Therapies for multiple sclerosis: considerations in the pediatric patient

Effect of fingolimod on MRI outcomes in patients with paediatric-onset multiple sclerosis: results from the phase 3 PARADIGMS study

OBJECTIVE

PARADIGMS demonstrated superior efficacy and comparable safety of fingolimod versus interferon β-1a (IFN β-1a) in paediatric-onset multiple sclerosis (PoMS). This study aimed to report all predefined MRI outcomes from this study.

METHODS

Patients with multiple sclerosis (MS) (aged 10-<18 years) were randomised to once-daily oral fingolimod (n=107) or once-weekly intramuscular IFN β-1a (n=108) in this flexible duration study. MRI was performed at baseline and every 6 months for up to 2 years or end of the study (EOS) in case of early treatment discontinuation/completion. Key MRI endpoints included the annualised rate of formation of new/newly enlarging T2 lesions, gadolinium-enhancing (Gd+) T1 lesions, new T1 hypointense lesions and combined unique active (CUA) lesions (6 months onward), changes in T2 and Gd+ T1 lesion volumes and annualised rate of brain atrophy (ARBA).

RESULTS

Of the randomised patients, 107 each were treated with fingolimod and IFN β-1a for up to 2 years. Fingolimod reduced the annualised rate of formation of new/newly enlarging T2 lesions (52.6%, p<0.001), number of Gd+ T1 lesions per scan (66.0%, p<0.001), annualised rate of new T1 hypointense lesions (62.8%, p<0.001) and CUA lesions per scan (60.7%, p<0.001) versus IFN β-1a at EOS. The percent increases from baseline in T2 (18.4% vs 32.4%, p<0.001) and Gd+ T1 (-72.3% vs 4.9%, p=0.001) lesion volumes and ARBA (-0.48% vs -0.80%, p=0.014) were lower with fingolimod versus IFN β-1a, the latter partially due to accelerated atrophy in the IFN β-1a group.

CONCLUSION

Fingolimod significantly reduced MRI activity and ARBA for up to 2 years versus IFN β-1a in PoMS.

Clinical characteristics and use of disease modifying therapy in the nationwide Danish cohort of paediatric onset multiple sclerosis

BACKGROUND

Several disease-modifying therapies (DMT) are being used in paediatric patients with multiple sclerosis (MS) despite the limited number of randomised controlled clinical trials leading to approved indication in children.

OBJECTIVES

The aim of this study was to describe clinical characteristics of the Danish population of paediatric onset MS, and the patterns of DMT utilisation in patients who started treatment before the age of 18 years.

METHODS

We conducted a nationwide population-based cohort study, including 347 children with paediatric-onset MS (<18 years). Subjects were followed until their 25^th birthday or end of follow-up.

RESULTS

Median age at onset and diagnosis was 15.8 years and 17.2, respectively. The majority of the children had monosymptomatic presentation. In total, 140 children received DMT before the age of 18. Most started treatment with a moderate-efficacy drug (90%) of which interferon-beta was the most used (80%). However, since oral treatments became available, these have increasingly been used. During follow-up, 108 children switched or discontinued DMT. Fingolimod was prescribed more frequently than natalizumab as escalation therapy.

CONCLUSION

We present that use of DMT in POMS varies over the observed period concurrently with the availability of disease modifying drugs with progressive use of oral and high-efficacy therapies.

Pharmacokinetics and pharmacodynamics of natalizumab in pediatric patients with RRMS

Objective

This phase I study investigated pharmacokinetic (PK) and pharmacodynamic (PD) profiles of natalizumab in pediatric patients with relapsing-remitting MS (RRMS).

Methods

Pediatric patients with RRMS who were prescribed natalizumab 300 mg IV every 4 weeks were enrolled. Blood samples were collected on days 1, 2, 8, 15, and 22 and at weeks 4, 8, 12, and 16 to estimate PK parameters; PD properties were evaluated by measuring α4-integrin saturation and lymphocyte counts over time. Natalizumab's safety profile was also evaluated.

