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Gakis G, Angelopoulos I, Panagoulias I, Mouzaki A. Current knowledge on multiple sclerosis pathophysiology, disability progression assessment and treatment options, and the role of autologous hematopoietic stem cell transplantation. Autoimmun Rev 2024; 23:103480. [PMID: 38008300 DOI: 10.1016/j.autrev.2023.103480] [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: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) that affects nearly 2.8 million people each year. MS distinguishes three main types: relapsing-remitting MS (RRMS), secondary progressive MS (SPMS) and primary progressive MS (PPMS). RRMS is the most common type, with the majority of patients eventually progressing to SPMS, in which neurological development is constant, whereas PPMS is characterized by a progressive course from disease onset. New or additional insights into the role of effector and regulatory cells of the immune and CNS systems, Epstein-Barr virus (EBV) infection, and the microbiome in the pathophysiology of MS have emerged, which may lead to the development of more targeted therapies that can halt or reverse neurodegeneration. Depending on the type and severity of the disease, various disease-modifying therapies (DMTs) are currently used for RRMS/SPMS and PPMS. As a last resort, and especially in highly active RRMS that does not respond to DMTs, autologous hematopoietic stem cell transplantation (AHSCT) is performed and has shown good results in reducing neuroinflammation. Nevertheless, the question of its potential role in preventing disability progression remains open. The aim of this review is to provide a comprehensive update on MS pathophysiology, assessment of MS disability progression and current treatments, and to examine the potential role of AHSCT in preventing disability progression.
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Affiliation(s)
- Georgios Gakis
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece
| | - Ioannis Angelopoulos
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece
| | - Ioannis Panagoulias
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece
| | - Athanasia Mouzaki
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece.
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2
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Deleu D, Garcia Canibano B, Elalamy O, Sayed Abdelmoneim M, Boshra A. Practical Guidance on the Use of Cladribine Tablets in the Management or Relapsing Multiple Sclerosis: Expert Opinion from Qatar. Degener Neurol Neuromuscul Dis 2023; 13:81-88. [PMID: 38105885 PMCID: PMC10725680 DOI: 10.2147/dnnd.s433459] [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: 08/01/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
The increasing availability of high-efficacy disease-modifying therapies (DMT) for the management of relapsing multiple sclerosis (RMS) has increased the potential for individualised patient management but has added complexity to the design of treatment regimens. The long-term application of immune reconstitution therapy (IRT) is supported by an increasing database of real world studies that have added important information on the long-term safety and efficacy of this approach. Cladribine tablets (CladT) is an IRT given as two annual short courses of treatment, following which a majority of patients then demonstrate no significant MS disease activity over a period of years. Whether, and how, to treat patients beyond the first two years of treatment remains a matter for debate, as clinical evidence accumulates. We, a group of neurologists who manage people with RMS in Qatar, provide our expert consensus recommendations on the application and long-term management of CladT therapy based on our experience with treatment in the last 5 years. These include pragmatic recommendations for people with MS disease activity in years 3 and 4 (ie up to four years following first dose of CladT), and for people with or without MS disease activity in subsequent years. We believe our recommendations will help to ensure the optimal application of CladT-based IRT, with the potential benefit for the patient of achieving prolonged periods free of both MS disease symptoms and the burden of regular applications of immunosuppressive DMT.
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Affiliation(s)
- Dirk Deleu
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Osama Elalamy
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Amir Boshra
- Merck Serono Middle East FZ-Ltd., Dubai, UAE, an affiliate of Merck KGaA, Dubai, United Arab Emirates
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3
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Rau D, Eichau S, Borriello G, Cerqueira J, Wagner C. Assessment of the treating physicians' first-hand experience with handling and satisfaction of ofatumumab therapy: findings from the PERITIA survey conducted in Europe. BMC Neurol 2023; 23:147. [PMID: 37038104 PMCID: PMC10084644 DOI: 10.1186/s12883-023-03190-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/28/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Real-world evidence on experience and satisfaction of ofatumumab as a treatment option for relapsing multiple sclerosis (RMS) is limited. OBJECTIVE To present cumulative responses from a questionnaire related to first-hand experience of treating physicians on handling and convenience of ofatumumab therapy along with concerns related to COVID-19. METHODS PERITIA was a multicentre survey conducted to collect responses from the ASCLEPIOS I/II trial investigators from Europe via an online questionnaire. RESULTS Forty-six physicians (Germany, n = 14; Spain, n = 12; Portugal, n = 10; Italy, n = 10) completed the survey. Overall, 43% of the physicians considered the benefit-risk ratio of ofatumumab as very good. Over 93% were in favour of ofatumumab self-administration at home and the majority (83%) believed it to be completely true that self-administration of ofatumumab eases the burden for patients in terms of time. All investigators would like to potentially use anti-CD20 therapy as a long-term strategy. Even during the COVID-19 pandemic, physicians were in favour of a self-administration of MS therapy at home over other anti-CD20 therapy infusions. CONCLUSION European neurologists who were part of this survey considered the benefit-risk-ratio of ofatumumab as favourable and the monthly self-administered subcutaneous injections offering convenience for patients in the clinical practice.
