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İsmayılov R, Talibov T, Gündüz T, Kürtüncü M. Parenchymal Neuro-Behçet's disease or Comorbid Behçet's disease with multiple sclerosis: A discriminative analysis of a complex clinical entity. Mult Scler Relat Disord 2024; 87:105684. [PMID: 38788360 DOI: 10.1016/j.msard.2024.105684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/11/2024] [Accepted: 05/12/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Patients with Behçet's disease (BD) may rarely manifest with cerebral white matter lesions resembling multiple sclerosis (MS). This may result in misdiagnosis due to diagnostic difficulties between parenchymal neuro-BD (pNBD) and MS. This study aims to elucidate the distinguishing features of patients with comorbid BD and MS (BD+MS) in comparison to those with pNBD and MS alone by focusing on clinical and laboratory features. We also aimed to identify the distinctive characteristics of BD+MS patients by comparing them to patients with pNBD and MS. METHODS The methodology of this study involved a retrospective analysis of patient records followed in the Department of Neurology at the Istanbul Faculty of Medicine, Istanbul University. The study population included patients diagnosed with pNBD, MS, and a comorbid condition of BD and MS (BD+MS). We assessed clinical, radiological, and laboratory data, including disease onset, annual relapse rates, Expanded Disability Status Scale (EDSS) progression, and cerebrospinal fluid examination. Several parameters were examined between the pNBD, MS, and BD+MS patient groups to find similarities and differences between subgroups. RESULTS Our study included 1,764 patients: 172 with pNBD, 1,574 with MS, and 18 with BD+MS. A predominance of females was noted in the BD+MS (72%, p < 0.001) and MS (69 %, p < 0.001) groups compared to pNBD (30 %). The median age at the onset of neurological symptoms was 35.5 (IQR: 16.8) years for BD+MS, 34.6 (13.6) years for pNBD, and 27.6 (13.3) years for MS (BD+MS vs. MS; p = 0.3, pNBD vs. MS, p = 0.7). Additionally, the number of attacks was notably different, with BD+MS patients experiencing a median of 3.5 (2.0) attacks compared to 3.0 (3.0) for MS patients and only 1.0 (1.0) for pNBD patients, suggesting a more active disease course in the MS and BD+MS groups compared to pNBD (p < 0.001). The median annualized relapse rate for BD+MS was 0.3 (0.2), which was lower than the rate of 0.4 (0.4) in MS (p = 0.048) and equivalent to the rate of 0.2 (0.3) in pNBD (p = 0.2). The time to the first relapse was similar to those with BD+MS and MS, but considerably shorter than in individuals with pNBD (p < 0.0001). The cerebrospinal fluid (CSF) analysis showed no significant differences in neutrophil and lymphocyte counts between BD+MS and MS patients but elevated levels in pNBD patients (p < 0.05). CSF protein levels were consistent across all groups (p = 0.1 and p = 0.7). Oligoclonal bands were detected in all patients with BD+MS, in the majority of MS patients (83.6 %), and a small percentage of pNBD patients (19.7 %), showing a notable distinction between the BD+MS and pNBD groups (p < 0.001). CONCLUSION Our study underscores the need for a skeptical approach in diagnosing and treating patients with BD who exhibit symptomatic MS-like MRI lesions. Our findings suggest that BD+MS is a distinct clinical entity, warranting specific diagnostic and treatment approaches. Our findings highlight that BD patients with MS-like lesions meeting MS diagnostic criteria should be managed as patients with comorbid MS and BD rather than pNBD.
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Affiliation(s)
- Rashad İsmayılov
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Tural Talibov
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Tuncay Gündüz
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Murat Kürtüncü
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey.
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Manuel AM, Gottlieb A, Freeman L, Zhao Z. Montelukast as a repurposable additive drug for standard-efficacy multiple sclerosis treatment: Emulating clinical trials with retrospective administrative health claims data. Mult Scler 2024; 30:696-706. [PMID: 38660773 PMCID: PMC11073911 DOI: 10.1177/13524585241240398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Effective and safe treatment options for multiple sclerosis (MS) are still needed. Montelukast, a leukotriene receptor antagonist (LTRA) currently indicated for asthma or allergic rhinitis, may provide an additional therapeutic approach. OBJECTIVE The study aimed to evaluate the effects of montelukast on the relapses of people with MS (pwMS). METHODS In this retrospective case-control study, two independent longitudinal claims datasets were used to emulate randomized clinical trials (RCTs). We identified pwMS aged 18-65 years, on MS disease-modifying therapies concomitantly, in de-identified claims from Optum's Clinformatics® Data Mart (CDM) and IQVIA PharMetrics® Plus for Academics. Cases included 483 pwMS on montelukast and with medication adherence in CDM and 208 in PharMetrics Plus for Academics. We randomly sampled controls from 35,330 pwMS without montelukast prescriptions in CDM and 10,128 in PharMetrics Plus for Academics. Relapses were measured over a 2-year period through inpatient hospitalization and corticosteroid claims. A doubly robust causal inference model estimated the effects of montelukast, adjusting for confounders and censored patients. RESULTS pwMS treated with montelukast demonstrated a statistically significant 23.6% reduction in relapses compared to non-users in 67.3% of emulated RCTs. CONCLUSION Real-world evidence suggested that montelukast reduces MS relapses, warranting future clinical trials and further research on LTRAs' potential mechanism in MS.
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Affiliation(s)
- Astrid M Manuel
- Center for Precision Health, McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, TX
| | - Assaf Gottlieb
- Center for Precision Health, McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, TX
| | - Leorah Freeman
- Neurology Department, Dell Medical School, The University of Texas at Austin, TX
| | - Zhongming Zhao
- Center for Precision Health, McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, TX
- Human Genetics Center, School of Public Health, University of Texas Health Science Center at Houston, TX
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3
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Hiramatsu K, Maeda H. Adult and pediatric relapsing multiple sclerosis phase II and phase III trial design and their primary end points: A systematic review. Clin Transl Sci 2024; 17:e13794. [PMID: 38708586 PMCID: PMC11070945 DOI: 10.1111/cts.13794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/22/2024] [Accepted: 04/01/2024] [Indexed: 05/07/2024] Open
Abstract
No systematic review of trial designs in patients with relapsing multiple sclerosis (RMS) was reported. This systematic review was conducted on the trial designs and primary end points (PEs) of phase II and III trials intended to modify the natural course of the disease in patients with RMS. The purpose of the study is to explore trends/topics and discussion points in clinical trial design and PE, comparing them to regulatory guidelines and expert recommendations. Three trial registration systems, ClinicalTrials.gov, the EU Clinical Trials Register, and the Japan Registry of Clinical Trials, were used and 60 trials were evaluated. The dominant clinical trial design was a randomized controlled parallel-arms trial and other details were as follows: in adult phase III confirmatory trials (n = 32), active-controlled double-blind trial (DBT) (53%) and active-controlled open-label assessor-masking trial (16%); in adult phase II dose-finding trials (n = 9), placebo- and active-controlled DBT (44%), placebo-controlled DBT (22%), and placebo-controlled add-on DBT (22%); and in pediatric phase III confirmatory trials (n = 8), active-controlled DBT (38%) and active-controlled open-label non-masking trial (25%). The most common PEs were as follows: in adult confirmatory trials, annual relapse rate (ARR) (56%) and no evidence of disease activity-3 (NEDA-3) (13%); in adult dose-finding trials, the cumulative number of T1 gadolinium-enhancing lesions (56%), combined unique active lesions (22%), and overall disability response score (22%); and in pediatric confirmatory trials, ARR (38%) and time to first relapse (25%). It was suggested that some parts of the regulatory guidelines and expert recommendations need to be revised.
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Affiliation(s)
- Katsutoshi Hiramatsu
- Department of Regulatory Science, Faculty of PharmacyMeiji Pharmaceutical UniversityTokyoJapan
| | - Hideki Maeda
- Department of Regulatory Science, Faculty of PharmacyMeiji Pharmaceutical UniversityTokyoJapan
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Ahmad H, Campbell JA, van der Mei I, Taylor BV, Xia Q, Zhao T, Palmer AJ. Estimating the disutility of relapse in relapsing-remitting and secondary progressive multiple sclerosis using the EQ-5D-5L, AQoL-8D, EQ-5D-5L-psychosocial, and SF-6D: implications for health economic evaluation models. Qual Life Res 2023; 32:3373-3387. [PMID: 37522942 PMCID: PMC10624739 DOI: 10.1007/s11136-023-03486-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND AND AIMS Relapses are an important clinical feature of multiple sclerosis (MS) that result in temporary negative changes in quality of life (QoL), measured by health state utilities (HSUs) (disutilities). We aimed to quantify disutilities of relapse in relapsing remitting MS (RRMS), secondary progressive MS (SPMS), and relapse onset MS [ROMS (including both RRMS and SPMS)] and examine these values by disability severity using four multi-attribute utility instruments (MAUIs). METHODS We estimated (crude and adjusted and stratified by disability severity) disutilities (representing the mean difference in HSUs of 'relapse' and 'no relapse' groups as well as 'unsure' and 'no relapse' groups) in RRMS (n = 1056), SPMS (n = 239), and ROMS (n = 1295) cohorts from the Australian MS Longitudinal Study's 2020 QoL survey, using the EQ-5D-5L, AQoL-8D, EQ-5D-5L-Psychosocial, and SF-6D MAUIs. RESULTS Adjusted mean overall disutilities of relapse in RMSS/SPMS/ROMS were - 0.101/- 0.149/- 0.129 (EQ-5D-5L), - 0.092/- 0.167/- 0.113 (AQoL-8D), - 0.080/- 0.139/- 0.097 (EQ-5D-5L-Psychosocial), and - 0.116/- 0.161/- 0.130 (SF-6D), approximately 1.5 times higher in SPMS than in RRMS, in all MAUI. All estimates were statistically significant and/or clinically meaningful. Adjusted disutilities of RRMS and ROMS demonstrated a U-shaped relationship between relapse disutilities and disability severity. Relapse disutilities were higher in 'severe' disability than 'mild' and 'moderate' in the SPMS cohort. CONCLUSION MS-related relapses are associated with substantial utility decrements. As the type and severity of MS influence disutility of relapse, the use of disability severity and MS-type-specific disutility inputs is recommended in future health economic evaluations of MS. Our study supports relapse management and prevention as major mechanisms to improve QoL in people with MS.
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Affiliation(s)
- Hasnat Ahmad
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
- Australian Government Department of Health and Aged Care, Canberra, Australia.
| | - Julie A Campbell
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Ingrid van der Mei
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Bruce V Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Qing Xia
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ting Zhao
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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Papathanasiou A, Hibbert A, Tallantyre E, Harding K, Selvam AP, Morgan M, Quainton C, Talaei M, Arun T, Ingram G, Law GR, Evangelou N. Real-world annualized relapse rates from contemporary multiple sclerosis clinics in the UK: a retrospective multicentre cohort study. Neurol Sci 2023; 44:3629-3635. [PMID: 37208584 PMCID: PMC10198787 DOI: 10.1007/s10072-023-06838-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/02/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Annualized relapse rate (ARR) is used as an outcome measure in multiple sclerosis (MS) clinical trials. Previous studies demonstrated that ARR has reduced in placebo groups between 1990 and 2012. This study aimed to estimate real-world ARRs from contemporary MS clinics in the UK, in order to improve the feasibility estimations for clinical trials and facilitate MS service planning. METHODS A multicentre observational, retrospective study of patients with MS from 5 tertiary neuroscience centres in the UK. We included all adult patients with a diagnosis of MS that had a relapse between 01/04/2020 and 30/06/2020. RESULTS One hundred thirteen out of 8783 patients had a relapse during the 3-month study period. Seventy-nine percent of the patients with a relapse were female, the mean age was 39 years, and the median disease duration was 4.5 years; 36% of the patients that had a relapse were on disease-modifying treatment. The ARR from all study sites was estimated at 0.05. The ARR for relapsing remitting MS (RRMS) was estimated at 0.08, while the ARR for secondary progressive MS (SPMS) was 0.01. CONCLUSIONS We report a lower ARR compared to previously reported rates in MS.