Results

PK parameters were similar to those reported in adult patients; natalizumab concentrations peaked approximately 1 day after infusion in most of the participants (Cmax 142.9 μg/mL, AUClast 47389.4 hr*μg/mL), followed by a biphasic decline with a rapid distribution phase and a slow elimination phase, with a terminal half-life of 215.1 hours. In terms of PD, both time course and magnitude of α4-integrin saturation and increase in lymphocyte counts were similar to those observed in adults. During the 16-week study follow-up, 3 adverse events attributed to natalizumab were observed; no unexpected safety events occurred.

Conclusions

PK profile, α4-integrin saturation, lymphocyte counts, and safety observed in these pediatric patients are comparable to those reported in adults.

Classification of evidence

This study provides Class I evidence that natalizumab PK/PD parameters and safety profile are similar in adults and pediatric patients in the short term. Longer studies, also including a larger number of younger subjects (aged 10-12 years), are required to further inform about long-term PK and PD parameters in pediatric patients with MS.

Pediatric-Onset Multiple Sclerosis: A Single Center Study

Pediatric-onset multiple sclerosis (POMS), once thought to be rare, is now being diagnosed in increasing numbers in children. Despite improvements to diagnostic criteria, the diagnosis and management of POMS remains challenging. The aim of this study is to retrospectively describe a growing POMS patient population seen at a single center over a 13 year period. Epidemiologic, clinical, neuroimaging, laboratory features and therapeutic management and outcome data were collected and analyzed. These data support associations between MS and environmental triggers such as obesity and vitamin D deficiency. Presenting symptoms, magnetic resonance imaging and laboratory findings were consistent with the existing literature; however, the prevalence of cortical lesions and abnormal saccadic pursuit is higher than other reports. Data also demonstrate a shift in practice from first- to second-line therapies over the observed period.

Bringing the HEET: The Argument for High-Efficacy Early Treatment for Pediatric-Onset Multiple Sclerosis

Pediatric-onset multiple sclerosis (POMS) is rarer than adult-onset disease, and represents a different diagnostic and treatment challenge to clinicians. We review POMS clinical and radiographic presentations, and explore important differences between POMS and adult-onset MS natural histories and long-term outcomes. Despite having more active disease, current treatment guidelines for patients with POMS endorse the off-label use of lower-efficacy disease-modifying therapies (DMTs) as first line. We review the available MS DMTs, their evidence for use in POMS, and the contrasting treatment strategies of high-efficacy early treatment and escalation therapy. We introduce a new treatment approach, the "high-efficacy early treatment", or HEET strategy, based on using directly observed, high-efficacy intravenously infused DMTs as first-line therapies. Like other proposed POMS treatment strategies, HEET will need to be prospectively studied, and all treatment decisions should be determined by an experienced neurologist, the patient, and his/her parents.

The Use of Natalizumab in Pediatric Patients With Active Relapsing Multiple Sclerosis: A Prospective Study

BACKGROUND

Pediatric multiple sclerosis (MS) has been increasingly recognized. In the absence of approved disease-modifying therapies (DMTs) for pediatric patients, clinicians resort to data extrapolated from clinical trials conducted in adults with MS. The objective of this article was to study the effectiveness and safety of natalizumab in with pediatric MS.

METHODS

Patients with pediatric MS (aged less than 18 years) who had been treated with natalizumab were followed up prospectively as part of the national MS registry. Data of relapsing patients who had at least a one-year follow-up were analyzed. The primary outcome measure was the annual relapse rate after natalizumab treatment. Secondary outcomes measures included the mean change in disease progression measured by the expanded disability status scale and the proportion of patients with radiologic activity (gadolinium-enhancing or new T2 lesions) at the last follow-up visit.

