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Buron MD, Kalincik T, Sellebjerg F, Sørensen PS, Magyari M. Effect of lateral therapy switches to oral moderate-efficacy drugs in multiple sclerosis: a nationwide cohort study. J Neurol Neurosurg Psychiatry 2021; 92:556-562. [PMID: 33436501 DOI: 10.1136/jnnp-2020-324869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/05/2020] [Accepted: 12/14/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Switching between first-line disease-modifying therapies in patients with clinically stable relapsing-remitting multiple sclerosis (RRMS) due to reasons other than disease activity is frequent, but evidence on the effect of this practice is limited. We investigated the effect of switching patients with stable RRMS on occurrences of disability accumulation, relapses and future treatment discontinuation. METHODS Using the Danish Multiple Sclerosis Registry, we identified patients with RRMS without disease activity who either (1) stayed on injectable platform therapy (interferon-β or glatiramer acetate) or (2) switched to dimethyl fumarate (DMF) or teriflunomide (TFL) and compared treatment outcomes using propensity-score-based methods and marginal structural models (MSM). RESULTS We included 3206 patients in the study. We found no change in risk of 6-month confirmed Expanded Disability Status Scale score worsening in patients switching to DMF (HR: 1.15, 95% CI 0.88 to 1.50) or TFL (HR: 1.16, 95% CI 0.92 to 1.46). The risk of suffering any relapse tended to decrease when switching to DMF (HR: 0.73, 95% CI 0.51 to 1.04) and tended to increase when switching to TFL (HR: 1.25, 95% CI 0.96 to 1.63). Absolute risk differences were small. MSM analyses showed similar results but did not find an increased relapse risk in TFL switchers. CONCLUSION Switching from injectable platform therapies to oral first-line therapies in patients with clinically stable RRMS does not increase the risk of disability accumulation. While the postswitch risk of relapses trended towards marginally higher on TFL, this trend was eliminated by adjustment for time-variant confounders.
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Affiliation(s)
- Mathias Due Buron
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark .,Danish Multiple Sclerosis Registry, Rigshospitalet, Copenhagen, Denmark
| | - Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Melbourne MS Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Danish Multiple Sclerosis Registry, Rigshospitalet, Copenhagen, Denmark
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2
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Koch-Henriksen N. It is safe to switch therapy from interferon beta or glatiramer acetate to oral therapy in patients with relapsing multiple sclerosis with stable disease. J Neurol Neurosurg Psychiatry 2021; 92:457. [PMID: 33563802 DOI: 10.1136/jnnp-2020-325684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Nils Koch-Henriksen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark .,The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Copenhagen, Denmark
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3
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Earla JR, Hutton GJ, Thornton DJ, Chen H, Johnson ML, Aparasu RR. Comparative treatment effectiveness of oral fingolimod and conventional injectable disease-modifying agents in multiple sclerosis. Pharmacotherapy 2021; 41:440-450. [PMID: 33641232 DOI: 10.1002/phar.2517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 01/29/2021] [Accepted: 01/31/2021] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVE To compare the effectiveness of oral fingolimod and conventional injectable disease-modifying agents (DMAs) using the composite endpoint of relapse or DMA treatment switch in patients with multiple sclerosis (MS). DESIGN A retrospective longitudinal cohort study. DATA SOURCE IBM MarketScan Commercial Claims and Encounters Database from 2010-2012. PATIENTS Adults (≥18 years) with MS diagnosis (ICD-9-CM:340) who newly initiated DMAs. INTERVENTION Oral fingolimod and conventional injectable DMAs (interferon beta and glatiramer acetate). MEASUREMENTS Composite endpoint of time to relapse or DMA treatment switch. MAIN RESULTS The incident study cohort consisted of 1997 MS patients who initiated oral fingolimod (15.6%) or injectable (84.4%) DMAs. The proportion of patients who had a composite endpoint (relapse/DMA treatment switch) in oral fingolimod and injectable DMA users was found to be 16.72% and 27.16%, respectively. The Cox PH regression model with stabilized IPTW revealed that fingolimod is equally effective as conventional injectable DMAs in reducing the risk of experiencing the composite endpoint of relapse or DMA switch (adjusted hazard ratio [aHR]: 0.67, 95% CI: 0.43-1.03). Additional analysis among patients who were adherent also found no significant difference in the composite endpoint (aHR: 0.70, 95% CI 0.49-1.15) between oral fingolimod and injectable DMA users. CONCLUSIONS Oral fingolimod has similar effectiveness as conventional injectable DMAs in reducing the risk of experiencing the composite endpoint (relapse or DMA treatment switch). In addition, when assessed independently, oral fingolimod showed no difference in reducing the time to relapse or DMA treatment switch compared to injectable DMAs.
