1
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Wiendl H, Gold R, Berger T, Derfuss T, Linker R, Mäurer M, Aktas O, Baum K, Berghoff M, Bittner S, Chan A, Czaplinski A, Deisenhammer F, Di Pauli F, Du Pasquier R, Enzinger C, Fertl E, Gass A, Gehring K, Gobbi C, Goebels N, Guger M, Haghikia A, Hartung HP, Heidenreich F, Hoffmann O, Kallmann B, Kleinschnitz C, Klotz L, Leussink VI, Leutmezer F, Limmroth V, Lünemann JD, Lutterotti A, Meuth SG, Meyding-Lamadé U, Platten M, Rieckmann P, Schmidt S, Tumani H, Weber F, Weber MS, Zettl UK, Ziemssen T, Zipp F. Multiple Sclerosis Therapy Consensus Group (MSTCG): position statement on disease-modifying therapies for multiple sclerosis (white paper). Ther Adv Neurol Disord 2021; 14:17562864211039648. [PMID: 34422112 PMCID: PMC8377320 DOI: 10.1177/17562864211039648] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/28/2021] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis is a complex, autoimmune-mediated disease of the central nervous system characterized by inflammatory demyelination and axonal/neuronal damage. The approval of various disease-modifying therapies and our increased understanding of disease mechanisms and evolution in recent years have significantly changed the prognosis and course of the disease. This update of the Multiple Sclerosis Therapy Consensus Group treatment recommendation focuses on the most important recommendations for disease-modifying therapies of multiple sclerosis in 2021. Our recommendations are based on current scientific evidence and apply to those medications approved in wide parts of Europe, particularly German-speaking countries (Germany, Austria, and Switzerland).
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Affiliation(s)
- Heinz Wiendl
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster
| | - Ralf Gold
- Neurologie, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Gudrunstraße 56, 44791 Bochum, Germany
| | - Thomas Berger
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Wien, Austria
| | - Tobias Derfuss
- Neurologische Klinik und Poliklinik, Universitätsspital Basel, Basel, Switzerland
| | - Ralf Linker
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Mathias Mäurer
- Neurologie und Neurologische Frührehabilitation, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, Würzburg, Germany
| | - Orhan Aktas
- Neurologische Klinik, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Karl Baum
- Neurologie, Klinik Hennigsdorf, Hennigsdorf, Germany
| | | | - Stefan Bittner
- Klinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew Chan
- Neurologie, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | | | | | | | | | - Christian Enzinger
- Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz, Austria
| | - Elisabeth Fertl
- Wiener Gesundheitsverbund, Neurologische Abteilung, Wien, Austria
| | - Achim Gass
- Neurologische Klinik, Universitätsmedizin Mannheim/Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Klaus Gehring
- Berufsverband Deutscher Nervenärzte (BVDN), Neurozentrum am Klosterforst, Itzehoe, Germany
| | | | - Norbert Goebels
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Guger
- Klinik für Neurologie 2, Kepler Universitätsklinikum, Linz, Austria
| | | | - Hans-Peter Hartung
- Klinik für Neurologie, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany; Klinik für Neurologie, Medizinische Universität Wien, Wien, Austria
| | - Fedor Heidenreich
- Diakovere Krankenhaus, Henriettenstift, Klinik für Neurologie und klinische Neurophysiologie, Hannover, Germany
| | - Olaf Hoffmann
- Klinik für Neurologie, Alexianer St. Josefs-Krankenhaus Potsdam, Potsdam, Germany; NeuroCure, Charité-Universitätsmedizin Berlin, Berlin, Germany; Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Germany
| | - Boris Kallmann