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Affiliation(s)
| | - Sara Eichau
- Hospital Universitario Virgen de La Macareona of Sevilla, Seville, Spain
| | - Giovanna Borriello
- MS Center, Neurology Unit, Fatebenefratelli San Pietro Hospital, Rome, Italy
| | | | - Carola Wagner
- Novartis Pharma GmbH, Nuremberg, Germany and working on behalf of Novartis Pharma Vertriebs GmbH, Nuremberg, Germany
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Swallow E, Pham T, Patterson-Lomba O, Yin L, Gomez-Lievano A, Liu J, Tencer T, Gupte-Singh K. Comparative efficacy and safety of ozanimod and ponesimod for relapsing multiple sclerosis: A matching-adjusted indirect comparison. Mult Scler Relat Disord 2023; 71:104551. [PMID: 36791623 DOI: 10.1016/j.msard.2023.104551] [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: 09/23/2022] [Revised: 01/10/2023] [Accepted: 02/03/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ozanimod and ponesimod are sphingosine 1-phosphate receptor modulators approved by the U.S. Food and Drug Administration for treatment of relapsing forms of multiple sclerosis (MS). Given that no head-to-head trials have assessed these two treatments, we performed a matching-adjusted indirect comparison (MAIC) to compare efficacy and safety outcomes between ozanimod and ponesimod for MS. METHODS A MAIC compared efficacy and safety of ozanimod and ponesimod at 2 years. Outcomes included annualized relapse rate (ARR) and percentage change from baseline in brain volume loss (BVL) as well as rates of any treatment-emergent adverse events (TEAEs), serious adverse events (AEs), AEs leading to discontinuation, and other safety outcomes. Individual patient-level data were obtained for ozanimod from the RADIANCE-B trial, while aggregate-level patient data were obtained for ponesimod from the OPTIMUM trial. The MAIC was not anchored owing to lack of a common comparator across the two trials. The following characteristics were matched between the trials' populations: age, sex, time since MS symptom onset, relapses in prior year, Expanded Disability Status Scale score, disease-modifying therapies received in the prior 2 years, absence of gadolinium-enhancing T1 lesions, and percentage of patients from Eastern Europe. RESULTS After matching, key baseline characteristics were balanced between patients receiving ozanimod and ponesimod. Compared with ponesimod, ozanimod had a numerically lower ARR (rate ratio: 0.80 [95% CI: 0.57, 1.10]) and was associated with a significant reduction in BVL (% change difference: 0.20 [95% CI: 0.05, 0.36]). Additionally, ozanimod was associated with a significantly lower risk of TEAEs (risk difference: -11.9% [95% CI: -16.8%, -7.0%]), AEs leading to discontinuation (-6.1% [95% CI: -8.9%, -3.4%]), and lymphocyte count <0.2 K/μL (-2.3% [95% CI: -4.2%, -0.5%]). There were no statistically significant differences in the other safety outcomes. CONCLUSION The MAIC results suggest that, compared with ponesimod, ozanimod is more effective in preserving brain volume, is comparable in terms of reducing relapse rates, and has a favorable safety profile.
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Affiliation(s)
- Elyse Swallow
- Analysis Group, Inc., 111 Huntington Ave., 14th floor, Boston, MA 02199, United States of America.
| | - Timothy Pham
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrence Township, NJ 08648, United States of America
| | - Oscar Patterson-Lomba
- Analysis Group, Inc., 111 Huntington Ave., 14th floor, Boston, MA 02199, United States of America
| | - Lei Yin
- Analysis Group, Inc., 333 S. Hope St., #27, Los Angeles, CA 90071, United States of America
| | - Andres Gomez-Lievano
- Analysis Group, Inc., 111 Huntington Ave., 14th floor, Boston, MA 02199, United States of America
| | - Jingyi Liu
- Analysis Group, Inc., 111 Huntington Ave., 14th floor, Boston, MA 02199, United States of America
| | - Tom Tencer
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrence Township, NJ 08648, United States of America
| | - Komal Gupte-Singh
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrence Township, NJ 08648, United States of America
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Stamatellos VP, Papazisis G. Safety and Monitoring of the Treatment with Disease-Modifying Therapies (DMTs) for Multiple Sclerosis (MS). Curr Rev Clin Exp Pharmacol 2023; 18:39-50. [PMID: 35418296 DOI: 10.2174/2772432817666220412110720] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 01/08/2022] [Accepted: 01/27/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Disease-Modifying Therapies (DMTs) for Multiple Sclerosis (MS) are widely used given their proven efficacy in the relapsing form of the disease, while recently, Siponimod and Ocrelizumab have been approved for the progressive forms of the disease. Currently, 22 diseasemodifying drugs are approved by the FDA, while in 2012, only nine were present in the market. From March 2019 until August 2020, six new drugs were approved. This rapid development of new DMTs highlighted the need to update our knowledge about their short and long-term safety. OBJECTIVE This review summarizes the available safety data for all the Disease-Modifying Therapies for Multiple Sclerosis and presents the monitoring plan before and during the treatment. METHODS A literature search was conducted using PUBMED and COCHRANE databases. Key journals and abstracts from major annual meetings of Neurology, references of relevant reviews, and relative articles were also manually searched. We prioritized systematic reviews, large randomized controlled trials (RCTs), prospective cohort studies, and other observational studies. Special attention was paid to guidelines and papers focusing on the safety and monitoring of DMTs. CONCLUSION Data for oral (Sphingosine 1-phosphate (S1P) receptor modulators, Fumarates, Teriflunomide, Cladribine), injectables (Interferons, Glatiramer acetate, Ofatumumab), and infusion therapies (Natalizumab, Ocrelizumab, Alemtuzumab) are presented.