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Affiliation(s)
- Jagadeswara R Earla
- Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | | | - Douglas J Thornton
- Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Hua Chen
- Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Michael L Johnson
- Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Rajender R Aparasu
- Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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4
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Ng HS, Zhu F, Kingwell E, Zhao Y, Yao S, Ekuma O, Svenson LW, Evans C, Fisk JD, Marrie RA, Tremlett H. Characteristics of a population-based multiple sclerosis cohort treated with disease-modifying drugs in a universal healthcare setting. Expert Rev Neurother 2020; 21:131-140. [PMID: 33146570 DOI: 10.1080/14737175.2021.1847085] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background: Relatively little is known about the use of disease-modifying drugs (DMDs) for multiple sclerosis (MS) in the population-based universal healthcare setting. This study aimed to describe the characteristics of a population-based cohort with MS and their DMD exposure in four Canadian provinces. Methods: We identified all adults (aged ≥18 years) with MS using linked population-based health administrative data. Individuals were followed from the most recent of their first MS or demyelinating event or 1 January 1996(study entry), to the earliest of death, emigration, or 31 March 2018(study end). Cohort characteristics examined included sex, age, socioeconomic status, and comorbidity burden. Results: Overall, 10,418/35,894 (29%) of MS cases filled a DMD prescription during the 22-year study period. Most were women (n = 7,683/10,418;74%), and 17% (n = 1,745/10,418) had some comorbidity (Charlson Comorbidity Index≥1) at study entry. Nearly 20% (n = 1,745/10,418) were aged ≥50 when filling their first DMD; the mean age was 39.6 years. Conclusions: Almost 1 in 6 people with MS had at least some comorbidity, and nearly 1 in 6 were ≥50 years old at the time of their first DMD. As these individuals are typically excluded from clinical trials, findings illustrate the need to understand the harms and benefits of DMD use in these understudied groups.
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Affiliation(s)
- Huah Shin Ng
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia , Vancouver, BC, Canada
| | - Feng Zhu
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia , Vancouver, BC, Canada
| | - Elaine Kingwell
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia , Vancouver, BC, Canada
| | - Yinshan Zhao
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia , Vancouver, BC, Canada
| | - Shenzhen Yao
- College of Pharmacy and Nutrition, University of Saskatchewan , Saskatoon, SK, Canada.,Health Quality Council , Saskatoon, SK, Canada
| | - Okechukwu Ekuma
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, MB, Canada
| | - Lawrence W Svenson
- Alberta Health , Edmonton, AB, Canada.,Division of Preventive Medicine & School of Public Health, University of Alberta , Edmonton, AB, Canada.,Community Health Sciences, Cumming School of Medicine, University of Calgary , Calgary, AB, Canada
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan , Saskatoon, SK, Canada
| | - John D Fisk
- Nova Scotia Health Authority and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine, Dalhousie University , Halifax, NS, Canada
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, MB, Canada
| | - Helen Tremlett
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia , Vancouver, BC, Canada
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5
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Vermersch P, Oh J, Cascione M, Oreja-Guevara C, Gobbi C, Travis LH, Myhr KM, Coyle PK. Teriflunomide vs injectable disease modifying therapies for relapsing forms of MS. Mult Scler Relat Disord 2020; 43:102158. [DOI: 10.1016/j.msard.2020.102158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/24/2020] [Accepted: 04/26/2020] [Indexed: 02/08/2023]
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6
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Patti F, Chisari CG, D'Amico E, Annovazzi P, Banfi P, Bergamaschi R, Clerici R, Conti MZ, Cortese A, Fantozzi R, Fischetti M, Frigo M, Gatto M, Immovilli P, Leoni S, Malucchi S, Maniscalco G, Marfia GA, Paolicelli D, Perini P, Serrati C, Sola P, Totaro R, Turano G, Valentino P, Zaffaroni M, Zuliani C, Centonze D. Clinical and patient determinants of changing therapy in relapsing-remitting multiple sclerosis (SWITCH study). Mult Scler Relat Disord 2020; 42:102124. [DOI: 10.1016/j.msard.2020.102124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 03/14/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022]
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7
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Butzkueven H, Trojano M, Kappos L, Spelman T, Wiendl H, Rosales K, Su R, Licata S, Ho PR, Campbell N. Clinical outcomes in patients who discontinue natalizumab therapy after 2 years in the Tysabri ® Observational Program (TOP). Mult Scler 2020; 27:410-419. [PMID: 32406786 DOI: 10.1177/1352458520917925] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Natalizumab is a highly efficacious therapy for relapsing-remitting multiple sclerosis (RRMS). Patients who discontinue natalizumab may experience return of MS disease activity. OBJECTIVE The aim of this study was to analyze predictors of post-natalizumab disease activity return. METHODS The Tysabri® Observational Program (TOP) is an ongoing observational study of natalizumab-treated RRMS patients. Patients discontinuing natalizumab are encouraged to remain in TOP. RESULTS Analyses included 3221 TOP patients. After ⩾2 years on natalizumab, relapse risk was twice as high for patients who switched to an oral therapy (n = 660, hazard ratio (HR) = 2.18, p < 0.001) and three times as high for patients who switched to an injectable therapy (n = 95, HR = 3.02, p < 0.001) as for those who stayed on natalizumab (n = 2466). Relapse rates after switching remained below pre-natalizumab rates. In patients who switched to an oral therapy, higher relapse risk was predicted by longer washout time, more pre-natalizumab relapses, higher Expanded Disability Status Scale score at natalizumab initiation, and shorter natalizumab treatment duration. CONCLUSION Patients who stayed on natalizumab had better clinical outcomes than those who switched to an oral or injectable therapy after ⩾2 years on natalizumab. These results highlight modifiable risk factors for disease activity return (e.g. natalizumab treatment duration and washout duration) to consider when making treatment decisions.