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Affiliation(s)
- Athanasios Papathanasiou
- Nottingham Centre for Multiple Sclerosis and Neuroinflammation, Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Aimee Hibbert
- Nottingham Centre for Multiple Sclerosis and Neuroinflammation, Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Emma Tallantyre
- Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Katharine Harding
- Department of Neurology, Aneurin Bevan University Health Board, Newport, UK
| | - Adithya Panneer Selvam
- Nottingham Centre for Multiple Sclerosis and Neuroinflammation, Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Matthew Morgan
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Charlotte Quainton
- Department of Neurology, Aneurin Bevan University Health Board, Newport, UK
| | - Maryam Talaei
- Department of Neurology, Morriston Hospital, Swansea, UK
| | - Tarunya Arun
- Department of Neurosciences, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Gillian Ingram
- Department of Neurology, Morriston Hospital, Swansea, UK
| | - Graham R Law
- School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Nikos Evangelou
- Mental Health and Clinical Neurosciences Academic Unit, University of Nottingham, Nottingham, UK
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Shahraki Z, Rastkar M, Rastkar E, Mohammadifar M, Mohamadi A, Ghajarzadeh M. Impact of menopause on relapse rate and disability level in patients with multiple sclerosis (MS): a systematic review and meta-analysis. BMC Neurol 2023; 23:316. [PMID: 37667181 PMCID: PMC10476298 DOI: 10.1186/s12883-023-03332-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/15/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Menopause is a physiologic phase in women's lives. Findings regarding multiple sclerosis (MS) course through menopause are diverse. So, we designed this systematic review and meta-analysis to estimate the impact of menopause on relapse rate, and disability status in women with MS. METHODS PubMed, Scopus, EMBASE, Web of Science, and google scholar were systematically searched by two independent researchers on January 1st, 2023. They also evaluated conference abstracts, and references of the included studies. In addition, data regarding the total number of participants, name of the first author of the publication, publication year, country of origin, disease duration, disease type, annual relapse rate, and Expanded Disability Status Scale (EDSS) before and after menopause were recorded. RESULTS A literature search revealed 1024 records. Twenty-one full texts were evaluated, and finally, four studies were included for meta-analysis. Mean ARR before menopause ranged between 0.21 and 0.37, and after menopause ranged between 0.13 and 0.08. The SMD of mean ARR ranged between - 1.04, and - 0.29, while the pooled SMD was estimated as -0.52(95% CI: -0.88, -0.15) (I2 = 73.6%, P = 0.02). The mean EDSS before menopause ranged between 1.5 and 2, and after menopause ranged between 2 and 3.1. The SMD of EDSS ranged between 0.46, and 0.71. The pooled SMD of EDSS change (after menopause-before menopause) estimated as 0.56(95% CI: 0.38, 0.73)(I2 = 0, P = 0.4). CONCLUSION The result of this systematic review and meta-analysis show that menopause can be associated with relapse rate reduction, unlike increase in disease-related disability in women with MS.
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Affiliation(s)
| | - Mohsen Rastkar
- Student's Scientific research center, Tehran University of Medical Sciences, Tehran, Iran
| | - Elnaz Rastkar
- Faculty of Medicine, Tabriz University of Medical Science, Tabriz, Iran
| | - Mehdi Mohammadifar
- Multiple Sclerosis Research Group (MSRG), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran
| | - Aida Mohamadi
- Multiple Sclerosis Research Group (MSRG), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Ghajarzadeh
- Multiple Sclerosis Research Group (MSRG), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran.
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.
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Fakhr F, Shaygannejad V, Khorrami M, Saberi L, Mirmosayyeb O, Sadeghi E, Kheirollahi M. ADAR Expression and Single Nucleotide Variants in Multiple Sclerosis Patients Affect the Response to Interferon Beta Therapy. Glob Med Genet 2023; 10:164-171. [PMID: 37501759 PMCID: PMC10370467 DOI: 10.1055/s-0043-1771001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Interferon (IFN)-β is the first-line disease management choice in multiple sclerosis (MS) with profound effects; however, in up to 50% of patients, clinical response does not occur. Ascertaining the responding state, need a long-term clinical follow-up, and this may lead to delay in use of other effective medications. IFN-induced cascade and its regulation is considered to play a major role in MS. Adenosine deaminase, RNA-specific (ADAR) dysregulation is important to IFN signaling pathway as an activity suppressor. Hence, we investigated the expression of ADAR and its single nucleotide variants of rs2229857 association with response to IFN-β in relapsing-remitting MS patients. mRNA levels and genotyping of rs2229857 in 167 MS patients were investigated via SYBR Green real-time (RT)-quantitative polymerase chain reaction and high-resolution melting RT PCR, respectively. The allele-A in rs2229857 and higher expression of ADAR were associated with poor response to IFN-β. Two response groups were significantly different in terms of annualized relapse rate, first symptoms, first extended disability status scale (EDSS), current EDSS, and the MS severity score. According to this study's findings, assessment of transcript levels and also variants in ADAR may be useful in identifying patients' response to IFN-β before starting treatment. Further investigations are needed to determine the potency of ADAR to be a predictive biomarker in drug responsiveness.
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Affiliation(s)
- Fatemeh Fakhr
- Department of Genetics and Molecular Biology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vahid Shaygannejad
- Department of Neurosciences Research Center, Alzahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Khorrami
- Department of Genetics and Molecular Biology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Leila Saberi
- Department of Genetics and Molecular Biology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Mirmosayyeb
- Department of Neurosciences Research Center, Alzahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Erfan Sadeghi
- Department of Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
- Department of Biostatistics and Epidemiology, Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Kheirollahi
- Department of Genetics and Molecular Biology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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8
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Levy M, Molazadeh N, Bilodeau PA, Vishnevetsky A, Lotan I, Salky R, Anderson M, Romanow G, Lechner-Scott J, Yeh EA, Giovannoni G. Multiple types of relapses in MOG antibody disease. Mult Scler Relat Disord 2023; 72:104613. [PMID: 36931080 DOI: 10.1016/j.msard.2023.104613] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Affiliation(s)
- Michael Levy
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America.
| | - Negar Molazadeh
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Philippe Antoine Bilodeau
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Anastasia Vishnevetsky
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Itay Lotan
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Rebecca Salky
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Monique Anderson
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Gabriela Romanow
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Jeannette Lechner-Scott
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - E Ann Yeh
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Gavin Giovannoni
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
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9
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Stefanou MI, Palaiodimou L, Theodorou A, Christodoulou MV, Tzartos JS, Tzanetakos D, Kitsos D, Chondrogianni M, Zouvelou V, Dardiotis E, Tzavellas E, Syrigou E, Benetou V, Paraskevas GP, Tsiodras S, Tsivgoulis G, Giannopoulos S. Safety of COVID-19 vaccines in multiple sclerosis: A systematic review and meta-analysis. Mult Scler 2023; 29:585-594. [PMID: 36722184 PMCID: PMC9895285 DOI: 10.1177/13524585221150881] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Data are sparse regarding the safety of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines in patients with multiple sclerosis (MS). OBJECTIVE To estimate (1) the pooled proportion of MS patients experiencing relapse among vaccine recipients; (2) the rate of transient neurological worsening, adverse events, and serious adverse events; (3) the previous outcomes of interest for different SARS-CoV-2 vaccine types. METHODS Systematic review and meta-analysis of pharmacovigilance registries and observational studies. RESULTS Nineteen observational studies comprising 14,755 MS patients who received 23,088 doses of COVID-19 vaccines were included. Mean age was 43.3 years (95% confidence interval (CI): 40-46.6); relapsing-remitting, secondary-progressive, primary-progressive MS and clinically isolated syndrome were diagnosed in 82.6% (95% CI: 73.9-89.8), 12.6% (95% CI: 6.3-20.8), 6.7% (95% CI: 4.2-9.9), and 2.9% (95% CI: 1-5.9) of cases, respectively. The pooled proportion of MS patients experiencing relapse at a mean time interval of 20 days (95% CI: 12-28.2) from vaccination was 1.9% (95% CI: 1.3%-2.6%; I2 = 78%), with the relapse risk being independent of the type of administered SARS-CoV-2-vaccine (p for subgroup differences = 0.7 for messenger RNA (mRNA), inactivated virus, and adenovector-based vaccines). After vaccination, transient neurological worsening was observed in 4.8% (95% CI: 2.3%-8.1%) of patients. Adverse events and serious adverse events were reported in 52.8% (95% CI: 46.7%-58.8%) and 0.1% (95% CI: 0%-0.2%) of vaccinations, respectively. CONCLUSION COVID-19 vaccination does not appear to increase the risk of relapse and serious adverse events in MS. Weighted against the risks of SARS-CoV-2-related complications and MS exacerbations, these safety data provide compelling pro-vaccination arguments for MS patients.
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Affiliation(s)
| | | | - Aikaterini Theodorou
- Second Department of Neurology, “Attikon”
University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Maria Veatriki Christodoulou
- Second Department of Neurology, “Attikon”
University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - John S Tzartos
- Second Department of Neurology, “Attikon”
University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Dimitrios Tzanetakos
- Second Department of Neurology, “Attikon”
University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Dimitrios Kitsos
- Second Department of Neurology, “Attikon”
University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Maria Chondrogianni
- Second Department of Neurology, “Attikon”
University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Vasiliki Zouvelou
- First Department of Neurology, Eginition
Hospital, School of Medicine, National and Kapodistrian University of
Athens, Athens, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Health Sciences, Faculty of Medicine, University of
Thessaly, Larissa, Greece
| | - Elias Tzavellas
- First Department of Psychiatry, Aiginition
Hospital, School of Medicine, National and Kapodistrian University of
Athens, Athens, Greece
| | | | - Vassiliki Benetou
- Department of Hygiene, Epidemiology and
Medical Statistics, National and Kapodistrian University of Athens, Athens,
Greece
| | - George P Paraskevas
- Second Department of Neurology, “Attikon”
University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine,
Attikon University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | | | - Sotirios Giannopoulos
- S Giannopoulos Second Department of
Neurology, “Attikon” University Hospital, School of Medicine, National and
Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece.
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10
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Wilkinson H, McGraw C, Chung K, Kyratsis Y. "Can I exercise? Would it help? Would it not?": exploring the experiences of people with relapsing remitting multiple sclerosis engaging with physical activity during a relapse: a qualitative study. Disabil Rehabil 2022:1-12. [PMID: 35727957 DOI: 10.1080/09638288.2022.2084774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Physical activity (PA) has been found to be beneficial for people with multiple sclerosis (pwMS) outside of the relapse period. However, little is known about how people experience PA during a relapse. This study investigates the experiences of pwMS engaging with PA during a relapse. MATERIALS AND METHODS The study followed an interpretivist approach, adopting a qualitative exploratory design. Semi-structured interviews were conducted with a purposive sample of 15 adults following a recent relapse. Transcripts were analysed in NVivo using framework analysis. RESULTS The experiences of participants were synthesised in three overarching themes: "on the road to recovery", "getting active but fearing repercussions", and "self-directed versus guided recovery". Barriers to PA included: feeling unwell, physical limitations, concerns about causing deterioration, worries that others would recognise their disability, and lack of professional support. Facilitators included: awareness of the benefits of PA, access to exercise resources, individualised advice and support from practitioners, and PA pitched at the right level. CONCLUSIONS Relapses can disrupt normal PA routines, making it challenging to return to PA. This article makes recommendations for supporting people to undertake PA, the timing and form of support, along with suggestions for further research exploring the safety of PA during a relapse. Implications for rehabilitationPeople with RRMS find it difficult to be physically active during a relapse.There are complex personal, social and environmental reasons why people find it hard to engage with physical activity (PA).Improved timely advice and customised support during a relapse can help reduce fears and enhance confidence with returning to PA.Physical activity recommendations should be tailored to individual's abilities to make them achievable, giving a sense of accomplishment and boosting motivation.