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Affiliation(s)
| | - Georgios Papazisis
- Clinical Trials Unit, Special Unit for Biomedical Research and Education & Department of Clinical Pharmacology School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Zhu C, Zhou Z, Roos I, Merlo D, Kalincik T, Ozakbas S, Skibina O, Kuhle J, Hodgkinson S, Boz C, Alroughani R, Lechner-Scott J, Barnett M, Izquierdo G, Prat A, Horakova D, Kubala Havrdova E, Macdonell R, Patti F, Khoury SJ, Slee M, Karabudak R, Onofrj M, Van Pesch V, Prevost J, Monif M, Jokubaitis V, van der Walt A, Butzkueven H. Comparing switch to ocrelizumab, cladribine or natalizumab after fingolimod treatment cessation in multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:1330-1337. [PMID: 36261289 DOI: 10.1136/jnnp-2022-330104] [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: 08/03/2022] [Accepted: 09/26/2022] [Indexed: 03/16/2023]
Abstract
BACKGROUND To compare the effectiveness and treatment persistence of ocrelizumab, cladribine and natalizumab in patients with relapsing-remitting multiple sclerosis switching from fingolimod. METHODS Using data from MSBase registry, this multicentre cohort study included subjects who had used fingolimod for ≥6 months and then switched to ocrelizumab, cladribine or natalizumab within 3 months after fingolimod discontinuation. We analysed relapse and disability outcomes after balancing covariates using an inverse-probability-treatment-weighting method. Propensity scores for the three treatments were obtained using multinomial-logistic regression. Due to the smaller number of cladribine users, comparisons of disability outcomes were limited to natalizumab and ocrelizumab. RESULTS Overall, 1045 patients switched to ocrelizumab (n=445), cladribine (n=76) or natalizumab (n=524) after fingolimod. The annualised relapse rate (ARR) for ocrelizumab was 0.07, natalizumab 0.11 and cladribine 0.25. Compared with natalizumab, the ARR ratio (95% confidence interval [CI]) was 0.67 (0.47 to 0.96) for ocrelizumab and 2.31 (1.30 to 4.10) for cladribine; the hazard ratio (95% CI) for time to first relapse was 0.57 (0.40 to 0.83) for ocrelizumab and 1.18 (0.47 to 2.93) for cladribine. Ocrelizumab users had an 89% lower discontinuation rate (95% CI, 0.07 to 0.20) than natalizumab, but also a 51% lower probability of confirmed disability improvement (95% CI, 0.32 to 0.73). There was no difference in disability accumulation. CONCLUSION After fingolimod cessation, ocrelizumab and natalizumab were more effective in reducing relapses than cladribine. Due to the low ARRs in all three treatment groups, additional observation time is required to determine if statistical difference in ARRs results in long-term disability differences.
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Affiliation(s)
- Chao Zhu
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Zhen Zhou
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Izanne Roos
- Clinical Outcomes Research Unit, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Daniel Merlo
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Tomas Kalincik
- Clinical Outcomes Research Unit, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | - Olga Skibina
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Suzanne Hodgkinson
- Departments of Nephrology and Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | | | - Jeannette Lechner-Scott
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University Newcastle, Newcastle, New South Wales, Australia
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | | | - Alexandre Prat
- Hôpital Notre Dame, CHUM and Universite de Montreal, Montreal, Québec, Canada
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | | | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy.,Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Samia Joseph Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mark Slee
- Flinders University, Adelaide, South Australia, Australia
| | - Rana Karabudak
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio, Chieti, Italy
| | | | - Julie Prevost
- Centre integre de sante et de services sociaux des Laurentides point de service de Saint-Jerome, Saint-Jerome, Quebec, Canada
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
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Matni M, Yamout B, Koussa S, Khamis C, Fleifel L, Sharifi S, Mohamed O. Economic evaluation of cladribine tablets in high disease activity (HDA) relapsing multiple sclerosis (RMS) patients in Lebanon. Mult Scler Relat Disord 2022; 67:104169. [PMID: 36150262 DOI: 10.1016/j.msard.2022.104169] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 08/22/2022] [Accepted: 09/08/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cladribine tablets are a newly launched short course oral treatment approved for high disease activity (HDA) relapsing multiple sclerosis (RMS). The current analysis assessed the cost-utility and budgetary impact of introducing cladribine tablets in HDA-RMS patients compared with other HDA-RMS therapies in Lebanon. METHODS The global cost-utility and budget impact models were adapted from Lebanese National Social Security Fund (NSSF) perspective. The data for the models' adaptation were retrieved from the literature and validated by Lebanese experts. The comparators considered in the cost-utility model were alemtuzumab, fingolimod, and natalizumab while budget impact analysis additionally considered dimethyl fumarate. A sensitivity analysis was also performed to assess the uncertainty in the analysis. RESULTS The cost-utility results showed that cladribine tablets are an economically dominant therapeutic strategy (i.e., less costly and better quality-adjusted life year [QALY]) compared to all comparators. The cost saving was driven by drug acquisition, administration, and monitoring costs; while incremental QALY gain was driven by differences in delayed Expanded Disability Status Scale progression. Sensitivity analysis showed that cladribine tablets have a high probability (99.3-100%) of being dominant at a threshold of 22,000 United States Dollars (approximately three times of gross domestic product) per QALY gained against different comparators. The budget impact analysis showed that the introduction of cladribine tablets would result in 5.0% to 21.5% savings in the overall budget over a period of five years. CONCLUSIONS Cladribine tablets are a cost-effective and a budget-saving treatment option for the treatment of HDA-RMS patients in Lebanon from the NSSF perspective.
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Affiliation(s)
- Mirna Matni
- National Social Security Funds, Beirut, Lebanon
| | - Bassem Yamout
- American University of Beirut Medical Center, Beirut, Lebanon
| | | | | | - Lora Fleifel
- Merck Serono Middle East FZ-Ltd, An Affiliate of Merck KGaA, Darmstadt, Germany.
