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Gonçalves R, De Decker S, Walmsley G, Maddox TW. Magnetic resonance imaging prognostic factors for survival and relapse in dogs with meningoencephalitis of unknown origin. Front Vet Sci 2024; 11:1370882. [PMID: 38482167 PMCID: PMC10933066 DOI: 10.3389/fvets.2024.1370882] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/13/2024] [Indexed: 08/07/2024] Open
Abstract
Introduction Canine meningoencephalitis of unknown origin (MUO) is a debilitating disease associated with high mortality. The prognostic value of magnetic resonance imaging (MRI) findings for predicting survival at 12 months and long-term relapse remains uncertain. Methods This was a retrospective cohort study evaluating the prognostic value of different MRI variables using multivariable logistic regression and Cox proportional hazards analysis. Results In total, 138 dogs were presumptively diagnosed with MUO. The most common location for lesions identified on MRI were the white matter tracts of the corona radiata and corpus callosum, followed by the frontal, sensorimotor and temporal cortices. Lower T2 lesion load (p = 0.006, OR = 0.942, CI = 0.902-0.983) was associated with longer survival and higher T1 post-contrast lesion load (p = 0.023, OR = 1.162, CI = 1.021-1.322) was associated with relapse. Discussion This study has identified prognostic factors that may help identify dogs at higher risk of death and relapse and therefore guide treatment recommendations.
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Affiliation(s)
- Rita Gonçalves
- Department of Veterinary Science, Small Animal Teaching Hospital, University of Liverpool, Neston, United Kingdom
- Department of Musculoskeletal and Ageing Science, Institute of Lifecourse and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Steven De Decker
- Department of Clinical Science and Services, Royal Veterinary College, University of London, London, United Kingdom
| | - Gemma Walmsley
- Department of Veterinary Science, Small Animal Teaching Hospital, University of Liverpool, Neston, United Kingdom
- Department of Musculoskeletal and Ageing Science, Institute of Lifecourse and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Thomas W. Maddox
- Department of Veterinary Science, Small Animal Teaching Hospital, University of Liverpool, Neston, United Kingdom
- Department of Musculoskeletal and Ageing Science, Institute of Lifecourse and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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2
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Pennington P, Weinstock-Guttman B, Kolb C, Jakimovski D, Sacca K, Benedict RHB, Eckert S, Stecker M, Lizarraga A, Dwyer MG, Schumacher CB, Bergsland N, Picco P, Bernitsas E, Zabad R, Pardo G, Negroski D, Belkin M, Hojnacki D, Zivadinov R. Communicating the relevance of neurodegeneration and brain atrophy to multiple sclerosis patients: patient, provider and researcher perspectives. J Neurol 2023; 270:1095-1119. [PMID: 36376729 DOI: 10.1007/s00415-022-11405-3] [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: 06/22/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022]
Abstract
Central nervous system (CNS) atrophy provides valuable additional evidence of an ongoing neurodegeneration independent of lesion accrual in persons with multiple sclerosis (PwMS). However, there are limitations for interpretation of CNS volume changes at individual patient-level. Patients are receiving information on the topic of atrophy through various sources, including media, patient support groups and conferences, and discussions with their providers. Whether or not the topic of CNS atrophy should be proactively discussed with PwMS during office appointments is currently controversial. This commentary/perspective article represents perspectives of PwMS, providers and researchers with recommendations for minimizing confusion and anxiety, and facilitating proactive discussion about brain atrophy, as an upcoming routine measure in evaluating disease progression and treatment response monitoring. The following recommendations were created based on application of patient's and provider's surveys, and various workshops held over a period of 2 years: (1) PwMS should receive basic information on understanding of brain functional anatomy, and explanation of inflammation and neurodegeneration; (2) the expertise for atrophy measurements should be characterized as evolving; (3) quality patient education materials on these topics should be provided; (4) the need for standardization of MRI exams has to be explained and communicated; (5) providers should discuss background on volumetric changes, including references to normal aging; (6) the limitations of brain volume assessments at an individual-level should be explained; (7) the timing and language used to convey this information should be individualized based on the patient's background and disease status; (8) a discussion guide may be a very helpful resource for use by providers/staff to support these discussions; (9) understanding the role of brain atrophy and other MRI metrics may elicit greater patient satisfaction and acceptance of the value of therapies that have proven efficacy around these outcomes; (10) the areas that represent possibilities for positive self-management of MS symptoms that foster hope for improvement should be emphasized, and in particular regarding use of physical and mental exercise that build or maintain brain reserve through increased network efficiency, and (11) an additional time during clinical visits should be allotted to discuss these topics, including creation of specific educational programs.
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Affiliation(s)
- Penny Pennington
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Channa Kolb
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Dejan Jakimovski
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 14203, USA
| | - Katherine Sacca
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | - Ralph H B Benedict
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Svetlana Eckert
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Marc Stecker
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | - Alexis Lizarraga
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Michael G Dwyer
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 14203, USA.,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Carol B Schumacher
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | - Niels Bergsland
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 14203, USA.,IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Patricia Picco
- Advisory Council, Buffalo Neuroimaging Analysis Center, Buffalo, NY, USA
| | | | - Rana Zabad
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Gabriel Pardo
- Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | | | - Martin Belkin
- Michigan Institute for Neurological Disorders (MIND), Farmington Hills, MI, USA
| | - David Hojnacki
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Robert Zivadinov
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 14203, USA. .,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA.
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3
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AbdelRazek MA, Tummala S, Khalid F, Tauhid S, Jalkh Y, Khalil S, Hurwitz S, Zurawski J, Bakshi R. Exploring the effect of glatiramer acetate on cerebral gray matter atrophy in multiple sclerosis. J Neurol Sci 2023; 444:120501. [PMID: 36481574 DOI: 10.1016/j.jns.2022.120501] [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: 06/13/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral gray matter (GM) atrophy is a proposed measure of neuroprotection in multiple sclerosis (MS). Glatiramer acetate (GA) limits clinical relapses, MRI lesions, and whole brain atrophy in relapsing-remitting MS (RRMS). The effect of GA on GM atrophy remains unclear. We assessed GM atrophy in patients with RRMS starting GA therapy in comparison to a cohort of patients with clinically benign RRMS (BMS). DESIGN/METHODS We studied 14 patients at GA start [age (mean ± SD) 44.2 ± 7.0 years, disease duration (DD) 7.2 ± 6.4 years, Expanded Disability Status Scale score (EDSS) (median,IQR) 1.0,2.0] and 6 patients with BMS [age 43.0 ± 6.1 years, DD 18.1 ± 8.4 years, EDSS 0.5,1.0]. Brain MRI was obtained at baseline and one year later (both groups) and two years later in all patients in the GA group except one who was lost to follow-up. Semi-automated algorithms assessed cerebral T2 hyperintense lesion volume (T2LV), white matter fraction (WMF), GM fraction (GMF), and brain parenchymal fraction (BPF). The exact Wilcoxon-Mann-Whitney test compared the groups. The Wilcoxon signed rank test assessed longitudinal changes within groups. RESULTS During the first year, MRI changes did not differ significantly between groups (p > 0.15). Within the BMS group, WMF and BPF decreased during the first year (p = 0.03). Within the GA group, there was no significant change in MRI measures during each annual period (p > 0.05). Over two years, the GA group had a significant increase in T2LV and decrease in WMF (p < 0.05), while GMF and BPF remained stable (p > 0.05). MRI changes in brain volumes (GMF or WMF) in the first year in the GA group were not significantly different from those in the BMS group (p > 0.5). CONCLUSIONS In this pilot study with a small sample size, patients with RRMS started on GA did not show significant GM or whole brain atrophy over 2 years, resembling MS patients with a clinically benign disease course.
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Affiliation(s)
| | - Subhash Tummala
- Departments of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Fariha Khalid
- Departments of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shahamat Tauhid
- Departments of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Youmna Jalkh
- Departments of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samar Khalil
- Departments of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shelley Hurwitz
- Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Zurawski
- Departments of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rohit Bakshi
- Departments of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Departments of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Ng HS, Zhu F, Kingwell E, Yao S, Ekuma O, Evans C, Fisk JD, Marrie RA, Zhao Y, Tremlett H. Disease-Modifying Drugs for Multiple Sclerosis and Association With Survival. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:9/5/e200005. [PMID: 35701187 PMCID: PMC9210547 DOI: 10.1212/nxi.0000000000200005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/22/2022] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND OBJECTIVES We examined the association between the disease-modifying drugs (DMDs) for multiple sclerosis (MS) and survival in a multiregion population-based study. METHODS We accessed multiple administrative health databases from 4 Canadian provinces. Persons with MS were identified and followed from the most recent of the first MS or demyelinating event or January 1, 1996 (index date), until death, emigration, or December 31, 2017. Association between the first-generation and second-generation DMDs and all-cause mortality was examined using stratified Cox proportional hazard models, reported as adjusted hazard ratios (aHRs). Timing of DMD initiation was explored, with findings reported at 2, 5, or 10 years postindex date, representing very early, early, or late initiation. RESULTS We identified 35,894 persons with MS; 72% were female. The mean age at index date was 44.5 years (SD = 13.6). The total person-years of follow-up while DMD-exposed was 89,180, and total person-years while unexposed was 342,217. Compared with no exposure, exposure to any DMD or to any first-generation DMD was associated with a 26% lower hazard of mortality (both aHRs 0.74; 95% CI 0.56-0.98), while any second-generation DMD exposure was associated with a 33% lower hazard (aHR 0.67; 95% CI 0.46-0.98). Earlier DMD initiation (beta-interferon or glatiramer acetate vs no exposure) was associated with a significant mortality effect (p < 0.05), while later initiation was not (95% CIs included 1). However, the survival advantage with earlier initiation diminished over time, no longer reaching statistical significance at 15 years postindex date. DISCUSSION Our study demonstrates an association between the DMDs for MS and improved survival in the real-world setting.