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Affiliation(s)
- Holly Wilkinson
- The National Hospital for Neurology and Neurosurgery, London, UK.,School of Health Sciences, City, University of London, London, UK
| | - Caroline McGraw
- School of Health Sciences, City, University of London, London, UK
| | - Karen Chung
- The National Hospital for Neurology and Neurosurgery, London, UK
| | - Yiannis Kyratsis
- Department of Organization Science, Faculty of Social Sciences, VU Amsterdam, Amsterdam, The Netherlands
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11
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Asha MZ, Al-Asaad Y, Khalil SF. The comparative efficacy and safety of anti-CD20 monoclonal antibodies for relapsing-remitting multiple sclerosis: A network meta-analysis. IBRO Neurosci Rep 2021; 11:103-111. [PMID: 34505112 PMCID: PMC8411244 DOI: 10.1016/j.ibneur.2021.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 07/14/2021] [Accepted: 08/20/2021] [Indexed: 01/08/2023] Open
Abstract
With the recent successful targeting of B lymphocytes in patients with multiple sclerosis (MS), treatment with anti-CD20 monoclonal antibodies (mAbs) may represent a promising managemental approach, particularly for those with relapsing/remitting MS (RRMS). A network meta-analysis was conducted based on a comprehensive search in Embase, PubMed, and the Cochrane Library to assess the comparative efficacy and safety of currently available anti-CD20 monoclonal antibodies (mAbs), including rituximab, ocrelizumab, and ofatumumab, versus a common comparator (interferon beta-1a [INFβ-1a]) in RRMS patients recruited in randomized clinical trials (RCTs). In a frequentist network meta-analytical model, annualized relapse rates (ARRs) and safety outcomes were expressed as risk ratios (RRs), whereas relapse-free events were expressed as odds ratios (ORs). Treatment ranking was performed using P-scores. The certainty of evidence was appraised using the GRADE approach. Five publications reported the outcomes of seven RCTs (3938 patients, 67.09% females). Compared to INFβ-1a, ocrelizumab reduced the risk of ARR (RR = 0.56, 95% CI, 0.50-0.64), serious adverse events (RR = 0.17, 95% CI, 0.09-0.30), and treatment discontinuation due to adverse events (SAEs, RR = 0.60, 95% CI, 0.39-0.93), and it was associated with higher odds of no relapses (OR = 2.47, 95% CI, 2.00-3.05). Ocrelizumab ranked best among all other treatments in terms of reducing ARR and SAEs. The quality of evidence was low for ocrelizumab, low to moderate for rituximab, and high for ofatumumab. Further large-sized, well-designed RCTs are needed to corroborate the efficacy and safety of ocrelizumab and other anti-CD20 mAbs in RRMS.
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12
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Poncet-Megemont L, Pereira B, Rollot F, Sormani MP, Clavelou P, Moisset X. Estimation of sample size in randomized controlled trials in multiple sclerosis studying annualized relapse rates: A systematic review. Mult Scler 2021; 28:1457-1466. [PMID: 34697961 DOI: 10.1177/13524585211052400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In multiple sclerosis (MS) studies, the most appropriate model for the distribution of the number of relapses was shown to be the negative binomial (NB) distribution. OBJECTIVE To determine whether the sample-size estimation (SSE) and the analysis of annualized relapse rates (ARRs) in randomized controlled trials (RCTs) were aligned and compare the SSE between normal and NB distributions. METHODS Systematic review of phase 3 and 4 RCTs for which the primary endpoint was ARR in relapsing remitting MS published since 2008 in pre-selected major medical journals. A PubMed search was performed on 30 November 2020. We checked whether the SSE and ARR analyses were congruent. We also performed standardized (fixed α/β, number of arms and overdispersion) SSEs using data collected from the studies. RESULTS Twenty articles (22 studies) were selected. NB distribution (or quasi-Poisson) was used for SSE in only 7/22 studies, whereas 21/22 used it for ARR analyses. SSE relying on NB regression necessitated a smaller sample size in 21/22 of our calculations. CONCLUSION SSE was rarely performed using the most appropriate model. However, the use of an NB model is recommended to optimize the number of included patients and to be congruent with the final analysis.
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Affiliation(s)
- Louis Poncet-Megemont
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Inserm, Neuro-Dol, Clermont-Ferrand, France
| | - Bruno Pereira
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Inserm, Neuro-Dol, Clermont-Ferrand, France
| | - Fabien Rollot
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France/Hospices Civils de Lyon, Hôpital Neurologique, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Bron, France/Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR 5292, Lyon, France/EUGENE DEVIC EDMUS Foundation Against Multiple Sclerosis, state-approved foundation, Bron, France
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa and Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Pierre Clavelou
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Inserm, Neuro-Dol, Clermont-Ferrand, France
| | - Xavier Moisset
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Inserm, Neuro-Dol, Clermont-Ferrand, France
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13
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Lopez JA, Denkova M, Ramanathan S, Dale RC, Brilot F. Pathogenesis of autoimmune demyelination: from multiple sclerosis to neuromyelitis optica spectrum disorders and myelin oligodendrocyte glycoprotein antibody-associated disease. Clin Transl Immunology 2021; 10:e1316. [PMID: 34336206 PMCID: PMC8312887 DOI: 10.1002/cti2.1316] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/20/2021] [Accepted: 07/01/2021] [Indexed: 12/16/2022] Open
Abstract
Autoimmunity plays a significant role in the pathogenesis of demyelination. Multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD) and myelin oligodendrocyte glycoprotein antibody‐associated disease (MOGAD) are now recognised as separate disease entities under the amalgam of human central nervous system demyelinating disorders. While these disorders share inherent similarities, investigations into their distinct clinical presentations and lesion pathologies have aided in differential diagnoses and understanding of disease pathogenesis. An interplay of various genetic and environmental factors contributes to each disease, many of which implicate an autoimmune response. The pivotal role of the adaptive immune system has been highlighted by the diagnostic autoantibodies in NMOSD and MOGAD, and the presence of autoreactive lymphocytes in MS lesions. While a number of autoantigens have been proposed in MS, recent emphasis on the contribution of B cells has shed new light on the well‐established understanding of T cell involvement in pathogenesis. This review aims to synthesise the clinical characteristics and pathological findings, discuss existing and emerging hypotheses regarding the aetiology of demyelination and evaluate recent pathogenicity studies involving T cells, B cells, and autoantibodies and their implications in human demyelination.
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Affiliation(s)
- Joseph A Lopez
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia.,Specialty of Child and Adolescent Health Faculty of Medicine and Health The University of Sydney Sydney NSW Australia
| | - Martina Denkova
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia.,School of Medical Sciences Faculty of Medicine and Health The University of Sydney Sydney NSW Australia
| | - Sudarshini Ramanathan
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia.,Sydney Medical School Faculty of Medicine and Health The University of Sydney Sydney NSW Australia.,Department of Neurology Concord Hospital Sydney NSW Australia
| | - Russell C Dale
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia.,Specialty of Child and Adolescent Health Faculty of Medicine and Health The University of Sydney Sydney NSW Australia.,Sydney Medical School Faculty of Medicine and Health The University of Sydney Sydney NSW Australia.,Brain and Mind Centre The University of Sydney Sydney NSW Australia
| | - Fabienne Brilot
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia.,Specialty of Child and Adolescent Health Faculty of Medicine and Health The University of Sydney Sydney NSW Australia.,School of Medical Sciences Faculty of Medicine and Health The University of Sydney Sydney NSW Australia.,Brain and Mind Centre The University of Sydney Sydney NSW Australia
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14
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Schwehr NA, Kuntz KM, Butler M, Enns EA, Shippee ND, Kingwell E, Tremlett H, Carpenter AF. Age-related decreases in relapses among adults with relapsing-onset multiple sclerosis. Mult Scler 2020; 26:1510-1518. [PMID: 31354041 PMCID: PMC6986982 DOI: 10.1177/1352458519866613] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Relapsing-onset multiple sclerosis (MS) typically starts in early- to mid-adulthood, yet the trajectory of disease activity over the subsequent lifetime remains poorly defined. Previous studies have not quantified the age-specific portion of decreases in annualized relapse rates (ARR). OBJECTIVE The aim of this article is to determine, under a range of disease-related assumptions, the age-specific component of decreases in ARR over time among adults with relapsing-onset MS. METHODS We used a simulation modeling approach to examine a range of assumptions about changes in ARR due to age versus disability status. Scenarios included variations in initial ARR and rate of worsening on the Expanded Disability Status Scale. Model parameters were developed through analysis of MS patients in British Columbia, Canada, and literature review. RESULTS We found a substantial age-specific decrease in ARR in all simulated scenarios, independent of disability worsening. Under a range of clinically plausible assumptions, 88%-97% of the decrease was attributed to age and 3%-13% to disability. The age-specific decrease ranged from 22% to 37% per 5 years for a wide range of initial ARR (0.33-1.0). CONCLUSION Decreases in ARR were due mostly to age rather than disability status. To facilitate informed decision making in MS, it is important to quantify the dynamic relationship between relapses and age.
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Affiliation(s)
- Natalie A Schwehr
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Karen M Kuntz
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Mary Butler
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Eva A Enns
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Nathan D Shippee
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Elaine Kingwell
- Division of Neurology, Faculty of Medicine, The University of British Columbia and Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada
| | - Helen Tremlett
- Division of Neurology, Faculty of Medicine, The University of British Columbia and Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada
| | - Adam F Carpenter
- Department of Neurology, Medical School, University of Minnesota and Brain Sciences Center, Veterans Affairs Medical Center, Minneapolis, MN, USA
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15
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Novotna M, Tvaroh A, Mares J. Clinical Parameters to Predict Future Clinical Disease Activity After Treatment Change to Higher-Dose Subcutaneous Interferon Beta-1a From Other Platform Injectables in Patients With Relapsing-Remitting Multiple Sclerosis. Front Neurol 2020; 11:944. [PMID: 32982947 PMCID: PMC7492204 DOI: 10.3389/fneur.2020.00944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 07/21/2020] [Indexed: 11/30/2022] Open
Abstract
Objective: To identify predictors of clinical disease activity after treatment change to higher-dose interferon beta-1a in relapsing-remitting multiple sclerosis (MS). Methods: This was a retrospective-prospective observational multicenter study. We enrolled patients with at least one relapse on platform injectable therapy who were changed to 44 μg interferon beta-1a. Our primary endpoint was the clinical disease activity-free (cDAF) status at 6, 12, 18, and 24 months. Secondary endponts included relapse-free status and disability progression-free status at different timepoints. The primary predictor of interest was the monosymptomatic vs. polysymptomatic index relapse, based on the number of affected functional systems from the Kurtzke scale during the last relapse prior to baseline. Other secondary predictors of clinical disease activity were analyzed based on different demographic and relapse characteristics. Kaplan-Meier estimates of the cumulative probability of remaining in cDAF status were performed. The time to clinical disease activity was compared between groups using univariate Kaplan-Meier analysis and multivariate Cox regression. Multivariate analyses were processed in the form of CART (Classification & Regression Trees). Results: A total of 300 patients entered the study; 233 (77.7%) of them completed the 24-month study period and 67 patients (22.3%) terminated early. The proportion of patients in cDAF status was 84.7, 69.5, 57.5, and 54.2% at 6, 12, 18, and 24 months. After 2 years of follow-up, 55.9% of patients remained relapse-free and 87.8% of patients remained disability progression-free. At all timepoints, the polysymptomatic index relapse was the most significant predictor of clinical disease activity of all studied variables. Hazard ratio of cDAF status for patients with monosymptomatic vs. polysymptomatic index relapse was 1.94 (95% CI 1.38–2.73). CART analyses also confirmed the polysymptomatic index relapse being the strongest predictor of clinical disease activity, followed by higher number of pre-baseline relapses with the most significant effect in the monosymptomatic index relapse group. The next strongest predictors of clinical disease activity were cerebellar syndrome as the most disabled Kurtzke functional system for the monosymptomatic relapse group, and age at first MS symptom ≥ 45 for the polysymptomatic relapse group. Conclusions: Patients with a polysymptomatic index relapse and/or higher number of relapses within 2 years prior to baseline are at high risk of clinical disease activity, despite treatment change to higher-dose interferon beta-1a from other platform injectable therapy. Trial registration: State Institute of Drug Control (SUKL), URL: http://www.sukl.eu/modules/nps/index.php?h=study&a=detail&id=958&lang=2, registration number 1205090000.