- Kallmann Neurologie, Multiple Sklerose Zentrum Bamberg, Bamberg, Germany
| | | | - Luisa Klotz
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Münster, Germany
| | | | - Fritz Leutmezer
- Neurologie, Universitäts-Klinik für Neurologie Wien, Wien, Austria
| | - Volker Limmroth
- Klinik für Neurologie, Krankenhaus Köln-Merheim, Köln, Germany
| | - Jan D Lünemann
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Münster, Germany
| | | | - Sven G Meuth
- Neurologische Klinik, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Michael Platten
- Neurologische Klinik, Universitätsmedizin Mannheim/Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Peter Rieckmann
- Medical Park, Fachklinik für Neurologie, Zentrum für Klinische Neuroplastizität, Bischofswiesen, Germany
| | - Stephan Schmidt
- Neurologie, Gesundheitszentrum St. Johannes Hospital, Bonn, Germany
| | - Hayrettin Tumani
- Fachklinik für Neurologie Dietenbronn, Akademisches Krankenhaus der Universität Ulm, Ulm, Germany
| | - Frank Weber
- Neurologie, Sana Kliniken, Cham, Switzerland
| | - Martin S Weber
- Institut für Neuropathologie, Neurologische Klinik, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Uwe K Zettl
- Klinik und Poliklinik für Neurologie, Zentrum für Nervenheilkunde, Universitätsmedizin Rostock, Rostock, Germany
| | - Tjalf Ziemssen
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Frauke Zipp
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
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2
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Wiendl H, Gold R, Berger T, Derfuss T, Linker R, Mäurer M, Stangel M, Aktas O, Baum K, Berghoff M, Bittner S, Chan A, Czaplinski A, Deisenhammer F, Di Pauli F, Du Pasquier R, Enzinger C, Fertl E, Gass A, Gehring K, Gobbi C, Goebels N, Guger M, Haghikia A, Hartung HP, Heidenreich F, Hoffmann O, Hunter ZR, Kallmann B, Kleinschnitz C, Klotz L, Leussink V, Leutmezer F, Limmroth V, Lünemann JD, Lutterotti A, Meuth SG, Meyding-Lamadé U, Platten M, Rieckmann P, Schmidt S, Tumani H, Weber MS, Weber F, Zettl UK, Ziemssen T, Zipp F. [Multiple sclerosis treatment consensus group (MSTCG): position paper on disease-modifying treatment of multiple sclerosis 2021 (white paper)]. DER NERVENARZT 2021; 92:773-801. [PMID: 34297142 PMCID: PMC8300076 DOI: 10.1007/s00115-021-01157-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 12/16/2022]
Abstract
Die Multiple Sklerose ist eine komplexe, autoimmun vermittelte Erkrankung des zentralen Nervensystems, charakterisiert durch inflammatorische Demyelinisierung sowie axonalen/neuronalen Schaden. Die Zulassung verschiedener verlaufsmodifizierender Therapien und unser verbessertes Verständnis der Krankheitsmechanismen und -entwicklung in den letzten Jahren haben die Prognose und den Verlauf der Erkrankung deutlich verändert. Diese Aktualisierung der Behandlungsempfehlung der Multiple Sklerose Therapie Konsensus Gruppe konzentriert sich auf die wichtigsten Empfehlungen für verlaufsmodifizierende Therapien der Multiplen Sklerose im Jahr 2021. Unsere Empfehlungen basieren auf aktuellen wissenschaftlichen Erkenntnissen und gelten für diejenigen Medikamente, die in weiten Teilen Europas, insbesondere in den deutschsprachigen Ländern (Deutschland, Österreich, Schweiz), zugelassen sind.
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Affiliation(s)
- Heinz Wiendl
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Westfälische Wilhelms-Universität Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland. .,Steuerungsgruppe der MSTKG, Münster, Deutschland. .,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.
| | - Ralf Gold
- Steuerungsgruppe der MSTKG, Münster, Deutschland. .,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland. .,Neurologie, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland.
