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Nold AK, Wittayer M, Weber CE, Platten M, Gass A, Eisele P. Short-term brain atrophy evolution after initiation of immunotherapy in a real-world multiple sclerosis cohort. J Neuroimaging 2023; 33:904-908. [PMID: 37491626 DOI: 10.1111/jon.13146] [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: 07/11/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND AND PURPOSE In multiple sclerosis (MS), brain atrophy measurements have emerged as an important biomarker reflecting neurodegeneration and disability progression. However, due to several potential confounders, investigation of brain atrophy in clinical routine and even in controlled clinical studies can be challenging. The aim of this study was to investigate the short-term dynamics of brain atrophy development after initiation of disease-modifying therapy (DMT) in a "real-world setting." METHODS In this retrospective study, we included MS patients starting DMT (natalizumab, fingolimod, dimethyl fumarate, or interferon-ß1a) or without DMT, availability of a baseline MRI, and two annual follow-up scans on the same MRI system. Two-timepoint percentage brain volume changes (PBVCs) were calculated. RESULTS Fifty-five MS patients (12 patients starting DMT with natalizumab, 7 fingolimod, 14 dimethyl fumarate, 11 interferon-ß1a, and 11 patients without DMT) were included. We found the highest PBVCs in the first 12 months after initiation of natalizumab treatment. Furthermore, the PBVCs in our study were very much comparable to the results observed by other groups, as well as for fingolimod, dimethyl fumarate, and interferon-ß1a. CONCLUSION We found PBVCs that are comparable to the results of previous studies, suggesting that brain atrophy, assessed on 3D MRI data sets acquired on the same 3T MRI, provides a robust MS biomarker.
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Affiliation(s)
- Ann-Kathrin Nold
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Matthias Wittayer
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Claudia E Weber
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Achim Gass
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | - Philipp Eisele
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center of Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
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Nakamura K, Mokliatchouk O, Arnold DL, Yousry TA, Kappos L, Richert N, Ayling-Rouse K, Miller C, Fisher E. Effects of Dimethyl Fumarate on Brain Atrophy in Relapsing-Remitting Multiple Sclerosis: Pooled Analysis Phase 3 DEFINE and CONFIRM Studies. Front Neurol 2022; 13:809273. [PMID: 35370887 PMCID: PMC8973916 DOI: 10.3389/fneur.2022.809273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Objective In the pivotal DEFINE and CONFIRM trials for dimethyl fumarate (DMF), patterns of brain volume changes were different, potentially due to low sample sizes and because MRIs were analyzed at two different reading centers. We evaluated effects of DMF on brain volume change in patients with multiple sclerosis (MS) through reanalysis of pooled images from DEFINE/CONFIRM trials in one reading center. Methods MRIs from DEFINE/CONFIRM at weeks 0, 24, 48, and 96 from patients randomized to twice-daily DMF or placebo (PBO) were reanalyzed at the Cleveland Clinic to measure brain parenchymal fraction (BPF). To account for pseudoatrophy, brain volume estimates were re-baselined to calculate changes for weeks 48–96. Results Across studies, 301 and 314 patients receiving DMF and PBO, respectively, had analyzable MRIs. In weeks 0–48, mean ± SE percentage change in BPF was −0.44 ± 0.04 vs. −0.34 ± 0.04% in DMF vs. PBO, respectively, whereas in weeks 48–96, mean ± SE percentage change in BPF was −0.27 ± 0.03 vs. −0.41 ± 0.04% in DMF vs. PBO, respectively. The mixed-effect model for repeated measures showed similar results: in weeks 48–96, estimated change (95% confidence interval) in BPF was −0.0021 (−0.0027, −0.0016) for DMF vs. −0.0033 (−0.0039, −0.0028) for PBO (35.9% reduction; p = 0.0025). Conclusions The lower rate of whole brain volume loss with DMF in this pooled BPF analysis in the second year vs. PBO is consistent with its effects on relapses, disability, and MRI lesions. Brain volume changes in the first year may be explained by pseudoatrophy effects also described in other MS clinical trials.