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Affiliation(s)
- Martina Novotna
- Department of Neurology and Center of Clinical Neuroscience, General University Hospital, Charles University, Prague, Czechia
| | - Ales Tvaroh
- Merck spol. s r.o, Prague, Czechia.,Department of Neurology, Krajska zdravotni, a.s.-Nemocnice Teplice, o.z., Teplice, Czechia
| | - Jan Mares
- Department of Neurology, MS Center, Faculty Hospital, Palacky University, Olomouc, Czechia
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16
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Schriefer D, Haase R, Ettle B, Ziemssen T. Patient- versus physician-reported relapses in multiple sclerosis: insights from a large observational study. Eur J Neurol 2020; 27:2531-2538. [PMID: 32643851 DOI: 10.1111/ene.14432] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE The patient's perspective is becoming increasingly important for endpoints in studies on multiple sclerosis. However, relapse data generated from the patient's perspective in combination with independent documentation by the physician are scarce. Our objective was to compare self-reported relapses by the patient to physician-documented relapses within a routine clinical practice setting of quarterly visits. METHODS Two-year data (n = 1921 patients) were extracted from two prospective, non-interventional, multicentre cohort studies in Germany. The number of relapses independently reported by patients and physicians was analysed. In addition, inter-rater reliability and measures of validity were evaluated. Patterns of associations were investigated in subgroup analysis of sociodemographic, clinical and patient-reported outcome measures. RESULTS Patients and physicians showed good overall agreement [κ = 0.78, 95% confidence interval (CI) 0.76-0.80]. Nevertheless, patients reported, on average, more relapses than physicians during follow-up (0.55 vs. 0.44; P < 0.001). Corresponding annualized relapse rates were 0.38 (95% CI 0.36-0.39) and 0.30 (95% CI 0.29-0.31), respectively. Differences between physicians and patients were particularly pronounced in patient groups with greater disability levels, decreased health-related quality of life or treatment satisfaction. The positive predictive value was 74.01% (95% CI 71.85-76.07), and the negative predictive value was 98.86% (95% CI 98.67-99.03). CONCLUSION Some disagreement on the occurrence of relapses appears in specific patient subgroups, where factors such as pseudo-relapses or confounding factors may have promoted over- or under-reporting.
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Affiliation(s)
- D Schriefer
- Centre of Clinical Neuroscience, Neurological University Clinic Dresden, Dresden, Germany
| | - R Haase
- Centre of Clinical Neuroscience, Neurological University Clinic Dresden, Dresden, Germany
| | - B Ettle
- Novartis Pharma GmbH, Nuremberg, Germany
| | - T Ziemssen
- Centre of Clinical Neuroscience, Neurological University Clinic Dresden, Dresden, Germany
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17
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Rooney S, Albalawi H, Paul L. Exercise in the management of multiple sclerosis relapses: current evidence and future perspectives. Neurodegener Dis Manag 2020; 10:103-115. [PMID: 32352357 DOI: 10.2217/nmt-2019-0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Relapses are a common feature of multiple sclerosis; however, recovery from relapses is often incomplete, with up to half of people experiencing residual disabilities postrelapse. Therefore, treatments are required to promote recovery of function and reduce the extent of residual disabilities postrelapse. Accordingly, this Perspective article explores the role of exercise in relapse management. Current evidence from two studies suggests that exercise in combination with steroid therapy improves disability and quality of life postrelapse, and may be more beneficial in promoting relapse recovery than steroid therapy alone. However, given the small number of studies and methodological limitations, further studies are required to understand the effects of exercise in relapse management and the mechanism through which exercise influences relapse recovery.
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Affiliation(s)
- Scott Rooney
- School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom, G4 0BA
| | - Hani Albalawi
- College of Applied Medical Sciences, University of Tabuk, Tabuk, Saudi Arabia, 47713
| | - Lorna Paul
- School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom, G4 0BA
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18
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Do disease-modifying drugs (DMD) have a positive impact on the occurrence of secondary progressive multiple sclerosis? Comment. Rev Neurol (Paris) 2020; 176:500-504. [PMID: 32278541 DOI: 10.1016/j.neurol.2020.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Very recent data from cohorts, such as that of the French Observatory of Multiple Sclerosis (OFSEP) and the MSBase cohort, are the subject of new statistical analyses using propensity scores that enable the matching of relapses frequency, EDSS, age, and sex ratio in patient populations for comparisons with each other, which reduces selection biases. The first data from these cohorts revealed a decline in transition to secondary progressive MS with the most effective disease-modifying drugs currently available, especially when these drugs were used early in the disease. However, these studies remain limited regarding the number of patients, the duration of follow-up, the use of imperfect methodologies, and the level of evidence remains low. The Gothenburg cohort in Sweden, which has been followed since the 1950s, found that 14% of benign non-progressive multiple sclerosis (MS) never evolved to secondary progression after more than 45 years of evolution. EDSS 7 was reached after 48 years of disease (median), and 50% evolved to secondary progressive MS after 15 years (consistent with data from the historic London, Ontario cohort). These data demonstrate that most people living with MS evolve without treatment to a significant long-term disability and that this evolution is closely linked to secondary progression (more than the relapse frequency). Benign forms appear as MS that never passes into secondary progressive MS. Recent data demonstrate that the delay until transition to secondary progression (more than 30 years in the MSBase cohort) and the delay in reaching EDSS 6 decreased since the introduction of disease-modifying drugs 20 years ago. However, randomized placebo-controlled trials do not last more than 2 or 3 years, and many biases may be involved in long-term follow-up studies: worsening patients who are lost to follow-up ("informative censoring" bias: only good responders to treatment remain primarily under the same long-term treatment and are followed); changes in the populations in the most recent studies with a lower rate of relapse and lower progression of disability at the beginning of the disease prior to initiating treatments; and environmental changes that remain largely misunderstood and may contribute to a natural evolution towards less severe disease.
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19
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Immunoglobulin G index as a biomarker of relapse response to corticosteroids during early stages of multiple sclerosis. Mult Scler Relat Disord 2020; 38:101495. [DOI: 10.1016/j.msard.2019.101495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/10/2019] [Accepted: 11/01/2019] [Indexed: 11/18/2022]
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Abstract
INTRODUCTION Cognitive impairment is prevalent and debilitating among persons with multiple sclerosis (MS). While many pharmacologic treatments have shown good efficacy in reducing clinical relapses, brain lesions, and improving certain physical symptoms, their efficacy for improving cognitive function is not well understood. OBJECTIVES The current systematic review aimed to evaluate the efficacy of pharmacologic treatments for improving cognitive function among persons with MS. METHODS A literature search was conducted through the PubMed and PsycINFO databases. Two independent reviewers assessed each paper, and a third reviewer weighed in if the two reviewers could not reach a consensus. Classification of evidence was determined using the 2017 American Academy of Neurology (AAN) criteria for therapeutic trials. Standardized effect sizes (Cohen's d) were calculated to compare across studies. RESULTS Eighty-seven journal articles published between 1990 and January 2020 were included in the current review. Overall, there is insufficient evidence to support the use of pharmacologic treatments to improve cognitive function in persons with MS. There were many contradictory findings observed in this review, which may be due to possible unidentified moderating treatment response variables and/or lack of standardization in assessment procedures. There was also an overreliance on statistical significance (most papers did not provide sizes of treatment effects), which may not be clinically meaningful. CONCLUSIONS Higher-quality randomized controlled trials are needed to establish the cognitive efficacy of pharmacologic treatments for MS-related cognitive dysfunction, with cognition as the primary endpoint. Researchers are urged to use standardized criteria (such as the AAN criteria) to guide their research designs. Clinicians should consider effect sizes of studies before deciding whether to prescribe certain medications to ameliorate cognitive symptoms.
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21
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Abstract
PURPOSE OF REVIEW This article provides an overview of the clinical and pathologic features of multiple sclerosis (MS) relapses and reviews evidence-based approaches to their treatment. RECENT FINDINGS Despite the increasing number and potency of MS treatments, relapses remain one of the more unpredictable and disconcerting disease aspects for many patients with MS, making their accurate recognition and treatment an essential component of good clinical care. The expanding range of relapse treatments now includes oral corticosteroids, comparable in efficacy to IV methylprednisolone at a fraction of the cost. While this development improves access to prompt treatment, it also underscores the importance of recognizing mimics of MS relapses to reduce corticosteroid overuse and its attendant risks. SUMMARY Like MS itself, MS relapse remains primarily a clinical diagnosis. The treatment options for MS relapse include corticosteroids, adrenocorticotropic hormone (ACTH), plasma exchange, and rehabilitation, used singly or sequentially, with the goal of limiting the duration and impact of associated disability. Even when treated promptly and effectively, clinical or subclinical sequelae of MS relapses frequently remain.
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22
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Giovannoni G, Brex PA, Dhiraj D, Fullarton J, Freddi M, Rodgers-Gray B, Schmierer K. Glatiramer acetate as a clinically and cost-effective treatment of relapsing multiple sclerosis over 10 years of use within the National Health Service: Final results from the UK Risk Sharing Scheme. Mult Scler J Exp Transl Clin 2019; 5:2055217319893103. [PMID: 31839981 PMCID: PMC6896140 DOI: 10.1177/2055217319893103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/08/2019] [Accepted: 11/14/2019] [Indexed: 12/13/2022] Open
Abstract
Background The UK Risk Sharing Scheme (RSS) provided information on the effect of first-line multiple sclerosis (MS) disease-modifying treatments on long-term disability. Objective The aim is to provide results specific to glatiramer acetate (GA; Copaxone®) from the final 10-year analysis of the RSS. Methods A Markov model was used to assess clinical effectiveness measured as Expanded Disability Status Scale (EDSS) progression and utility loss. Untreated patients from the British Columbia MS cohort (1980-1995) were used as a 'virtual comparator' group. A separate Markov model assessed cost-effectiveness, based on a 50-year time horizon (with a 50% treatment waning effect imposed at 10 years) and using NHS list price (£513.95 per 28 days). Results were expressed in quality-adjusted life years (QALYs). Results In total, 755 patients with relapsing-remitting MS (RRMS) received GA, with a mean follow-up of 7.1 (standard deviation 1.3) years. EDSS progression was reduced by 23% (progression ratio 76.7, 95% confidence interval [CI] 69.0-84.3) and utility loss by 39% (progression ratio 61.0, 95% CI 52.7-69.3) compared with no treatment. There was no persistent waning in GA treatment effect over time (EDSS: p = 0.093; utilities: p = 0.119). The cost per QALY was £17,841. Conclusion GA had a beneficial effect on long-term disability and was a cost-effective treatment for RRMS.