| | - Shahdak Sharifi
- Merck Serono Middle East FZ-Ltd, An Affiliate of Merck KGaA, Darmstadt, Germany
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8
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Glasmacher SA, Kearns PK, Hassan Z, Connick P, Tauber S, Reetz K, Foley P, Chandran S. The influence of disease-modifying therapy on hidden disability burden in people with newly diagnosed relapsing-remitting multiple sclerosis. Mult Scler Relat Disord 2022; 63:103837. [PMID: 35576728 DOI: 10.1016/j.msard.2022.103837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/02/2022] [Accepted: 04/28/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND In addition to motor disability, "hidden disability" such as depression, anxiety, fatigue, sleep disturbance, cognitive impairment and pain is a major complaint of people with multiple sclerosis. We explored changes in hidden disability burden in the early post-diagnostic period and examined the hypothesis that disease modifying therapies have a beneficial effect on hidden disability burden. METHODS Adults with recently diagnosed (< 6 months) relapsing-remitting multiple sclerosis (n = 440, mean age 37.4 ± 10.4, 76% female), from a national multicentre cohort study (FutureMS) underwent testing with clinical and neuropsychological instruments as well as brain MRI at baseline and after 12-months. Disease modifying therapies were only started after baseline assessment and were classified into injectables (n = 70, interferons, glatiramer acetate), other DMTs (n = 215) and no DMT (n = 117, reference). Sensitivity analyses were undertaken using alternative classifications (disease modifying therapy vs none, and a 3-category system). We performed latent transition analysis with hidden disability burden as the latent variable including propensity score weights. RESULTS We identified three classes with low (58%), moderate (25%) and high (17%) hidden disability burden. 70% did not transition ("unchanged", reference), 26% transitioned into a lower burden class ("improvement") and 4% transitioned into a higher burden class ("worsening"). Median treatment duration was 11 months (IQR 9-12). Injectables [OR 1.3 (95%CIs 0.7, 2.3); P = 0.4] and other DMTs [OR 1.4 (95%CIs 0.9, 2.1); P = 0.2] were not associated with significant change in hidden disability burden in either direction ("improvement" or "worsening"). In the alternative 3-category classification, category 2 treatment (fingolimod, cladribine, n = 22) was associated with improvement [OR 4.3 (2.6, 7.0); P < 0.001]. CONCLUSION Hidden disability was present in most newly diagnosed people with multiple sclerosis. The majority remained unchanged and approximately a quarter improved over the immediate post-diagnostic period. Disease modifying therapy had no significant influence on hidden disability burden in the study period of one year following diagnosis. The trend towards favourable outcomes with fingolimod and cladribine should be interpreted with caution due to the small sample size. Our exploratory data are observational, with scope for attendant biases, but highlight the need for further study including longer-term evaluation as well as randomised trials for non-motor disability.
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Affiliation(s)
- Stella A Glasmacher
- Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, University of Edinburgh, Edinburgh, UK; Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, UK; RWTH Aachen University, Department of Neurology, Aachen, Germany
| | - Patrick Ka Kearns
- Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, University of Edinburgh, Edinburgh, UK; Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, UK; MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Zackary Hassan
- Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, University of Edinburgh, Edinburgh, UK; Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, UK
| | - Peter Connick
- Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, University of Edinburgh, Edinburgh, UK; Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, UK
| | - Simone Tauber
- RWTH Aachen University, Department of Neurology, Aachen, Germany
| | - Kathrin Reetz
- RWTH Aachen University, Department of Neurology, Aachen, Germany; JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH, Jülich, Germany
| | - Peter Foley
- Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, University of Edinburgh, Edinburgh, UK; Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, UK
| | - Siddharthan Chandran
- Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, University of Edinburgh, Edinburgh, UK; Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, UK; Euan MacDonald Centre for Motor Neurone Disease Research, Chancellor's Building, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute at University of Edinburgh, Chancellor's Building, Edinburgh, UK.
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9
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Avxentyev NA, Davydovskaya MV, Makarova YV, Frolov MY, Klabukova DL. [Pharmacoeconomic aspects of using cladribine (in tablets) for treatment of adult patients with remitting multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:30-36. [PMID: 34481433 DOI: 10.17116/jnevro202112108130] [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: 11/18/2022]
Abstract
OBJECTIVE To conduct a pharmacoeconomic analysis of using cladribine (in tablets) as a second-line treatment option for adult patients with highly active remitting multiple sclerosis in Russia. MATERIAL AND METHODS Current treatment practice of highly active multiple sclerosis (natalizumab, fingolimod, alemtuzumab, ocrelizumab) was considered as a comparator for cladribine (in tablets). Clinical and economic study was conducted using the «cost minimization» method. For budget impact analysis cost of using cladribine (in tablets) was compared to the cost of using current treatment practice. RESULTS Cladribine in tablets is a cost-saving alternative for treatment of patients with highly active multiple sclerosis compared to the current treatment practice. Within a 4-year period direct medical costs reduction is 2 million RUB (50.1%) per person. CONCLUSION In case of switching the patients, who are currently provided with other disease modifying drugs, to cladribine, in 4 years health budget will save up to 6284 million RUB (50.1%).