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Affiliation(s)
- Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Alfred Campus, Monash University, Melbourne, VIC, Australia/Department of Neurology, Box Hill Hospital, Monash University, Box Hill, VIC, Australia
| | - Maria Trojano
- Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Tim Spelman
- Department of Medicine and Melbourne Brain Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Heinz Wiendl
- Department of Neurology-Inflammatory Disorders of the Nervous System and Neuro-Oncology, University of Münster, Münster, Germany
| | | | - Ray Su
- Biogen, Cambridge, MA, USA
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8
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Desai RJ, Mahesri M, Gagne JJ, Hurley E, Tong A, Chitnis T, Minden S, Spettell CM, Matlin OS, Shrank WH, Choudhry NK. Utilization Patterns of Oral Disease-Modifying Drugs in Commercially Insured Patients with Multiple Sclerosis. J Manag Care Spec Pharm 2019; 25:113-121. [PMID: 30589630 PMCID: PMC10397781 DOI: 10.18553/jmcp.2019.25.1.113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The approval of new oral disease-modifying drugs (DMDs), such as fingolimod, dimethyl fumarate (DMF), and teriflunamide, has considerably expanded treatment options for relapsing forms of multiple sclerosis (MS). However, data describing the use of these agents in routine clinical practice are limited. OBJECTIVE To describe time trends and identify factors associated with oral DMD treatment initiation and switching among individuals with MS. METHODS Using data from a large sample of commercially insured patients, we evaluated changes over time in the proportion of MS patients who initiated treatment with an oral DMD and who switched from an injectable DMD to an oral DMD between 2009 and 2014 in the United States. We evaluated predictors of oral DMD use using conditional logistic regression in 2 groups matched on calendar time: oral DMD initiators matched to injectable DMDs initiators and oral DMD switchers matched to those who switched to a second injectable DMD. RESULTS Our cohort included 7,576 individuals who initiated a DMD and 1,342 who switched DMDs, of which oral DMDs accounted for 6% and 39%, respectively. Oral DMD initiation and switching steadily increased from 5% to 16% and 35% to 84%, respectively, between 2011 and 2014, with DMF being the most commonly used agent. Of the potential predictors with clinical significance, a recent neurologist consultation (OR = 1.60; 95% CI = 1.20-2.15) and emergency department visit (OR = 1.43; 95% CI = 1.01-2.01) were significantly associated with oral DMD initiation. History of depression was noted to be a potential predictor of oral DMD initiation; however, the estimate for this predictor did not reach statistical significance (OR = 1.35; 95% CI = 0.99-1.84). No clinically relevant factors measured in our data were associated with switching to an oral DMD. CONCLUSIONS Oral DMDs were found to be routinely used as second-line treatment. However, we identified few factors predictive of oral DMD initiation or switching, which implies that their selection is driven by patient and/or physician preferences. DISCLOSURES This study was funded by CVS Caremark through an unrestricted research grant to Brigham and Women's Hospital. Shrank and Matlin were employees of, and shareholders in, CVS Health at the time of the study; they report no financial interests in products or services that are related to the subject of this study. Spettell is an employee of, and shareholder in, Aetna. Chitnis serves on clinical trial advisory boards for Novartis and Genzyme-Sanofi; has consulted for Bayer, Biogen Idec, Celgene, Novartis, Merck-Serono, and Genentech-Roche; and has received research support from NIH, National Multiple Sclerosis Society, Peabody Foundation, Consortium for MS Centers, Guthy Jackson Charitable Foundation, EMD-Serono, Novartis Biogen, and Verily. Desai reports receiving a research grant from Merck for unrelated work. Gagne is principal investigator of a research grant from Novartis Pharmaceuticals Corporation to the Brigham and Women's Hospital and has received grant support from Eli Lilly, all for unrelated work. He is also a consultant to Aetion and Optum. Minden reports grants from Biogen and other fees from Genentech, EMD Serano, Avanir, and Novartis, unrelated to this study. The other authors have no conflicts to report. This study was presented as a poster at the International Society for Pharmacoepidemiology 32nd Annual Meeting; August 25-28, 2016; Dublin, Ireland.
