of California San Diego, 9452 Medical Center Drive, Ste 4W-222, La Jolla, San Diego, CA, 92037, USA
| | - Ashley E Fair
- Department of Neurosciences, University of California San Diego, 9452 Medical Center Drive, Ste 4W-222, La Jolla, San Diego, CA, 92037, USA
| | - Paige E Sumowski
- Department of Neurosciences, University of California San Diego, 9452 Medical Center Drive, Ste 4W-222, La Jolla, San Diego, CA, 92037, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, 9452 Medical Center Drive, Ste 4W-222, La Jolla, San Diego, CA, 92037, USA.
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16
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Ozen NPA, Dursun EG, Tuncer A, Karabudak R. Navigating the discontinuation of multiple sclerosis first line treatments: A paradigm shift in patient care. Mult Scler Relat Disord 2024; 84:105503. [PMID: 38422633 DOI: 10.1016/j.msard.2024.105503] [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: 01/19/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND This retrospective study, conducted between 2005 and 2016, investigated the outcomes of patients with multiple sclerosis (MS) who discontinued injectable first-line disease-modifying therapies (DMTs). The study aimed to identify factors influencing treatment discontinuation and assess the impact of discontinuation on disease progression. METHODS Data was collected from 2,270 patients who received injectable DMTs for at least two years and subsequently discontinued treatment due to clinical and MRI remission, side effects, or noncompliance. Patients were categorized into two groups: those stable after discontinuation (SAD) and those with relapse after discontinuation (RAD). Survival analysis and logistic regression were employed to assess factors influencing treatment discontinuation. RESULTS Of the 60 patients who discontinued DMTs, one-third (n = 20) remained stable, while 40 patients experienced clinical and/or MRI activity during follow-up. The SAD group had a significantly later age at treatment discontinuation compared to RAD patients (35.9 ± 11.1 vs. 30.7 ± 6.1, p = 0.025). Patients below 40 years old had a higher likelihood of experiencing worsening (75 %), while those over 50 years old demonstrated an 80 % stability rate. SAD patients used DMTs for a more extended period than RAD patients (69.1 ± 47.3 vs. 46.6 ± 20.3 months, p = 0.012). A notable proportion (42.9 %) of worsened patients discontinued DMTs without consulting a physician, emphasizing potential challenges in treatment adherence. After treatment discontinuation, RAD patients experienced relapses after a median of 21.0 months. Survival analysis suggested a more favorable disease course for patients who discontinued treatment after achieving a stable period (p = 0.237), with evidence of differentiation between groups after four years. Regression analysis indicated that older age at discontinuation had a favorable impact on relapse probability (HR: 0.904; p = 0.031; 95 % CI: 0.825, 0.991). Reasons for discontinuation unrelated to disease stability showed a positive but imprecise effect on relapse probability. CONCLUSION This study provides insights into the outcomes of MS patients discontinuing injectable DMTs, emphasizing the importance of age at discontinuation and reasons for treatment cessation in predicting disease progression. The findings suggest that discontinuation after achieving stability may lead to more favorable outcomes, highlighting the need for personalized treatment decisions in MS management. Further research is warranted to validate these findings and inform clinical practices.
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Affiliation(s)
- Nazire Pinar Acar Ozen
- Hacettepe University Faculty of Medicine, Department of Neurology, Sihhiye, Ankara 06100, Turkey; Hacettepe University MS Research and Application Center, Turkey.
| | - Ece Gok Dursun
- Hacettepe University Faculty of Medicine, Department of Neurology, Sihhiye, Ankara 06100, Turkey
| | - Asli Tuncer
- Hacettepe University Faculty of Medicine, Department of Neurology, Sihhiye, Ankara 06100, Turkey; Hacettepe University MS Research and Application Center, Turkey
| | - Rana Karabudak
- Hacettepe University Faculty of Medicine, Department of Neurology, Sihhiye, Ankara 06100, Turkey; Hacettepe University MS Research and Application Center, Turkey
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17
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Frahm N, Ellenberger D, Stahmann A, Fneish F, Lüftenegger D, Salmen HC, Schirduan K, Schaak TPA, Flachenecker P, Kleinschnitz C, Paul F, Krefting D, Zettl UK, Peters M, Warnke C. Treatment switches of disease-modifying therapies in people with multiple sclerosis: long-term experience from the German MS Registry. Ther Adv Neurol Disord 2024; 17:17562864241239740. [PMID: 38560408 PMCID: PMC10981260 DOI: 10.1177/17562864241239740] [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: 06/27/2023] [Accepted: 02/14/2024] [Indexed: 04/04/2024] Open
Abstract
Background The spectrum of disease-modifying therapies (DMTs) for people with multiple sclerosis (PwMS) has expanded over years, but data on treatment strategies is largely lacking. DMT switches are common clinical practice. Objective To compare switchers and non-switchers, characterize the first DMT switch and identify reasons and predictors for switching the first DMT. Methods Data on 2722 PwMS from the German MS Registry were retrospectively analyzed regarding sociodemographic/clinical differences between 1361 switchers (PwMS discontinuing the first DMT) and non-switchers matched according to age, sex, and observation period. Frequencies of first and second DMTs were calculated and switch reasons identified. Predictors for DMT switches were revealed using univariable and multivariable regression models. Results Switchers and non-switchers differed significantly regarding time to first DMT, education, calendar period of the first DMT start (2014-2017 versus 2018-2021), first DMT class used [mild-to-moderate efficacy (MME) versus high-efficacy (HE) DMT], time on first DMT, and disease activity at first DMT start or cessation/last follow-up. The majority of PwMS started with MME DMTs (77.1%), with the most common being glatiramer acetate, dimethyl/diroximel fumarate, and beta-interferon variants. Switchers changed treatment more often to HE DMTs (39.6%), most commonly sphingosine-1-phosphate receptor modulators, anti-CD20 monoclonal antibodies, and natalizumab. Fewer PwMS switched to MME DMTs (35.9%), with the most common being dimethyl/diroximel fumarate, teriflunomide, or beta-interferon. Among 1045 PwMS with sufficient data (76.8% of 1361 switchers), the most frequent reasons for discontinuing the first DMT were disease activity despite DMT (63.1%), adverse events (17.1%), and patient request (8.3%). Predictors for the first DMT switch were MME DMT as initial treatment [odds ratio (OR) = 2.83 (1.76-4.61), p < 0.001; reference: HE DMT], first DMT initiation between 2014 and 2017 [OR = 11.55 (6.93-19.94), p < 0.001; reference: 2018-2021], and shorter time on first DMT [OR = 0.22 (0.18-0.27), p < 0.001]. Conclusion The initial use of MME DMTs was among the strongest predictors of DMT discontinuation in a large German retrospective MS cohort, arguing for the need for prospective treatment strategy trials, not only but also on the initial broad use of HE DMTs in PwMS.