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Affiliation(s)
- N A Avxentyev
- Financial Research Institute, Moscow, Russia.,The Russian Presidential Academy of National Economy and Public Administration, Moscow, Russia
| | - M V Davydovskaya
- Clinical and Economic Analysis Scientific-Practical Center of the Moscow Region Healthcare Ministry, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
| | - Y V Makarova
- The Russian Presidential Academy of National Economy and Public Administration, Moscow, Russia
| | - M Yu Frolov
- Volgograd State Medical University, Volgograd, Russia.,Volgograd Medical Scientific Center, Volgograd, Russia
| | - D L Klabukova
- Clinical and Economic Analysis Scientific-Practical Center of the Moscow Region Healthcare Ministry, Moscow, Russia
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10
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Simpson A, Mowry EM, Newsome SD. Early Aggressive Treatment Approaches for Multiple Sclerosis. Curr Treat Options Neurol 2021; 23:19. [PMID: 34025110 PMCID: PMC8121641 DOI: 10.1007/s11940-021-00677-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review presents a comprehensive analysis of the current high-efficacy disease-modifying therapies (DMTs) available for treatment of multiple sclerosis (MS). We discuss the existing approved and emerging therapeutics in patients with relapsing and progressive forms of MS using data from clinical trials and observational studies. Treatment considerations in pediatric and pregnant populations are also reviewed. Finally, we discuss the treatment paradigms of the escalation and early aggressive approaches to treatment of MS, with review of ongoing clinical trials to compare these approaches. RECENT FINDINGS Natalizumab has shown promising data on efficacy in not only randomized trials but also observational studies when compared with placebo, the injectable DMTs, and fingolimod. The anti-CD20 B cell depleting therapies (rituximab, ocrelizumab, and ofatumumab) have also demonstrated superiority in randomized clinical trials compared to their comparator group (placebo, interferon, and teriflunomide, respectively) and rituximab has shown in observational studies to be more effective than older injectable therapies and some of the oral therapies. Alemtuzumab has shown good efficacy in randomized controlled trials and observational studies yet has several potentially severe side effects limiting its use. Mitoxantrone has similarly demonstrated significant reduction in new disease activity compared to placebo but is rarely used due to its severe side effects. Cladribine is an oral DMT often grouped in discussion with other higher efficacy DMTs but may be slightly less effective than the other therapies described in this review. Many emerging targets for therapeutic intervention are currently under investigation that may prove to be beneficial in early aggressive MS, including autologous hematopoietic stem cell transplantation. SUMMARY Traditionally, MS has been treated with an escalation approach, starting patients on a modestly effective DMT and subsequently escalating to a higher efficacy DMT when there is evidence of clinical and/or radiologic breakthrough activity. With the development of higher efficacy therapies and emerging data showing the potential positive long-term impact of these therapies when started earlier in the disease course, many clinicians have shifted to an early aggressive treatment approach in which patients are initially started on a higher efficacy DMT. Two clinical trials, the TRaditional versus Early Aggressive Therapy for MS (TREAT-MS) trial and the Determining the Effectiveness of earLy Intensive Versus Escalation approaches for the treatment of Relapsing-remitting MS (DELIVER-MS) trial, aim to directly compare these treatment strategies and their impact on clinical and radiologic outcomes.
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Affiliation(s)
- Alexandra Simpson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Ellen M. Mowry
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Scott D. Newsome
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
- Division of Neuroimmunology and Neurological Infections, Johns Hopkins Hospital, 600 North Wolfe St., Pathology 627, Baltimore, MD 21287 USA
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The development and impact of cladribine on lymphoid and myeloid cells in multiple sclerosis. Mult Scler Relat Disord 2021; 52:102962. [PMID: 33901971 DOI: 10.1016/j.msard.2021.102962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/28/2021] [Accepted: 04/09/2021] [Indexed: 11/21/2022]
Abstract
Cladribine is an approved selective immune reconstitution therapy for relapsing-remitting MS (RRMS). It was first developed and used to treat various forms of cancer, particularly leukemia via parenteral administration. The oral tablet version of cladribine was later developed to treat RRMS, an autoimmune disorder of the central nervous system (CNS) with periods of relapse and remission. Cladribine is found to selectively deplete adaptive immune cell types, and its role on innate immune cells is largely unknown. Among the lymphocyte populations and subtypes, the magnitude and kinetics of depletion by cladribine vary substantially. The current consensus on the selective cytotoxic effect of cladribine is that it is dependent on the deoxycytidine kinase (DCK) to 5'nucleotidase (5-NT) ratio of the immune cell type. Nonetheless, there are some discrepancies that cannot be fully elucidated by the DCK:5-NT ratio paradigm. This review aims to delineate the development and pharmacological properties of cladribine, and elucidate its influence on lymphoid and myeloid cells in MS.
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Zanghì A, Gallo A, Avolio C, Capuano R, Lucchini M, Petracca M, Bonavita S, Lanzillo R, Ferraro D, Curti E, Buccafusca M, Callari G, Barone S, Pontillo G, Abbadessa G, Di Francescantonio V, Signoriello E, Lus G, Sola P, Granella F, Valentino P, Mirabella M, Patti F, D'Amico E. Exit Strategies in Natalizumab-Treated RRMS at High Risk of Progressive Multifocal Leukoencephalopathy: a Multicentre Comparison Study. Neurotherapeutics 2021; 18:1166-1174. [PMID: 33844155 PMCID: PMC8423885 DOI: 10.1007/s13311-021-01037-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 11/27/2022] Open
Abstract
The main aim of the study is to evaluate the efficacy and safety profile of ocrelizumab (OCR), rituximab (RTX), and cladribine (CLA), employed as natalizumab (NTZ) exit strategies in relapsing-remitting multiple sclerosis (RRMS) patients at high-risk for progressive multifocal leukoencephalopathy (PML). This is a multicentre, retrospective, real-world study on consecutive RRMS patients from eleven tertiary Italian MS centres, who switched from NTZ to OCR, RTX, and CLA from January 1st, 2019, to December 31st, 2019. The primary study outcomes were the annualized relapse rate (ARR) and magnetic resonance imaging (MRI) outcome. Treatment effects were estimated by the inverse probability treatment weighting (IPTW), based on propensity-score (PS) approach. Additional endpoint included confirmed disability progression (CDP) as measured by Expanded Disability Status Scale and adverse events (AEs). Patients satisfying predefined inclusion and exclusion criteria were 120; 64 switched to OCR, 36 to RTX, and 20 to CLA. Patients from the 3 groups did not show differences for baseline characteristics, also after post hoc analysis. The IPTW PS-adjusted models revealed that patients on OCR had a lower risk for ARR than patients on CLA (ExpBOCR 0.485, CI 95% 0.264-0.893, p = 0.020). This result was confirmed also for 12-month MRI activity (ExpBOCR 0.248 CI 95% 0.065-0.948, p = 0.042). No differences were found in other pairwise comparisons (OCR vs RTX and RTX vs CLA) for the investigated outcomes. AEs were similar among the 3 groups. Anti-CD20 drugs were revealed to be effective and safe options as NTZ exit strategies. All investigated DMTs showed a good safety profile.