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Affiliation(s)
- Kunio Nakamura
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | - Douglas L. Arnold
- McConnell Brain Imaging Center, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Tarek A. Yousry
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Institute of Neurology, London, United Kingdom
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | | | | | | | - Elizabeth Fisher
- Biogen, Cambridge, MA, United States
- *Correspondence: Elizabeth Fisher
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Natalizumab Induces Changes of Cerebrospinal Fluid Measures in Multiple Sclerosis. Diagnostics (Basel) 2021; 11:diagnostics11122230. [PMID: 34943468 PMCID: PMC8699923 DOI: 10.3390/diagnostics11122230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/19/2021] [Accepted: 11/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background: There is a lack of knowledge about the evolution of cerebrospinal fluid (CSF) markers in multiple sclerosis (MS) patients undergoing natalizumab treatment. Aim: We aimed to evaluate the effect of natalizumab on basic inflammatory CSF and MRI measures. Methods: Together, 411 patients were screened for eligibility and 93 subjects with ≥2 CSF examinations ≤6 months before and ≥12 months after natalizumab initiation were recruited. The effect of natalizumab on CSF as well as clinical and paraclinical measures was analyzed using adjusted mixed models. Results: Natalizumab induced a decrease in CSF leukocytes (p < 1 × 10−15), CSF protein (p = 0.00007), the albumin quotient (p = 0.007), the IgG quotient (p = 6 × 10−15), the IgM quotient (p = 0.0002), the IgG index (p = 0.0004), the IgM index (p = 0.003) and the number of CSF-restricted oligoclonal bands (OCBs) (p = 0.0005). CSF-restricted OCBs positivity dropped from 94.6% to 86% but 26 patients (28%) had an increased number of OCBs at the follow-up. The baseline to follow-up EDSS and T2-LV were stable; a decrease in the relapse rate was consistent with a decrease in the CSF inflammatory markers and previous knowledge about the effectiveness of natalizumab. The average annualized brain volume loss during the follow-up was −0.50% (IQR = −0.96, −0.16) and was predicted by the baseline IgM index (B = −0.37; p = 0.003). Conclusions: Natalizumab is associated with a reduction of basic CSF inflammatory measures supporting its strong anti-inflammatory properties. The IgM index at the baseline predicted future brain volume loss during the course of natalizumab treatment.
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Grahl S, Bussas M, Wiestler B, Eichinger P, Gaser C, Kirschke J, Zimmer C, Berthele A, Hemmer B, Mühlau M. Differential Effects of Fingolimod and Natalizumab on Magnetic Resonance Imaging Measures in Relapsing-Remitting Multiple Sclerosis. Neurotherapeutics 2021; 18:2589-2597. [PMID: 34561843 PMCID: PMC8804113 DOI: 10.1007/s13311-021-01118-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/24/2022] Open
Abstract
Fingolimod and natalizumab are approved disease-modifying drugs in relapsing-remitting multiple sclerosis (RRMS). The two drugs have different modes of action and may therefore influence different aspects of MS-related tissue damage. In this retrospective cohort study, we longitudinally compared patients treated with fingolimod and patients treated with natalizumab by measures based on structural magnetic resonance imaging (MRI). We included patients with RRMS given that two standardized MRI scans under the same drug were available with an interval of at least 6 months both from therapy start to baseline scan and from baseline scan to follow-up scan. After matching for age, baseline and follow-up scans from 93 patients (fingolimod, 48; natalizumab, 45) were investigated. Mean follow-up time was 1.9 years. We determined the number of new white matter lesions as well as thalamic, cortical, and whole-brain atrophy. After scaling for time of the interscan interval, measures were analyzed by group comparisons and, to account for demographic and clinical characteristics, by multiple regression models and a binary logistic regression model. Compared to natalizumab, fingolimod treatment went along with more new white matter lesions (median [interquartile range, IQR] 0.0 [0.0; 0.7] vs. 0.0 [0.0; 0.0] /year; p < 0.01) whereas whole-brain atrophy was lower (median [IQR] 0.2 [0.0; 0.5] vs. 0.5 [0.2; 1.0] %/year; p = 0.01). These significant differences were confirmed by multiple regression models and the binary logistic regression model. In conclusion, our observation is compatible with stronger neuroprotective properties of fingolimod compared to natalizumab.