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Affiliation(s)
- Niklas Frahm
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, Hannover, Niedersachsen 30171, Germany
| | - David Ellenberger
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Hannover, Germany
| | - Alexander Stahmann
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Hannover, Germany
| | - Firas Fneish
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Hannover, Germany
| | | | | | | | | | | | - Christoph Kleinschnitz
- Department of Neurology and Center of Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Dagmar Krefting
- Department of Medical Informatics, University Medical Center Göttingen, Göttingen, Germany
| | - Uwe K. Zettl
- Department of Neurology, Neuroimmunological Section, University Medical Center of Rostock, Rostock, Germany
| | - Melanie Peters
- German MS Registry, Gesellschaft für Versorgungsforschung mbH (Society for Health Care Research [GfV]), Hannover, Germany
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University Hospital of Cologne, Cologne, Germany
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18
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Chataway J, Williams T, Li V, Marrie RA, Ontaneda D, Fox RJ. Clinical trials for progressive multiple sclerosis: progress, new lessons learned, and remaining challenges. Lancet Neurol 2024; 23:277-301. [PMID: 38365380 DOI: 10.1016/s1474-4422(24)00027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/04/2023] [Accepted: 01/12/2024] [Indexed: 02/18/2024]
Abstract
Despite the success of disease-modifying treatments in relapsing multiple sclerosis, for many individuals living with multiple sclerosis, progressive disability continues to accrue. How to interrupt the complex pathological processes underlying progression remains a daunting and ongoing challenge. Since 2014, several immunomodulatory approaches that have modest but clinically meaningful effects have been approved for the management of progressive multiple sclerosis, primarily for people who have active inflammatory disease. The approval of these drugs required large phase 3 trials that were sufficiently powered to detect meaningful effects on disability. New classes of drug, such as Bruton tyrosine-kinase inhibitors, are coming to the end of their trial stages, several candidate neuroprotective compounds have been successful in phase 2 trials, and innovative approaches to remyelination are now also being explored in clinical trials. Work continues to define intermediate outcomes that can provide results in phase 2 trials more quickly than disability measures, and more efficient trial designs, such as multi-arm multi-stage and futility approaches, are increasingly being used. Collaborations between patient organisations, pharmaceutical companies, and academic researchers will be crucial to ensure that future trials maintain this momentum and generate results that are relevant for people living with progressive multiple sclerosis.
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Affiliation(s)
- Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK; Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK.
| | - Thomas Williams
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Vivien Li
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Ruth Ann Marrie
- Departments of Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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19
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Carlson AK, Amin M, Cohen JA. Drugs Targeting CD20 in Multiple Sclerosis: Pharmacology, Efficacy, Safety, and Tolerability. Drugs 2024; 84:285-304. [PMID: 38480630 PMCID: PMC10982103 DOI: 10.1007/s40265-024-02011-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 04/02/2024]
Abstract
Currently, there are four monoclonal antibodies (mAbs) that target the cluster of differentiation (CD) 20 receptor available to treat multiple sclerosis (MS): rituximab, ocrelizumab, ofatumumab, and ublituximab. B-cell depletion therapy has changed the therapeutic landscape of MS through robust efficacy on clinical manifestations and MRI lesion activity, and the currently available anti-CD20 mAb therapies for use in MS are a cornerstone of highly effective disease-modifying treatment. Ocrelizumab is currently the only therapy with regulatory approval for primary progressive MS. There are currently few data regarding the relative efficacy of these therapies, though several clinical trials are ongoing. Safety concerns applicable to this class of therapeutics relate primarily to immunogenicity and mechanism of action, and include infusion-related or injection-related reactions, development of hypogammaglobulinemia (leading to increased infection and malignancy risk), and decreased vaccine response. Exploration of alternative dose/dosing schedules might be an effective strategy for mitigating these risks. Future development of biosimilar medications might make these therapies more readily available. Although anti-CD20 mAb therapies have led to significant improvements in disease outcomes, CNS-penetrant therapies are still needed to more effectively address the compartmentalized inflammation thought to play an important role in disability progression.