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Affiliation(s)
- Aurora Zanghì
- Department "G.F. Ingrassia", MS Center, Organization University of Catania, Catania, Italy
| | - Antonio Gallo
- MS Center I Division of Neurology, University Della Campania "L. Vanvitelli", Naples, Italy
| | - Carlo Avolio
- Department of Medical and Surgical Sciences Head of Multiple Sclerosis Center Dept. of Neurosciences, University of Foggia, Foggia, Italy
| | - Rocco Capuano
- MS Center I Division of Neurology, University Della Campania "L. Vanvitelli", Naples, Italy
| | - Matteo Lucchini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Istituto di Neurologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Petracca
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Simona Bonavita
- Dipartimento Di Scienze Mediche E Chirurgiche Avanzate, Università Della Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138, Naples, Italy
| | - Roberta Lanzillo
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Diana Ferraro
- University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Curti
- Multiple Sclerosis Centre, Department of General Medicine, Parma University Hospital, Parma, Italy
| | | | | | - Stefania Barone
- Azienda Ospedaliera Universitaria "Mater Domini", Catanzaro, Italy
| | - Giuseppe Pontillo
- Department of Advanced Biomedical Sciences, University "Federico II", Naples, Italy
- Department of Electrical Engineering and Information Technology, , University "Federico II", Naples, Italy
| | - Gianmarco Abbadessa
- Dipartimento Di Scienze Mediche E Chirurgiche Avanzate, Università Della Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138, Napoli, Italy
| | - Valeria Di Francescantonio
- Department of Medical and Surgical Sciences Head of Multiple Sclerosis Center Dept. of Neurosciences, University of Foggia, Foggia, Italy
| | - Elisabetta Signoriello
- Department of Clinical and Experimental Medicine, Multiple Sclerosis Center, II Division of Neurology, Second University of Naples, Naples, Italy
| | - Giacomo Lus
- Department of Clinical and Experimental Medicine, Multiple Sclerosis Center, II Division of Neurology, Second University of Naples, Naples, Italy
| | - Patrizia Sola
- University of Modena and Reggio Emilia, Modena, Italy
| | - Franco Granella
- Multiple Sclerosis Centre, Department of General Medicine, Parma University Hospital, Parma, Italy
- Unit of Neurosciences, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paola Valentino
- Azienda Ospedaliera Universitaria "Mater Domini", Catanzaro, Italy
| | - Massimiliano Mirabella
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Istituto di Neurologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Patti
- Department "G.F. Ingrassia", MS Center, Organization University of Catania, Catania, Italy
| | - Emanuele D'Amico
- Department "G.F. Ingrassia", MS Center, Organization University of Catania, Catania, Italy.
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Comparative Efficacy and Safety of Ozanimod and Dimethyl Fumarate for Relapsing-Remitting Multiple Sclerosis Using Matching-Adjusted Indirect Comparison. CNS Drugs 2021; 35:795-804. [PMID: 33847901 PMCID: PMC8310468 DOI: 10.1007/s40263-021-00805-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with multiple sclerosis (MS) experience relapses and sustained disability progression. Since 2004, the number of disease-modifying therapies (DMTs) for MS has grown substantially. As a result, patients, healthcare providers, and insurers are increasingly interested in comparative efficacy and safety evaluations to distinguish between treatment options, but head-to-head studies between DMTs are limited. OBJECTIVE The aim of the current study was to compare efficacy and safety outcomes with the DMTs ozanimod and dimethyl fumarate (DMF) using a matching-adjusted indirect comparison (MAIC) to adjust for cross-trial differences in study design and population. METHODS A systematic literature review was performed to identify clinical studies evaluating the efficacy and safety of ozanimod compared with DMF. Individual patient-level data (IPD) for ozanimod were obtained from the SUNBEAM and RADIANCE Part B trials, and aggregate-level patient data (APD) for DMF were obtained from CONFIRM and DEFINE. A MAIC is used to weight IPD to APD based on important baseline patient characteristics considered to be effect modifiers or prognostic factors in order to balance the covariate distribution to establish more homogenous trial populations. Once trial populations are determined to be sufficiently homogenous, outcomes of interest are estimated and used to generate treatment effects between the weighted IPD and APD. We used MAIC methodology to compare efficacy and safety outcomes of interest between ozanimod 1.0 mg once daily (OD) and DMF 240 mg twice daily (BID), including confirmed disability progression (CDP) at 3 and 6 months, annualized relapse rate (ARR), proportion of patients relapsed, overall adverse events (AEs), serious AEs (SAEs), and discontinuations due to AEs. RESULTS After matching patient data, baseline patient characteristics were balanced between patients receiving ozanimod and those receiving DMF. Compared with DMF, ozanimod demonstrated significantly improved CDP at 3 months (hazard ratio 0.67; 95% confidence interval [CI] 0.53-0.86), ARR (rate ratio [RR] 0.80; 95% CI 0.67-0.97), proportion of patients relapsed (odds ratio [OR] 0.66; 95% CI 0.52-0.83), overall AEs (OR 0.11; 95% CI 0.08-0.16), SAEs (OR 0.27; 95% CI 0.19-0.39), and discontinuations (OR 0.11; 95% CI 0.07-0.17). CDP at 6 months did not differ significantly between the two agents (RR 0.89; 95% CI 0.62-1.26). CONCLUSIONS After adjustment of baseline patient characteristics, the MAIC demonstrated that the efficacy and safety of ozanimod 1.0 mg OD was superior to that of DMF 240 mg BID. Although a MAIC is less likely to produce biased estimates than a naïve or a standard indirect treatment comparison via a common comparator, limitations include potential confounding due to unobserved and thus unaccounted for baseline differences.