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Affiliation(s)
- Rishi J. Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Joshua J. Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Eimir Hurley
- Centre for Health Policy and Management, Trinity College, Dublin, Ireland
| | - Angela Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Tanuja Chitnis
- Department of Neurology Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Sarah Minden
- Department of Psychiatry, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Niteesh K. Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
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9
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Niino M, Ohashi T, Ochi H, Nakashima I, Shimizu Y, Matsui M. Japanese guidelines for dimethyl fumarate. ACTA ACUST UNITED AC 2018. [DOI: 10.1111/cen3.12477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Masaaki Niino
- Department of Clinical Research Hokkaido Medical Center Sapporo Japan
| | - Takashi Ohashi
- Department of Neurology Tokyo Women's Medical University Yachiyo Medical Center Chiba Japan
| | - Hirofumi Ochi
- Department of Neurology and Geriatric Medicine Ehime University Graduate School of Medicine Toon Japan
| | - Ichiro Nakashima
- Department of Neurology Tohoku Medical and Pharmaceutical University Sendai Japan
| | - Yuko Shimizu
- Department of Neurology Tokyo Women's Medical University School of Medicine Tokyo Japan
| | - Makoto Matsui
- Department of Neurology Kanazawa Medical University Ishikawa Japan
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10
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Managing Multiple Sclerosis: Treatment Initiation, Modification, and Sequencing. Can J Neurol Sci 2018; 45:489-503. [DOI: 10.1017/cjn.2018.17] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AbstractRecent therapeutic advances in the management of multiple sclerosis (MS) have raised questions about the selection of appropriate patient candidates for various treatments and, if the plan is to move from one treatment to another, the appropriate sequencing of these therapies. The selected approach should provide optimal disease management without limiting future therapeutic options based on safety concerns, and recognize potential future treatments and the possibility of combination therapies. Additional challenges include incorporation of patient needs and preferences into the overall therapeutic approach, in order to ensure optimal outcomes in the short and long term. The objective of this manuscript is to provide an overview of what is currently known regarding the impact of various therapies for MS on future therapeutic choices (sequencing). In this context, we reviewed the available evidence in support of various treatments and, based on the presence of disease activity, suggested a scheme for switching or escalating therapy with the main focus on sequencing of therapeutic approaches.
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11
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Belleudi V, Trotta F, Vecchi S, Amato L, Addis A, Davoli M. Studies on drug switchability showed heterogeneity in methodological approaches: a scoping review. J Clin Epidemiol 2018; 101:5-16. [PMID: 29777799 DOI: 10.1016/j.jclinepi.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/18/2018] [Accepted: 05/09/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Several drugs share the same therapeutic indication, including those undergoing patent expiration. Concerns on the interchangeability are frequent in clinical practice, challenging the evaluation of switchability through observational research. The objective of this study was to conduct a scoping review of observational studies on drug switchability to identify methodological strategies adopted to deal with bias and confounding. METHODS We searched PubMed, EMBASE, and Web of Science (updated January 31, 2017) to identify studies evaluating switchability in terms of effectiveness/safety outcomes or compliance. Three reviewers independently screened studies extracting all characteristics. Strategies to address confounding, particularly previous drug use and switching reasons, were considered. All findings were summarized in descriptive analyses. RESULTS Thirty-two studies, published in the last 10 years, met the inclusion criteria. Epilepsy, cardiovascular, and rheumatology were the most frequently represented clinical areas. Seventy-five percent of the studies reported data on effectiveness/safety outcomes. The most frequent study design was cohort (65.6%) followed by case-control (21.9%) and self-controlled (12.5%). Case-control and case-crossover studies showed homogeneous methodological strategies to deal with bias and confounding. Among cohort studies, the confounding associated with previous drug use was addressed introducing variables in multivariate model (47.3%) or selecting only adherent patients (14.3%). Around 30% of cohort studies did not report reasons for switching. In the remaining 70%, clinical parameters or previous occurrence of outcomes was measured to identify switching connected with lack of effectiveness or adverse events. CONCLUSION This study represents a starting point for researchers and administrators who are approaching the investigation and assessment of issues related to interchangeability of drugs.