RESULTS

Thirty-two patients with pediatric MS had been treated with natalizumab for at least 12 months, of whom 72% were females. The mean age at onset and disease duration were 14.9 ± 2.6 and 5.1 ± 3.1 years, respectively. Most patients (n = 21, 66%) had breakthrough disease on first-line disease-modifying therapies. The mean number of natalizumab infusions was 34.5 ± 18. The annual relapse rate was significantly reduced (1.66 ± 0.5 vs 0.06 ± 0.25; P < 0.001), whereas the mean expanded disability status score improved (3.3 ± 1.3 vs 2.2 ± 1.0; P < 0.001) at the last follow-up visits. The proportion of patients with magnetic resonance imaging activity was significantly reduced (93.8% versus 12.5%; P < 0.001). No major adverse events were observed.

CONCLUSION

In our pediatric MS cohort with aggressive or breakthrough disease, treatment with natalizumab was effective in reducing clinical and radiologic disease activity. Natalizumab has a similar clinical efficacy and safety profile as in adult MS.

Oral Dimethyl Fumarate in Children With Multiple Sclerosis: A Dual-Center Study

BACKGROUND

First-line injectable therapies for multiple sclerosis in children may be ineffective or not well-tolerated. There is therefore an urgent need to explore oral medications for pediatric multiple sclerosis. We review our dual-center experience with oral dimethyl fumarate.

METHODS

This study was a retrospective review of children 18 years of age or less with multiple sclerosis treated with dimethyl fumarate at Yale University and the University of Colorado. Clinical, demographic, and magnetic resonance imaging parameters were analyzed.

RESULTS

We identified 13 children treated with oral dimethyl fumarate for a median of 15.0 months (range, 1 to 25). Dimethyl fumarate was utilized as first-line therapy in five children (38%). Ten children (77%) tolerated dose escalation to the usual adult dose of 240 mg twice daily. Nine children had ≥12 months of follow-up on treatment. Eight of nine (89%) displayed stabilized or reduced relapse rates and disability scores on treatment. Nine children underwent brain magnetic resonance imaging performed after 12 or more months of therapy. New T2 lesions were observed in three children (33%), one of whom had been nonadherent to treatment. Common side effects included facial flushing (8/13, 62%), gastrointestinal discomfort (7/13, 54%), rash (3/13, 23%), and malaise (2/13, 15%). Three children (23%) discontinued treatment because of side effects. No patients displayed laboratory abnormalities including lymphopenia or abnormal liver transaminases. There were no reported infections.

CONCLUSIONS

Oral dimethyl fumarate appears to be safe and generally well tolerated in children with multiple sclerosis. Formal clinical trials to evaluate efficacy are ongoing.

Multiple sclerosis in the very young: a case report and review of the literature

Onset of multiple sclerosis (MS) in the very young (<10 years) is uncommon. We describe a 2 year old girl with MS, the youngest reported case in the USA. She presented to an outside hospital with acute onset of ataxia on three occasions before presenting to our institution, initially misdiagnosed as acute disseminated encephalomyelitis and treated with intravenous methylprednisolone. MRI of the brain during each presentation revealed new areas of demyelination. Initial cerebrospinal fluid (CSF) studies and MRI of the spine were normal. Repeat MRI of the brain at our institution, 7 months later, revealed new demyelinating lesions and CSF analysis revealed elevated myelin basic protein, negative oligoclonal band and neuromyelitis optica immunoglobulin and normal IgG synthesis. Her clinical presentation with multiple relapses and new MRI findings validated the diagnosis of MS.

Myelin oligodendrocyte glycoprotein antibodies are associated with a non-MS course in children

Objective:

To determine whether myelin oligodendrocyte glycoprotein antibodies (MOG-Abs) were predictive of a demyelination phenotype in children presenting with acquired demyelinating syndrome (ADS).