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Affiliation(s)
- Alise K Carlson
- Mellen Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Ave U10, Cleveland, OH, 44195, USA
| | - Moein Amin
- Mellen Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Ave U10, Cleveland, OH, 44195, USA
| | - Jeffrey A Cohen
- Mellen Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Ave U10, Cleveland, OH, 44195, USA.
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20
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Jalaleddini K, Bermel RA, Talente B, Weinstein D, Qureshi F, Rasmussen M, Menon S, Amarapala M, Jordan K, Ghoreyshi A, McCurdy S, Edgeworth M. A US payer perspective health economic model assessing value of monitoring disease activity to inform discontinuation and re-initiation of DMT in multiple sclerosis. Mult Scler 2024; 30:432-442. [PMID: 38374525 DOI: 10.1177/13524585241227372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
OBJECTIVES We evaluate the potential clinical and cost impacts of discontinuing disease-modifying therapy (DMT) in people with multiple sclerosis (PwMS) when age-related immunosenescence can reduce DMT efficacy while increasing associated risks. METHODS A Markov model simulated clinical and cost impacts to the patient and payers when a proportion of eligible patients with relapsing remitting multiple sclerosis (RRMS) discontinue DMT. Eligibility was defined as age >55 years, an RRMS diagnosis of >5 years, and no history of relapses for 5 years. Increasing the proportion of eligible patients willing to discontinue therapy was also modeled. Clinical and cost inputs were from published literature. RESULTS Difference in EDSS progression between eligible patients who did and did not attempt discontinuation was not significant. After 1 year of eligibility, per-patient costs were $96k lower in the cohort that attempted discontinuation; however a higher proportion of relapses were seen in this group. When the proportion of patients willing to discontinue DMT increased, clinical findings remained consistent while the average cost per patient decreased. CONCLUSION While there are increased clinical and cost benefits as more eligible patients attempt discontinuation, the risk of relapses can increase. Timely disease monitoring is required to manage safe DMT discontinuation.
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Affiliation(s)
| | - Robert A Bermel
- Mellen Center for Multiple Sclerosis, Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | - Sreeranjani Menon
- Boston Healthcare Associates, Inc. (now a Veranex company), Boston, MA, USA
| | - Miyuru Amarapala
- Boston Healthcare Associates, Inc. (now a Veranex company), Boston, MA, USA
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21
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Knowles S, Middleton R, Cooze B, Farkas I, Leung YY, Allen K, Winslade M, Owen DRJ, Magliozzi R, Reynolds R, Neal JW, Pearson O, Nicholas R, Pickrell WO, Howell OW. Comparing the Pathology, Clinical, and Demographic Characteristics of Younger and Older-Onset Multiple Sclerosis. Ann Neurol 2024; 95:471-486. [PMID: 38061895 DOI: 10.1002/ana.26843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/13/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Older people with multiple sclerosis (MS) have a less active radiological and clinical presentation, but many still attain significant levels of disability; but what drives worsening disability in this group? METHODS We used data from the UK MS Register to characterize demographics and clinical features of late-onset multiple sclerosis (LOMS; symptom onset at ≥50 years), compared with adult-onset MS (AOMS; onset 18-49 years). We performed a pathology study of a separate MS cohort with a later onset (n = 18, mean age of onset 54 years) versus AOMS (n = 23, mean age of onset 29 years). RESULTS In the Register cohort, there were 1,608 (9.4%) with LOMS. When compared with AOMS, there was a lower proportion of women, a higher proportion of primary progressive MS, a higher level of disability at diagnosis (median MS impact scale 36.7 vs. 28.3, p < 0.001), and a higher proportion of gait-related initial symptoms. People with LOMS were less likely to receive a high efficacy disease-modifying treatment and attained substantial disability sooner. Controlling for age of death and sex, neuron density in the thalamus and pons decreased with onset-age, whereas actively demyelinating lesions and compartmentalized inflammation was greatest in AOMS. Only neuron density, and not demyelination or the extent of compartmentalized inflammation, correlated with disability outcomes in older-onset MS patients. INTERPRETATION The more progressive nature of older-onset MS is associated with significant neurodegeneration, but infrequent inflammatory demyelination. These findings have implications for the assessment and treatment of MS in older people. ANN NEUROL 2024;95:471-486.