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Affiliation(s)
- Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
| | - Francesco Trotta
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Simona Vecchi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Laura Amato
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Antonio Addis
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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12
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Berger T, Adamczyk-Sowa M, Csépány T, Fazekas F, Hojs Fabjan T, Horáková D, Illes Z, Klimová E, Leutmezer F, Rejdak K, Rozsa C, Šega Jazbec S, Szilasiová J, Turčáni P, Vachová M, Vécsei L, Havrdová E. Management of multiple sclerosis patients in central European countries: current needs and potential solutions. Ther Adv Neurol Disord 2018; 11:1756286418759189. [PMID: 29511382 PMCID: PMC5826096 DOI: 10.1177/1756286418759189] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/04/2017] [Indexed: 12/31/2022] Open
Abstract
Multiple sclerosis (MS) experts in Europe are facing rapidly rising demands of excellence due to the increasing complexity of MS therapy and management. A central European expert board of MS experts met to identify needs and obstacles with respect to raising quality of MS care in central and Eastern European countries. There are substantial variations across countries regarding delivery of care and its cost structure, as well as access to treatment. To date, Eastern European countries are often less able to afford reimbursement of immunomodulatory agents than Western countries. Overall, approximately 40% of working-age patients are not working due to MS. Costs rise steeply with increasing disability; indirect costs constitute the bulk of the financial burden in patients with severe MS. Magnetic resonance imaging (MRI) assessment is meanwhile obligatory as the diagnostic interface in the management of MS patients. Recommended measures directed at improving quality of care include the collection of patient data in registries, enhanced education of healthcare professionals, implementation of national strategies aiming at reducing regional variation, optimization of approval processes, and removal of administrative barriers. Local partnerships with authorities such as those that represent the interests of employees can contribute to leverage the importance of epidemiological data. The need for education extends to (neuro)radiologists who are responsible for reporting MRI findings in expert quality. Dissemination of the Magnetic Resonance Imaging in MS (MAGNIMS) protocol would be an important step in this context. Also, clinical freedom of choice is rated as essential. Physicians should have access to a range of treatment options due to the complexity of disease. Guidelines such as the upcoming EAN-ECTRIMS clinical practice guideline also aim at providing a basis for argumentation in negotiations with national health authorities.
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Affiliation(s)
- Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Monika Adamczyk-Sowa
- Department of Neurology in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Tünde Csépány
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Tanja Hojs Fabjan
- Department of Neurology, University Medical Centre Maribor, Maribor, Slovenia
| | - Dana Horáková
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Zsolt Illes
- Department of Neurology, University of Southern Denmark, Odense, Denmark
| | - Eleonóra Klimová
- Department of Neurology, University of Prešov and Teaching Hospital of JA Reiman, Prešov, Slovakia
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Csilla Rozsa
- Department of Neurology, Jahn Ferenc Dél-pesti Hospital, Budapest, Hungary
| | - Saša Šega Jazbec
- Department of Neurology, University of Ljubljana, Ljubljana, Slovenia
| | - Jarmila Szilasiová
- Department of Neurology, Pavol Jozef Šafárik University and University Hospital L Pasteur, Košice, Slovakia
| | - Peter Turčáni
- Department of Neurology, Comenius University, Bratislava, Slovakia
| | | | - László Vécsei
- Department of Neurology and MTA-SZTE Neuroscience Research Group, University of Szeged, Szeged, Hungary
| | - Eva Havrdová
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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13
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Schapira AHV. Advances and insights into neurological practice 2016−17. Eur J Neurol 2017; 24:1425-1434. [DOI: 10.1111/ene.13480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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14
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Elkjaer ML, Molnar T, Illes Z. Teriflunomide for multiple sclerosis in real-world setting. Acta Neurol Scand 2017; 136:447-453. [PMID: 28321835 DOI: 10.1111/ane.12755] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Teriflunomide 14 mg is a once-daily oral disease-modifying treatment for relapsing-remitting multiple sclerosis. We examined adverse event (AE) profile and efficacy in real life. MATERIALS AND METHODS In this observational cohort study, we retrospectively examined 1521 blood samples and data of 102 patients followed for up to 28 months. RESULTS The number of female patients starting teriflunomide peaked in the fifth decade, 10 years later compared to male patients (P<.001), reflecting pregnancy concerns. Seventy-six percentages of patients shifted to teriflunomide from treatment with interferon-beta. Expanded disability status scale improved in 11% of patients (18.2±3.6 months follow-up) and remained constant in 67.5% (15±5.3 months follow-up). Of ten relapses, three occurred within 6 months after starting treatment. Seventeen patients (16.5%) discontinued teriflunomide: 53% because of AEs and 29% because of relapse. Levels of alanine aminotransferase (ALT) remained normal in 95.3% of the blood samples and remained below 1.5 times the upper limit of normal in 91% of the 4.7% abnormal samples. One-third of the patients had abnormal ALT values at least once. Haematological abnormalities were found in <4% of the blood samples, but at least one abnormal value was observed in up to 21% of the patients. CONCLUSIONS Efficacy and safety of teriflunomide in real-life setting support data obtained by the pivotal trials. Laboratory abnormalities are rare among the large number of samples, but patients may commonly have a single mild, abnormal value if frequently tested.