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Hobart J, Butzkueven H, Haartsen J, Ziemssen T, Lane T, Giovannoni G. Timely intervention, monitoring and education MATTERS in MS (TIME MATTERS in MS): Development of a globally applicable quality improvement tool. Mult Scler J Exp Transl Clin 2022; 8:20552173221124023. [PMID: 36105273 PMCID: PMC9465618 DOI: 10.1177/20552173221124023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/11/2022] [Indexed: 11/15/2022] Open
Abstract
Background Previously, consensus MS care standards were defined by MS specialist
neurologists from 19 countries. We developed, piloted and refined an
Excel-based quality improvement tool to enable MS services to benchmark
against these standards. Here, we examine the refined tool. Objective To determine the applicability of the quality improvement tool in different
healthcare settings. Methods MS centres across the globe were invited to pilot the quality improvement
tool by coding the medical records of 36 adults with MS. We invited feedback
on user friendliness, quality improvement tool usefulness and relevance of
data collected. Results Seventeen centres from 14 countries participated; 14 completed the
post-service evaluation survey. Over 50% of responders rated the tool ‘very
easy’ or ‘easy’ to use and ‘very relevant’ to their service. Almost 85% of
responders (11/13) planned to introduce changes to their service, including
improvements in documentation, communication, interactions with colleagues
and referrals; 85% would use a future shorter version of the tool. Conclusions The quality improvement tool can enable MS centres globally to benchmark
their services. Widespread uptake of a shorter tool may help MS centres to
work towards achieving consensus standards for brain health-focused care.
Incorporation into routine clinical practice would drive adoption.
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Affiliation(s)
- Jeremy Hobart
- Clinical Neurology and Health Measurement, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Helmut Butzkueven
- van Cleef Roet Centre for Neuroscience, Department of Neuroscience, Alfred Health, Monash University, Melbourne, VIC, Australia
| | - Jodi Haartsen
- Client Engagement and Wellbeing, Multiple Sclerosis Limited, Blackburn, VIC, Australia
| | - Tjalf Ziemssen
- Center for Clinical Neuroscience, Department of Neurology, Carl Gustav Carus University Hospital Dresden, Dresden, Germany
| | | | - Gavin Giovannoni
- Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
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6
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Collongues N, Becker G, Jolivel V, Ayme-Dietrich E, de Seze J, Binamé F, Patte-Mensah C, Monassier L, Mensah-Nyagan AG. A Narrative Review on Axonal Neuroprotection in Multiple Sclerosis. Neurol Ther 2022; 11:981-1042. [PMID: 35610531 PMCID: PMC9338208 DOI: 10.1007/s40120-022-00363-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/03/2022] [Indexed: 01/08/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) resulting in demyelination and neurodegeneration. The therapeutic strategy is now largely based on reducing inflammation with immunosuppressive drugs. Unfortunately, when disease progression is observed, no drug offers neuroprotection apart from its anti-inflammatory effect. In this review, we explore current knowledge on the assessment of neurodegeneration in MS and look at putative targets that might prove useful in protecting the axon from degeneration. Among them, Bruton's tyrosine kinase inhibitors, anti-apoptotic and antioxidant agents, sex hormones, statins, channel blockers, growth factors, and molecules preventing glutamate excitotoxicity have already been studied. Some of them have reached phase III clinical trials and carry a great message of hope for our patients with MS.
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Affiliation(s)
- Nicolas Collongues
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France. .,Center for Clinical Investigation, INSERM U1434, Strasbourg, France. .,Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France. .,University Department of Pharmacology, Addictology, Toxicology and Therapeutic, Strasbourg University, Strasbourg, France.
| | - Guillaume Becker
- University Department of Pharmacology, Addictology, Toxicology and Therapeutic, Strasbourg University, Strasbourg, France.,NeuroCardiovascular Pharmacology and Toxicology Laboratory, UR7296, University Hospital of Strasbourg, Strasbourg, France
| | - Valérie Jolivel
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Estelle Ayme-Dietrich
- University Department of Pharmacology, Addictology, Toxicology and Therapeutic, Strasbourg University, Strasbourg, France.,NeuroCardiovascular Pharmacology and Toxicology Laboratory, UR7296, University Hospital of Strasbourg, Strasbourg, France
| | - Jérôme de Seze
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France.,Center for Clinical Investigation, INSERM U1434, Strasbourg, France.,Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Fabien Binamé
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Christine Patte-Mensah
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | - Laurent Monassier
- University Department of Pharmacology, Addictology, Toxicology and Therapeutic, Strasbourg University, Strasbourg, France.,NeuroCardiovascular Pharmacology and Toxicology Laboratory, UR7296, University Hospital of Strasbourg, Strasbourg, France
| | - Ayikoé Guy Mensah-Nyagan
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
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7
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Honce JM, Nair KV, Hoyt BD, Seale RA, Sillau S, Engebretson E, Schurr B, Corboy JR, Vollmer TL, Alvarez E. Brain Atrophy Rates for Stable Multiple Sclerosis Patients on Long-Term Fingolimod versus Glatiramer Acetate. Front Neurol 2020; 11:1045. [PMID: 33071934 PMCID: PMC7538802 DOI: 10.3389/fneur.2020.01045] [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: 06/22/2020] [Accepted: 08/10/2020] [Indexed: 12/31/2022] Open
Abstract
Background: Clinically stable multiple sclerosis (MS) patients on long-term therapy often have negligible acute inflammation on MRI. Brain atrophy may provide insight into subclinical disease progression in such populations. Objective: This study aims to compare brain atrophy for age- and gender-matched MS patients treated for >2 years with fingolimod (FTY) or glatiramer acetate (GA), examining brain volume, cognition, and patient-reported outcomes (PROs). Methods: Stable relapsing-MS patients, age 18-60, on FTY or GA for >2 years were followed up for 2 years. MRI brain and lesion volumes, cognitive measures, and PROs were collected at baseline and annually. Results: Forty-four FTY and forty-three GA patients completed baseline and year 2 visits. No differences in age, gender, or education were observed. Median EDSS was 2.0GA and 2.5FTY (p = 0.22). Treatment duration was longer for GA, 6.50GA vs. 3.73FTY years (p < 0.001). Baseline geometric mean T2LV were different, GA = 1,009.29 cm3 vs. FTY = 2,404.67 cm3 (p = 0.0071). Baseline brain volumes were similar, GA = 1,508 cm3 vs. FTY = 1,489 cm3 (p = 0.2381). Annualized atrophy rates, adjusted for baseline and at mean baseline value, were GA = -0.2775% vs. FTY = -0.2967% (p = 0.7979). No differences in cognitive measures or PROs were observed. Conclusions: Stable MS patients on long-term treatment with FTY and GA have similar brain volume loss rates. Differences in baseline disease severity may suggest patients with more aggressive disease treated with FTY may achieve similar brain volume loss rates as patients with milder baseline disease on GA.
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Affiliation(s)
- Justin M Honce
- Department of Radiology, University of Colorado Hospital, Aurora, CO, United States
| | - Kavita V Nair
- Department of Clinical Pharmacy, University of Colorado, Aurora, CO, United States.,Department of Neurology, University of Colorado and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, United States
| | - Brian D Hoyt
- Department of Neurology, University of Colorado and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, United States.,Department of Neurosurgery, University of Colorado, Aurora, CO, United States
| | - Rebecca A Seale
- Department of Neurology, University of Colorado and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, United States
| | - Stefan Sillau
- Department of Neurology, University of Colorado and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, United States
| | - Eric Engebretson
- Department of Neurology, University of Colorado and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, United States
| | - Brittany Schurr
- Department of Neurology, University of Colorado and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, United States
| | - John R Corboy
- Department of Neurology, University of Colorado and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, United States
| | - Timothy L Vollmer
- Department of Neurology, University of Colorado and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, United States
| | - Enrique Alvarez
- Department of Neurology, University of Colorado and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora, CO, United States
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8
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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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9
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Andravizou A, Dardiotis E, Artemiadis A, Sokratous M, Siokas V, Tsouris Z, Aloizou AM, Nikolaidis I, Bakirtzis C, Tsivgoulis G, Deretzi G, Grigoriadis N, Bogdanos DP, Hadjigeorgiou GM. Brain atrophy in multiple sclerosis: mechanisms, clinical relevance and treatment options. AUTO- IMMUNITY HIGHLIGHTS 2019; 10:7. [PMID: 32257063 PMCID: PMC7065319 DOI: 10.1186/s13317-019-0117-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/28/2019] [Indexed: 12/23/2022]
Abstract
Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system characterized by focal or diffuse inflammation, demyelination, axonal loss and neurodegeneration. Brain atrophy can be seen in the earliest stages of MS, progresses faster compared to healthy adults, and is a reliable predictor of future physical and cognitive disability. In addition, it is widely accepted to be a valid, sensitive and reproducible measure of neurodegeneration in MS. Reducing the rate of brain atrophy has only recently been incorporated as a critical endpoint into the clinical trials of new or emerging disease modifying drugs (DMDs) in MS. With the advent of easily accessible neuroimaging softwares along with the accumulating evidence, clinicians may be able to use brain atrophy measures in their everyday clinical practice to monitor disease course and response to DMDs. In this review, we will describe the different mechanisms contributing to brain atrophy, their clinical relevance on disease presentation and course and the effect of current or emergent DMDs on brain atrophy and neuroprotection.