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Affiliation(s)
- Sarah Knowles
- UK MS Register, Swansea University Medical School, Swansea University, Swansea, UK
| | - Rod Middleton
- UK MS Register, Swansea University Medical School, Swansea University, Swansea, UK
| | - Benjamin Cooze
- Department of Neurosciences, Swansea University Medical School, Swansea University, Swansea, UK
| | - Ildiko Farkas
- Division of Brain Sciences, Imperial College London, London, UK
| | | | - Kelsey Allen
- Department of Neurosciences, Swansea University Medical School, Swansea University, Swansea, UK
| | - Molly Winslade
- Department of Neurosciences, Swansea University Medical School, Swansea University, Swansea, UK
| | - David R J Owen
- Division of Brain Sciences, Imperial College London, London, UK
| | - Roberta Magliozzi
- Division of Brain Sciences, Imperial College London, London, UK
- Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
| | | | - James W Neal
- Department of Neurosciences, Swansea University Medical School, Swansea University, Swansea, UK
| | - Owen Pearson
- Neurology Department, Morriston Hospital, Swansea Bay University Health Board, Port Talbot, UK
| | - Richard Nicholas
- UK MS Register, Swansea University Medical School, Swansea University, Swansea, UK
- Division of Brain Sciences, Imperial College London, London, UK
| | - W Owen Pickrell
- Department of Neurosciences, Swansea University Medical School, Swansea University, Swansea, UK
- Neurology Department, Morriston Hospital, Swansea Bay University Health Board, Port Talbot, UK
| | - Owain W Howell
- Department of Neurosciences, Swansea University Medical School, Swansea University, Swansea, UK
- Division of Brain Sciences, Imperial College London, London, UK
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22
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Jakimovski D, Kavak KS, Coyle PK, Goodman AD, Gottesman M, Zivadinov R, Weinstock-Guttman B. Disease-modifying treatment, long-term outcomes and transition to progressive multiple sclerosis: data based on the New York State MS Consortium. J Neurol 2024; 271:711-722. [PMID: 37995009 DOI: 10.1007/s00415-023-12099-x] [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: 07/07/2023] [Revised: 10/01/2023] [Accepted: 11/03/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND The impact of disease-modifying treatments (DMTs) on multiple sclerosis (MS) long-term outcomes is continuously evolving. Retrospective analyses of large and long-term registries could provide information regarding general disease trajectories and risk factors that are commonly not investigated in shorter clinical trial settings. METHODS Retrospective observational study of people with MS (pwMS) registered in New York State MS Consortium (NYSMSC) since 1996. Disability outcomes of reaching sustained Expanded Disability Status Scale (EDSS) scores of 4.0, 6.0 and transition to secondary-progressive MS (SPMS) were confirmed at follow-up. Four DMT categories were determined (1) continuous DMT use, (2) discontinued DMT, (3) (re)started DMT and (4) never treated with DMT. Patient-reported outcomes (PRO) were acquired using LIFEware system. Kaplan-Meier survival curves and adjusted analysis of covariance (ANCOVA) were used to determine the rate and factors related to disability progression. RESULTS Total of 1893 pwMS were included with baseline average age of 43.2 years (SD = 10.4), 9.6 years of disease duration (SD = 8.8), median EDSS of 3.0 (IQR 2.0-3.5) and average follow-up time of 6.9 years (SD = 4.9). In addition to being male, older, more disabled and reporting worse PROs at baseline, pwMS who discontinued DMT had more than 5.5 times greater risk of reaching sustained EDSS of 4.0 (OR = 5.56, 95% CI 2.78-11.0, p < 0.001). Similarly, pwMS who discontinued DMT during the NYSMSC follow-up had 3.8- and 4.7-times greater risk to reach sustained EDSS 6.0 (OR = 3.86, 95% CI 2.12-7.02, p < 0.001), and to transition to SPMS (OR = 4.77, 95% CI 2.9-7.87, p < 0.001). Propensity matching analysis confirmed the worse clinical outcomes. CONCLUSIONS In addition to known predictors of long-term clinical outcomes, pwMS who discontinue DMT have worse long-term disability trajectory when compared to both early and late DMT starters. PRO-based indicators may suggest worse clinical outcomes.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 1010 Main Street, Buffalo, NY, 14202, USA
| | - Katelyn S Kavak
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 1010 Main Street, Buffalo, NY, 14202, USA
| | - Patricia K Coyle
- Department of Neurology, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Andrew D Goodman
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | | | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 1010 Main Street, Buffalo, NY, 14202, USA.
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23
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Abdelrahman A, Alvarez E. Advances in Multiple Sclerosis Neurotherapeutics, Neuroprotection, and Risk Mitigation Strategies. Neurol Clin 2024; 42:115-135. [PMID: 37980110 DOI: 10.1016/j.ncl.2023.08.002] [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] [Indexed: 11/20/2023]
Abstract
The treatment of patients with relapsing multiple sclerosis (MS) has advanced tremendously over the past few decades. More efficacious therapies have been approved, which can significantly reduce the inflammatory process of relapsing MS. Neuroprotection by controlling this pathophysiology is important given our current limitations to control progressive MS and induce neurorepair. Here, the authors discuss the current landscape of neurotherapeutics for relapsing MS focusing on newer disease-modifying treatments and their use. Risk mitigation of these medications can greatly improve their safety and improve their benefit-risk balance. The authors discuss treatment strategies for risk mitigation including treatment discontinuation and de-escalation.
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Affiliation(s)
- Ahmad Abdelrahman
- Department of Neurology, Rocky Mountain MS Center at the University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Enrique Alvarez
- Department of Neurology, Rocky Mountain MS Center at the University of Colorado Anschutz Medical Center, University of Colorado, Aurora, CO, USA.