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Affiliation(s)
- M. L. Elkjaer
- Department of Neurology; Odense University Hospital; Odense Denmark
| | - T. Molnar
- Department of Anesthesiology and Intensive Care; University of Pecs; Pecs Hungary
| | - Z. Illes
- Department of Neurology; Odense University Hospital; Odense Denmark
- Department of Clinical Research; University of Southern Denmark; Odense Denmark
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15
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Kalincik T, Manouchehrinia A, Sobisek L, Jokubaitis V, Spelman T, Horakova D, Havrdova E, Trojano M, Izquierdo G, Lugaresi A, Girard M, Prat A, Duquette P, Grammond P, Sola P, Hupperts R, Grand'Maison F, Pucci E, Boz C, Alroughani R, Van Pesch V, Lechner-Scott J, Terzi M, Bergamaschi R, Iuliano G, Granella F, Spitaleri D, Shaygannejad V, Oreja-Guevara C, Slee M, Ampapa R, Verheul F, McCombe P, Olascoaga J, Amato MP, Vucic S, Hodgkinson S, Ramo-Tello C, Flechter S, Cristiano E, Rozsa C, Moore F, Luis Sanchez-Menoyo J, Laura Saladino M, Barnett M, Hillert J, Butzkueven H. Towards personalized therapy for multiple sclerosis: prediction of individual treatment response. Brain 2017; 140:2426-2443. [PMID: 29050389 DOI: 10.1093/brain/awx185] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/20/2017] [Indexed: 11/14/2022] Open
Abstract
Timely initiation of effective therapy is crucial for preventing disability in multiple sclerosis; however, treatment response varies greatly among patients. Comprehensive predictive models of individual treatment response are lacking. Our aims were: (i) to develop predictive algorithms for individual treatment response using demographic, clinical and paraclinical predictors in patients with multiple sclerosis; and (ii) to evaluate accuracy, and internal and external validity of these algorithms. This study evaluated 27 demographic, clinical and paraclinical predictors of individual response to seven disease-modifying therapies in MSBase, a large global cohort study. Treatment response was analysed separately for disability progression, disability regression, relapse frequency, conversion to secondary progressive disease, change in the cumulative disease burden, and the probability of treatment discontinuation. Multivariable survival and generalized linear models were used, together with the principal component analysis to reduce model dimensionality and prevent overparameterization. Accuracy of the individual prediction was tested and its internal validity was evaluated in a separate, non-overlapping cohort. External validity was evaluated in a geographically distinct cohort, the Swedish Multiple Sclerosis Registry. In the training cohort (n = 8513), the most prominent modifiers of treatment response comprised age, disease duration, disease course, previous relapse activity, disability, predominant relapse phenotype and previous therapy. Importantly, the magnitude and direction of the associations varied among therapies and disease outcomes. Higher probability of disability progression during treatment with injectable therapies was predominantly associated with a greater disability at treatment start and the previous therapy. For fingolimod, natalizumab or mitoxantrone, it was mainly associated with lower pretreatment relapse activity. The probability of disability regression was predominantly associated with pre-baseline disability, therapy and relapse activity. Relapse incidence was associated with pretreatment relapse activity, age and relapsing disease course, with the strength of these associations varying among therapies. Accuracy and internal validity (n = 1196) of the resulting predictive models was high (>80%) for relapse incidence during the first year and for disability outcomes, moderate for relapse incidence in Years 2-4 and for the change in the cumulative disease burden, and low for conversion to secondary progressive disease and treatment discontinuation. External validation showed similar results, demonstrating high external validity for disability and relapse outcomes, moderate external validity for cumulative disease burden and low external validity for conversion to secondary progressive disease and treatment discontinuation. We conclude that demographic, clinical and paraclinical information helps predict individual response to disease-modifying therapies at the time of their commencement.