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Affiliation(s)
- Athina Andravizou
- Department of Neurology, Laboratory of Neurogenetics, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Biopolis, Mezourlo Hill, 41100 Larissa, Greece
| | - Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Biopolis, Mezourlo Hill, 41100 Larissa, Greece
| | - Artemios Artemiadis
- Immunogenetics Laboratory, 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, Aeginition Hospital, Vas. Sophias Ave 72-74, 11528 Athens, Greece
| | - Maria Sokratous
- Department of Neurology, Laboratory of Neurogenetics, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Biopolis, Mezourlo Hill, 41100 Larissa, Greece
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University General Hospital of Larissa, University of Thessaly, Viopolis, 40500 Larissa, Greece
| | - Vasileios Siokas
- Department of Neurology, Laboratory of Neurogenetics, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Biopolis, Mezourlo Hill, 41100 Larissa, Greece
| | - Zisis Tsouris
- Department of Neurology, Laboratory of Neurogenetics, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Biopolis, Mezourlo Hill, 41100 Larissa, Greece
| | - Athina-Maria Aloizou
- Department of Neurology, Laboratory of Neurogenetics, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Biopolis, Mezourlo Hill, 41100 Larissa, Greece
| | - Ioannis Nikolaidis
- Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Bakirtzis
- Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Georgia Deretzi
- Department of Neurology, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nikolaos Grigoriadis
- Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios P. Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University General Hospital of Larissa, University of Thessaly, Viopolis, 40500 Larissa, Greece
| | - Georgios M. Hadjigeorgiou
- Department of Neurology, Laboratory of Neurogenetics, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Biopolis, Mezourlo Hill, 41100 Larissa, Greece
- Department of Neurology, Medical School, University of Cyprus, Nicosia, Cyprus
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10
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Prod'homme T, Zamvil SS. The Evolving Mechanisms of Action of Glatiramer Acetate. Cold Spring Harb Perspect Med 2019; 9:cshperspect.a029249. [PMID: 29440323 DOI: 10.1101/cshperspect.a029249] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Glatiramer acetate (GA) is a synthetic amino acid copolymer that is approved for treatment of relapsing remitting multiple sclerosis (RRMS) and clinically isolated syndrome (CIS). GA reduces multiple sclerosis (MS) disease activity and has shown comparable efficacy with high-dose interferon-β. The mechanism of action (MOA) of GA has long been an enigma. Originally, it was recognized that GA treatment promoted expansion of GA-reactive T-helper 2 and regulatory T cells, and induced the release of neurotrophic factors. However, GA treatment influences both innate and adaptive immune compartments, and it is now recognized that antigen-presenting cells (APCs) are the initial cellular targets for GA. The anti-inflammatory (M2) APCs induced following treatment with GA are responsible for the induction of anti-inflammatory T cells that contribute to its therapeutic benefit. Here, we review studies that have shaped our current understanding of the MOA of GA.
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Affiliation(s)
| | - Scott S Zamvil
- Department of Neurology and Program in Immunology, University of California, San Francisco, San Francisco, California 94158
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11
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Enduring Clinical Value of Copaxone® (Glatiramer Acetate) in Multiple Sclerosis after 20 Years of Use. Mult Scler Int 2019; 2019:7151685. [PMID: 30775037 PMCID: PMC6350531 DOI: 10.1155/2019/7151685] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 06/29/2018] [Accepted: 11/29/2018] [Indexed: 11/18/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic progressive neurodegenerative demyelinating disease affecting the central nervous system. Glatiramer acetate (GA; Copaxone®) was the first disease-modifying treatment (DMT) for MS successfully tested in humans (1977) and was approved by the US Food and Drug Administration in December 1996. Since then, there have been numerous developments in the MS field: advances in neuroimaging allowing more rapid and accurate diagnosis; the availability of a range of DMTs including immunosuppressant monoclonal antibodies and oral agents; a more holistic approach to treatment by multidisciplinary teams; and an improved awareness of the need to consider a patient's preferences and patient-reported outcomes such as quality of life. The use of GA has endured throughout these advances. The purpose of this article is to provide an overview of the important developments in the MS field during the 20 years since GA was approved and to review clinical data for GA in MS, with the aim of understanding the continued and widespread use of GA. Both drug-related (efficacy versus side-effect profile and monitoring requirements) and patient factors (preferences regarding mode of administration and possible pregnancy) will be explored.
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12
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Hobart J, Bowen A, Pepper G, Crofts H, Eberhard L, Berger T, Boyko A, Boz C, Butzkueven H, Celius EG, Drulovic J, Flores J, Horáková D, Lebrun-Frénay C, Marrie RA, Overell J, Piehl F, Rasmussen PV, Sá MJ, Sîrbu CA, Skromne E, Torkildsen Ø, van Pesch V, Vollmer T, Zakaria M, Ziemssen T, Giovannoni G. International consensus on quality standards for brain health-focused care in multiple sclerosis. Mult Scler 2018; 25:1809-1818. [PMID: 30381987 PMCID: PMC6826858 DOI: 10.1177/1352458518809326] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Time matters in multiple sclerosis (MS). Irreversible neural damage and cell loss occur from disease onset. The MS community has endorsed a management strategy of prompt diagnosis, timely intervention and regular proactive monitoring of treatment effectiveness and disease activity to improve outcomes in people with MS. Objectives: We sought to develop internationally applicable quality standards for timely, brain health–focused MS care. Methods: A panel of MS specialist neurologists participated in an iterative, online, modified Delphi process to define ‘core’, ‘achievable’ and ‘aspirational’ time frames reflecting minimum, good and high care standards, respectively. A multidisciplinary Reviewing Group (MS nurses, people with MS, allied healthcare professionals) provided insights ensuring recommendations reflected perspectives from multiple stakeholders. Results: Twenty-one MS neurologists from 19 countries reached consensus on most core (25/27), achievable (25/27) and aspirational (22/27) time frames at the end of five rounds. Agreed standards cover six aspects of the care pathway: symptom onset, referral and diagnosis, treatment decisions, lifestyle, disease monitoring and managing new symptoms. Conclusion: These quality standards for core, achievable and aspirational care provide MS teams with a three-level framework for service evaluation, benchmarking and improvement. They have the potential to produce a profound change in the care of people with MS.
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Affiliation(s)
- Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Amy Bowen
- NHS RightCare, NHS England, London, UK
| | | | | | | | - Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexey Boyko
- Department of Neurology, Neurosurgery and Medical Genetics, Pirogov Russian National Research Medical University, Moscow, Russia/Demyelinating Diseases Center, Yusupov Hospital, Moscow, Russia
| | - Cavit Boz
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | - Helmut Butzkueven
- MS and Neuroimmunology Unit, Alfred Health and Eastern Health, Monash University, Melbourne, VIC, Australia
| | | | - Jelena Drulovic
- Department for Immune-Mediated Disorders of the Central Nervous System, Clinic of Neurology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - José Flores
- National Institute of Neurology and Neurosurgery, ABC Medical Center, Mexico City, Mexico
| | - Dana Horáková
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | | | - 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
| | - James Overell
- Glasgow MS Clinical Research Centre, Queen Elizabeth University Hospital, Glasgow, UK
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Maria José Sá
- MS Clinic, Department of Neurology, Centro Hospitalar São João, Faculty of Health Sciences, University Fernando Pessoa, Porto, Portugal
| | - Carmen-Adella Sîrbu
- Clinic of Neurology, Central Military Emergency University Hospital, Bucharest, Romania
| | - Eli Skromne
- Instituto Mexicano de Neurociencias, Hospital Angeles Lomas, Mexico City, Mexico
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Vincent van Pesch
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Timothy Vollmer
- Department of Neurology, University of Colorado, Denver, CO, USA
| | - Magd Zakaria
- Department of Neurology, Ain Shams University, Cairo, Egypt
| | - Tjalf Ziemssen
- Department of Neurology, MS Center Dresden, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Gavin Giovannoni
- Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
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13
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Riemenschneider M, Hvid LG, Stenager E, Dalgas U. Is there an overlooked “window of opportunity” in MS exercise therapy? Perspectives for early MS rehabilitation. Mult Scler 2018; 24:886-894. [DOI: 10.1177/1352458518777377] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
While early medical treatment has proven effective in MS, early-phase MS rehabilitation has not gained much attention in MS research and clinical practice. Exercise therapy is one of the most promising treatment strategies in MS rehabilitation. Here, we provide a topical review investigating when exercise therapy is initiated in existing MS studies, showing that exercise is initiated at a rather late disease stage, where it predominantly serves as a symptomatic treatment. Recent findings in MS suggest that exercise may have neuroprotective and disease-modifying effects. Such findings along with the findings from medical trials that an early-stage “window of opportunity” exists leads to the proposal that early exercise therapy should be an increased focus in research and clinical practice for persons with MS. A further perspective relates to other rehabilitation interventions that are also initiated at a later disease stage, as these may also take advantage of an early-phase approach.