Method:

Sixty-five children with a first episode of ADS (12 acute disseminated encephalomyelitis, 24 optic neuritis, 18 transverse myelitis, 11 other clinically isolated syndrome) were identified from 2 national demyelination programs in the United Kingdom and France. Acute serum samples were tested for MOG-Abs by cell-based assay. Antibodies were used to predict diagnosis of multiple sclerosis (MS) at 1 year.

Results:

Twenty-three of 65 (35%) children had MOG-Abs. Antibody-positive and antibody-negative patients were not clinically different at presentation, but identification of MOG-Abs predicted a non-MS course at 1-year follow-up: only 2/23 (9%) MOG-Ab–positive patients were diagnosed with MS compared to 16/42 (38%) MOG-Ab–negative patients (p = 0.019, Fisher exact test). Antibody positivity at outset was a useful predictor for a non-MS disease course, with a positive predictive value of 91% (95% confidence interval [CI] 72–99), negative predictive value of 38% (95% CI 24–54), positive likelihood ratio of 4.02 (CI 1.0–15.4), and odds ratio of 6.5 (CI 1.3–31.3).

Conclusions:

MOG-Abs are found at presentation in 35% of patients with childhood ADS, across a range of demyelinating disorders. Antibody positivity can be useful in predicting a non-MS disease course at onset.

Multiple sclerosis in children and adolescents. An important differential diagnosis of acute neurological disease

AIM

Multiple sclerosis (MS) has traditionally been considered a disease of adults. However, in recent years, there have been numerous reports about the disease occurring in childhood and adolescence. The purpose of this article is to document Norwegian experience of this population based on clinical observations and neuroradiological findings.

METHODS

Children and adolescents diagnosed with MS at the Department of Child Neurology, Oslo University Hospital, between 1 January 2004 and 1 May 2012 were included. Gender, previous diseases, age, symptoms at first attack, spinal fluid findings and cerebral magnetic resonance tomography (MRI) findings were recorded. The course of the disease, treatment and sequelae was noted.

RESULTS

The study includes 18 patients who received MS diagnosis. Median age at onset was 10 years and six months. The presenting symptoms and MRI findings varied. Almost all patients were treated with steroids in the acute phase and later with interferon-beta. Some patients were treated with natalizumab when there was lack of efficiency of interferon-beta. Seven patients developed permanent, moderate sequelae in terms of motor, sensory, or cerebellar symptoms. Nine patients had cognitive difficulties and 11 specified increased fatigability.

CONCLUSION

MS in children and adolescents is a disease with varying acute neurological symptoms and findings. The patients were treated with the same medicines as adults with MS and tolerated it well. We found that cognitive sequelae and fatigue were common also in this young age group.

Multiple sclerosis in children: an update on clinical diagnosis, therapeutic strategies, and research

The clinical features, diagnostic challenges, neuroimaging appearance, therapeutic options, and pathobiological research progress in childhood-and adolescent-onset multiple sclerosis have been informed by many new insights in the past 7 years. National programmes in several countries, collaborative research efforts, and an established international paediatric multiple sclerosis study group have contributed to revised clinical diagnostic definitions, identified clinical features of multiple sclerosis that differ by age of onset, and made recommendations regarding the treatment of paediatric multiple sclerosis. The relative risks conveyed by genetic and environmental factors to paediatric multiple sclerosis have been the subject of several large cohort studies. MRI features have been characterised in terms of qualitative descriptions of lesion distribution and applicability of MRI aspects to multiple sclerosis diagnostic criteria, and quantitative studies have assessed total lesion burden and the effect of the disease on global and regional brain volume. Humoral-based and cell-based assays have identified antibodies against myelin, potassium-channel proteins, and T-cell profiles that support an adult-like T-cell repertoire and cellular reactivity against myelin in paediatric patients with multiple sclerosis. Finally, the safety and efficacy of standard first-line therapies in paediatric multiple sclerosis populations are now appreciated in more detail, and consensus views on the future conduct and feasibility of phase 3 trials for new drugs have been proposed.