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Affiliation(s)
- Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, 300 Grattan St, Melbourne, 3050, Australia.,Department of Neurology, Royal Melbourne Hospital, 300 Grattan St, Melbourne, 3050, Australia
| | - Ali Manouchehrinia
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, SE-17177, Sweden
| | - Lukas Sobisek
- Department of Neurology and Center of Clinical Neuroscience, General University Hospital and Charles University in Prague, Katerinska 30, Prague, 12808, Czech Republic.,Department of Statistics and Probability, University of Economics in Prague, Winston Churchill Sq 1938/4, Prague, 13067, Czech Republic
| | - Vilija Jokubaitis
- Department of Neurology, Royal Melbourne Hospital, 300 Grattan St, Melbourne, 3050, Australia.,Department of Medicine, University of Melbourne, 300 Grattan St, Melbourne, 3050, Australia
| | - Tim Spelman
- Department of Neurology, Royal Melbourne Hospital, 300 Grattan St, Melbourne, 3050, Australia.,Department of Medicine, University of Melbourne, 300 Grattan St, Melbourne, 3050, Australia
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, General University Hospital and Charles University in Prague, Katerinska 30, Prague, 12808, Czech Republic
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, General University Hospital and Charles University in Prague, Katerinska 30, Prague, 12808, Czech Republic
| | - Maria Trojano
- University of Bari, Via Calefati 53, Bari, 70122, Italy
| | - Guillermo Izquierdo
- Hospital Universitario Virgen Macarena, Amador de los Rios 48-50. 4a, Sevilla, 41003, Spain
| | - Alessandra Lugaresi
- Department of Neuroscience, Imaging and Clinical Sciences, University 'G. d'Annunzio', Via dei Vestini, Chieti, 66100, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Via dei Vestini, Bologna, 66100, Italy
| | - Marc Girard
- Hopital Notre Dame, 1560 Sherbrooke East, Montreal, H2L 4M1, Canada; CHUM and Universite de Montreal, Montreal, Canada
| | - Alexandre Prat
- Hopital Notre Dame, 1560 Sherbrooke East, Montreal, H2L 4M1, Canada; CHUM and Universite de Montreal, Montreal, Canada
| | - Pierre Duquette
- Hopital Notre Dame, 1560 Sherbrooke East, Montreal, H2L 4M1, Canada; CHUM and Universite de Montreal, Montreal, Canada
| | - Pierre Grammond
- Centre de réadaptation déficience physique Chaudière-Appalache, 9500 blvd Centre-Hospitalier, Levis, G6X 0A1, Canada
| | - Patrizia Sola
- Nuovo Ospedale Civile Sant'Agostino/Estense, via giardini 1355, Modena, 41100, Italy
| | - Raymond Hupperts
- Zuyderland Ziekenhuis, Walramstraat 23, Sittard, 6131 BK, The Netherlands
| | | | - Eugenio Pucci
- Azienda Sanitaria Unica Regionale Marche - AV3, Via Santa Lucia 2, Macerata, 62100, Italy
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Karadeniz Technical University, Trabzon, 61080, Turkey
| | - Raed Alroughani
- Amiri Hospital, P.O. Box 1661. Qurtoba, Kuwait, 73767, Kuwait
| | - Vincent Van Pesch
- Cliniques Universitaires Saint-Luc, avenue Hippocrate, 10 UCL10/80, Brussels, 1200 BXL, Belgium
| | | | - Murat Terzi
- Ondokuz Mayis University, Medical Faculty, Kurupelit, Samsun, 55160, Turkey
| | - Roberto Bergamaschi
- C. Mondino National Neurological Institute, via Mondino 2, Pavia, 27100, Italy
| | - Gerardo Iuliano
- Ospedali Riuniti di Salerno, Via s. Leonardo, Salerno, 84100, Italy
| | | | - Daniele Spitaleri
- Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino, Contrada Amoretta, Avellino, 83100, Italy
| | | | - Celia Oreja-Guevara
- Hospital Universitario La Paz, Paseo de la Castellana 261, Madrid, 28050, Spain
| | - Mark Slee
- Flinders Medical Centre, Flinders Drive, Adelaide, 5042, Australia
| | - Radek Ampapa
- Nemocnice Jihlava, Vrchlickeho 59, Jihlava, 58633, Czech Republic
| | - Freek Verheul
- Groene Hart ziekenhuis, bleulandweg 10, Gouda, 2800 BB, The Netherlands
| | - Pamela McCombe
- Royal Brisbane and Women's Hospital, 33 North Street, Spring Hill, QLD 4000, Australia
| | - Javier Olascoaga
- Hospital Donostia, Paseo de Begiristain, San Sebastián, 20014, Spain
| | - Maria Pia Amato
- University of Florence, Viale Morgagni 85, Florence, 50134, Italy
| | - Steve Vucic
- Westmead Hospital, Hawkesbury Rd, Sydney, 2145, Australia
| | | | | | - Shlomo Flechter
- Assaf Harofeh Medical Center, Zerifin, Beer-Yaakov, 70100, Israel
| | | | - Csilla Rozsa
- Jahn Ferenc Teaching Hospital, Köves u. 1., Budapest, 1101, Hungary
| | - Fraser Moore
- Jewish General Hospital, 3755 Cote-Sainte-Catherine, Montreal, J7A 4T8, Canada
| | | | - Maria Laura Saladino
- INEBA - Institute of Neuroscience Buenos Aires, Guardia Vieja 4435, Buenos Aires, C1192AAW, Argentina
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney, 100 Mallett, Camperdown, 2050, Australia
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, SE-17177, Sweden
| | - Helmut Butzkueven
- Department of Neurology, Royal Melbourne Hospital, 300 Grattan St, Melbourne, 3050, Australia.,Department of Medicine, University of Melbourne, 300 Grattan St, Melbourne, 3050, Australia.,Department of Neurology, Box Hill Hospital, Monash University, Melbourne, Australia
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16
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Trojano M, Tintore M, Montalban X, Hillert J, Kalincik T, Iaffaldano P, Spelman T, Sormani MP, Butzkueven H. Treatment decisions in multiple sclerosis — insights from real-world observational studies. Nat Rev Neurol 2017; 13:105-118. [DOI: 10.1038/nrneurol.2016.188] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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17