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Affiliation(s)
- Morten Riemenschneider
- Department of Public Health, Section of Sport Science, Aarhus University, Aarhus C, Denmark
| | - Lars G Hvid
- Department of Public Health, Section of Sport Science, Aarhus University, Aarhus C, Denmark
| | - Egon Stenager
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark/Department of Neurology, MS-Clinic of Southern Jutland (Sønderborg, Esbjerg, Kolding), Sønderborg, Denmark
| | - Ulrik Dalgas
- Department of Public Health, Section of Sport Science, Aarhus University, Aarhus C, Denmark
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The long-term impact of early treatment of multiple sclerosis on the risk of disability pension. J Neurol 2018; 265:701-707. [PMID: 29392457 PMCID: PMC5834562 DOI: 10.1007/s00415-018-8764-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/12/2018] [Accepted: 01/23/2018] [Indexed: 12/30/2022]
Abstract
Objective The objective of this retrospective, observational study was to estimate the long-term impact of early treatment of multiple sclerosis (MS) on the risk of disability pension. Methods Our cohort comprised patients with MS in Sweden, identified in a nationwide disease-specific register (the Swedish Multiple Sclerosis Registry), who started treatment with a disease-modifying drug (DMD) between January 1, 2002, and December 31, 2012. We analyzed the association between time from onset of MS to treatment initiation and full-time disability pension using survival analysis. Results Our sample comprised 2477 patients. Unadjusted Kaplan–Meier failure functions showed that patients who started treatment within six months after onset had a lower risk of disability pension across follow-up compared with patients initiating therapy after 12 months. Outcomes from the univariate Cox proportional hazards model showed that time from onset to treatment initiation (in years) was significantly associated with disability pension (HR 1.03, p < 0.001). Outcomes from the multivariable Cox proportional hazards model showed that patients who started treatment within 6 months after onset had, on average, a 36% lower risk (HR 0.74, p = 0.010) of full-time disability pension during follow-up compared with patients starting treatment after 18 months when controlling for age, sex, marital status, university education, and prevalent comorbidities. Conclusions We show that early treatment with DMDs of MS is associated with a significantly reduced risk of disability pension. Our findings highlight the potential long-term benefits of early treatment of MS and should be helpful to inform ongoing discussion on the optimum medical management of the disease. Electronic supplementary material The online version of this article (10.1007/s00415-018-8764-4) contains supplementary material, which is available to authorized users.
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15
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Grossman I, Knappertz V, Laifenfeld D, Ross C, Zeskind B, Kolitz S, Ladkani D, Hayardeny L, Loupe P, Laufer R, Hayden M. Pharmacogenomics strategies to optimize treatments for multiple sclerosis: Insights from clinical research. Prog Neurobiol 2017; 152:114-130. [DOI: 10.1016/j.pneurobio.2016.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 02/10/2016] [Accepted: 02/27/2016] [Indexed: 12/13/2022]
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16
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Alroughani R, Deleu D, El Salem K, Al-Hashel J, Alexander KJ, Abdelrazek MA, Aljishi A, Alkhaboori J, Al Azri F, Al Zadjali N, Hbahbih M, Sokrab TE, Said M, Rovira À. A regional consensus recommendation on brain atrophy as an outcome measure in multiple sclerosis. BMC Neurol 2016; 16:240. [PMID: 27881095 PMCID: PMC5121973 DOI: 10.1186/s12883-016-0762-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 11/15/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic autoimmune disease characterized by inflammatory and neurodegenerative processes leading to irreversible neurological impairment. Brain atrophy occurs early in the course of the disease at a rate greater than the general population. Brain volume loss (BVL) is associated with disability progression and cognitive impairment in patients with MS; hence its value as a potential target in monitoring and treating MS is discussed. METHODS A group of MS neurologists and neuro-radiologists reviewed the current literature on brain atrophy and discussed the challenges in assessing and implementing brain atrophy measurements in clinical practice. The panel used a voting system to reach a consensus and the votes were counted for the proposed set of questions for cognitive and brain atrophy assessments. RESULTS The panel of experts was able to identify recent studies, which demonstrated the correlation between BVL and future worsening of disability and cognition. The current evidence revealed that reduction of BVL could be achieved with different disease-modifying therapies (DMTs). BVL provided a better treatment and monitoring strategy when it is combined to the composite measures of "no evidence of disease activity" (NEDA). The panel recommended a set of cognitive assessment tools and MRI methods and software applications that may help in capturing and measuring the underlying MS pathology with high degree of specificity. CONCLUSION BVL was considered to be a useful measurement to longitudinally assess disease progression and cognitive function in patients with MS. Brain atrophy measurement was recommended to be incorporated into the concept of NEDA. Consequently, a consensus recommendation was reached in anticipation for implementation of the use of cognitive assessment and brain atrophy measurements on a regional level.
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Affiliation(s)
- Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Kuwait City, Kuwait.
- Neurology Clinic, Dasman Diabetes Institute, Dasman, Kuwait.
| | - Dirk Deleu
- Division of Neurology (Neuroscience Institute), Hamad General Hospital, Doha, Qatar
| | - Khalid El Salem
- Department of Neurology, Jordan University of Science and Technology, King Abdullah University Hospital, Irbid, Jordan
| | - Jasem Al-Hashel
- Department of Neurology, Ibn Sina Hospital, Kuwait City, Kuwait
| | | | | | - Adel Aljishi
- Department of Neurology, Salmaniya Hospital & AGU, Manama, Bahrain
| | | | - Faisal Al Azri
- Department of Radiology, Sultan Qaboos University Hospital, Muscat, Oman
| | | | | | - Tag Eldin Sokrab
- Division of Neurology (Neuroscience Institute), Hamad General Center, Doha, Qatar
| | - Mohamed Said
- Medical Manger-Gulf Countries, Novartis pharmaceuticals, Dubai, United Arab Emirates
| | - Àlex Rovira
- Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Yokoyama K, Hattori N. Immunomodulatory effects of glatiramer acetate as they relate to stage-specific immune dysregulation in multiple sclerosis. Nihon Yakurigaku Zasshi 2016; 148:105-20. [PMID: 27478050 DOI: 10.1254/fpj.148.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Giovannoni G, Butzkueven H, Dhib-Jalbut S, Hobart J, Kobelt G, Pepper G, Sormani MP, Thalheim C, Traboulsee A, Vollmer T. Brain health: time matters in multiple sclerosis. Mult Scler Relat Disord 2016; 9 Suppl 1:S5-S48. [PMID: 27640924 DOI: 10.1016/j.msard.2016.07.003] [Citation(s) in RCA: 247] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 01/10/2023]
Abstract
INTRODUCTION We present international consensus recommendations for improving diagnosis, management and treatment access in multiple sclerosis (MS). Our vision is that these will be used widely among those committed to creating a better future for people with MS and their families. METHODS Structured discussions and literature searches conducted in 2015 examined the personal and economic impact of MS, current practice in diagnosis, treatment and management, definitions of disease activity and barriers to accessing disease-modifying therapies (DMTs). RESULTS Delays often occur before a person with symptoms suggestive of MS sees a neurologist. Campaigns to raise awareness of MS are needed, as are initiatives to improve access to MS healthcare professionals and services. We recommend a clear treatment goal: to maximize neurological reserve, cognitive function and physical function by reducing disease activity. Treatment should start early, with DMT and lifestyle measures. All parameters that predict relapses and disability progression should be included in the definition of disease activity and monitored regularly when practical. On suboptimal control of disease activity, switching to a DMT with a different mechanism of action should be considered. A shared decision-making process that embodies dialogue and considers all appropriate DMTs should be implemented. Monitoring data should be recorded formally in registries to generate real-world evidence. In many jurisdictions, access to DMTs is limited. To improve treatment access the relevant bodies should consider all costs to all parties when conducting economic evaluations and encourage the continuing investigation, development and use of cost-effective therapeutic strategies and alternative financing models. CONCLUSIONS The consensus findings of an international author group recommend a therapeutic strategy based on proactive monitoring and shared decision-making in MS. Early diagnosis and improved treatment access are also key components.
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Affiliation(s)
- Gavin Giovannoni
- Queen Mary University London, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK.
| | - Helmut Butzkueven
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.
| | - Suhayl Dhib-Jalbut
- Department of Neurology, RUTGERS-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK.
| | | | | | | | | | - Anthony Traboulsee
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Timothy Vollmer
- Department of Neurology, University of Colorado Denver, Aurora, CO, USA.
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Comi G, Amato MP, Bertolotto A, Centonze D, De Stefano N, Farina C, Gallo P, Ghezzi A, Grimaldi LM, Mancardi G, Marrosu MG, Montanari E, Patti F, Pozzilli C, Provinciali L, Salvetti M, Tedeschi G, Trojano M. The heritage of glatiramer acetate and its use in multiple sclerosis. ACTA ACUST UNITED AC 2016. [DOI: 10.1186/s40893-016-0010-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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20
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Tolerability and Safety of Combined Glatiramer Acetate and N-Acetylcysteine in Relapsing-Remitting Multiple Sclerosis. Clin Neuropharmacol 2016; 38:127-31. [PMID: 26166235 DOI: 10.1097/wnf.0000000000000090] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an autoimmune disorder of the central nervous system where inflammation and neurodegeneration play key roles. Mounting evidence implicates oxidative stress in the development of irreversible neuronal and glial injury in this condition. N-acetylcysteine (NAC) is a sulfhydryl amino acid derivative with antioxidant and antiapoptotic properties. Administration of NAC to mice attenuated the induction of or improved experimental autoimmune encephalomyelitis (an MS model). METHODS We performed an open-label study to explore the tolerability and safety of the combination of glatiramer acetate (GA) and NAC in patients with relapsing-remitting multiple sclerosis at the outpatient MS clinics of the Jewish General Hospital and Hôpital Charles Lemoyne, Montreal, Canada. Seven patients with relapsing-remitting multiple sclerosis with at least one T1 gadolinium-enhancing lesion on screening magnetic resonance imaging were recruited. Treatment consisted of a 10-week run-in period followed by 36-week treatment with a combination of GA 20 mg subcutaneously once daily plus NAC 2.5 g orally twice daily. Outcome measures included safety and tolerability, redox biochemistry, and magnetic resonance imaging effect. RESULTS Treatment with the combination of GA and NAC was safe and well tolerated. CONCLUSIONS In light of the favorable safety profile, an efficacy-demonstrating study may be considered.