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Affiliation(s)
- G Giovannoni
- Blizard Institute, Barts, and The London School of Medicine and Dentistry, Queen Mary University London, UK
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, UK
| | - P A Brex
- King's College Hospital NHS Foundation Trust, UK
| | | | | | | | | | - K Schmierer
- Blizard Institute, Barts, and The London School of Medicine and Dentistry, Queen Mary University London, UK
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, UK
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23
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Kalincik T. Real-world studies provide reliable comparisons of disease modifying therapies in MS - Yes. Mult Scler 2019; 26:159-161. [PMID: 31478790 DOI: 10.1177/1352458519830613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
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24
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Tang Y, Fitzpatrick R. Sample size calculation for the Andersen‐Gill model comparing rates of recurrent events. Stat Med 2019; 38:4819-4827. [DOI: 10.1002/sim.8335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 06/11/2019] [Accepted: 06/25/2019] [Indexed: 11/06/2022]
Affiliation(s)
| | - Ronan Fitzpatrick
- Statistical Solutions Ltd. 4500 Avenue 4000, Cork Airport Business Park Cork, T12 NX7D Ireland
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Rhodes JK, Schindler D, Rao SM, Venegas F, Bruzik ET, Gabel W, Williams JR, Phillips GA, Mullen CC, Freiburger JL, Mourany L, Reece C, Miller DM, Bethoux F, Bermel RA, Krupp LB, Mowry EM, Alberts J, Rudick RA. Multiple Sclerosis Performance Test: Technical Development and Usability. Adv Ther 2019; 36:1741-1755. [PMID: 31054035 PMCID: PMC6824297 DOI: 10.1007/s12325-019-00958-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Indexed: 11/28/2022]
Abstract
Introduction In the clinic, the assessment of patients with multiple sclerosis (MS) is typically qualitative and non-standardized. Objectives To describe the MS Performance Test (MSPT), an iPad Air® 2 (Apple, Cupertino, CA, USA)-based neurological assessment platform allowing patients to input relevant information without the aid of a medical technician, creating a longitudinal, clinically meaningful, digital medical record. To report results from human factor (HF) and usability studies, and the initial large-scale implementation in a practice setting. Methods The HF study examined use-error patterns in small groups of MS patients and healthy controls (n = 14), the usability study assessed the effectiveness of patient interaction with the tool by patients with a range of MS disability (n = 60) in a clinical setting, and the implementation study deployed the MSPT across a diverse population of patients (n = 1000) in a large MS center for routine clinical care. Results MSPT assessments were completed by all users in the HF study; minor changes to design were recommended. In the usability study, 73% of patients with MS completed the MSPT, with an average administration time of 32 min; 85% described their experience with the tool as satisfactory. In the initial implementation for routine care, 84% of patients with MS completed the MSPT, with an average administration time of 28 min. Conclusion Patients with MS with varying disability levels completed the MSPT with minimal or no supervision, resulting in comprehensive, efficient, standardized, quantitative, clinically meaningful data collection as part of routine medical care, thus allowing for large-scale, real-world evidence generation. Funding Biogen. Trial Registration NCT02664324. Electronic supplementary material The online version of this article (10.1007/s12325-019-00958-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - David Schindler
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
- Qr8 Health, Boston, MA, USA
| | - Stephen M Rao
- Lou Ruvo Center for Brain Health, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | | | | | | | | | - Jaime L Freiburger
- Lou Ruvo Center for Brain Health, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lyla Mourany
- Lou Ruvo Center for Brain Health, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Christine Reece
- Lou Ruvo Center for Brain Health, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Deborah M Miller
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Francois Bethoux
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert A Bermel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lauren B Krupp
- New York University Langone Medical Center, New York, NY, USA
| | | | - Jay Alberts
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Asano M, Eitzen A, Hawken K, Delima L, Finlayson M. Factors Associated with Postrelapse Rehabilitation Use in Multiple Sclerosis: A Pilot Survey. Int J MS Care 2019; 21:93-99. [PMID: 31191174 DOI: 10.7224/1537-2073.2017-092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Most people with multiple sclerosis (MS) have periodic and unpredictable relapses as part of their disease course. Relapses often affect functional abilities, resulting in diminished productivity and lower quality of life. Considering the effects, rehabilitation can play an important role in facilitating recovery; yet, the current literature suggests a lack of postrelapse rehabilitation services use. This study aims to document postrelapse rehabilitation services use and estimate the extent to which predisposing characteristics, perceived need, and enabling resources were associated with postrelapse rehabilitation services use in adults with MS. Methods This cross-sectional study used convenience sampling, and data from 73 adults with MS who recently had a relapse in the United States and Canada were analyzed. Results A total of 25 participants (34.2%) reported using postrelapse rehabilitation services. The regression model identified three variables associated with postrelapse rehabilitation services use: age (odds ratio [OR], 1.075), self-reported quality of life (considerably affected by the most recent relapse [OR, 5.717]), and presence of helpful health care providers (for obtaining postrelapse rehabilitation services [OR, 5.382]). Conclusions Most participants experienced a range of symptoms or limitations because of their most recent relapse, affecting their daily activity and quality of life. However, only one-third of the participants reported using postrelapse rehabilitation services, which focused on the improvement of their physical health. Regression modeling revealed that three population characteristics of the Andersen Behavioral Model of Health Services Utilization were associated with postrelapse rehabilitation services use.
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Metz LM. Clinically Isolated Syndrome and Early Relapsing Multiple Sclerosis. Continuum (Minneap Minn) 2019; 25:670-688. [DOI: 10.1212/con.0000000000000729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Rezaee M, Izadi S, Keshavarz K, Borhanihaghighi A, Ravangard R. Fingolimod versus natalizumab in patients with relapsing remitting multiple sclerosis: a cost-effectiveness and cost-utility study in Iran. J Med Econ 2019; 22:297-305. [PMID: 30561242 DOI: 10.1080/13696998.2018.1560750] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AIMS Multiple sclerosis (MS) is a chronic, autoimmune, and inflammatory disease. If the first-line medicines are not effective enough, specialists will prescribe second-line medicines, such as natalizumab and fingolimod. This study aimed to compare the cost-effectiveness and cost-utility of fingolimod with those of natalizumab in patients with relapsing-remitting multiple sclerosis (RRMS) in Iran, Fars province in 2016. MATERIALS AND METHODS This study was a cost-effectiveness and cost-utility study in which a Markov model was used. The study used the census method to evaluate 81 patients with MS in Iran, Fars province who were being treated with fingolimod and natalizumab. In this study, costs were collected from the societal perspective, and the outcomes were the mean of relapse avoided rate and QALY. The cost data collection form, Kurtzke Expanded Disability Status Scale, and EQ-5D-3L questionnaire were used to collect the required data. RESULTS The results showed that, compared to natalizumab, patients who used fingolimod had decreased costs (58,087 vs 201,707), increased QALYs (8.09 vs 7.37), and a better relapse avoided rate (6.27 vs 5.83) per patient over the lifetime. The results of the sensitivity analysis showed that the results of the study were robust. Also, the results of the scatter plots showed that fingolimod was more cost-effective based on the QALY and relapse avoided rate in 62% and 56%, respectively, of the simulations for the thresholds below $15,657 for the studied patients. CONCLUSIONS According to the results of this study, the cost-effectiveness and cost-utility of fingolimod were higher than those of natalizumab. Therefore, it is recommended that treatment with fingolimod be the first priority of second-line treatment for MS patients, and policy-makers and health managers are encouraged to make efforts in order to increase insurance coverage and reduce the out-of-pocket payments of these patients.
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Affiliation(s)
- Mehdi Rezaee
- a Department of Health Economics, School of Management and Medical Information Sciences , Shiraz University of Medical Sciences , Shiraz , Iran
- b Student Research Committee, School of Management and Medical Information Sciences , Shiraz University of Medical Sciences , Shiraz , Iran
| | - Sadegh Izadi
- c Clinical Neurology Research Center , Medical School, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Khosro Keshavarz
- a Department of Health Economics, School of Management and Medical Information Sciences , Shiraz University of Medical Sciences , Shiraz , Iran
- d Health Human Resources Research Center, School of Management and Medical Information Sciences , Shiraz University of Medical Sciences , Shiraz , Iran
| | - Afshin Borhanihaghighi
- c Clinical Neurology Research Center , Medical School, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Ramin Ravangard
- d Health Human Resources Research Center, School of Management and Medical Information Sciences , Shiraz University of Medical Sciences , Shiraz , Iran
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Palace J, Duddy M, Lawton M, Bregenzer T, Zhu F, Boggild M, Piske B, Robertson NP, Oger J, Tremlett H, Tilling K, Ben-Shlomo Y, Lilford R, Dobson C. Assessing the long-term effectiveness of interferon-beta and glatiramer acetate in multiple sclerosis: final 10-year results from the UK multiple sclerosis risk-sharing scheme. J Neurol Neurosurg Psychiatry 2019; 90:251-260. [PMID: 30242090 PMCID: PMC6518464 DOI: 10.1136/jnnp-2018-318360] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/14/2018] [Accepted: 07/07/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Because multiple sclerosis (MS) is a chronic disease causing disability over decades, it is crucial to know if the short-term effects of disease-modifying therapies reported in randomised controlled trials reduce long-term disability. This 10-year prospective observational study of disability outcomes (Expanded Disability Status Scale (EDSS) and utility) was set up, in conjunction with a risk-sharing agreement between payers and producers, to investigate this issue. METHODS The outcomes of the UK treated patients were compared with a modelled untreated control based on the British Columbia MS data set to assess the long-term effectiveness of these treatments. Two complementary analysis models were used: a multilevel model (MLM) and a continuous Markov model. RESULTS 4862 patients with MS were eligible for the primary analysis (mean and median follow-up times 8.7 and 10 years). EDSS worsening was reduced by 28% (MLM), 7% (Markov) and 24% time-adjusted Markov in the total cohort, and by 31% (MLM) and 14% (Markov) for relapsing remitting patients. The utility worsening was reduced by 23%-24% in the total cohort and by 24%-31% in the RR patients depending on the model used. All sensitivity analyses showed a treatment effect. There was a 4-year (CI 2.7 to 5.3) delay to EDSS 6.0. An apparent waning of treatment effect with time was seen. Subgroup analyses suggested better treatment effects in those treated earlier and with lower EDSS scores. CONCLUSIONS This study supports a beneficial effect on long-term disability with first-line MS disease-modifying treatments, which is clinically meaningful. However the waning effect noted requires further study.
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Affiliation(s)
- Jacqueline Palace
- Clinical Neurology, The Oxford University Hospitals Trust, Oxford, UK
| | - Martin Duddy
- Department of Neurology, The Newcastle upon Tyne Hospitals Trust, Newcastle upon Tyne, UK
| | - Michael Lawton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Feng Zhu
- Department of Medicine (Neurology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Mike Boggild
- The Townsville Hospital, Townsville, Queensland, Australia
| | | | - Neil P Robertson
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Cardiff, UK
| | - Joel Oger
- Department of Medicine (Neurology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Helen Tremlett
- Department of Medicine (Neurology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Kate Tilling
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Zhang Y, Salter A, Wallström E, Cutter G, Stüve O. Evolution of clinical trials in multiple sclerosis. Ther Adv Neurol Disord 2019; 12:1756286419826547. [PMID: 30833985 PMCID: PMC6391540 DOI: 10.1177/1756286419826547] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 12/17/2018] [Indexed: 01/08/2023] Open
Abstract
Clinical trials have advanced the treatment of multiple sclerosis (MS) by demonstrating the safety and efficacy of disease-modifying therapies (DMTs). This review discusses major changes to MS clinical trials in the era of DMTs. As treatment options for MS continue to increase, patients in modern MS trials present earlier and with milder disease compared with historic MS populations. While placebo-controlled trials for some questions may still be relevant, DMT trials in relapsing–remitting MS (RRMS) are no longer ethical. The replacement of the placebo arm by an active comparator arm in trials have raised the cost of trials by requiring larger sample sizes to detect on-study changes in treatment effects. Efforts to improve trial efficiency in RRMS have focused on exploring adaptive designs and relying on sensitive magnetic resonance imaging measures of disease activity. In trials for progressive forms of MS (PMS), the lack of sensitive outcome measures that can be used in shorter-term trials have delayed the development of effective treatments. Recent shifting of the focus to advancing trials in PMS has identified paraclinical outcome measurements with improved potential, and the testing of agents for neuroprotection and remyelination is in progress.