| | - Thomas Berger
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Universitätsklinik für Neurologie, Medizinische Universität Wien, Wien, Österreich
| | - Tobias Derfuss
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Neurologische Klinik und Poliklinik, Universitätsspital Basel, Basel, Schweiz
| | - Ralf Linker
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Klinik und Poliklinik für Neurologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Mathias Mäurer
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Neurologie und Neurologische Frührehabilitation, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, Würzburg, Deutschland
| | - Martin Stangel
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Klinische Neuroimmunologie und Neurochemie, Klinik für Neurologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Orhan Aktas
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Karl Baum
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Martin Berghoff
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Stefan Bittner
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Andrew Chan
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Adam Czaplinski
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | | | - Franziska Di Pauli
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Renaud Du Pasquier
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Christian Enzinger
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Elisabeth Fertl
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Achim Gass
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Klaus Gehring
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Claudio Gobbi
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Norbert Goebels
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Michael Guger
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Aiden Haghikia
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Hans-Peter Hartung
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Fedor Heidenreich
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Olaf Hoffmann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Zoë R Hunter
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Boris Kallmann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | | | - Luisa Klotz
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Verena Leussink
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Fritz Leutmezer
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Volker Limmroth
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Jan D Lünemann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Andreas Lutterotti
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Sven G Meuth
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Uta Meyding-Lamadé
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Michael Platten
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Peter Rieckmann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Stephan Schmidt
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Hayrettin Tumani
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Martin S Weber
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Frank Weber
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Uwe K Zettl
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Tjalf Ziemssen
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Frauke Zipp
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
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3
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Richter D, Faissner S, Bartig D, Tönges L, Hellwig K, Ayzenberg I, Krogias C, Gold R. The impact of the COVID-19 pandemic on hospitalizations and plasmapheresis therapy in multiple sclerosis and neuromyelitis optica spectrum disorder: a nationwide analysis from Germany. Ther Adv Neurol Disord 2021; 14:17562864211030656. [PMID: 34285719 PMCID: PMC8267031 DOI: 10.1177/17562864211030656] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/16/2021] [Indexed: 01/30/2023] Open
Abstract
Background: Many countries worldwide reported side effects of the coronavirus disease 2019 (COVID-19) pandemic that have influenced the care of patients with other diseases in both acute and elective settings. Patients with multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) represent the major patient population suffering from an autoimmune inflammatory demyelinating disease of the central nervous system. We aimed to analyze MS and NMOSD hospitalizations, the application of plasmapheresis therapy, and the dynamic during different periods of the COVID-19 pandemic in Germany. Methods: We conducted a nationwide retrospective cross-sectional study using the administrative database of all hospitalized patients with the main diagnosis of MS and NMOSD, including the information on the application of plasmapheresis therapy. We included full-year data from 1463 hospitals of all MS and NMOSD patients hospitalized in 2019 and 2020 in Germany (n = 87,453). We compared case numbers and plasmapheresis therapy rates of the different pandemic periods in 2020 with the corresponding periods in 2019. Results: We observed a substantial decline of MS and NMOSD patients’ hospitalizations during the different pandemic periods, with the most remarkable decline during the first wave of the pandemic (First diagnosis of MS: −16.8%; relapsing-remitting MS: −34.0%; secondary progressive MS: −48.9%; primary progressive MS: −43.8%; NMOSD: −19.2%). Treatment rates with plasmapheresis increased for MS and NMOSD patients in 2020 compared to 2019 (1.8% versus 1.6%, p = 0.003; 14.0% versus 9.3%, p < 0.001), with a substantial increase during the first wave of the pandemic, especially in NMOSD patients (19.7% versus 8.4%, p < 0.001). Conclusion: There was a marked decline of MS and NMOSD patients’ hospitalizations during the different pandemic periods in 2020, with the most substantial reduction during the pandemic’s first wave and in progressive MS patients. MS and NMOSD patients who needed rescue relapse treatment continued to receive plasmapheresis therapy in Germany.