Treatment Optimization in MS: Canadian MS Working Group Updated Recommendations

The Canadian Multiple Sclerosis Working Group (CMSWG) developed practical recommendations in 2004 to assist clinicians in optimizing the use of disease-modifying therapies (DMT) in patients with relapsing multiple sclerosis. The CMSWG convened to review how disease activity is assessed, propose a more current approach for assessing suboptimal response, and to suggest a scheme for switching or escalating treatment. Practical criteria for relapses, Expanded Disability Status Scale (EDSS) progression and MRI were developed to classify the clinical level of concern as Low, Medium and High. The group concluded that a change in treatment may be considered in any RRMS patient if there is a high level of concern in any one domain (relapses, progression or MRI), a medium level of concern in any two domains, or a low level of concern in all three domains. These recommendations for assessing treatment response should assist clinicians in making more rational choices in their management of relapsing MS patients.

Safety and efficacy of mitoxantrone in pediatric patients with aggressive multiple sclerosis

OBJECTIVE

The purpose of this study was to assess the safety and efficacy of mitoxantrone (MX) in pediatric patients with aggressive multiple sclerosis (MS).

METHODS

A retrospective analysis on pediatric MS patients treated with MX was performed with regards to demographic/clinical parameters and magnetic resonance imaging (MRI) findings.

RESULTS

19 definite pediatric MS cases with mean ± SD age of 15.4 ± 2.8 years underwent 20 mg MX for control of their severe/frequent relapses, high EDSS score or new and active brain MRI lesions. After a median [IQR] follow-up period of 30[12-60] months, 14 cases (73%) were relapse free; the EDSS score decreased by at least 0.5 in 16 cases (84.2%); and gadolinium-enhancing lesion volume fell by 84.2% in 16 cases. Adverse events included nausea and vomiting, fatigue, alopecia, palpitation, cardiomyopathy and mild leukopenia. All adverse events were mild and transient.

CONCLUSION

Our results suggest MX is a good candidate for treatment of children with worsening RRMS and SPMS. Recommendations regarding patient selection, treatment administration, and close follow-up should be considered. Continuing research is needed to establish its efficacy and safety profile in a multinational collaboration with careful follow-up of adverse events.

Quantitative determination of regional lesion volume and distribution in children and adults with relapsing-remitting multiple sclerosis

Introduction

Onset of MS occurs during childhood in about 5% of cases. It is unclear whether very young age at MS onset, when the nervous system is still myelinating, affects MS lesion accrual or regional distribution.

Objective

To compare the frequency, volume and distribution of T2 and T1 lesions in children and adults with relapsing-remitting multiple sclerosis (RRMS).

Methods

Lesions were segmented on T2- and T1-weighted MRI images from 29 children and 29 adults with RRMS, matched for disease duration.

Results

All subjects exhibited T2-weighted brain lesions. Children had higher whole-brain T2-weighted-lesion-volume (T2LV) compared to adults (mean (SD) in cm³: 12.76(2.7) vs. 10.03(3.4), p<0.0013). The supratentorial-T2LV was similar in children and adults (8.45(1.7) vs. 7.94(1.7), mean (SD), p = 0.2582), but adults were more likely to have supratentorial lesions (96.5% vs. 68.9%, p<0.012). Children were more likely to have infratentorial-T2-weighted lesions (75.9% vs. 43.4%, p<0.03), specifically in the brainstem (62.1% vs. 26.7%, p<0.019) and the pons (48.3% vs. 17.24%, p<0.024), had higher infratentorial-T2-weighted-lesion counts (4.1(5.6) vs. 1.45(2.3), p<0.021), a greater infratentorial-T2LV (4.31(2.7) vs. 2.08(2.4), p<0.0013), and a greater infratentorial-T1-weighted-lesion-volume (T1LV) (3.7(2.5) vs. 1.08(1.9), p<0.0007). Whole-brain-T1LV was higher in children (9.3(2.5) vs. 6.43(2.1), p>0.001). Adult MS patients had higher supratentorial-T1LV (5.5(0.92) vs. 6.41(2.1), mean (SD), p<0.034), whereas children were more likely to have infratentorial-T1-weighted lesions (58.6% vs. 23.3%, p<0.015).