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Ziemssen T, Kern R, Cornelissen C. Study design of PANGAEA 2.0, a non-interventional study on RRMS patients to be switched to fingolimod. BMC Neurol 2016; 16:129. [PMID: 27502119 PMCID: PMC4977700 DOI: 10.1186/s12883-016-0648-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 07/26/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The therapeutic options for patients with Multiple Sclerosis (MS) have steadily increased due to the approval of new substances that now supplement traditional first-line agents, demanding a paradigm shift in the assessment of disease activity and treatment response in clinical routine. Here, we report the study design of PANGAEA 2.0 (Post-Authorization Non-interventional GermAn treatment benefit study of GilEnyA in MS patients), a non-interventional study in patients with relapsing-remitting MS (RRMS) identify patients with disease activity and monitor their disease course after treatment switch to fingolimod (Gilenya®), an oral medication approved for patients with highly active RRMS. METHOD/DESIGN In the first phase of the PANGAEA 2.0 study the disease activity status of patients receiving a disease-modifying therapy (DMT) is evaluated in order to identify patients at risk of disease progression. This evaluation is based on outcome parameters for both clinical disease activity and magnetic resonance imaging (MRI), and subclinical measures, describing disease activity from the physician's and the patient's perspective. In the second phase of the study, 1500 RRMS patients identified as being non-responders and switched to fingolimod (oral, 0.5 mg/daily) are followed-up for 3 years. Data on relapse activity, disability progression, MRI lesions, and brain volume loss will be assessed in accordance to 'no evidence of disease activity-4' (NEDA-4). The modified Rio score, currently validated for the evaluation of treatment response to interferons, will be used to evaluate the treatment response to fingolimod. The MS management software MSDS3D will guide physicians through the complex processes of diagnosis and treatment. A sub-study further analyzes the benefits of a standardized quantitative evaluation of routine MRI scans by a central reading facility. PANGAEA 2.0 is being conducted between June 2015 and December 2019 in 350 neurological practices and centers in Germany, including 100 centers participating in the sub-study. DISCUSSION PANGAEA 2.0 will not only evaluate the long-term benefit of a treatment change to fingolimod but also the applicability of new concepts of data acquisition, assessment of MS disease activity and evaluation of treatment response for the in clinical routine. TRIAL REGISTRATION BfArM6532; Trial Registration Date: 20/05/2015.
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Affiliation(s)
- Tjalf Ziemssen
- Zentrum für klinische Neurowissenschaften, Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 43, D-01307, Dresden, Germany.
| | - Raimar Kern
- Zentrum für klinische Neurowissenschaften, Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 43, D-01307, Dresden, Germany
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18
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Kalincik T, Butzkueven H. Observational data: Understanding the real MS world. Mult Scler 2016; 22:1642-1648. [DOI: 10.1177/1352458516653667] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 05/16/2016] [Indexed: 11/16/2022]
Abstract
Randomised clinical trials are the primary source of evidence, guiding the use of disease-modifying drugs in multiple sclerosis. However, the spectrum of questions that can be answered in the trial setting is relatively narrow. ‘Real-world’ observational data analysis has always been the major source of evidence for epidemiology, aetiology, outcomes and prognostics, but is now also increasingly used to study treatment effectiveness. While analyses of observational cohorts typically offer superior power, generalisability and duration of follow-up relative to prospective randomised trials, they are also subject to multiple biases. It is the role of researchers to mitigate bias and to ensure the results of observational studies are robust and valid. In this review of observational data research, we provide an overview of the inherent biases, the available mitigation strategies, and the state and direction of contemporary treatment outcomes research. The review will help clinicians critically appraise published results of observational studies.
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Affiliation(s)
- Tomas Kalincik
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Helmut Butzkueven
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/Box Hill Hospital, Monash University, Box Hill, VIC, Australia
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19
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Miclea A, Leussink VI, Hartung HP, Gold R, Hoepner R. Safety and efficacy of dimethyl fumarate in multiple sclerosis: a multi-center observational study. J Neurol 2016; 263:1626-32. [DOI: 10.1007/s00415-016-8175-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 05/14/2016] [Indexed: 12/15/2022]
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