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Affiliation(s)
- Daniel Richter
- Department of Neurology, Ruhr University Bochum, St. Josef-Hospital Bochum, Gudrunstrasse 56, Bochum, 44791 Germany
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Hoeflich A, Fitzner B, Walz C, Hecker M, Tuchscherer A, Bastian M, Brenmoehl J, Schröder I, Willenberg HS, Reincke M, Zettl UK. Systemic Effects by Intrathecal Administration of Triamcinolone Acetonide in Patients With Multiple Sclerosis. Front Endocrinol (Lausanne) 2020; 11:574. [PMID: 32982971 PMCID: PMC7481359 DOI: 10.3389/fendo.2020.00574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
In patients suffering from multiple sclerosis (MS), intrathecal injection of triamcinolone acetonide (TCA) has been shown to improve symptoms of spasticity. Although repeated intrathecal injection of TCA has been used in a number of studies in late-stage MS patients with spinal cord involvement, no clinical-chemical data are available on the distribution of TCA in cerebrospinal fluid (CSF) or serum. Moreover, the effects of intrathecal TCA administration on the concentrations of endogenous steroids remain poorly understood. Therefore, we have quantified TCA and selected endogenous steroids in CSF and serum of TCA-treated MS patients suffering from spasticity. Concentrations of steroids were quantified by LC-MS, ELISA, or ECLIA and compared with the blood-brain barrier status, diagnosed with the Reibergram. The concentration of TCA in CSF significantly increased during each treatment cycle up to >5 μg/ml both in male and female patients (p < 0.001). Repeated TCA administration also evoked serum concentrations of TCA up to >30 ng/ml (p < 0.001) and severely depressed serum levels of cortisol and corticosterone (p < 0.001). In addition, concentrations of circulating estrogen were significantly suppressed (p < 0.001). Due to the potent suppressive effects of TCA on steroid hormone concentrations both in the brain and in the periphery, we recommend careful surveillance of adrenal function following repeated intrathecal TCA injections in MS patients.
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Affiliation(s)
- Andreas Hoeflich
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
- *Correspondence: Andreas Hoeflich
| | - Brit Fitzner
- Neuroimmunological Section, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Christina Walz
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Michael Hecker
- Neuroimmunological Section, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Armin Tuchscherer
- Institute of Genetics and Biometry, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Manuela Bastian
- Institute for Clinical Chemistry and Laboratory Medicine, Rostock University Medical Center, Rostock, Germany
| | - Julia Brenmoehl
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Ina Schröder
- Neuroimmunological Section, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Holger S. Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Uwe Klaus Zettl
- Neuroimmunological Section, Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Uwe Klaus Zettl
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5
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Hoeflich A, Fitzner B, Walz C, Hecker M, Tuchscherer A, Brenmoehl J, Zettl UK. Reduced Fragmentation of IGFBP-2 and IGFBP-3 as a Potential Mechanism for Decreased Ratio of IGF-II to IGFBPs in Cerebrospinal Fluid in Response to Repeated Intrathecal Administration of Triamcinolone Acetonide in Patients With Multiple Sclerosis. Front Endocrinol (Lausanne) 2020; 11:565557. [PMID: 33469444 PMCID: PMC7813808 DOI: 10.3389/fendo.2020.565557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic autoimmune disease of the brain and spinal cord causing a wide range of symptoms such as impaired walking capability, spasticity, fatigue, and pain. The insulin-like growth factor (IGF) system has regulatory functions for the induction of inflammatory pathways in experimental encephalomyelitis. We have therefore assessed expression and regulation of the IGF system on the level of IGFs and IGFBPs in serum and cerebrospinal fluid (CSF) in the course of four repeated triamcinolone acetonide (TCA) administrations in two female and four male MS patients. Sample series of 20 treatment cycles were analyzed. IGF-I and IGF-II were quantified by ELISAs, and IGFBPs were analyzed by quantitative Western ligand (qWLB) and Western immunoblotting (WIB) in order to differentiate intact and fragmented IGFBPs. The ratios of fragmented to intact IGFBP-2 and -3 were calculated in serum and CSF. Finally, the ratios of IGF-I and IGF-II to the total IGF-binding activity, quantified by qWLB, were determined as an indicator of IGF-related bioactivity. After the fourth TCA administration, the average level of IGF-I was increased in serum (p < 0.001). The increase of IGF-I concentrations in serum resulted in an increased ratio of IGF-I to IGFBPs in the circulation. By contrast in CSF, fragmentation of IGFBP-2 and IGFBP-3 and the ratio of IGF-II to intact IGFBPs were decreased at the fourth TCA administration (p < 0.01). Furthermore, reduced fragmentation of IGFBP-3 in CSF was accompanied by increased concentrations of intact IGFBP-3 (p < 0.001). We conclude that reduced fragmentation of IGFBPs and concomitant reduction of IGF-II to IGFBP ratios indicate regulation of bioactivity of IGF-II in CSF during repeated intrathecal TCA administration in MS patients.