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Affiliation(s)
- Yinan Zhang
- Department of Neurology and Neurotherapeutics, the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amber Salter
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Erik Wallström
- Sanofi Genzyme, Neuro and Gene Therapy, Cambridge, MA, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Olaf Stüve
- Neurology Section, VA North Texas Health Care System, Medical Service, 4500 South Lancaster Rd., Dallas, TX 75216, USADepartment of Neurology, Klinikum rechts der Isar, Technische Universität München, Germany
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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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Abstract
Multiple sclerosis (MS), a chronic autoimmune disorder, affects the central nervous system (CNS). It affects the brain, spinal cord, and optic nerve, leading to problems with vision, balance, muscle control, and other basic bodily functions. MS relapse (MSR) involves an acute inflammatory demyelinating reaction within the CNS. This review focuses on the main factors involved in MSR based on a detailed literature search. Evidence suggests that MSR is influenced by age, sex, pregnancy, serum levels of Vitamin D, interactions between genetic and environmental factors, and infectious diseases. Many of these factors are modifiable and require the attention of patients and health-care providers if favorable outcomes are to be realized. Identification of MSR risk factors can help in the development of therapies that could be used to manage MS and MSR.
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Affiliation(s)
- Fatemah Omar Kamel
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Nicholas RS, Han E, Raffel J, Chataway J, Friede T. Over three decades study populations in progressive multiple sclerosis have become older and more disabled, but have lower on-trial progression rates: A systematic review and meta-analysis of 43 randomised placebo-controlled trials. Mult Scler 2018; 25:1462-1471. [PMID: 30141723 DOI: 10.1177/1352458518794063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Progression is the major driver of disability and cost in multiple sclerosis (MS). However, the search for treatments in progressive multiple sclerosis (PMS) has not mirrored the success in relapsing MS. OBJECTIVES To assess changes in PMS trials over time. METHODS PubMed, MEDLINE and Embase were searched to identify randomised, double-blind, placebo-controlled trials in PMS. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used, study quality was assessed and trends were examined by regression. RESULTS Placebo groups of 43 studies published between 1988 and 2018 were included. The mean age at trial entry increased by 9.8 years per decade (95% confidence interval (CI): [2.7; 4.9]; p < 0.001). Mean baseline Expanded Disability Status Scale (EDSS) scores increased by 0.36 points (95% CI: [0.09; 0.62]; p = 0.009) and disease durations at baseline were prolonged by 1.8 years (95% CI: [0.7; 2.9]; p = 0.003) per decade. The trials became larger, specifically placebo groups increased by about 222 patients (95% CI: [36; 409]; p = 0.021) and 88 patients (95% CI: [12; 165]; p = 0.025) per decade for primary progressive multiple sclerosis (PPMS) and secondary progressive multiple sclerosis (SPMS), respectively. The proportion of patients on placebo experiencing disability progression within 24 months decreased by 7.6 percentage points (95% CI: [1.2; 14.1]; p = 0.022) per year. CONCLUSION Over three decades, PMS trial populations changed and are now older, with a longer disease duration and more disability, with lower on-trial progression rates.
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Affiliation(s)
- Richard S Nicholas
- Centre for Neuroinflammation and Neurodegeneration, Faculty of Medicine, Imperial College London, London, UK
| | - Erika Han
- Centre for Neuroinflammation and Neurodegeneration, Faculty of Medicine, Imperial College London, London, UK
| | - Joel Raffel
- Centre for Neuroinflammation and Neurodegeneration, Faculty of Medicine, Imperial College London, London, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
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Alsaqa'aby MF, Vaidya V, Khreis N, Khairallah TA, Al-Jedai AH. Cost-effectiveness of oral agents in relapsing-remitting multiple sclerosis compared to interferon-based therapy in Saudi Arabia. Ann Saudi Med 2017; 37:433-443. [PMID: 29229891 PMCID: PMC6074120 DOI: 10.5144/0256-4947.2017.433] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Promising clinical and humanistic outcomes are associated with the use of new oral agents in the treatment of relapsing-remitting multiple sclerosis (RRMS). This is the first cost-effectiveness study comparing these medications in Saudi Arabia. OBJECTIVES We aimed to compare the cost-effectiveness of fingolimod, teriflunomide, dimethyl fumarate, and interferon (IFN)-b1a products (Avonex and Rebif) as first-line therapies in the treatment of patients with RRMS from a Saudi payer perspective. DESIGN Cohort Simulation Model (Markov Model). SETTING Tertiary care hospital. METHODS A hypothetical cohort of 1000 RRMS Saudi patients was assumed to enter a Markov model model with a time horizon of 20 years and an annual cycle length. The model was developed based on an expanded disability status scale (EDSS) to evaluate the cost-effectiveness of the five disease-modifying drugs (DMDs) from a healthcare system perspective. Data on EDSS progression and relapse rates were obtained from the literature; cost data were obtained from King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. Results were expressed as incremental cost-effectiveness ratios (ICERs) and net monetary benefits (NMB) in Saudi Riyals and converted to equivalent $US. The base-case willingness-to-pay (WTP) threshold was assumed to be $100000 (SAR375000). One-way sensitivity analysis and probabilistic sensitivity analysis were conducted to test the robustness of the model. MAIN OUTCOME MEASURES ICERs and NMB. RESULTS The base-case analysis results showed Rebif as the optimal therapy at a WTP threshold of $100000. Avonex had the lowest ICER value of $337282/QALY when compared to Rebif. One-way sensitivity analysis demonstrated that the results were sensitive to utility weights of health state three and four and the cost of Rebif. CONCLUSION None of the DMDs were found to be cost-effective in the treatment of RRMS at a WTP threshold of $100000 in this analysis. The DMDs would only be cost-effective at a WTP above $300000. LIMITATIONS The current analysis did not reflect the Saudi population preference in valuation of health states and did not consider the societal perspective in terms of cost.
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Affiliation(s)
- Mai F Alsaqa'aby
- Mai F. Alsaqa'aby Pharmaceutical Care Division, MBC 11,, King Faisal Specialist Hospital and Research Centre,, PO Box 3354, Riyadh 11211, Saudi Arabia, T: +966-11-216919 loc 38631 MCD: 48112, , ORCID: http://orcid.org/0000.0001-8369-5044
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Hernandez L, Guo S, Toro-Diaz H, Carroll S, Syed Farooq SF. Peginterferon beta-1a versus other self-injectable disease-modifying therapies in the treatment of relapsing-remitting multiple sclerosis in Scotland: a cost-effectiveness analysis. J Med Econ 2017; 20:228-238. [PMID: 27730845 DOI: 10.1080/13696998.2016.1247712] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIMS Peginterferon beta-1a 125 mcg administered subcutaneously every 2 weeks, a new disease-modifying therapy (DMT) for relapsing-remitting multiple sclerosis (RRMS), was approved in January 2015 by the Scottish Medicines Consortium. This study assesses long-term clinical and economic outcomes of peginterferon beta-1a compared with other self-injectable DMTs (interferon beta-1a [22 mcg, 30 mcg, and 44 mcg], interferon beta-1b, and glatiramer acetate 20 mg) in the treatment of RRMS, from the National Health Service and Personal Social Services perspective in Scotland. METHODS A previously published, validated Markov cohort model was adapted for this analysis. The model estimates changes in patient disability, occurrence of relapses, and other adverse events, and translates them into quality-adjusted life years and costs. Natural history data came from the ADVANCE trial of peginterferon beta-1a, the London Ontario (Canada) database, and a large population-based MS survey in the UK. The comparative efficacy of each DMT vs placebo was obtained from a network meta-analysis. Costs (2015 British Pounds) were obtained from public databases and literature. Clinical and economic outcomes were projected over 30 years and discounted at 3.5% per year. RESULTS Over 30 years, peginterferon beta-1a was dominant compared with interferon beta-1a (22, 30, and 44 mcg), and interferon beta-1b, and cost-effective compared with glatiramer acetate 20 mg. Results were most sensitive to variations in each DMT's efficacy and acquisition costs. Deterministic and probabilistic sensitivity analyses confirmed the robustness of the results. LIMITATIONS The impact of improved adherence with peginterferon beta-1a on clinical and economic outcomes and the impact of subsequent DMTs after treatment discontinuation were not considered. Oral and infused DMTs were not included as comparators. Conclusion Long-term treatment with peginterferon beta-1a improves clinical outcomes, while its cost profile makes it either dominant or cost-effective compared with other self-injectable DMTs for the treatment of RRMS in Scotland.
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Capra R, Cordioli C, Rasia S, Gallo F, Signori A, Sormani MP. Assessing long-term prognosis improvement as a consequence of treatment pattern changes in MS. Mult Scler 2017; 23:1757-1761. [PMID: 28080255 DOI: 10.1177/1352458516687402] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess whether the age at which multiple sclerosis (MS) patients reach Expanded Disability Status Scale (EDSS) milestones changed as long as new drugs for the treatment of MS became available. METHODS We evaluated the long-term impact of therapies on disability progression assessing whether there is a detectable delay in the age at which patients reached EDSS milestones in more recent years. We used data collected over more than 30 years in the Center of Brescia, Italy. We compared the age at EDSS = 6 among patients diagnosed with relapsing-remitting MS in different time periods, adjusting for age at diagnosis and median interval among EDSS visits, by a multivariate Cox model. RESULTS A total of 1324 MS patients were included. Patients diagnosed in more recent periods reached EDSS = 6 at an older age: the rate at which patients reached EDSS = 6 in those diagnosed in 1991-1995 was similar to those diagnosed in 1980-1990 (hazard ratio ( HR) = 1.09, p = 0.68) and to those diagnosed in 1996-2000 ( HR = 0.85, p = 0.44), it was reduced by 37% in patients diagnosed in 2001-2005 ( HR = 0.63, p = 0.05), by 46% in patients diagnosed in 2006-2010 ( HR = 0.54, p < 0.02). CONCLUSION A clear modification of MS course is observed after 2000; among other causes, this can be associated to the changes in the treatment patterns experienced in those years.