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Nakamura K, Elliott C, Lee H, Narayanan S, Arnold DL. Brain volume increase after discontinuing natalizumab therapy: Evidence for reversible pseudoatrophy. Mult Scler Relat Disord 2024; 81:105123. [PMID: 37976981 DOI: 10.1016/j.msard.2023.105123] [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: 12/12/2022] [Revised: 09/02/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND The phenomenon of pseudoatropy after initiation of anti-inflammatory therapy is believed to be reversible, but a rebound in brain volume following cessation of highly-effective therapy has not been reported. OBJECTIVES To evaluate brain volume change in a treatment interruption study (RESTORE) in which relapsing-remitting multiple sclerosis (RRMS) patients were randomized to switch from natalizumab to placebo, from natalizumab to once-monthly intravenous methylprednisolone (IVMP), or to remain on natalizumab. METHODS T2 lesion volume (T2LV), baseline normalized brain volumes, and follow-up percent brain volume changes (PBVC) were calculated. Approximate T2 relaxation-time (pT2) was calculated within the brain mask and the T2 lesions to estimate changes in water content. Linear mixed effects models were used to detect differences in T2LV, pT2 in whole brain, pT2 in T2-weighted lesions, and PBVC among the placebo, natalizumab, and IVMP groups. We also estimated contributions of T2LV and pT2 (in whole brain and T2 lesions) to PBVC. RESULTS T2LV increased in the placebo group (by 0.66 ml/year, p<0.0001) and IVMP (+1.98 ml/year, p = 0.05) groups relative to the natalizumab group. The rates of PBVC were significantly different: -0.239%/year with continued natalizumab and +0.126 %/year after switch to placebo (p = 0.03), while the IVMP group showed brain volume loss (-0.74 %/ year, p = 0.08). pT2 was not statistically different between the groups (p ≥ 0.29) and did not have significant effects on PBVC (p ≥ 0.25). CONCLUSION The increase in the brain volume in patients witching from natalizumab to placebo is consistent with reversal of so-called pseudoatrophy after starting natalizumab.
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Affiliation(s)
- Kunio Nakamura
- McConnell Brain Imaging Centre, Montreal Neurological Institute Hospital, and Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, QC H3A 2B4, Canada; Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, ND20, Cleveland, Ohio 44195, USA.
| | - Colm Elliott
- Centre for Intelligent Machines, McGill University, 3480 Rue University, Montréal, QC H3A 2A7, Canada. NeuroRx Research, 3575 Park Avenue, Suite #5322, Montreal, Quebec H2 × 4B3, Canada; NeuroRx Research, 3575 Park Avenue, Suite #5322, Montreal, Quebec H2 × 4B3, Canada
| | - Hyunwoo Lee
- McConnell Brain Imaging Centre, Montreal Neurological Institute Hospital, and Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, QC H3A 2B4, Canada; Division of Neurology, Department of Medicine, University of British Columbia S154-2211 Wesbrook Mall, Vancouver, BC V6T2B5, Canada
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute Hospital, and Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, QC H3A 2B4, Canada; NeuroRx Research, 3575 Park Avenue, Suite #5322, Montreal, Quebec H2 × 4B3, Canada
| | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute Hospital, and Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, QC H3A 2B4, Canada; NeuroRx Research, 3575 Park Avenue, Suite #5322, Montreal, Quebec H2 × 4B3, Canada
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25
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Kondo A, Ikeguchi R, Kitagawa K, Shimizu Y. Disease Activity and Progression of Disability in Multiple Sclerosis Patients Aged Over 50 With or Without Disease-Modifying Drug Treatment: A Retrospective Cohort Study. Cureus 2023; 15:e49927. [PMID: 38058522 PMCID: PMC10697689 DOI: 10.7759/cureus.49927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2023] [Indexed: 12/08/2023] Open
Abstract
Background This study aimed to clarify the need for disease-modifying drug (DMD) treatment in elderly patients with multiple sclerosis (MS) aged 50 years or older. MS is an autoimmune, demyelinating disease of the central nervous system that predominantly affects young women. Various DMDs are effective in preventing relapses and slowing the progression of disability in patients with MS. Although disease activity in MS is believed to decrease with aging, a consensus on the appropriate DMD treatment for elderly patients with MS is lacking. Methodology This study included elderly patients with MS (>50 years old). We compared the occurrence of relapses, worsening of disability, and conversion to secondary progressive MS (SPMS) between patients with DMD treatment and those without. Logistic regression analysis was performed to determine the predictors of these outcomes. Confounding factors were adjusted using propensity scores. Results From January 1991 to October 2022, 76 elderly patients with MS were included. The mean age at the last visit was 57.4 ± 6.3 years, with 51 patients being female. The mean age of onset of MS was 37.1 ± 10.1 years. Fifty-four patients were included in the DMD treatment group. The overall relapse rate was 38% (33% and 48% in the DMD treatment and untreated groups, respectively). No significant differences in relapse rates (p = 0.72) or in the Expanded Disability Status Scale (EDSS) scores were identified between the two groups. Kaplan-Meier curves showed no differences in the time to first relapse within five years between the two groups. Additionally, no significant predictors of relapse were identified. Among 61 patients with relapsing-remitting MS, 25% converted to SPMS during the observation period. Logistic regression analysis showed that older age at the final visit and the presence of brainstem lesions at the age of 50 years were associated with a higher rate of transition to SPMS. Conclusions In the present study, no significant difference was found in the rate of relapse, disability progression, and conversion to SPMS between the DMD treatment and untreated groups in elderly patients with MS. Therefore, in patients without long-term relapse, no poor prognostic functional factors or predictors of conversion to SPMS, discontinuation of DMDs may be considered. In addition, the presence of brainstem lesions at 50 years of age may predict the conversion to SPMS. Thus, the continuation of DMD or conversion to an appropriate DMD should be considered in patients with brainstem lesions at 50 years of age.