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Tafazzoli A, Chavan A, Harty G, Moller J, Wong SL. Efficiency Model of Cladribine Tablets Versus Infusion-Based Disease-Modifying Drugs for Patients with Relapsing-Remitting Multiple Sclerosis. Adv Ther 2020; 37:3791-3806. [PMID: 32647909 DOI: 10.1007/s12325-020-01426-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION To develop a simulation model assessing the efficiency of using cladribine tablets versus infusion-based disease-modifying drugs (DMDs) for the treatment of relapsing-remitting multiple sclerosis (RRMS) from a facility perspective in the UK. METHODS A scheduling algorithm was developed to simulate day-case admissions and calculate the mean changes to resource use and time burden for patients in a facility that transitions from infusion-based treatments to cladribine tablets over 1 year. Model inputs and assumptions were based on previous research and expert opinion. Model validation and quality checks were performed and additional scenario analyses were also conducted. RESULTS The model successfully scheduled all infusion treatments in the base case and no patients were left off the schedule as a result of lack of capacity. Modeled base-case outcomes increased in future scenarios owing to a 35% increase in demand. The introduction of cladribine tablets reduced these impacts. Specifically, the difference in mean daily utilization was reduced in the future scenario from 13% to 3% as 8% of patients moved to cladribine tablets; annual administration costs decreased by 96% and annual time burden decreased by 90%. Results from additional scenarios showed the largest benefits from switching current infusion patients to cladribine tablets were realized in facilities having moderate to high resource utilization. CONCLUSIONS This model provides facility decision-makers the ability to assess the efficiency of using cladribine tablets rather than an infusion-based DMD. The simulation quantified the benefits gained from reducing the burden on facility resources by switching some patients with RRMS from infusion-based DMDs to cladribine tablets. Overall, modeled outcomes increased in future scenarios owing to an increase in demand, although the introduction of cladribine tablets reduced this impact.
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Affiliation(s)
- Ali Tafazzoli
- Evidence Synthesis, Modeling and Communication, Evidera, Bethesda, MD, USA
| | - Ameya Chavan
- Evidence Synthesis, Modeling and Communication, Evidera, Bethesda, MD, USA
| | - Gerard Harty
- Global Evidence and Value Development, Global Research and Development, EMD Serono, Inc, Billerica, MA, USA.
| | - Jorgen Moller
- Evidence Synthesis, Modeling and Communication, Evidera, London, UK
| | - Schiffon L Wong
- Global Evidence and Value Development, Global Research and Development, EMD Serono, Inc, Billerica, MA, USA
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Alroughani R, Inshasi J, Al-Asmi A, Alqallaf A, Al Salti A, Shatila A, Boshra A, Canibano B, Deleu D, Al Sharoqi I, Al Khabouri J. Expert consensus from the Arabian Gulf on selecting disease-modifying treatment for people with multiple sclerosis according to disease activity. Postgrad Med 2020; 132:368-376. [PMID: 32089038 DOI: 10.1080/00325481.2020.1734394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent research has expanded our understanding of the natural history and clinical course of multiple sclerosis (MS) in the Arabian Gulf region. In addition, the number of available therapies for MS has increased greatly in recent years, which complicates considerably the design of therapeutic regimens. We, an expert group of physicians practising in Arabian Gulf countries, present pragmatic consensus recommendations for the use of disease-modifying therapy, according to the level of MS disease activity, according to objective criteria, and prior treatment (if any) received by a given patient.
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Affiliation(s)
| | - Jihad Inshasi
- Department of Neurology, Rashid Hospital , Dubai, United Arab Emirates.,Dubai Medical College, Dubai Health Authority (DHA) , Dubai, United Arab Emirates
| | - Abdullah Al-Asmi
- Neurology Unit, College of Medicine and Health Sciences, Sultan Qaboos University , Muscat, Oman
| | | | | | - Ahmed Shatila
- Neurology Department, Sheikh Shakhbout Medical City , Aby Dhabi, United Arab Emirates
| | - Amir Boshra
- Neurology and Immunology Medical Affairs - Patient Support Program, Gulf Region, Merck Serono Middle East FZ LTD , Dubai, United Arab Emirates
| | - Beatriz Canibano
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation , Doha, Qatar
| | - Dirk Deleu
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation , Doha, Qatar
| | - Isa Al Sharoqi
- Department of Neuroscience, Salmaniya Medical Complex , Manama, Bahrain.,Neurology Department, Ministry of Health , Manama, Bahrain
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Abstract
INTRODUCTION Cost assessment modelling (CAM) of treatments in highly active relapsing multiple sclerosis was conducted. METHODS The CAM was developed using the R programming language. The PICOSTEPS health technology assessment framework was applied in the CAM. Modelled patients were 280 adults with highly active relapsing multiple sclerosis eligible for disease-modifying treatment. Intervention was cladribine tablets, a new and reimbursed oral treatment for highly active relapsing multiple sclerosis in Finland. Comparators included fingolimod, the most used oral reimbursed treatment for the highly active disease, and natalizumab, the most used intravenous treatment, and a treatment mix (80% use fingolimod, 20% use natalizumab) in Finland. Outcomes presented expected annual and cumulative drug-associated costs in the overall population and per patient. Setting was modelled public specialist care in Finland. Time was set to 4 years, without discounting. Effects covered expected drug-associated costs (screening, acquisition, administration, monitoring, adverse events, travelling, productivity). Perspective was a limited societal perspective. Sensitivity analyses regarding all PICOSTEPS components were conducted. RESULTS Cladribine tablets were projected to be cost saving in comparison to fingolimod, natalizumab and treatment mix. The respective modelled savings were €4,598,742, €16,249,701 and €6,928,934 in the overall population, and €16,424, €58,035 and €24,746 per patient, respectively, during the 4 years. The most important cost driver was drug costs, representing 96.3%, 96.0% and 83.4% of modelled costs associated with cladribine tablets, fingolimod and natalizumab, respectively. Cladribine tablets sustained their affordability in the sensitivity analyses. From the perspective of health care payer, cladribine tablets' savings were projected to be €4,514,509, €15,145,366 and €6,640,680 in the overall population, and €16,123, €54,091 and €23,717 per patient in comparison to fingolimod, natalizumab and treatment mix, respectively. CONCLUSION Based on the CAM, cladribine tablets were projected to robustly save modelled drug-associated costs in comparison to fingolimod, natalizumab and their mix in Finland.