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Affiliation(s)
- Ruggero Capra
- Multiple Sclerosis Center, Spedali Civili di Brescia, Montichiari Hospital, Montichiari, Italy/University of Genoa, Genoa, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Center, Spedali Civili di Brescia, Montichiari Hospital, Montichiari, Italy/University of Genoa, Genoa, Italy
| | - Sarah Rasia
- Multiple Sclerosis Center, Spedali Civili di Brescia, Montichiari Hospital, Montichiari, Italy/University of Genoa, Genoa, Italy
| | - Fabio Gallo
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Alessio Signori
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Freedman MS, Montalban X, Miller AE, Dive-Pouletty C, Hass S, Thangavelu K, Leist TP. Comparing outcomes from clinical studies of oral disease-modifying therapies (dimethyl fumarate, fingolimod, and teriflunomide) in relapsing MS: Assessing absolute differences using a number needed to treat analysis. Mult Scler Relat Disord 2016; 10:204-212. [DOI: 10.1016/j.msard.2016.10.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/30/2016] [Accepted: 10/31/2016] [Indexed: 11/16/2022]
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Eckstein C, Bhatti MT. Currently approved and emerging oral therapies in multiple sclerosis: An update for the ophthalmologist. Surv Ophthalmol 2016; 61:318-32. [DOI: 10.1016/j.survophthal.2015.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 12/07/2015] [Indexed: 12/14/2022]
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Tramacere I, Del Giovane C, Salanti G, D'Amico R, Filippini G. Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2015; 2015:CD011381. [PMID: 26384035 PMCID: PMC9235409 DOI: 10.1002/14651858.cd011381.pub2] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Different therapeutic strategies are available for the treatment of people with relapsing-remitting multiple sclerosis (RRMS), including immunomodulators, immunosuppressants and biologics. Although there is consensus that these therapies reduce the frequency of relapses, their relative benefit in delaying new relapses or disability worsening remains unclear due to the limited number of direct comparison trials. OBJECTIVES To compare the benefit and acceptability of interferon beta-1b, interferon beta-1a (Avonex, Rebif), glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab, pegylated interferon beta-1a, daclizumab, laquinimod, azathioprine and immunoglobulins for the treatment of people with RRMS and to provide a ranking of these treatments according to their benefit and acceptability, defined as the proportion of participants who withdrew due to any adverse event. SEARCH METHODS We searched the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group Trials Register, which contains trials from CENTRAL (2014, Issue 9), MEDLINE (1966 to 2014), EMBASE (1974 to 2014), CINAHL (1981 to 2014), LILACS (1982 to 2014), clinicaltrials.gov and the WHO trials registry, and US Food and Drug Administration (FDA) reports. We ran the most recent search in September 2014. SELECTION CRITERIA Randomised controlled trials (RCTs) that studied one or more of the 15 treatments as monotherapy, compared to placebo or to another active agent, for use in adults with RRMS. DATA COLLECTION AND ANALYSIS Two authors independently identified studies from the search results and performed data extraction. We performed data synthesis by pairwise meta-analysis and network meta-analysis. We assessed the quality of the body of evidence for outcomes within the network meta-analysis according to GRADE, as very low, low, moderate or high. MAIN RESULTS We included 39 studies in this review, in which 25,113 participants were randomised. The majority of the included trials were short-term studies, with a median duration of 24 months. Twenty-four (60%) were placebo-controlled and 15 (40%) were head-to-head studies.Network meta-analysis showed that, in terms of a protective effect against the recurrence of relapses in RRMS during the first 24 months of treatment, alemtuzumab, mitoxantrone, natalizumab, and fingolimod outperformed other drugs. The most effective drug was alemtuzumab (risk ratio (RR) versus placebo 0.46, 95% confidence interval (CI) 0.38 to 0.55; surface under the cumulative ranking curve (SUCRA) 96%; moderate quality evidence), followed by mitoxantrone (RR 0.47, 95% CI 0.27 to 0.81; SUCRA 92%; very low quality evidence), natalizumab (RR 0.56, 95% CI 0.47 to 0.66; SUCRA 88%; high quality evidence), and fingolimod (RR 0.72, 95% CI 0.64 to 0.81; SUCRA 71%; moderate quality evidence).Disability worsening was based on a surrogate marker, defined as irreversible worsening confirmed at three-month follow-up, measured during the first 24 months in the majority of included studies. Both direct and indirect comparisons revealed that the most effective treatments were mitoxantrone (RR versus placebo 0.20, 95% CI 0.05 to 0.84; SUCRA 96%; low quality evidence), alemtuzumab (RR 0.35, 95% CI 0.26 to 0.48; SUCRA 94%; low quality evidence), and natalizumab (RR 0.64, 95% CI 0.49 to 0.85; SUCRA 74%; moderate quality evidence).Almost all of the agents included in this review were associated with a higher proportion of participants who withdrew due to any adverse event compared to placebo. Based on the network meta-analysis methodology, the corresponding RR estimates versus placebo over the first 24 months of follow-up were: mitoxantrone 9.92 (95% CI 0.54 to 168.84), fingolimod 1.69 (95% CI 1.32 to 2.17), natalizumab 1.53 (95% CI 0.93 to 2.53), and alemtuzumab 0.72 (95% CI 0.32 to 1.61).Information on serious adverse events (SAEs) was scanty, characterised by heterogeneous results and based on a very low number of events observed during the short-term duration of the trials included in this review. AUTHORS' CONCLUSIONS Conservative interpretation of these results is warranted, since most of the included treatments have been evaluated in few trials. The GRADE approach recommends providing implications for practice based on moderate to high quality evidence. Our review shows that alemtuzumab, natalizumab, and fingolimod are the best choices for preventing clinical relapses in people with RRMS, but this evidence is limited to the first 24 months of follow-up. For the prevention of disability worsening in the short term (24 months), only natalizumab shows a beneficial effect on the basis of moderate quality evidence (all of the other estimates were based on low to very low quality evidence). Currently, therefore, insufficient evidence is available to evaluate treatments for the prevention of irreversible disability worsening.There are two additional major concerns that have to be considered. First, the benefit of all of these treatments beyond two years is uncertain and this is a relevant issue for a disease with a duration of 30 to 40 years. Second, short-term trials provide scanty and poorly reported safety data and do not provide useful evidence in order to obtain a reliable risk profile of treatments. In order to provide long-term information on the safety of the treatments included in this review, it will be necessary also to evaluate non-randomised studies and post-marketing reports released from the regulatory agencies. Finally, more than 70% of the studies included in this review were sponsored by pharmaceutical companies and this may have influenced the results.There are three needs that the research agenda should address. First, randomised trials of direct comparisons between active agents would be useful, avoiding further placebo-controlled studies. Second, follow-up of the original trial cohorts should be mandatory. Third, more studies are needed to assess the medium and long-term benefit and safety of immunotherapies and the comparative safety of different agents.
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Affiliation(s)
- Irene Tramacere
- Neuroepidemiology Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Giovanni Celoria, 11, Milano, Italy, 20133
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Röver C, Nicholas R, Straube S, Friede T. Changing EDSS Progression in Placebo Cohorts in Relapsing MS: A Systematic Review and Meta-Regression. PLoS One 2015; 10:e0137052. [PMID: 26327532 PMCID: PMC4556534 DOI: 10.1371/journal.pone.0137052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/12/2015] [Indexed: 11/19/2022] Open
Abstract
Background Recent systematic reviews of randomised controlled trials (RCTs) in relapsing multiple sclerosis (RMS) revealed a decrease in placebo annualized relapse rates (ARR) over the past two decades. Furthermore, regression to the mean effects were observed in ARR and MRI lesion counts. It is unclear whether disease progression measured by the expanded disability status scale (EDSS) exhibits similar features. Methods A systematic review of RCTs in RMS was conducted extracting data on EDSS and baseline characteristics. The logarithmic odds of disease progression were modelled to investigate time trends. Random-effects models were used to account for between-study variability; all investigated models included trial duration as a predictor to correct for unequal study durations. Meta-regressions were conducted to assess the prognostic value of a number of study-level baseline variables. Results The systematic literature search identified 39 studies, including a total of 19,714 patients. The proportion of patients in placebo controls experiencing a disease progression decreased over the years (p<0.001). Meta-regression identified associated covariates including the size of the study and its duration that in part explained the time trend. Progression probabilities tended to be lower in the second year of a study compared to the first year with a reduction of 28% in progression odds from year 1 to year 2 (p = 0.017). Conclusion EDSS disease progression exhibits similar behaviour over time as the ARR and point to changes in trial characteristics over the years. This needs to be considered in comparisons between historical and recent trials.
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Affiliation(s)
- Christian Röver
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | | | - Sebastian Straube
- Division of Preventive Medicine, University of Alberta, Edmonton, AB, T6G 2T4, Canada
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
- * E-mail:
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Gajofatto A, Benedetti MD. Treatment strategies for multiple sclerosis: When to start, when to change, when to stop? World J Clin Cases 2015; 3:545-555. [PMID: 26244148 PMCID: PMC4517331 DOI: 10.12998/wjcc.v3.i7.545] [Citation(s) in RCA: 161] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 03/02/2015] [Accepted: 05/06/2015] [Indexed: 02/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory condition of the central nervous system determined by a presumed autoimmune process mainly directed against myelin components but also involving axons and neurons. Acute demyelination shows as clinical relapses that may fully or partially resolve, while chronic demyelination and neuroaxonal injury lead to persistent and irreversible neurological symptoms, often progressing over time. Currently approved disease-modifying therapies are immunomodulatory or immunosuppressive drugs that significantly although variably reduce the frequency of attacks of the relapsing forms of the disease. However, they have limited efficacy in preventing the transition to the progressive phase of MS and are of no benefit after it has started. It is therefore likely that the potential advantage of a given treatment is condensed in a relatively limited window of opportunity for each patient, depending on individual characteristics and disease stage, most frequently but not necessarily in the early phase of the disease. In addition, a sizable proportion of patients with MS may have a very mild clinical course not requiring a disease-modifying therapy. Finally, individual response to existing therapies for MS varies significantly across subjects and the risk of serious adverse events remains an issue, particularly for the newest agents. The present review is aimed at critically describing current treatment strategies for MS with a particular focus on the decision of starting, switching and stopping commercially available immunomodulatory and immunosuppressive therapies.
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The Lived Experience of Multiple Sclerosis Relapse: How Adults with Multiple Sclerosis Processed Their Relapse Experience and Evaluated Their Need for Postrelapse Care. Mult Scler Int 2015; 2015:351416. [PMID: 26075095 PMCID: PMC4444598 DOI: 10.1155/2015/351416] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 04/23/2015] [Indexed: 11/17/2022] Open
Abstract
Background. Multiple sclerosis (MS) relapses can take a toll on individuals' health and quality of life. Given such consequences of relapses, postrelapse care beyond pharmacological approaches may play an important role in recovery. Nevertheless, how individuals with MS process their relapse experience and manage the consequences is still uncertain. Purpose. We conducted a qualitative study to understand relapse experiences and postrelapse care need from perspectives of adults with MS and identify relapse management patterns. Methods. We interviewed 17 adults with MS. Results. By examining combinations of three categories related to relapse experience, we identified four relapse management patterns: (i) Active Relapse Manager, (ii) Early-Stage Proactive Relapse Monitor, (iii) Adapted Passive Relapse Manager, and (iv) Passive Relapse Monitor. The relapse management patterns appear to associate strongly with the appraisal of the experience. Conclusions. The results of this study suggest the importance of understanding each patient beyond their functional limitations and the potential need for multidisciplinary postrelapse care which goes past restoring functional limitations at the acute phase. Future research to further understand the relapse management process at all stages of the healthcare continuum is a crucial step toward developing strategies to advance the current postrelapse care and to facilitate optimal recovery.