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Affiliation(s)
- Andreas Hoeflich
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
- *Correspondence: Andreas Hoeflich, ; Uwe Klaus Zettl,
| | - Brit Fitzner
- Department of Neurology, Neuroimmunological Section, University Medicine Rostock, Rostock, Germany
| | - Christina Walz
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Michael Hecker
- Department of Neurology, Neuroimmunological Section, University Medicine Rostock, Rostock, Germany
| | - Armin Tuchscherer
- Institute of Genetics and Biometry, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Julia Brenmoehl
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Uwe Klaus Zettl
- Department of Neurology, Neuroimmunological Section, University Medicine Rostock, Rostock, Germany
- *Correspondence: Andreas Hoeflich, ; Uwe Klaus Zettl,
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6
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Vohl K, Duscha A, Gisevius B, Kaisler J, Gold R, Haghikia A. Predictors for Therapy Response to Intrathecal Corticosteroid Therapy in Multiple Sclerosis. Front Neurol 2019; 10:132. [PMID: 30853935 PMCID: PMC6395388 DOI: 10.3389/fneur.2019.00132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 01/31/2019] [Indexed: 12/03/2022] Open
Abstract
Objective: The autoimmune disease Multiple Sclerosis (MS) represents a heterogeneous disease pattern with an individual course that may lead to permanent disability. In addition to immuno-modulating therapies patients benefit from symptomatic approaches like intrathecal corticosteroid therapy (ICT), which is frequently applied in a growing number of centers in Germany. ICT reduces spasticity, which elongates patient's walking distance and speed, thus improves quality of life. Methods: In our study we set out to investigate cerebrospinal fluid (CSF) parameters and clinical predictors for response to ICT. Therefore, we analyzed 811 CSF samples collected from 354 patients over a time period of 12 years. Patients who received ICT were divided in two groups (improving or active group) depending on their EDSS-progress. As control groups we analyzed data of ICT naïve patients, who were divided in the two groups as well. Additionally we observed the clinical progress after receiving ICT by comparison of patients in both groups. Results: The results showed clinical data had a significant influence on the probability to benefit from ICT. The probability (shown by Odds Ratio of 1.77–2.43) to belong to the improving group in contrast to the active group is significantly (p < 0.0001) higher at later stages of disease with early disease onset (< 35 years, OR = 2.43) and higher EDSS at timepoint of ICT-initiation (EDSS > 6, OR = 2.06). Additionally, we observed lower CSF cell counts (6.68 ± 1.37 μl) and lower total CSF protein (412 ± 18.25 mg/l) of patients who responded to ICT compared to patients who did not (p < 0.05). In the control group no significant differences were revealed. Furthermore analyses of our data revealed patients belonging to the improving group reach an EDSS of 6 after ICT-initiation less often than patients of the active group (after 13 years 39.8% in the improving group, 67.8% in the active group). Conclusion: Our study implies two relevant messages: (i) although the study was not designed to prospectively assess clinical data, in this cohort no severe side effects were observed under ICT; (ii) disease onset, EDSS, CSF cell count, and total protein may serve as predictive markers for therapy response.