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Affiliation(s)
- Akihiro Kondo
- Department of Neurology, Tokyo Women's Medical University, Tokyo, JPN
| | - Ryotaro Ikeguchi
- Department of Neurology, Tokyo Women's Medical University, Tokyo, JPN
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University, Tokyo, JPN
| | - Yuko Shimizu
- Department of Neurology, Tokyo Women's Medical University, Tokyo, JPN
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Aoun R, Gratch D, Kaminetzky D, Kister I. Immune Checkpoint Inhibitors in Patients with Pre-existing Neurologic Autoimmune Disorders. Curr Neurol Neurosci Rep 2023; 23:735-750. [PMID: 37870664 DOI: 10.1007/s11910-023-01306-x] [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] [Accepted: 09/11/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE OF REVIEW The use of immune checkpoint inhibitors (ICIs) for oncologic indications is associated with immune-related adverse events (irAEs). Patients with pre-existing autoimmune diseases are at increased risk of irAEs and have largely been excluded from clinical trials of ICIs. Therefore, there is limited data on the safety of safety of ICIs in patients with pre-existing neurologic autoimmune diseases (nAIDs) such as myasthenia gravis and multiple sclerosis. This review aims to synthesize the literature on the post-marketing experience with ICI in patients with pre-existing nAID and to discuss possible strategies for mitigating the risk of post-ICI nAID relapses. RECENT FINDINGS Patients with pre-existing myasthenia gravis (MG), myositis, and paraneoplastic encephalitis appear highly susceptible to neurologic relapses of their underlying neurologic disorder following ICI initiation; these relapses can cause considerable morbidity and mortality. In patients with multiple sclerosis (MS), the risk and severity of MS relapses following ICI appears to be relatively lower compared to MG. Preliminary evidence suggests that older MS patients with no recent focal neuroinflammatory activity may be safely treated with ICI. Among the several case reports of ICI in patients with a history of Guillain-Barre syndrome (GBS), neurologic worsening was only recorded in one patient who was in the acute phase of GBS at the time of ICI start. Initiating an ICI in a patient with pre-existing nAID involves a complex risk-benefit discussion between the patient, their oncologist, and neurologist. Relevant issues to consider before ICI include the choice of disease-modifying therapy for nAID (if any) and strategies for promptly identifying and managing nAID relapses should they occur. Currently, the literature consists mainly of case reports and case series, subject to publication bias. Prospective studies of ICI in patients with nAID are needed to improve the level of evidence.
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Affiliation(s)
- Raissa Aoun
- Department of Neurology, NYU Grossman School of Medicine, 550 1st Ave, New York, NY, 10016, USA
| | - Daniel Gratch
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, 5 East 98th St, New York, NY, 10029, USA
| | - David Kaminetzky
- Department of Oncology, NYU Grossman School of Medicine, 550 1st Ave, New York, NY, 10016, USA
| | - Ilya Kister
- NYU Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Grossman School of Medicine, 240 East 38th St, New York, NY, 10016, USA.
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27
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Bose G, Healy BC, Saxena S, Saleh F, Glanz BI, Bakshi R, Weiner HL, Chitnis T. Increasing Neurofilament and Glial Fibrillary Acidic Protein After Treatment Discontinuation Predicts Multiple Sclerosis Disease Activity. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200167. [PMID: 37813595 PMCID: PMC10574823 DOI: 10.1212/nxi.0000000000200167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Stable patients with multiple sclerosis (MS) may discontinue treatment, but the risk of disease activity is unknown. Serum neurofilament light chain (sNfL) and serum glial fibrillary acidic protein (sGFAP) are biomarkers of subclinical disease activity and may help risk stratification. In this study, sNfL and sGFAP levels in stable patients were evaluated before and after treatment discontinuation to determine association with disease activity. METHODS This observational study included patients enrolled in the Comprehensive Longitudinal Investigation in MS at the Brigham and Women's Hospital who discontinued treatment after >2 years disease activity-free. Two serum samples within 2 years, before and after treatment stop, were sent for sNfL and sGFAP measurements by single-molecule array. Biannual neurologic examinations and yearly MRI scans determined disease activity by 3 time-to-event outcomes: 6-month confirmed disability worsening (CDW), clinical attacks, and MRI activity (new T2 or contrast-enhancing lesions). Associations between each outcome and log-transformed sNfL and sGFAP levels pretreatment stop and posttreatment stop and the percent change were estimated using multivariable Cox regression analysis adjusting for age, disability, disease duration, and duration from attack before treatment stop. RESULTS Seventy-eight patients (92% female) discontinued treatment at a median (interquartile range) age of 48.5 years (39.0-55.7) and disease duration of 12.3 years (7.5-18.8) and were followed up for 6.3 years (4.2-8.5). CDW occurred in 27 patients (35%), new attacks in 19 (24%), and new MRI activity in 26 (33%). Higher posttreatment stop sNfL level was associated with CDW (adjusted hazard ratio (aHR) 2.80, 95% CI 1.36-5.76, p = 0.005) and new MRI activity (aHR 3.09, 95% CI 1.42-6.70, p = 0.004). Patients who had >100% increase in sNfL level from pretreatment stop to posttreatment stop had greater risk of CDW (HR 3.87, 95% CI 1.4-10.7, p = 0.009) and developing new MRI activity (HR 4.02, 95% CI 1.51-10.7, p = 0.005). Patients who had >50% increase in sGFAP level also had greater risk of CDW (HR 5.34, 95% CI 1.4-19.9, p = 0.012) and developing new MRI activity (HR 5.16, 95% CI 1.71-15.6, p = 0.004). DISCUSSION Stable patients who discontinue treatment may be risk stratified by sNfL and sGFAP levels measured before and after discontinuing treatment. Further studies are needed to validate findings and determine whether resuming treatment in patients with increasing biomarker levels reduces risk of subsequent disease activity.