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Abstract
A rapidly changing set of drugs for treatment of multiple sclerosis (MS) leads to the necessity of searching for predictors of their efficacy. Understanding of pathogenetic processes in MS and mechanisms of action of different drugs play an important role in the search for markers of potential responders. The author analyses the presently accumulated information on the original drug copaxone (glatiramer acetate) including current concepts on the mechanism of action, long-term safety and efficacy. Data on the frequency and significance of adverse effects during treatment with glatiramer acetate as well as on the influence of the drug on pregnancy, postpartum course of MS and development of the infant who received glatiramer acetate prenatally compared to other disease-modifying drugs are presented.
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Affiliation(s)
- D S Kasatkin
- Department of Nervous Diseases with Medical Genetics and Neurosurgery 'Yaroslavl state medical University', Yaroslavl, Russia
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22
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Ziemssen T, Derfuss T, de Stefano N, Giovannoni G, Palavra F, Tomic D, Vollmer T, Schippling S. Optimizing treatment success in multiple sclerosis. J Neurol 2015; 263:1053-65. [PMID: 26705122 PMCID: PMC4893374 DOI: 10.1007/s00415-015-7986-y] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 11/25/2015] [Indexed: 01/01/2023]
Abstract
Despite important advances in the treatment of multiple sclerosis (MS) over recent years, the introduction of several disease-modifying therapies (DMTs), the burden of progressive disability and premature mortality associated with the condition remains substantial. This burden, together with the high healthcare and societal costs associated with MS, creates a compelling case for early treatment optimization with highly efficacious therapies. Often, patients receive several first-line therapies, while more recent and in part more effective treatments are still being introduced only after these have failed. However, with the availability of highly efficacious therapies, a novel treatment strategy has emerged, where the aim is to achieve no evidence of disease activity (NEDA). Achieving NEDA necessitates regular monitoring of relapses, disability and functionality. However, there is only a poor correlation between conventional magnetic resonance imaging measures like T2 hyperintense lesion burden and the level of clinical disability. Hence, MRI-based measures of brain atrophy have emerged in recent years potentially reflecting the magnitude of MS-related neuroaxonal damage. Currently available DMTs differ markedly in their effects on brain atrophy: some, such as fingolimod, have been shown to significantly slow brain volume loss, compared to placebo, whereas others have shown either no, inconsistent, or delayed effects. In addition to regular monitoring, treatment optimization also requires early intervention with efficacious therapies, because accumulating evidence shows that effective intervention during a limited period early in the course of MS is critical for maintaining neurological function and preventing subsequent disability. Together, the advent of new MS therapies and evolving management strategies offer exciting new opportunities to optimize treatment outcomes.
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Affiliation(s)
- Tjalf Ziemssen
- MS Center Dresden, Center of Clinical Neuroscience, Neurological Clinic, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Tobias Derfuss
- MS Center Dresden, Center of Clinical Neuroscience, Neurological Clinic, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Nicola de Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Gavin Giovannoni
- Queen Mary University London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Filipe Palavra
- Neurology-Neuroimmunology Department, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Tim Vollmer
- University of Colorado Health Sciences Center, Aurora, CO, USA
| | - Sven Schippling
- Department of Neurology, Neuroimmunology and Multiple Sclerosis Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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23
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The natural history of brain volume loss among patients with multiple sclerosis: A systematic literature review and meta-analysis. J Neurol Sci 2015; 357:8-18. [DOI: 10.1016/j.jns.2015.07.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 06/15/2015] [Accepted: 07/09/2015] [Indexed: 11/21/2022]
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Broadley SA, Barnett MH, Boggild M, Brew BJ, Butzkueven H, Heard R, Hodgkinson S, Kermode AG, Lechner‐Scott J, Macdonell RAL, Marriott M, Mason DF, Parratt J, Reddel SW, Shaw CP, Slee M, Spies JM, Taylor BV, Carroll WM, Kilpatrick TJ, King J, McCombe PA, Pollard JD, Willoughby E. A new era in the treatment of multiple sclerosis. Med J Aust 2015. [DOI: 10.5694/mja14.01218] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Simon A Broadley
- Griffith University, Gold Coast, QLD
- Gold Coast University Hospital, Gold Coast, QLD
| | | | | | - Bruce J Brew
- St Vincent's Hospital/University of New South Wales, Sydney, NSW
| | - Helmut Butzkueven
- Royal Melbourne Hospital/University of Melbourne, Melbourne, VIC
- Monash University, Melbourne, VIC
| | | | | | - Allan G Kermode
- University of Western Australia, Perth, WA
- Murdoch University, Perth, WA
| | | | | | - Mark Marriott
- Royal Melbourne Hospital/University of Melbourne, Melbourne, VIC
| | | | | | | | | | | | | | | | | | | | - John King
- Royal Melbourne Hospital/University of Melbourne, Melbourne, VIC
| | - Pamela A McCombe
- University of Queensland Centre for Clinical Research, Brisbane, QLD
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Vidal-Jordana A, Sastre-Garriga J, Rovira A, Montalban X. Treating relapsing-remitting multiple sclerosis: therapy effects on brain atrophy. J Neurol 2015; 262:2617-26. [PMID: 26041617 DOI: 10.1007/s00415-015-7798-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/22/2015] [Accepted: 05/25/2015] [Indexed: 01/06/2023]
Abstract
Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system with a complex and heterogeneous pathology that may ultimately lead to neurodegeneration and brain atrophy. Brain volume loss in MS is known to occur early in the disease course and to be clinically relevant, as it has been related to disability progression. Nowadays, brain volume loss is relatively easy to measure with different automated, reproducible and accurate software tools. Therefore, most of (if not all) the newest clinical trials have incorporated brain volume outcomes as a measure of treatment effect. With this review, we aimed to update and summarize all existing data regarding brain volume and RRMS treatment in clinical trials as well as in open-label observational studies of drugs with positive results in its primary outcome in at least one phase III trial as of March 2014.
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Affiliation(s)
- Angela Vidal-Jordana
- Department of Neurology-Neuroimmunology and Multiple Sclerosis Centre of Catalonia (Cemcat), Edifici Cemcat, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Department of Neurology-Neuroimmunology and Multiple Sclerosis Centre of Catalonia (Cemcat), Edifici Cemcat, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Alex Rovira
- Magnetic Resonance Unit, Radiology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Montalban
- Department of Neurology-Neuroimmunology and Multiple Sclerosis Centre of Catalonia (Cemcat), Edifici Cemcat, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain
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Izquierdo G, García-Agua Soler N, Rus M, García-Ruiz AJ. Effectiveness of glatiramer acetate compared to other multiple sclerosis therapies. Brain Behav 2015; 5:e00337. [PMID: 26085963 PMCID: PMC4467772 DOI: 10.1002/brb3.337] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 02/13/2015] [Accepted: 03/10/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of glatiramer acetate (GA) compared to other multiple sclerosis (MS) therapies in routine clinical practice. MATERIALS AND METHODS Observational cohort study carried out in MS patients treated with GA (GA cohort) or other MS therapies -switched from GA- (non-GA cohort). Study data were obtained through review of our MS patient database. The primary endpoint was the Expanded Disability Status Scale (EDSS) scores reached at the end of treatment/last check-up. RESULTS A total of 180 patients were included: GA cohort n = 120, non-GA cohort n = 60. Patients in the GA cohort showed better EDSS scores at the end of treatment/last check-up (mean ± SD, 2.8 ± 1.8 vs. 3.9 ± 2.2; P = 0.001) and were 1.65 times more likely to show better EDSS scores compared to the non-GA cohort (odds ratio, 0.606; 95%CI, 0.436-0.843; P = 0.003). Patients in the GA cohort showed longer mean time to reach EDSS scores of 6 (209.1 [95%CI, 187.6-230.6] vs. 164.3 [95% CI, 137.0-191.6] months; P = 0.004) and slower disability progression (hazard ratio, 0.415 [95%CI, 0.286-0.603]; P < 0.001). The annualized relapse rate was lower in the GA cohort (mean ± SD, 0.5 ± 0.5 vs. 0.8 ± 0.5; P = 0.001) and patients' quality of life was improved in this study cohort compared to the non-GA cohort (mean ± SD, 0.7 ± 0.1 vs. 0.6 ± 0.2; P = 0.01). CONCLUSIONS GA may slow down the progression of EDSS scores to a greater extent than other MS therapies, as well as achieving a greater reduction in relapses and a greater improvement in patients' quality of life. Switching from GA to other MS therapies has not proved to entail a better response to treatment.