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Swallow E, Patterson-Lomba O, Yin L, Mehta R, Pelletier C, Kao D, Sheffield JK, Stonehouse T, Signorovitch J. Comparative safety and efficacy of ozanimod versus fingolimod for relapsing multiple sclerosis. J Comp Eff Res 2020; 9:275-285. [PMID: 31948278 DOI: 10.2217/cer-2019-0169] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Aim: Ozanimod and fingolimod are sphingosine 1-phosphate receptor-modulating therapies for relapsing multiple sclerosis. Patients & methods: Comparative effectiveness was assessed by matching adjusted indirect comparisons of safety and efficacy trial outcomes at first-dose cardiac monitoring, 1 year and 2 years. Results: After adjustment, baseline characteristics were similar. Ozanimod was associated with a lower risk of extended first-dose monitoring, conduction abnormalities including atrioventricular block. One-year risks of any adverse event (AE), mean lymphocyte count reductions and abnormal liver enzymes were lower with ozanimod. Two-year risks of AEs leading to discontinuation, any AEs, herpetic infections, bradycardia and abnormal liver enzymes were lower with ozanimod. Analyses of efficacy outcomes were similar. Conclusion: Ozanimod appears to have a favorable benefit-risk profile versus fingolimod.
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Affiliation(s)
- Elyse Swallow
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199, USA
| | | | - Lei Yin
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199, USA
| | - Rina Mehta
- US HEOR, Bristol-Myers Squibb, 86 Morris Avenue, Summit, NJ 07901, USA
| | - Corey Pelletier
- US HEOR, Bristol-Myers Squibb, 86 Morris Avenue, Summit, NJ 07901, USA
| | - David Kao
- US HEOR, Bristol-Myers Squibb, 86 Morris Avenue, Summit, NJ 07901, USA
| | - James K Sheffield
- US HEOR, Bristol-Myers Squibb, 86 Morris Avenue, Summit, NJ 07901, USA
| | - Tim Stonehouse
- US HEOR, Bristol-Myers Squibb, 86 Morris Avenue, Summit, NJ 07901, USA
| | - James Signorovitch
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199, USA
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Michels RE, de Fransesco M, Mahajan K, Hengstman GJD, Schiffers KMH, Budhia S, Harty G, Krol M. Cost Effectiveness of Cladribine Tablets for the Treatment of Relapsing-Remitting Multiple Sclerosis in The Netherlands. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:857-873. [PMID: 31444659 PMCID: PMC6885501 DOI: 10.1007/s40258-019-00500-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cladribine tablets have recently become available in The Netherlands for patients with relapsing-remitting multiple sclerosis (RRMS) as a disease-modifying agent that reduces the frequency and severity of relapses and delays disability progression. OBJECTIVE The aim of this study was to evaluate the cost effectiveness of cladribine tablets, compared with alternative options, in the treatment of RRMS patients with high disease activity (HDA) and patients with rapidly evolving severe (RES) MS in The Netherlands. METHODS A Markov model was developed simulating the costs and effects of RRMS treatment. For HDA, alemtuzumab and fingolimod were used as comparators; natalizumab was used for the RES subpopulation. The analysis included a societal perspective and a value-of-information (VOI) analysis. RESULTS For the HDA subpopulation, treatment with cladribine tablets was the cost-effective (dominant) strategy compared with alemtuzumab and fingolimod, with 50.9% and 98.2%, respectively, probability of being cost effective at a threshold of €50,000/QALY gained and a net monetary benefit (NMB) of €10,866 and €151,115, respectively. For the RES subpopulation, treatment with cladribine tablets dominated treatment with natalizumab, with 94.1% probability of being cost effective at a threshold of €50,000/QALY gained and an NMB of €122,986. Note that these outcomes are driven by the lower costs of cladribine tablets. Efficacy differences were small, very uncertain, and likely not clinically meaningful. The probabilistic sensitivity analyses showed significant overlap in the credible intervals for total lifetime QALY outcomes and costs of cladribine tablets and all relevant comparators. The population-level VOI amounted to €19,295,441. CONCLUSIONS The base-case analysis shows that treatment of RRMS with cladribine tablets is cost effective versus alemtuzumab and fingolimod in HDA patients, and cost effective versus natalizumab in RES patients, at a threshold of €50,000. Driven by the lower costs, cladribine tablets were cost effective (dominant) in all base-case analyses. However, given that outcomes are based on indirect comparisons and post hoc subgroup analysis, as well as the uncertainty surrounding the outcomes, the results presented in this paper should be interpreted with caution.
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Affiliation(s)
- Renée Else Michels
- IQVIA, Real World Evidence Solutions, Herikerbergweg 314, 1101 CT, Amsterdam, The Netherlands
| | | | | | - Gerald J D Hengstman
- Department of Neurology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | | | - Sangeeta Budhia
- PAREXEL International, PAREXEL Access Consulting, London, UK
| | - Gerard Harty
- EMD Serono, a business of Merck KGaA, Boston, MA, USA
| | - Marieke Krol
- IQVIA, Real World Evidence Solutions, Herikerbergweg 314, 1101 CT, Amsterdam, The Netherlands.
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