Discussion

Onset of MS during childhood is associated with a higher volume of brain lesions in the first few years of disease relative to adults. Children with MS are more likely than adults to have T2 and T1 lesions in the infratentorial white matter, raising the possibility of preferential immune targeting of more mature myelin. Children with MS have a lower supratentorial T1 lesion burden, possibly reflecting more effective remyelination and repair in brain regions that are still engaged in active primary myelination.

Clinical and MRI activity as determinants of sample size for pediatric multiple sclerosis trials

OBJECTIVE

To estimate sample sizes for pediatric multiple sclerosis (MS) trials using new T2 lesion count, annualized relapse rate (ARR), and time to first relapse (TTFR) endpoints.

METHODS

Poisson and negative binomial models were fit to new T2 lesion and relapse count data, and negative binomial time-to-event and exponential models were fit to TTFR data of 42 children with MS enrolled in a national prospective cohort study. Simulations were performed by resampling from the best-fitting model of new T2 lesion count, number of relapses, or TTFR, under various assumptions of the effect size, trial duration, and model parameters.

RESULTS

Assuming a 50% reduction in new T2 lesions over 6 months, 90 patients/arm are required, whereas 165 patients/arm are required for a 40% treatment effect. Sample sizes for 2-year trials using relapse-related endpoints are lower than that for 1-year trials. For 2-year trials and a conservative assumption of overdispersion (ϑ), sample sizes range from 70 patients/arm (using ARR) to 105 patients/arm (TTFR) for a 50% reduction in relapses, and 230 patients/arm (ARR) to 365 patients/arm (TTFR) for a 30% relapse reduction. Assuming a less conservative ϑ, 2-year trials using ARR require 45 patients/arm (60 patients/arm for TTFR) for a 50% reduction in relapses and 145 patients/arm (200 patients/arm for TTFR) for a 30% reduction.

CONCLUSION

Six-month phase II trials using new T2 lesion count as an endpoint are feasible in the pediatric MS population; however, trials powered on ARR or TTFR will need to be 2 years in duration and will require multicentered collaboration.

Risk of multiple sclerosis after a first demyelinating syndrome in an Australian Paediatric cohort: clinical, radiological features and application of the McDonald 2010 MRI criteria

Background:

The risk of multiple sclerosis (MS) is dependent on multiple variables, including geographical location. There is increasing interest in the early recognition and treatment of MS in children.

Method:

Using univariate and multivariate analysis, we determined the clinical and radiological features that were predictive of MS in 88 children from New South Wales, Australia, with a first acute demyelinating syndrome (ADS) who were followed for a minimum of one year. We tested the McDonald, KIDMUS, Callen and Verhey MRI criteria for paediatric MS.

Results:

After a mean follow-up of 5.2 years, 13/88 (15%) of children had MS. Using multivariate analysis, preceding infection was protective of MS, and corpus callosal lesions, the combined presence of both well and poorly demarcated lesions, and contrast-enhancing lesions on MRI were predictive of MS. The sensitivity and specificity of the respective radiological criteria were McDonald 2005 (69%, 68%), McDonald 2010 (58%, 95%), KIDMUS (8%, 100%), Callen (69%, 85%) and Verhey (62%, 84%). When McDonald 2010 criteria were applied to baseline and serial scans, the sensitivity and specificity was 91% and 93%.

Conclusion:

Despite the long follow-up, the risk of MS appears lower in New South Wales children compared to previously reported cohorts. Radiological features are more predictive than clinical features in predicting MS. The McDonald 2010 criteria performed well although the dissemination in time criteria on baseline scans is difficult to apply to children with encephalopathy.