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Affiliation(s)
- Gauruv Bose
- From the Department of Neurology (G.B., B.C.H., S.S., F.S., B.I.G., R.B., H.L.W., T.C.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (G.B., B.C.H., B.I.G., R.B., H.L.W., T.C.), Boston, MA; The University of Ottawa and Ottawa Hospital Research Institute (G.B.), Ottawa, Canada
| | - Brian C Healy
- From the Department of Neurology (G.B., B.C.H., S.S., F.S., B.I.G., R.B., H.L.W., T.C.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (G.B., B.C.H., B.I.G., R.B., H.L.W., T.C.), Boston, MA; The University of Ottawa and Ottawa Hospital Research Institute (G.B.), Ottawa, Canada
| | - Shrishti Saxena
- From the Department of Neurology (G.B., B.C.H., S.S., F.S., B.I.G., R.B., H.L.W., T.C.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (G.B., B.C.H., B.I.G., R.B., H.L.W., T.C.), Boston, MA; The University of Ottawa and Ottawa Hospital Research Institute (G.B.), Ottawa, Canada
| | - Fermisk Saleh
- From the Department of Neurology (G.B., B.C.H., S.S., F.S., B.I.G., R.B., H.L.W., T.C.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (G.B., B.C.H., B.I.G., R.B., H.L.W., T.C.), Boston, MA; The University of Ottawa and Ottawa Hospital Research Institute (G.B.), Ottawa, Canada
| | - Bonnie I Glanz
- From the Department of Neurology (G.B., B.C.H., S.S., F.S., B.I.G., R.B., H.L.W., T.C.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (G.B., B.C.H., B.I.G., R.B., H.L.W., T.C.), Boston, MA; The University of Ottawa and Ottawa Hospital Research Institute (G.B.), Ottawa, Canada
| | - Rohit Bakshi
- From the Department of Neurology (G.B., B.C.H., S.S., F.S., B.I.G., R.B., H.L.W., T.C.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (G.B., B.C.H., B.I.G., R.B., H.L.W., T.C.), Boston, MA; The University of Ottawa and Ottawa Hospital Research Institute (G.B.), Ottawa, Canada
| | - Howard L Weiner
- From the Department of Neurology (G.B., B.C.H., S.S., F.S., B.I.G., R.B., H.L.W., T.C.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (G.B., B.C.H., B.I.G., R.B., H.L.W., T.C.), Boston, MA; The University of Ottawa and Ottawa Hospital Research Institute (G.B.), Ottawa, Canada
| | - Tanuja Chitnis
- From the Department of Neurology (G.B., B.C.H., S.S., F.S., B.I.G., R.B., H.L.W., T.C.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (G.B., B.C.H., B.I.G., R.B., H.L.W., T.C.), Boston, MA; The University of Ottawa and Ottawa Hospital Research Institute (G.B.), Ottawa, Canada.
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Thakolwiboon S, Mills EA, Yang J, Doty J, Belkin MI, Cho T, Schultz C, Mao-Draayer Y. Immunosenescence and multiple sclerosis: inflammaging for prognosis and therapeutic consideration. FRONTIERS IN AGING 2023; 4:1234572. [PMID: 37900152 PMCID: PMC10603254 DOI: 10.3389/fragi.2023.1234572] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/29/2023] [Indexed: 10/31/2023]
Abstract
Aging is associated with a progressive decline of innate and adaptive immune responses, called immunosenescence. This phenomenon links to different multiple sclerosis (MS) disease courses among different age groups. While clinical relapse and active demyelination are mainly related to the altered adaptive immunity, including invasion of T- and B-lymphocytes, impairment of innate immune cell (e.g., microglia, astrocyte) function is the main contributor to disability progression and neurodegeneration. Most patients with MS manifest the relapsing-remitting phenotype at a younger age, while progressive phenotypes are mainly seen in older patients. Current disease-modifying therapies (DMTs) primarily targeting adaptive immunity are less efficacious in older patients, suggesting that immunosenescence plays a role in treatment response. This review summarizes the recent immune mechanistic studies regarding immunosenescence in patients with MS and discusses the clinical implications of these findings.