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Affiliation(s)
- S Grahl
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- TUM Neuroimaging, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - M Bussas
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- TUM Neuroimaging, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - B Wiestler
- Department of Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - P Eichinger
- Department of Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - C Gaser
- Department of Psychiatry and Department of Neurology, Jena University Hospital, Jena, Germany
| | - J Kirschke
- Department of Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - C Zimmer
- Department of Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - A Berthele
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - B Hemmer
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Feodor-Lynen-Str. 17, 81377, Munich, Germany
| | - M Mühlau
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- TUM Neuroimaging, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
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Davidescu EI, Odajiu I, Sandu CD, Ghergu A, Luca D, Mureșanu DF, Popescu BO. Real-World Data Regarding Long-Term Administration of Natalizumab from a Neurology Department along Literature Review. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2021; 21:326-334. [PMID: 34455973 DOI: 10.2174/1871527320666210827113733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 06/21/2021] [Accepted: 07/03/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Natalizumab is a humanized monoclonal antibody with high efficacy and an acceptable safety profile used in the treatment of patients with multiple sclerosis (MS). OBJECTIVES Our aim was to report data regarding long-term administration of Natalizumab in patients with relapsing-remitting multiple sclerosis (RRMS) from our clinic. METHODS A retrospective observational study was performed including RRMS patients who underwent treatment with ≥ 24 Natalizumab infusions. We analyzed the EDSS values, the relapse rate and the rate and type of adverse events related to Natalizumab administration. RESULTS 51 subjects were included with a predominance of women (62.74%), an average age of 40.43±1.49 years, a mean disease duration of 9.86±0.7 years and mean number of Natalizumab infusions of 45.58±2.74. An increased number of patients (80.39%) were relapse-free and there was observed a mild reduction of the mean EDSS value following Natalizumab initiation in patients who had not been treated with other disease modifying therapies anteriorly. Among the encountered adverse events we registered: increased liver transaminases (13.72%), local infections (7.84%) and dysmenorrhea in one patient. The rate of severe adverse events was 3.92 and there were registered no cases of Progressive Multifocal Leukoencephalopathy (PML). CONCLUSIONS Natalizumab proves to be effective, has an adequate safety profile and can be administered with good tolerability for a rather extended period of time, provided that the patients are closely monitored.
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Affiliation(s)
- Eugenia Irene Davidescu
- Department of Clinical Neurosciences, "Carol Davila" University of Medicine and Pharmacy, Bucharest. Romania
| | - Irina Odajiu
- Neurology Department, Colentina Clinical Hospital, Bucharest. Romania
| | | | - Amalia Ghergu
- Neurology Department, Colentina Clinical Hospital, Bucharest. Romania
| | - Dimela Luca
- Neurology Department, Colentina Clinical Hospital, Bucharest. Romania
| | - Dafin Fior Mureșanu
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca. Romania
| | - Bogdan Ovidiu Popescu
- Department of Clinical Neurosciences, "Carol Davila" University of Medicine and Pharmacy, Bucharest. Romania
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Alvarez E, Nair KV, Hoyt BD, Seale RA, Sillau S, Miravalle A, Engebretson E, Schurr B, Corboy JR, Vollmer TL, Honce JM. Brain atrophy rates in patients with multiple sclerosis on long term natalizumab resembles healthy controls. Mult Scler Relat Disord 2021; 55:103170. [PMID: 34364034 DOI: 10.1016/j.msard.2021.103170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/28/2021] [Accepted: 07/22/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clinically stable multiple sclerosis (MS) patients often have negligible inflammatory MRI changes. Brain atrophy may provide insight into subclinical disease progression. The objective was to compare brain atrophy rates in stable patients on long term natalizumab treatment vs. age and gender matched healthy non-MS controls (HC) prospectively over two-years examining brain volume, cognition, and patient reported outcomes (PROs). METHODS MS patients treated with natalizumab for a minimum of 2 years, age 18-60 were recruited and compared with age- and gender-matched healthy controls (HC). Both groups were followed prospectively to obtain two years of consecutive magnetic resonance imaging, clinical and PRO data. Baseline normalized brain volume (NBV), yearly T2 lesion volume (T2LV), and percent brain volume change (PBVC) were measured using SIENAX, JIM 6.0, and SIENA respectively. Neuropsychological tests from the MACFIMS battery were selected to optimize assessments for impairments in the domains of information processing speed and memory. Patient reported outcomes (PROs) for domains of physical, mental and social quality of life were evaluated using the NeuroQol short forms. RESULTS Forty-eight natalizumab and 62 HC completed all study visits. At baseline, unadjusted mean NBV (natalizumab=1508.80cm (Popescu et al., 2013) vs. HC=1539.23cm (Popescu et al., 2013); p=0.033) and median baseline T2LV (natalizumab=1724.62mm (Popescu et al., 2013) vs. HC=44.20mm (Popescu et al., 2013); p=<0.0001) were different. The mean PBVC at year 2, adjusted for gender and baseline age was -0.57% (CI: 0.7620, -0.3716) for natalizumab and -0.50% (-0.7208, -0.2831) for HC, but the difference between groups was not statistically significant (0.073%; p=0.62). Over the 2-year period, HC demonstrated mild improvements in some cognitive tests vs. natalizumab subjects. However, PROs were similar between the two groups. CONCLUSION Stable MS patients on natalizumab have similar brain volume loss as people who do not have MS, suggesting normalization of brain atrophy.