Pediatric multiple sclerosis: pathobiological, clinical, and magnetic resonance imaging features

In this article, the pathobiological, clinical, and treatment aspects of pediatric-onset multiple sclerosis (MS) are summarized, and the conventional magnetic resonance (MR) imaging (ie, T1-weighted, proton-density, and T2-weighted imaging) features of MS in children are discussed, as well as the application of MR imaging in the diagnosis of pediatric-onset MS and in prediction of MS in children with an incident central nervous system demyelination. Insights gained from studies comparing MR imaging features of pediatric-onset and adult-onset MS are presented.

Ethical challenges in paediatric clinical trials in multiple sclerosis

Children and adolescents with multiple sclerosis (MS) are reported to show high rates of relapse early in the course of the disease as well as cognitive deterioration over time. Immunomodulatory therapies developed for adult MS patients are currently the standard first-line agents for most paediatric MS patients. Available data indicate that the three interferon-beta preparations and glatiramer acetate are safe and well tolerated in children and adolescents with MS, and provide preliminary indications of efficacy in terms of relapse rate reduction. However, these treatments are only partly effective and their routes of administration can be bothersome, particularly for children. Emerging therapies for MS offer promise for improved disease control and long-term clinical outcome, with the advantage of an oral administration for some of them. The future approval of these new medications requires clinical trial consideration of such therapies in the paediatric population. Many of these new agents carry a higher risk for serious adverse events with increased toxicity and still undefined long-term side effects. There are ethical issues as well as issues related to feasibility that must be borne in mind when planning investigation trials for new pharmacological agents in the paediatric population, including immunological maturity, key period of exposure to numerous community-acquired infections, neurodevelopmental factors, in addition to short-term and long-term age-related toxicities. Furthermore, the lack of a large enough paediatric MS population worldwide limits some designs and the feasibility of participation in all the studies. Emerging new therapies have the potential to optimize the care of both paediatric and adult patients with MS. Future treatment trials in children and adolescents with MS will require a multicentre design, definition and selection of key outcome measures, and identification of the most promising therapies. Risks versus benefits of each specific treatment should be weighed and comprehensively discussed.

Perfil descritivo de esclerose múltipla com início até os 16 anos nos pacientes de um centro de referência do estado de São Paulo

OBJETIVO: Descrever o perfil de pacientes com esclerose múltipla iniciada até os 16 anos de idade no litoral do estado de São Paulo, Brasil. DESCRIÇÃO DOS CASOS: Análise retrospectiva das características dos pacientes que tiveram o episódio inicial de esclerose múltipla até os 16 anos. Nesta situação encontravam-se nove meninas e quatro meninos (7,1% da população total de esclerose múltipla da região). A idade média por ocasião do diagnóstico foi de 13,9 anos (variação entre 8 e 16), sendo a média atual de 19,5 anos (12 a 28). A apresentação inicial da doença foi: ataxia (quatro casos), neurite óptica (dois), motora cortical (dois), sensitiva cortical (dois), distonia (dois) e esclerose múltipla medular (um). Todos os pacientes iniciaram com a forma remitente-recorrente da esclerose múltipla e dois deles, atualmente, apresentam a forma progressiva secundária. COMENTÁRIOS: A esclerose múltipla com início até os 16 anos precisa ser adequadamente registrada e discutida entre pediatras, neurologistas e neuropediatras. Poucos médicos têm bom conhecimento desta condição e a demora no diagnóstico e no tratamento pode ter consequências devastadoras para essas crianças e adolescentes.

Pediatric multiple sclerosis-a challenging demyelinating disease: case report and brief review of the literature

Multiple sclerosis (MS) is an inflammatory, demyelinating, neurodegenerative disorder of the central nervous system (CNS) of unknown etiology. The peak onset is between age 20 and 40 years and usually affects more women than men. Although much knowledge has been achieved on the diagnosis and treatment of adult patients with MS, it remains a matter of debate and controversy in childhood. We present a case of MS in 9-year-old girl, review the current state of the knowledge on pediatric MS, and discuss the available tools for the diagnosis and treatment.