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Affiliation(s)
- Guillermo Izquierdo
- Department of Neurology, Hospital Universitario Virgen Macarena Avenida Dr. Fedriani, 3, 41009, Seville, Spain
| | - Nuria García-Agua Soler
- Chair of Health Economics and Rational Drug Use, School of Medicine, University of Málaga Boulevard Louis Pasteur, 32, 29071, Málaga, Spain
| | - Macarena Rus
- Department of Neurology, Hospital Universitario Virgen Macarena Avenida Dr. Fedriani, 3, 41009, Seville, Spain
| | - Antonio José García-Ruiz
- Chair of Health Economics and Rational Drug Use, School of Medicine, University of Málaga Boulevard Louis Pasteur, 32, 29071, Málaga, Spain ; Department of Pharmacology and Clinical Therapeutics, School of Medicine, University of Málaga Boulevard Louis Pasteur, 32, 29071, Málaga, Spain
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Boster AL, Ford CC, Neudorfer O, Gilgun-Sherki Y. Glatiramer acetate: long-term safety and efficacy in relapsing-remitting multiple sclerosis. Expert Rev Neurother 2015; 15:575-86. [DOI: 10.1586/14737175.2015.1040768] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Long-term effectiveness of glatiramer acetate in clinical practice conditions. J Clin Neurosci 2014; 21:2212-8. [DOI: 10.1016/j.jocn.2014.05.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 05/25/2014] [Indexed: 11/21/2022]
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Amann M, Andělová M, Pfister A, Mueller-Lenke N, Traud S, Reinhardt J, Magon S, Bendfeldt K, Kappos L, Radue EW, Stippich C, Sprenger T. Subcortical brain segmentation of two dimensional T1-weighted data sets with FMRIB's Integrated Registration and Segmentation Tool (FIRST). NEUROIMAGE-CLINICAL 2014; 7:43-52. [PMID: 25610766 PMCID: PMC4299953 DOI: 10.1016/j.nicl.2014.11.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 11/05/2014] [Accepted: 11/12/2014] [Indexed: 12/16/2022]
Abstract
Brain atrophy has been identified as an important contributing factor to the development of disability in multiple sclerosis (MS). In this respect, more and more interest is focussing on the role of deep grey matter (DGM) areas. Novel data analysis pipelines are available for the automatic segmentation of DGM using three-dimensional (3D) MRI data. However, in clinical trials, often no such high-resolution data are acquired and hence no conclusions regarding the impact of new treatments on DGM atrophy were possible so far. In this work, we used FMRIB's Integrated Registration and Segmentation Tool (FIRST) to evaluate the possibility of segmenting DGM structures using standard two-dimensional (2D) T1-weighted MRI. In a cohort of 70 MS patients, both 2D and 3D T1-weighted data were acquired. The thalamus, putamen, pallidum, nucleus accumbens, and caudate nucleus were bilaterally segmented using FIRST. Volumes were calculated for each structure and for the sum of basal ganglia (BG) as well as for the total DGM. The accuracy and reliability of the 2D data segmentation were compared with the respective results of 3D segmentations using volume difference, volume overlap and intra-class correlation coefficients (ICCs). The mean differences for the individual substructures were between 1.3% (putamen) and −25.2% (nucleus accumbens). The respective values for the BG were −2.7% and for DGM 1.3%. Mean volume overlap was between 89.1% (thalamus) and 61.5% (nucleus accumbens); BG: 84.1%; DGM: 86.3%. Regarding ICC, all structures showed good agreement with the exception of the nucleus accumbens. The results of the segmentation were additionally validated through expert manual delineation of the caudate nucleus and putamen in a subset of the 3D data. In conclusion, we demonstrate that subcortical segmentation of 2D data are feasible using FIRST. The larger subcortical GM structures can be segmented with high consistency. This forms the basis for the application of FIRST in large 2D MRI data sets of clinical trials in order to determine the impact of therapeutic interventions on DGM atrophy in MS. Segmentation of deep grey matter (DGM) using 2-dimensional MRI data is challenging. We performed a systematic comparison between 2 and 3D data segmentation using FIRST. The DGM volumes of 70 multiple sclerosis patients were statistically compared. We found a good agreement of the segmentation results for the large DGM structures. Our results indicate that FIRST is suitable for the segmentation of 2D data sets acquired in multicentre studies.
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Affiliation(s)
- Michael Amann
- Department of Neurology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland ; Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Petersgraben 4, Basel 4031, Switzerland
| | - Michaela Andělová
- Department of Neurology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Armanda Pfister
- Department of Neurology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Nicole Mueller-Lenke
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Petersgraben 4, Basel 4031, Switzerland ; Medical Image Analysis Center (MIAC), Schanzenstrasse 55, Basel 4031, Switzerland
| | - Stefan Traud
- Medical Image Analysis Center (MIAC), Schanzenstrasse 55, Basel 4031, Switzerland
| | - Julia Reinhardt
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Petersgraben 4, Basel 4031, Switzerland
| | - Stefano Magon
- Department of Neurology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Kerstin Bendfeldt
- Medical Image Analysis Center (MIAC), Schanzenstrasse 55, Basel 4031, Switzerland
| | - Ludwig Kappos
- Department of Neurology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Ernst-Wilhelm Radue
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Petersgraben 4, Basel 4031, Switzerland ; Medical Image Analysis Center (MIAC), Schanzenstrasse 55, Basel 4031, Switzerland
| | - Christoph Stippich
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Petersgraben 4, Basel 4031, Switzerland
| | - Till Sprenger
- Department of Neurology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland ; Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Petersgraben 4, Basel 4031, Switzerland
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Johnson KP. Glatiramer acetate for treatment of relapsing–remitting multiple sclerosis. Expert Rev Neurother 2014; 12:371-84. [DOI: 10.1586/ern.12.25] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Caporro M, Disanto G, Gobbi C, Zecca C. Two decades of subcutaneous glatiramer acetate injection: current role of the standard dose, and new high-dose low-frequency glatiramer acetate in relapsing-remitting multiple sclerosis treatment. Patient Prefer Adherence 2014; 8:1123-34. [PMID: 25170258 PMCID: PMC4144933 DOI: 10.2147/ppa.s68698] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Glatiramer acetate, a synthetic amino acid polymer analog of myelin basic protein, is one of the first approved drugs for the treatment of relapsing-remitting multiple sclerosis. Several clinical trials have shown consistent and sustained efficacy of glatiramer acetate 20 mg subcutaneously daily in reducing relapses and new demyelinating lesions on magnetic resonance imaging in patients with relapsing-remitting multiple sclerosis, as well as comparable efficacy to high-dose interferon beta. Some preclinical and clinical data suggest a neuroprotective role for glatiramer acetate in multiple sclerosis. Glatiramer acetate is associated with a relatively favorable side-effect profile, and importantly this was confirmed also during long-term use. Glatiramer acetate is the only multiple sclerosis treatment compound that has gained the US Food and Drug Administration pregnancy category B. All these data support its current use as a first-line treatment option for patients with clinical isolated syndrome or relapsing-remitting multiple sclerosis. More recent data have shown that high-dose glatiramer acetate (ie, 40 mg) given three times weekly is effective, safe, and well tolerated in the treatment of relapsing-remitting multiple sclerosis, prompting the approval of this dosage in the US in early 2014. This high-dose, lower-frequency glatiramer acetate might represent a new, more convenient regimen of administration, and this might enhance patients' adherence to the treatment, crucial for optimal disease control.
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Affiliation(s)
- Matteo Caporro
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Giulio Disanto
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Claudio Gobbi
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Chiara Zecca
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Lugano, Switzerland
- Correspondence: Chiara Zecca, Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, 46 Via Tesserete, Lugano 6903, Switzerland, Tel +41 91 811 6921, Fax +41 91 811 6915, Email
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Messina S, Patti F. The pharmacokinetics of glatiramer acetate for multiple sclerosis treatment. Expert Opin Drug Metab Toxicol 2013; 9:1349-59. [PMID: 23795716 DOI: 10.1517/17425255.2013.811489] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a T-cell-mediated disease affecting the central nervous system (CNS), characterized by demyelination and axonal degeneration. INF-β1b was the first drug approved for MS patients in 1993. In 1996, glatiramer acetate (GA), a synthetic copolymer, was approved in the USA for the treatment of relapsing-remitting MS (RRMS) and clinically isolated syndrome (CIS). Although the immunological action of GA has been fully investigated, the exact mechanisms of action of GA are still not completely elucidated. Several in vitro studies on mice and human antigen-presenting cells (APCs) have shown that GA is able to bind to the major histocompatibility complex (MHC), on the surface of APCs, recognizing myelin basic protein (MBP). AREAS COVERED This review explores the pharmacological characteristics of GA, its mechanism of action and its pharmacokinetics properties. The article also provides information on the efficacy, tolerability and an overview of the most important clinical data on GA. EXPERT OPINION Despite the development of novel compounds, it is not surprising that GA is, to date, one of the most prescribed drugs for RRMS patients and CIS patients. The proven efficacy and the mild adverse events, makes GA a good therapeutic option in the early stage of the disease. This is particularly useful for patients who suffer flu-like symptoms from other RRMS therapies as an alternative.
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Affiliation(s)
- Silvia Messina
- Department G.F. Ingrassia, Section of Neurosciences, Università degli studi di Catania , Via S. Sofia, 78, Catania , Italy +0953782642 ; +0953782626 ;
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Comi G, Martinelli V, Rodegher M, Moiola L, Leocani L, Bajenaru O, Carra A, Elovaara I, Fazekas F, Hartung HP, Hillert J, King J, Komoly S, Lubetzki C, Montalban X, Myhr KM, Preziosa P, Ravnborg M, Rieckmann P, Rocca MA, Wynn D, Young C, Filippi M. Effects of early treatment with glatiramer acetate in patients with clinically isolated syndrome. Mult Scler 2012; 19:1074-83. [PMID: 23234810 DOI: 10.1177/1352458512469695] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The placebo-controlled phase of the PreCISe study showed that glatiramer acetate delayed onset of clinically definite multiple sclerosis (CDMS) in patients with clinically isolated syndrome and brain lesions on MRI. OBJECTIVE To compare the effects of early versus delayed glatiramer acetate treatment in the open-label phase of PreCISe. METHODS Patients with a clinically isolated syndrome suggestive of MS with unifocal manifestation and ≥2 T2-weighted brain lesions were randomized to receive glatiramer acetate 20 mg/d (early-treatment, n=198) or placebo (delayed-treatment, n=211) for 36 months or until conversion to CDMS, followed by open-label glatiramer acetate treatment for two years. RESULTS Early glatiramer acetate treatment reduced CDMS conversion risk by 41% (hazard ratio 0.59, 95% confidence interval 0.44-0.80; p=0.0005) versus delayed-treatment, and was associated with a 972-day delay (185%) in conversion to CDMS, less brain atrophy (-28%, p=0.0209), fewer new T2 lesions/year (-42%, <0.0001) and lower T2 lesion volume (-22%, p=0.0005) versus delayed treatment. Adverse events were consistent with the established safety profile of glatiramer acetate. CONCLUSIONS Effects of early glatiramer acetate treatment on the rate of conversion to CDMS and on MRI measures of disease activity and lesion burden support initiating glatiramer acetate treatment soon after the first clinical symptoms suggestive of MS and continuing treatment to sustain benefits.