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Cocco E, Marrosu MG. Profile of PEGylated interferon beta in the treatment of relapsing-remitting multiple sclerosis. Ther Clin Risk Manag 2015; 11:759-66. [PMID: 26056458 PMCID: PMC4431469 DOI: 10.2147/tcrm.s69123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Several treatments are currently available for relapsing-remitting multiple sclerosis. Among them, interferon (IFN) beta remains a valid treatment approach because of its good benefit/risk profile. Due to the need for frequent administration (weekly, at a minimum), the use of IFN beta is limited by uncomfortable side effects that could reduce adherence to and persistence with the treatment. The use of subcutaneous polyethylene glycol (PEG)ylated interferon beta-1a (PEG-IFN) has been proposed to offer a better combination of pharmacokinetic and pharmacodynamic profiles and therapy-related side effects. A 125 μg dose of PEG-IFN given every 2 or 4 weeks was tested in two Phase I studies and shown to be as safe and efficient as IFN beta-1a but with a longer half-life. A Phase III trial (ADVANCE) comparing 125 μg of PEG-IFN given every 2 or 4 weeks with placebo in 1,512 patients with relapsing-remitting multiple sclerosis showed significant reductions in both the annualized relapse rate (ARR) and the occurrence of new or newly enlarged T2 brain lesions in both experimental groups versus placebo after the first year. Moreover, 38% fewer patients showed progression of disability (P=0.04) in the PEG-IFN groups. During the second year, the ARR was further reduced in the PEG-IFN 2-week treatment group (0.230 at 1 year versus 0.178 at 2 years) and was maintained in the 4-week treatment group. Patients who received immediate PEG-IFN treatment showed improved clinical efficacy (ARR, risk of relapse, 12-week disability progression) and magnetic resonance imaging parameters (new T2 and newly enlarging lesions, gadolinium-positive lesions) compared with those with delayed treatment. The effects were more evident with the 2-week dose for all endpoints considered. Furthermore, PEG-IFN was well tolerated, and no new safety concerns arose. In conclusion, PEG-IFN has good efficacy and a good safety profile. The available data support the use of PEG-IFN as a suitable therapeutic option in patients with relapsing-remitting multiple sclerosis.
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Affiliation(s)
- Eleonora Cocco
- Multiple Sclerosis Center, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy
| | - Maria Giovanna Marrosu
- Multiple Sclerosis Center, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy
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Nickerson M, Cofield SS, Tyry T, Salter AR, Cutter GR, Marrie RA. Impact of multiple sclerosis relapse: The NARCOMS participant perspective. Mult Scler Relat Disord 2015; 4:234-40. [DOI: 10.1016/j.msard.2015.03.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 03/13/2015] [Accepted: 03/18/2015] [Indexed: 11/17/2022]
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Palace J, Duddy M, Bregenzer T, Lawton M, Zhu F, Boggild M, Piske B, Robertson NP, Oger J, Tremlett H, Tilling K, Ben-Shlomo Y, Dobson C. Effectiveness and cost-effectiveness of interferon beta and glatiramer acetate in the UK Multiple Sclerosis Risk Sharing Scheme at 6 years: a clinical cohort study with natural history comparator. Lancet Neurol 2015; 14:497-505. [PMID: 25841667 DOI: 10.1016/s1474-4422(15)00018-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 02/24/2015] [Accepted: 02/27/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND In 2002, the UK's National Institute for Clinical Excellence (NICE) concluded that interferon beta and glatiramer acetate would be cost effective as disease-modifying therapies (DMTs) for multiple sclerosis only if the short-term disability benefits reported in clinical trials were maintained. The UK Multiple Sclerosis Risk Sharing Scheme (RSS) was established to assess whether disability progression was consistent with a cost-effectiveness target of £36 000 per quality-adjusted life-year projected over 20 years. We aimed to evaluate the long-term effectiveness and cost-effectiveness of these DMTs by comparing a cohort of patients with relapsing-remitting multiple sclerosis enrolled in the UK RSS with a natural history cohort from British Columbia, Canada. METHODS In our clinical cohort we included patients starting a DMT who were enrolled in the UK RSS who had relapsing multiple sclerosis at baseline and had at least one further clinical assessment. In our control cohort we included patients in the British Columbia multiple sclerosis database (BCMS; data collection 1980-96) who met the same eligibility criteria as for the RSS cohort. We compared disability progression at 6 years for RSS patients with untreated progression modelled from BCMS patients using continuous Markov and multilevel models. The primary outcomes were the progression ratio (treated vs untreated) measured both in Expanded Disability Status Scale (EDSS) score and utility. A ratio of less than 100% for EDSS implied slower than expected progression on treatment compared with off treatment; a utility ratio of 62% or less implied that the DMTs were cost effective. FINDINGS 5610 patients starting a DMT were enrolled in the UK RSS between Jan 14, 2002, and July 13, 2005 (72 sites), of whom 4137 were included in our clinical cohort. We included 898 BCMS patients in the control cohort who met the RSS inclusion criteria and had at least one EDSS score after baseline. RSS patients had a mean follow-up of 5·1 years (SD 1·4). Both models showed slower EDSS progression than predicted for untreated controls (Markov model, 75·8% [95% CI 71·4-80·2]; multilevel model, 60·0% [56·6-63·4]). Utility ratios were consistent with cost-effectiveness (Markov model, 58·5% [95% CI 54·2-62·8]; multilevel model, 57·1% [53·0-61·2]). INTERPRETATION Findings from this large observational study of treatment with interferon beta or glatiramer acetate provide evidence that their effects on disability in patients with relapsing-remitting multiple sclerosis are maintained and cost effective over 6 years. Similar modelling approaches could be applied to other chronic diseases for which long-term controlled trials are not feasible. FUNDING Health Departments of England, Wales, Scotland, and Northern Ireland, Biogen Idec, Merck Serono, Bayer Schering Pharmaceuticals, Teva Pharmaceuticals Industries, UK National Institute of Health Research's Health Technology Assessment Programme.
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Affiliation(s)
- Jacqueline Palace
- Department of Clinical Neurology, Oxford University Hospitals Trust, Oxford, UK
| | - Martin Duddy
- Department of Neurology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Thomas Bregenzer
- Department of Biostatistics, PAREXEL International, Berlin, Germany
| | - Michael Lawton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Feng Zhu
- Department of Medicine (Neurology), University of British Columbia, Vancouver, BC, Canada
| | - Mike Boggild
- Department of Neurology, The Townsville Hospital, Townsville, QLD, Australia
| | - Benjamin Piske
- Department of Biostatistics, PAREXEL International, Berlin, Germany
| | - Neil P Robertson
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Joel Oger
- Department of Medicine (Neurology), University of British Columbia, Vancouver, BC, Canada
| | - Helen Tremlett
- Department of Medicine (Neurology), University of British Columbia, Vancouver, BC, Canada
| | - Kate Tilling
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Yoav Ben-Shlomo
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Karabudak R, Dahdaleh M, Aljumah M, Alroughani R, Alsharoqi IA, AlTahan AM, Bohlega SA, Daif A, Deleu D, Amous A, Inshasi JS, Rieckmann P, Sahraian MA, Yamout BI. Functional clinical outcomes in multiple sclerosis: Current status and future prospects. Mult Scler Relat Disord 2015; 4:192-201. [PMID: 26008936 DOI: 10.1016/j.msard.2015.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/23/2015] [Accepted: 03/14/2015] [Indexed: 11/29/2022]
Abstract
For decades, the Expanded Disability Status Scale (EDSS) has been the principal measure of disability in clinical trials in patients with multiple sclerosis (MS) and in clinical practice. However, this test is dominated by effects on ambulation. Composite endpoints may provide a more sensitive measure of MS-related disability through the measurement of additional neurological functions. The MS Functional Composite (MSFC) includes a walking test (25-ft walk) plus tests of upper extremity dexterity (9-hole peg test) and cognitive function (Paced Auditory serial Addition test [PASAT]). Replacing PASAT with the Symbol Digit Modality test, a more sensitive test preferred by patients, may improve the clinical utility of the MSFC. In addition, disease-specific measures of QoL may be used alongside the MSFC (which does not include measurement of QoL). Clinical data suggest that disease-modifying therapies may delay or prevent relapse, and better composite measures will be valuable in the assessment of disease activity-free status in people with MS.
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Affiliation(s)
- Rana Karabudak
- Hacettepe University Hospitals, Dept. of Neurology, Neuroimmunology Unit, Ankara, Turkey.
| | - Maurice Dahdaleh
- Department of Internal Medicine, Neurology Section, Arab Medical Center and Khalidi Hospital, Amman, Jordan
| | - Mohammed Aljumah
- King Abdullah International Medical Research Center, King Saud Ben Abdulaziz University for Health Sciences, NGHA, Riyadh, Saudi Arabia; Prince Mohammed bin Abdul-Aziz Hospital, Ministry of Health, Riyadh, Saudi Arabia
| | - Raed Alroughani
- Division of Neurology, Amiri Hospital, Kuwait; Division of Neurology, Dasman Diabetes Institute, Kuwait
| | - I Ahmed Alsharoqi
- Clinical Neurosciences Department, Salmaniya Medical Complex, Manama, Bahrain
| | - Abdulrahman M AlTahan
- Neurology Section, King Khalid University Hospital, King Saud University and Dallah Hospital, Saudi Arabia
| | - Saeed A Bohlega
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulkader Daif
- Neurology Section, King Khalid University Hospital, King Saud University and Dallah Hospital, Saudi Arabia
| | - Dirk Deleu
- Department of Neurology (Medicine), Hamad Medical Corporation, Doha, Qatar
| | - Amer Amous
- Merck Serono Intercontinental Region, Dubai, United Arab Emirates
| | - Jihad S Inshasi
- Neurology Department, Rashid Hospital and Dubai Medical College, Dubai Health Authority, United Arab Emirates
| | | | - Mohammed A Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Iran
| | - Bassem I Yamout
- Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
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Freedman MS, Abdoli M. Evaluating response to disease-modifying therapy in relapsing multiple sclerosis. Expert Rev Neurother 2015; 15:407-23. [DOI: 10.1586/14737175.2015.1023711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Stellmann JP, Stürner KH, Young KL, Siemonsen S, Friede T, Heesen C. Regression to the mean and predictors of MRI disease activity in RRMS placebo cohorts--is there a place for baseline-to-treatment studies in MS? PLoS One 2015; 10:e0116559. [PMID: 25659100 PMCID: PMC4319835 DOI: 10.1371/journal.pone.0116559] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/10/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Gadolinium-enhancing (GD+) lesions and T2 lesions are MRI outcomes for phase-2 treatment trials in relapsing-remitting Multiple Sclerosis (RRMS). Little is known about predictors of lesion development and regression-to-the-mean, which is an important aspect in early baseline-to-treatment trials. OBJECTIVES To quantify regression-to-the-mean and identify predictors of MRI lesion development in placebo cohorts. METHODS 21 Phase-2 and Phase-3 trials were identified by a systematic literature research. Random-effects meta-analyses were performed to estimate development of T2 and GD+ after 6 months (phase-2) or 2 years (phase-3). Predictors of lesion development were evaluated with mixed-effect meta-regression. RESULTS The mean number of GD+-lesions per scan was similar after 6 months (1.19, 95%CI: 0.87-1.51) and 2 years (1.19, 95%CI: 1.00-1.39). 39% of the patients were without new T2-lesion after 6 month and 19% after 2 years (95%CI: 12-25%). Mean number of baseline GD+-lesions was the best predictor for new lesions after 6 months. CONCLUSION Baseline GD-enhancing lesions predict evolution of Gd- and T2 lesions after 6 months and might be used to control for regression to the mean effects. Overall, proof-of-concept studies with a baseline to treatment design have to face a regression to 1.2 GD+lesions per scan within 6 months.
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Affiliation(s)
- Jan-Patrick Stellmann
- Institute for Neuroimmunology and MS (inims) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klarissa Hanja Stürner
- Institute for Neuroimmunology and MS (inims) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kim Lea Young
- Institute for Neuroimmunology and MS (inims) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Siemonsen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Heesen
- Institute for Neuroimmunology and MS (inims) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Sormani MP, Bruzzi P. Can we measure long-term treatment effects in multiple sclerosis? Nat Rev Neurol 2014; 11:176-82. [DOI: 10.1038/nrneurol.2014.237] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Tramacere I, Del Giovane C, Salanti G, D'Amico R, Pacchetti I, Filippini G. Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011381] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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