New treatments and treatment goals for patients with relapsing-remitting multiple sclerosis

PURPOSE OF REVIEW

The aims of this article are to review emerging therapies for multiple sclerosis (MS) and to consider new approaches to assessment and achievement of treatment success in patients with this disease.

RECENT FINDINGS

A number of disease-modifying therapies for MS, including oral agents, are in advanced development and likely to be available soon. Fingolimod has been approved recently by the US Food and Drug Administration. Agents in development include alemtuzumab, BG-12, daclizumab, teriflunomide, laquinimod, and B-cell-targeted monoclonal antibodies ocrelizumab and ofatumumab. The advent of emerging efficacious therapies has set the stage for re-evaluation of treatment goals for patients with MS. Freedom from disease, defined by the absence of relapses, disability progression, and radiologic evidence of disease activity, is increasingly seen as the measure of treatment success.

SUMMARY

New MS treatments may provide the basis for aggressive early intervention in patients with MS and intensification of treatment when disease is not controlled. The availability of therapies that can achieve higher treatment goals may significantly improve long-term outcomes for MS patients.

Immunotherapies in neurologic disorders

Therapy for autoimmune demyelinating disorders has evolved rapidly over the past 10 years to include traditional immunosuppressants as well as novel biologicals. Antibody-mediated neuromuscular disorders are treated with therapies that acutely modulate pathogenic antibodies or chronically inhibit the humoral immune response. In other inflammatory autoimmune disorders of the peripheral and central nervous system, corticosteroids, often combined with conventional immunosuppression, and immunomodulatory treatments are used. Because autoimmune neurologic disorders are so diverse, evidence from randomized controlled trials is limited for most of the immunotherapies used in neurology. This review provides an overview of the immunotherapies currently used for neurologic disorders.

Consensus statement: evaluation of new and existing therapeutics for pediatric multiple sclerosis

New therapies are being evaluated by clinical trials and, if efficacious, introduced for the treatment of adult MS. The role of these new and existing agents in the management of pediatric MS has yet to be defined. Pediatric investigation plans are now required by the Food and Drug Administration and European Medicines Agency for approval of new biological agents, providing an important opportunity to gather much-needed data for clinicians caring for children and adolescents with MS. However, challenges include the small number of patients, and the need for efficient yet comprehensive study designs incorporating factors necessary to inform the clinical care of children with MS. The elected Steering committee of the International Pediatric MS Study Group (IPMSSG) conducted a structured review of existing data on the disease-modifying therapies in pediatric MS and developed a consensus statement, which was further modified by the IPMSSG general membership, using an online survey tool. Fifty-one IPMSSG members from 21 countries responded to the survey, and 50 approved the final statement. Consensus recommendations regarding use of existing first- and second-line therapies, as well as a proposed definition for inadequate treatment response, are presented. Recommendations for the use and evaluation of emerging therapies (currently in phase III clinical trials or recently approved for adult MS) are discussed. The IPMSSG endorses the inclusion of pediatric MS patients in trials evaluating appropriate new and emerging therapies. Mechanisms for conducting high-impact, multicenter studies, including long-term follow-up in pediatric MS, are required to ensure that all MS patients, irrespective of age, benefit from advances in MS therapeutics.

Noninfectious central nervous system inflammatory disorders

Acute central nervous system (CNS) inflammation may occur as a monophasic illness or may represent the first attack of a chronic inflammatory disorder, such as multiple sclerosis, neuromyelitis optica, or CNS vasculitis. We review essential components of the initial assessment, diagnostic workup, acute and chronic management strategies, and research issues pertaining to children with CNS inflammatory diseases and suggest methods for these competencies to be attained during the course of child neurology residency training.