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Affiliation(s)
- Giancarlo Comi
- Institute of Experimental Neurology, Department of Neurology, University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy
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Vigeveno RM, Wiebenga OT, Wattjes MP, Geurts JJG, Barkhof F. Shifting imaging targets in multiple sclerosis: from inflammation to neurodegeneration. J Magn Reson Imaging 2012; 36:1-19. [PMID: 22696123 DOI: 10.1002/jmri.23578] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Classically multiple sclerosis (MS) has been regarded as an auto-immune disease of the white matter in the central nervous system leading to severe disability over the course of several decades. Current therapeutic strategies in MS are mostly based on either immune suppression or immune modulation. Although effective in decreasing relapse frequency and severity as well as delaying disease progression, MS pathology ensues nonetheless. In the last decade it became evident that gray matter pathology plays an important role in disease progression and helps explaining certain aspects of MS-related disability such as cognitive decline. Conventional MRI outcome measures commonly used in clinical trials are sufficient to demonstrate an anti-inflammatory drug-effect but lack pathological specificity and are poor to moderate predictors of disability. In this article, we review new insights in gray matter pathology and functional reorganization in MS and how these novel fields in MS research may validate and establish new MRI outcome measures, aid in the development of new therapeutic strategies for neuroprotection and neurorepair, and may lead to development of novel predictive measures of disability and disease progression in MS.
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Affiliation(s)
- René M Vigeveno
- VU University Medical Center, Department of Radiology, Amsterdam, the Netherlands
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Giovannoni G, Southam E, Waubant E. Systematic review of disease-modifying therapies to assess unmet needs in multiple sclerosis: tolerability and adherence. Mult Scler 2012; 18:932-46. [PMID: 22249762 DOI: 10.1177/1352458511433302] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Reviews of therapeutic drugs usually focus on the highly selected and closely monitored patient populations from randomized controlled trials. The objective of this study was to review systematically the tolerability and adherence of multiple sclerosis disease-modifying therapies, using data from both randomized controlled trials and observational settings. Relevant literature was identified using predefined search terms, and adverse event and study discontinuation data were extracted and categorized according to study type (randomized controlled trial or observational) and study duration. A total of 151 papers were selected for analysis; 33% were classified as randomized controlled trials and 62% as observational studies. Most of the papers concerned interferon preparations and glatiramer acetate; the limited available information on mitoxantrone and natalizumab precluded extensive examination of these. The most common adverse events were flu-like symptoms (interferon therapies only) and injection-site reactions. Mean discontinuation rates ranged from 16% to 27%. There were no marked differences in tolerability or adherence data from randomized controlled trials and observational studies, but the incidence of adverse events remained high in lengthy studies and discontinuations accumulated with time. The present systematic review of randomized clinical trial and observational data highlights the tolerability and adherence issues associated with commonly used first-line multiple sclerosis treatments.
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Affiliation(s)
- G Giovannoni
- Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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Comi G, Cohen JA, Arnold DL, Wynn D, Filippi M. Phase III dose-comparison study of glatiramer acetate for multiple sclerosis. Ann Neurol 2011; 69:75-82. [DOI: 10.1002/ana.22316] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
BACKGROUND This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2004 , Issue 1 . Art. No.: CD004678. DOI: 10.1002/14651858.CD004678)Previous studies have shown that glatiramer acetate (Copaxone (R)), a synthetic amino acid polymer is effective in experimental allergic encephalomyelitis (EAE), and improve the outcome of patients with multiple sclerosis (MS). OBJECTIVES To verify the clinical efficacy of glatiramer acetate in the treatment of MS patients with relapsing remitting (RR) and progressive (P) course. SEARCH STRATEGY We searched the Cochrane MS Group Trials Register (26 March 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2009), MEDLINE (PubMed) (January 1966 to 26 March 2009), EMBASE (January 1988 to 26 March 2009) and hand searching of symposia reports (1990-2009). SELECTION CRITERIA All randomised controlled trials (RCTs) comparing glatiramer acetate and placebo in patients with definite MS, whatever the administration schedule and disease course, were eligible for this review. DATA COLLECTION AND ANALYSIS Both patients with RR and P MS were analysed. Study protocols were comparable across trials. No major flaws were found in methodological quality. However, efficacy of blinding should be balanced against side effects, including injection-site reactions. MAIN RESULTS Among 409 retrieved references, we identified 16 RCTs; six of them, published between 1987 and 2007, met the selection criteria and were included in this review. Five hundred and forty RR patients and 1049 PMS contributed to the analysis. In RR MS, a decrease in the mean EDSS score (-0.33 and -0.45), was found respectively at 2 years and 35 months without any significant effect on sustained disease progression. The reduction of mean number of relapse was evident at 1 year (-0.35 ) 2 years (-0.51 ) and 35 months (-0.64), but significant studies ' heterogeneity was found. The number of hospitalisations and steroid courses were significantly reduced. No benefit was shown in P MS patients. No major toxicity was found. The most common systemic adverse event was a transient and self-limiting patterned reaction of flushing, chest tightness, sweating, palpitations, anxiety. Local injection-site reactions were observed in up to a half of patients treated with glatiramer acetate, thus making a blind assessment of outcomes questionable. AUTHORS' CONCLUSIONS Glatiramer acetate did show a partial efficacy in RR MS in term of relapse -related clinical outcomes, without any significant effect on clinical progression of disease measured as sustained disability. The drug is not effective in progressive MS patients.
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Affiliation(s)
- Loredana La Mantia
- Department of Neuroscience, Fondazione I.R.C.C.S. - Istituto Neurologico C. Besta, Via Celoria, 11, Milano, Italy, 20133
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Mesaros S, Rocca M, Sormani M, Valsasina P, Markowitz C, De Stefano N, Montalban X, Barkhof F, Ranjeva J, Sailer M, Kappos L, Comi G, Filippi M. Bimonthly assessment of magnetization transfer magnetic resonance imaging parameters in multiple sclerosis: a 14-month, multicentre, follow-up study. Mult Scler 2010; 16:325-31. [PMID: 20086023 DOI: 10.1177/1352458509358713] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study was performed to assess the temporal evolution of damage within lesions and the normal-appearing white matter, measured using frequent magnetization transfer (MT) MRI, in relapsing-remitting multiple sclerosis (RRMS). The relationship of MT ratio (MTR) changes with measures of lesion burden, and the sample sizes needed to demonstrate a treatment effect on MTR metrics in placebo-controlled MS trials were also investigated. Bimonthly brain conventional and MT MRI scans were acquired from 42 patients with RRMS enrolled in the placebo arm of a 14-month, double-blind trial. Longitudinal MRI changes were evaluated using a random effect linear model accounting for repeated measures, and adjusted for centre effects. The Expanded Disability Status Scale (EDSS) score remained stable over the study period. A weak, but not statistically significant, decrease over time was detected for normal-appearing brain tissue (NABT) average MTR (-0.02% per visit; p = 0.14), and MTR peak height (-0.15 per visit; p = 0.17), while average lesion MTR showed a significant decrease over the study period (-0.07% per visit; p = 0.03). At each visit, all MTR variables were significantly correlated with T2 lesion volume (LV) (average coefficients of correlation ranging from -0.54 to -0.28, and p-values from <0.001 to 0.02). At each visit, NABT average MTR was also significantly correlated with T1-hypointense LV (average coefficient of correlation = -0.57, p < 0.001). The estimation of the sample sizes required to demonstrate a reduction of average lesion MTR (the only parameter with a significant decrease over the follow-up) ranged from 101 to 154 patients to detect a treatment effect of 50% in a 1-year trial with a power of 90%. The steady correlation observed between conventional and MT MRI measures over time supports the hypothesis of axonal degeneration of fibres passing through focal lesions as one of the factors contributing to the overall MS burden.
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Affiliation(s)
- S Mesaros
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, 20132 Milan Italy
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Johnson KP, Due DL. Benefits of glatiramer acetate in the treatment of relapsing-remitting multiple sclerosis. Expert Rev Pharmacoecon Outcomes Res 2009; 9:205-14. [PMID: 19527092 DOI: 10.1586/erp.09.20] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Relapsing-remitting multiple sclerosis is a chronic, progressive disorder marked by repeated exacerbations that lead to increases in neurological disability. Glatiramer acetate and the IFN-betas are recommended as first-line agents for relapsing-remitting multiple sclerosis owing to their potential to reduce frequency and severity of relapses, decrease development of new brain lesions and delay permanent disability. After three decades of study, the preponderance of the evidence suggests that the efficacy of glatiramer acetate is similar to the IFN-betas and new data collected in more naturalistic settings suggest that it may provide improved quality of life, increased productivity and cost-effectiveness. This article will review this evidence including data from very recent head-to-head clinical trials and pharmacoeconomic analyses of cost-effectiveness.