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Affiliation(s)
- Enrique Alvarez
- Department of Neurology, Rocky Mountain Multiple Sclerosis Center at the University of Colorado, 1635 Aurora Court, Aurora, CO 80045 USA
| | - Kavita V Nair
- Department of Neurology, Rocky Mountain Multiple Sclerosis Center at the University of Colorado, 1635 Aurora Court, Aurora, CO 80045 USA; Department of Clinical Pharmacy, University of Colorado, 12850 East Montview Boulevard, Aurora, CO 80045 USA
| | - Brian D Hoyt
- Department of Neurosurgery, University of Colorado, 12631 East 17th Avenue, Aurora, CO 80045 USA
| | - Rebecca A Seale
- Department of Neurology, Rocky Mountain Multiple Sclerosis Center at the University of Colorado, 1635 Aurora Court, Aurora, CO 80045 USA
| | - Stefan Sillau
- Department of Neurology, Rocky Mountain Multiple Sclerosis Center at the University of Colorado, 1635 Aurora Court, Aurora, CO 80045 USA
| | - Augusto Miravalle
- Advanced Neurology, 2121 E Harmony Rd Ste #180, Fort Collins, CO 80528 USA
| | - Eric Engebretson
- Department of Neurology, Rocky Mountain Multiple Sclerosis Center at the University of Colorado, 1635 Aurora Court, Aurora, CO 80045 USA
| | - Brittany Schurr
- Department of Neurology, Rocky Mountain Multiple Sclerosis Center at the University of Colorado, 1635 Aurora Court, Aurora, CO 80045 USA
| | - John R Corboy
- Department of Neurology, Rocky Mountain Multiple Sclerosis Center at the University of Colorado, 1635 Aurora Court, Aurora, CO 80045 USA
| | - Timothy L Vollmer
- Department of Neurology, Rocky Mountain Multiple Sclerosis Center at the University of Colorado, 1635 Aurora Court, Aurora, CO 80045 USA
| | - Justin M Honce
- Department of Radiology, University of Colorado Hospital, 12401 East 17th Avenue, Aurora, CO 80045 USA.
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Approved and Emerging Disease Modifying Therapies on Neurodegeneration in Multiple Sclerosis. Int J Mol Sci 2020; 21:ijms21124312. [PMID: 32560364 PMCID: PMC7348940 DOI: 10.3390/ijms21124312] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 12/16/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune, chronic, progressive disease leading to a combination of inflammation, demyelination, and neurodegeneration throughout the central nervous system (CNS). The outcome of these processes can be visualized in magnetic resonance imaging (MRI) scans as brain atrophy, or brain volume loss (BVL), as well as lesions, “black holes” and spinal cord atrophy. MRI outcomes such as BVL have been used as biomarkers of neurodegeneration and other measures of MS disease progression in clinical research settings. Several FDA-approved medications seek to alleviate disease progression by reducing the impact of such factors as demyelination and neurodegeneration, but there are still many shortcomings that current clinical research aims to mitigate. This review attempts to provide an overview of the FDA-approved medications available for treating multiple sclerosis and their effect on neurodegeneration, measured by BVL.
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