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Affiliation(s)
- Katja Vohl
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Alexander Duscha
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Barbara Gisevius
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Johannes Kaisler
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Aiden Haghikia
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
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Pitarokoili K, Sgodzai M, Grüter T, Bachir H, Motte J, Ambrosius B, Pedreiturria X, Yoon MS, Gold R. Intrathecal triamcinolone acetonide exerts anti-inflammatory effects on Lewis rat experimental autoimmune neuritis and direct anti-oxidative effects on Schwann cells. J Neuroinflammation 2019; 16:58. [PMID: 30851725 PMCID: PMC6408772 DOI: 10.1186/s12974-019-1445-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/25/2019] [Indexed: 02/08/2023] Open
Abstract
Background Corticosteroids dominate in the treatment of chronic autoimmune neuropathies although long-term use is characterized by devastating side effects. Methods We introduce the intrathecal application of the synthetic steroid triamcinolone (TRIAM) as a novel therapeutic option in experimental autoimmune neuritis in Lewis rats Results After immunization with neuritogenic P2 peptide, we show a dose-dependent therapeutic effect of one intrathecal injection of 0.3 or 0.6 mg/kg TRIAM on clinical and electrophysiological parameters of neuritis with a lower degree of inflammatory infiltrates (T cells and macrophages) and demyelination in the sciatic nerve. In vitro studies in Schwann cell cultures showed an increased expression of IL-1 receptor antagonist and reduced expression of Toll-like receptor 4 after incubation with TRIAM as well as a protective effect of TRIAM against oxidative stress after H2O2 exposure. Conclusion Intrathecal TRIAM application could be a novel immunomodulatory and potentially neuroprotective option for autoimmune neuropathies with a direct effect on Schwann cells.
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Affiliation(s)
- Kalliopi Pitarokoili
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany.
| | - Melissa Sgodzai
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Hussein Bachir
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Björn Ambrosius
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Xiomara Pedreiturria
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Min-Suk Yoon
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
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Patejdl R, Zettl UK. Spasticity in multiple sclerosis: Contribution of inflammation, autoimmune mediated neuronal damage and therapeutic interventions. Autoimmun Rev 2017; 16:925-936. [PMID: 28698092 DOI: 10.1016/j.autrev.2017.07.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 05/26/2017] [Indexed: 12/19/2022]
Abstract
In contrast to other diseases that go along with spasticity (e.g. spinal cord injury), spasticity in chronic autoimmune diseases involving the CNS is complicated by the ongoing damage of neuronal networks that leads to permanent changes in the clinical picture of spasticity. Multiple sclerosis (MS) is the most frequent autoimmune disease of the central nervous system (CNS) and spasticity is one of the most disabling symptoms. It occurs in more than 80% MS patients at some point of the disease and is associated with impaired ambulation, pain and the development of contractures. Besides causing cumulative structural damage, neuroinflammation occurring in MS leads to dynamic changes in motor circuit function and muscle tone that are caused by cytokines, prostaglandins, reactive oxygen species and stress hormones that affect neuronal circuits and thereby spasticity. The situation is complicated further by the fact that therapeutics used for the immunotherapy of MS may worsen spasticity and drugs used for the symptomatic treatment of spasticity have been shown to have the potential to alter immune cell function and CNS autoimmunity itself. This review summarizes the current knowledge on the immunologic pathways that are involved in the development, maintenance, dynamic changes and pharmacological modulation of spasticity in MS.
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Affiliation(s)
- Robert Patejdl
- University of Rostock, Department of Physiology, Germany.
| | - Uwe K Zettl
- University of Rostock, Department of Neurology, Division of Neuroimmunology, Germany
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Zettl UK, Rommer P, Hipp P, Patejdl R. Evidence for the efficacy and effectiveness of THC-CBD oromucosal spray in symptom management of patients with spasticity due to multiple sclerosis. Ther Adv Neurol Disord 2016; 9:9-30. [PMID: 26788128 PMCID: PMC4710104 DOI: 10.1177/1756285615612659] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Spasticity, one of the main symptoms of multiple sclerosis (MS), can affect more than 80% of MS patients during the course of their disease and is often not treated adequately. δ-9-Tetrahydrocannabinol-cannabidiol (THC-CBD) oromucosal spray is a plant-derived, standardized cannabinoid-based oromucosal spray medicine for add-on treatment of moderate to severe, resistant multiple sclerosis-induced spasticity. This article reviews the current evidence for the efficacy and safety, with dizziness and fatigue as the most common treatment-related adverse events, being mostly mild to moderate in severity. Results from both randomized controlled phase III studies involving about,1600 MS patients or 1500 patient-years and recently published studies on everyday clinical practice involving more than 1000 patients or more than,1000 patient-years are presented.