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Korteweg T, Rovaris M, Neacsu V, Filippi M, Comi G, Uitdehaag BM, Knol DL, Polman CH, Barkhof F, Vrenken H. Can rate of brain atrophy in multiple sclerosis be explained by clinical and MRI characteristics? Mult Scler 2008; 15:465-71. [DOI: 10.1177/1352458508100505] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Multiple sclerosis (MS) is characterized, besides focal lesions, by brain atrophy. The determinants of atrophy rates in individual patients are poorly understood. Aim This study investigated the predictive value of clinical and magnetic resonance imaging (MRI) factors, including short-term changes thereof, for concurrent and future atrophy evolution using Spearman’s rank correlations and stepwise multiple linear regression. Methods We retrospectively identified a group of 115 active, early relapsing-remitting (RR) patients relatively homogeneous in terms of disease course and MRI activity compared to a second group of 96 patients with broader spectrum of MS phenotypes and inactive scans. All patients had undergone three MRI investigations with interscan intervals of at least 12 and 24 months, respectively. Results In the RR patients, 23% of variance in concurrent atrophy rates (over the first interval) could be explained by the combination of baseline T2 lesion volume and change in EDSS score over the first interval, whereas only 6% in future atrophy rates (over the second interval) was explained. In the heterogeneous group, 20.2% of the variance in future atrophy rates could be explained, but slightly less in concurrent atrophy rates (16.2%). Conclusion We concluded that variance in brain atrophy rates can partially be explained by clinical and MRI measures of disease. Future atrophy rates in individual MS patients are difficult to predict even when including previous atrophy rates.
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Affiliation(s)
- T Korteweg
- Department of Radiology, VU University Medical Centre, Amsterdam, The Netherlands
| | - M Rovaris
- Neuroimaging Research Unit, Department of Neurology, Scientific Institute and University Ospedale San Raffaele, Milan, Italy
| | - V Neacsu
- Department of Radiology, VU University Medical Centre, Amsterdam, The Netherlands
| | - M Filippi
- Neuroimaging Research Unit, Department of Neurology, Scientific Institute and University Ospedale San Raffaele, Milan, Italy
| | - G Comi
- Neuroimaging Research Unit, Department of Neurology, Scientific Institute and University Ospedale San Raffaele, Milan, Italy
| | - BM Uitdehaag
- Department of Clinical Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands; Department of Neurology, VU University Medical Centre, Amsterdam, The Netherlands
| | - DL Knol
- Department of Clinical Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
| | - CH Polman
- Department of Neurology, VU University Medical Centre, Amsterdam, The Netherlands
| | - F Barkhof
- Department of Radiology, VU University Medical Centre, Amsterdam, The Netherlands
| | - H Vrenken
- Department of Radiology, VU University Medical Centre, Amsterdam, The Netherlands; Department of Physics and Medical Technology, VU University Medical Centre, Amsterdam, The Netherlands
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Capobianco M, Rizzo A, Malucchi S, Sperli F, Di Sapio A, Oggero A, Zaffaroni M, Ghezzi A, Bertolotto A. Glatiramer acetate is a treatment option in neutralising antibodies to interferon-beta-positive patients. Neurol Sci 2008; 29 Suppl 2:S227-9. [PMID: 18690500 DOI: 10.1007/s10072-008-0945-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Neutralising antibodies develop in 15% of interferon-beta (IFNbeta)-treated patients, causing the reduction of the clinical effects of the treatment. This is the first study that shows that switching patients from IFNbeta to glatiramer acetate (GA) in case of neutralising antibodies (NAb) positivity is effective in reducing relapse rate and in delaying the time to first relapse. In conclusion, our data suggest the use of GA in NAb-positive patients.
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Affiliation(s)
- Marco Capobianco
- Centro di Riferimento Regionale Sclerosi Multipla e Neurobiologia Clinica, AOU S. Luigi Gonzaga, Regione Gonzole 10, 10043, Orbassano, TO, Italy.
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Abstract
PURPOSE OF REVIEW The aim of this article is to review the latest clinical trials in neurological diseases where magnetic resonance imaging was used to assess treatment outcome. RECENT FINDINGS The unique sensitivity of magnetic resonance imaging for detecting disorders in the brain has made it an attractive noninvasive tool for assessing treatment efficacy in several diseases. Volumetric and functional magnetic resonance imaging have proved to represent robust biomarkers for the evaluation of anti-Alzheimer treatments, and have demonstrated a significant impact of cholinesterase inhibitors. The optimization of thrombolytic therapy in acute ischemic stroke has concentrated on the quantification of the ischemic penumbra, using perfusion-weighted and diffusion-weighted imaging. Standard assessment of T2 or fluid-attenuated inversion recovery lesion load remains the method of choice to evaluate new therapeutic strategy in multiple sclerosis. Other nonconventional quantitative magnetic resonance imaging techniques such as magnetic resonance volumetry, magnetization transfer imaging, diffusion-weighted imaging, or magnetic resonance spectroscopy are increasingly used in the field. SUMMARY Magnetic resonance imaging has become a major surrogate marker of treatment response in clinical trials of neurological disorders, offering the possibility to reduce the required sample size or to shorten the duration of the trial.
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Affiliation(s)
- Carolina Ciumas
- CTRS-INSERM IDEE (Institut Des Epilepsies de l'Enfant et de l'adolescent), INSERM U821, CERMEP imagerie du vivant, and Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and Université Claude Bernard Lyon 1, Lyon, France
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Mesaros S, Rocca MA, Sormani MP, Charil A, Comi G, Filippi M. Clinical and conventional MRI predictors of disability and brain atrophy accumulation in RRMS. A large scale, short-term follow-up study. J Neurol 2008; 255:1378-83. [PMID: 18584233 DOI: 10.1007/s00415-008-0924-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 01/23/2008] [Accepted: 03/05/2008] [Indexed: 11/26/2022]
Abstract
To assess the value of clinical and MRI variables in predicting short-term brain atrophy accumulation and clinical evolution in a large cohort of patients with RRMS, we studied a cohort of 548 patients, previously enrolled as a placebo arm of a 14-month, double-blind trial of oral glatiramer acetate (GA). A logistic regression model with EDSS progression as the dependent variable was built to assess baseline clinical and MRI variables associated with clinical worsening during follow-up. In 466 patients with complete central brain atrophy assessment, another linear regression model with percentage central brain volume change (PCBVC) as the dependent variable was built to assess baseline clinical and MRI variables associated with atrophy development.A total of 80 patients (15%) had EDSS progression over the follow-up period. Factors independently predicting the probability to have a clinical progression were lower EDSS (OR = 0.78, 95% CI = 0.62-0.97 p = 0.02) and higher T2 LL (OR = 1.022, 95% CI = 1.006-1.038, p = 0.007) at baseline. In the 466 patients with atrophy assessment, PCBVC declined, on average, by -2.0% (SD = 2.8) (p < 0.001) over the follow-up. The multivariate PCBVC analysis revealed that the PCBVC decrease was independently correlated with higher EDSS (p = 0.03) and T2 LL (p = 0.005) at baseline. The squared correlation coefficients of the composite scores made up of EDSS and T2 LL considered together were able to explain only 3 % of the variance in disability progression and only 4 % of the variance of PCBVC.In RRMS patients, clinical and conventional MRI findings at baseline only modestly predict shortterm accumulation of brain atrophy and disability. These data confirm the need to develop clinical and MRI measures more sensitive towards the more disabling aspects of the disease.
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Affiliation(s)
- Sarlota Mesaros
- Neuroimaging Research Unit, Scientific Institute and University H San Raffaele, Via Olgettina 60, 20132, Milan, Italy
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de Oliveira TDMG, Fiore APP, Fragoso YD. Adherence to glatiramer acetate treatment for multiple sclerosis: the Brazilian experience. Patient Prefer Adherence 2008; 2:41-6. [PMID: 19920943 PMCID: PMC2770403 DOI: 10.2147/ppa.s2255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Multiple sclerosis is a chronic disease characterized by demyelination and neurodegeneration of the central nervous system. Immunomodulatory treatment is possible at an early stage of the disease, and consists of injections of either beta-interferon or glatiramer acetate. The drugs are not curative, and the need for frequent injections may give rise to a serious problem regarding adherence to treatment. The present study analyzed the database of all Brazilian patients using glatiramer acetate between June 2003 and December 2006 who had enrolled in the patient program run by the pharmaceutical company commercializing the drug. The rate of treatment discontinuation was 10% over this period, and the main reason for suspending the drug was medical decisions (47% of all discontinuations), rather than side effects or the patient's choice. The present work did not take into consideration the regularity of injections and the main objective was to assess discontinuation. It was concluded that adequate healthcare, education, and a specific program for patients were the factors responsible for this 90% adherence to glatiramer acetate treatment in Brazil.
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Affiliation(s)
| | - Ana Patricia Peres Fiore
- Medical School of Universidade Metropolitana de Santos and Reference Center for Multiple Sclerosis of the coastal region of the State of São Paulo (DRS-IV), Brazil
| | - Yára Dadalti Fragoso
- Medical School of Universidade Metropolitana de Santos and Reference Center for Multiple Sclerosis of the coastal region of the State of São Paulo (DRS-IV), Brazil
- Correspondence: Yára Dadalti Fragoso Universidade Metropolitana de Santos, Rua da Constituição 374, CEP 11015-470, Santos SP, Brazil, Tel/fax +55 13 32263400, Email
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