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Affiliation(s)
| | - Elizabeth A. Mills
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Jennifer Yang
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Jonathan Doty
- Michigan Institute for Neurological Disorders, Farmington Hills, MI, United States
| | - Martin I. Belkin
- Michigan Institute for Neurological Disorders, Farmington Hills, MI, United States
| | - Thomas Cho
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Charles Schultz
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Yang Mao-Draayer
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
- Michigan Institute for Neurological Disorders, Farmington Hills, MI, United States
- Autoimmune Center of Excellence, University of Michigan, Ann Arbor, MI, United States
- Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan, Ann Arbor, MI, United States
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29
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Prosperini L, Haggiag S, Ruggieri S, Tortorella C, Gasperini C. Stopping Disease-Modifying Treatments in Multiple Sclerosis: A Systematic Review and Meta-Analysis of Real-World Studies. CNS Drugs 2023; 37:915-927. [PMID: 37740822 DOI: 10.1007/s40263-023-01038-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND The question of whether multiple sclerosis requires life-long disease-modifying treatments (DMTs) remains unanswered. Some studies suggest that older patients with stable disease may safely discontinue their DMTs, yet comprehensive evidence-based data are scarce and real-world studies have provided mixed results. OBJECTIVE The aim of this study was to assess the rate of disease reactivation and associated risk factors after discontinuation of DMTs in patients with multiple sclerosis. METHODS We searched scientific databases (PubMed/MEDLINE, Scopus and Google Scholar) to identify real-world studies published until 31 July, 2023 that reported the number of patients who experienced relapses and/or disability accrual (outcomes of interest) following a therapy discontinuation longer than 12 months. Magnetic resonance activity and treatment re-start after DMT discontinuation were also considered as additional outcomes. We excluded studies where therapy discontinuation was explicitly related to an unintended or planned pregnancy or preceded a treatment switch. We ran random-effects meta-analyses, subgroup analyses and meta-regression models to provide pooled estimates of post-discontinuation relapse and disability events, and to identify their potential moderators (predictors). RESULTS After an independent screening, 22 articles met the eligibility criteria, yielding a pooled sample size of 2942 patients followed for 1-7 years after discontinuation (11,689 patient-years). The pooled rates for relapse and disability events were 6.7 and 5.8 per 100 patient-years, respectively. However, available data did not allow us to disentangle isolated disability accrual from relapse-associated worsening. Studies including older patients (β = -0.65, p = 0.006), patients with a longer exposure to DMTs (β = -2.22, p = 0.001) and patients with a longer period of disease stability (β = -2.74, p = 0.002) showed a lower risk of relapse events. According to meta-regression equations, the risk of relapse events after DMT discontinuation became negligible (arbitrarily set at < 1% per year) at approximately 60 years of age, and after either 10 years of DMT exposure, or 8 years of disease stability. Additional analyses showed pooled rates for magnetic resonance imaging activity and re-start events of 16.7 and 17.5 per 100 patient-years, respectively. CONCLUSIONS Based on our quantitative synthesis of real-world data, in the absence of definitive answers from clinical trials, DMT discontinuation appears feasible with a high degree of certainty in selected patients. While our findings are robust regarding relapse events, future efforts are warranted to determine if DMT discontinuation is associated with isolated disability accrual.
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Affiliation(s)
- Luca Prosperini
- Department of Neurology, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152, Rome, Italy.
| | - Shalom Haggiag
- Department of Neurology, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152, Rome, Italy
| | - Serena Ruggieri
- Department of Human Neurosciences, Sapienza University, Viale dell'Università 30, 00185, Rome, Italy
- Neuroimmunology Unit, Santa Lucia Foundation, Via del Fosso di Fiorano 64/65, 00143, Rome, Italy
| | - Carla Tortorella
- Department of Neurology, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152, Rome, Italy
| | - Claudio Gasperini
- Department of Neurology, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152, Rome, Italy
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30
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Krysko KM. Discontinuing disease-modifying multiple sclerosis therapies. Lancet Neurol 2023; 22:543-545. [PMID: 37353269 DOI: 10.1016/s1474-4422(23)00200-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/19/2023] [Indexed: 06/25/2023]
Affiliation(s)
- Kristen M Krysko
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada; BARLO MS Centre, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
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31
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Tumani H, Coyle PK, Cárcamo C, Cordioli C, López PA, Peterka M, Ramo-Tello C, Zuluaga MI, Koster T, Vignos M. Treatment of older patients with multiple sclerosis: Results of an International Delphi Survey. Mult Scler J Exp Transl Clin 2023; 9:20552173231198588. [PMID: 37720692 PMCID: PMC10501080 DOI: 10.1177/20552173231198588] [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: 05/02/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Background People over age 50-55 have historically been excluded from randomized clinical trials for multiple sclerosis (MS). However, more than half of those living with an MS diagnosis are over 55. Objective Explore the unique considerations of treating older people with MS (PwMS) using an iterative and structured Delphi-based assessment to gather expert opinions. Methods Eight MS neurologists with an interest in older PwMS developed a 2-round survey. Survey respondents were qualified neurologists with ≥3 years' experience, personally responsible for treatment decisions, and treating ≥20 patients per month, of whom ≥10% were ≥50 years old. Consensus was defined as ≥75% agreement on questions with categorical responses or as a mean score ≥4 on questions with numerical responses. Results In Survey 1, 224 neurologists responded; 180 of these completed Survey 2. Limited consensus was reached with varying levels of agreement on several topics including identification and assessment of older patients; factors relating to treatment decisions including immunosenescence and comorbidities; considerations for high-efficacy treatments; de-escalation or discontinuation of treatment; effects of COVID-19; and unmet needs for treating this population. Conclusion The results of this Delphi process highlight the need for targeted studies to create guidance for the care of older PwMS.
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Affiliation(s)
| | - Patricia K Coyle
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Claudia Cárcamo
- Department of Neurology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cinzia Cordioli
- Multiple Sclerosis Center, ASST Spedali Civili Di Brescia, Montichiari (Brescia), Italy
| | - Pablo A López
- Neuroimmunology Unit, Department of Neuroscience, Hospital Alemán, Buenos Aires, Argentina
| | - Marek Peterka
- Department of Neurology, Charles University, Prague, Czech Republic
- Faculty of Medicine and University Hospital, Pilsen, Czech Republic
| | - Cristina Ramo-Tello
- Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Faculty of Medicine and University Hospital, Pilsen, Czech Republic
| | | | - Thijs Koster
- Biogen, Cambridge, MA, USA, at the time of this study
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