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Affiliation(s)
- Uwe K. Zettl
- Department of Neurology, University of Rostock, Gehlsheimer Straße 20, D-18147 Rostock, Germany
| | - Paulus Rommer
- Department of Neurology, University of Rostock, Germany
- Department of Neurology, Medical University of Vienna, Austria
| | | | - Robert Patejdl
- Department of Neurology, University of Rostock, Germany Oscar-Langendorff-Institute of Physiology, University of Rostock, Germany
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Rommer PS, Kamin F, Abu-Mugheisib M, Koehler W, Hoffmann F, Winkelmann A, Benecke R, Zettl UK. Long-Term Effects of Repeated Cycles of Intrathecal Triamcinolone Acetonide on Spasticity in MS Patients. CNS Neurosci Ther 2015; 22:74-9. [PMID: 26584946 DOI: 10.1111/cns.12474] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/28/2015] [Accepted: 10/05/2015] [Indexed: 11/26/2022] Open
Abstract
MAIN PROBLEM Spasticity is a common feature in patients with multiple sclerosis (MS). Although options have broadened over the last years, there are still patients with no response to common therapeutic agents. Intrathecal administered triamcinolone acetonide (TCA) has been tested for spasticity in patients with MS. However, the long run effects are not known so far. The aim of this study was to evaluate the effects of repeated cycles of intrathecal TCA instillations on clinical parameters. METHODS A total of 54 patients with clinically definite MS and no response to commonly utilized antispastic drugs were enrolled. TCA was administered every 3 months for a period of 9 months. Clinical assessments including spasticity, disability (EDSS), mobility (walking distance, and timed 25-foot walk), bladder function, and quality of life were carried out prior to and at the end of each treatment cycle. RESULTS Repeated TCA treatment led to repeated effects on spasticity (P < 0.01). Bladder function improved in every 10th patient. Quality of life improved during each cycle but did not reach significance at the end of study (P = 0.09). However, long-lasting improvement on spasticity or EDSS was not shown at end of the study. Effects diminished over 3 months. CONCLUSION Repeated TCA instillations led to replicable effects on spasticity; subgroup analyses suggest that higher spasticity, more frequent treatments, and higher EDSS may lead to pronounced effects on spasticity and EDSS. Intrathecal TCA treatment was safe and no severe side effects occurred. We hypothesize a significant time dependence of re-administration of TCA and that an interval of 3 months between the treatments might be too long.
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Affiliation(s)
- Paulus Stefan Rommer
- Department of Neurology, University of Rostock, Rostock, Germany.,Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Frank Kamin
- Department of Neurology, University of Rostock, Rostock, Germany.,Department of Pathology, MVZ Hochstraße, Brandenburg an der Havel, Germany
| | - Mazen Abu-Mugheisib
- Department of Neurology, University of Rostock, Rostock, Germany.,Department of Neurology, Klinikum Braunschweig, Braunschweig, Germany
| | | | | | | | - Reiner Benecke
- Department of Neurology, University of Rostock, Rostock, Germany
| | - Uwe Klaus Zettl
- Department of Neurology, University of Rostock, Rostock, Germany
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11
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Müller T, Lütge S. Biochemical indicators for neuronal regeneration during intrathecal triamcinolone application in multiple sclerosis. Neural Regen Res 2015; 10:377-9. [PMID: 25878582 PMCID: PMC4396096 DOI: 10.4103/1673-5374.153682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2015] [Indexed: 11/04/2022] Open
Affiliation(s)
- Thomas Müller
- Department of Neurology, St. Joseph Hospital Berlin-Weißensee, Berlin, Germany
| | - Sven Lütge
- Department of Neurology, St. Joseph Hospital Berlin-Weißensee, Berlin, Germany
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