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Tallantyre EC, Dobson R, Froud JLJ, St John FA, Anderson VM, Arun T, Buckley L, Evangelou N, Ford HL, Galea I, George S, Gray OM, Hibbert AM, Hu M, Hughes SE, Ingram G, Kalra S, Lim CE, Mathews JTM, McDonnell GV, Mescall N, Norris S, Ramsay SJ, Rice CM, Russell MJ, Shawe‐Taylor MJ, Williams TE, Harding KE, Robertson NP. Real-world persistence of multiple sclerosis disease-modifying therapies. Eur J Neurol 2024; 31:e16289. [PMID: 38567516 PMCID: PMC11235620 DOI: 10.1111/ene.16289] [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: 11/26/2023] [Revised: 02/26/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND PURPOSE Treatment persistence is the continuation of therapy over time. It reflects a combination of treatment efficacy and tolerability. We aimed to describe real-world rates of persistence on disease-modifying therapies (DMTs) for people with multiple sclerosis (pwMS) and reasons for DMT discontinuation. METHODS Treatment data on 4366 consecutive people with relapse-onset multiple sclerosis (MS) were pooled from 13 UK specialist centres during 2021. Inclusion criteria were exposure to at least one MS DMT and a complete history of DMT prescribing. PwMS in blinded clinical trials were excluded. Data collected included sex, age at MS onset, age at DMT initiation, DMT treatment dates, and reasons for stopping or switching DMT. For pwMS who had received immune reconstituting therapies (cladribine/alemtuzumab), discontinuation date was defined as starting an alternative DMT. Kaplan-Meier survival analyses were used to express DMT persistence. RESULTS In 6997 treatment events (1.6 per person with MS), median time spent on any single maintenance DMT was 4.3 years (95% confidence interval = 4.1-4.5 years). The commonest overall reasons for DMT discontinuation were adverse events (35.0%) and lack of efficacy (30.3%). After 10 years, 20% of people treated with alemtuzumab had received another subsequent DMT, compared to 82% of people treated with interferon or glatiramer acetate. CONCLUSIONS Immune reconstituting DMTs may have the highest potential to offer a single treatment for relapsing MS. Comparative data on DMT persistence and reasons for discontinuation are valuable to inform treatment decisions and in personalizing treatment in MS.
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Affiliation(s)
- Emma C. Tallantyre
- Division of Psychological Medicine and Clinical NeurosciencesCardiff UniversityCardiffUK
- Department of NeurologyUniversity Hospital of WalesCardiffUK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population HealthQueen Mary University LondonLondonUK
- Department of Neurology, Royal London HospitalBarts Health NHS TrustLondonUK
| | - Joseph L. J. Froud
- Division of Psychological Medicine and Clinical NeurosciencesCardiff UniversityCardiffUK
- Postgraduate DepartmentSt Thomas' HospitalLondonUK
| | - Frederika A. St John
- Division of Psychological Medicine and Clinical NeurosciencesCardiff UniversityCardiffUK
| | - Valerie M. Anderson
- Division of Psychological Medicine and Clinical NeurosciencesCardiff UniversityCardiffUK
| | - Tarunya Arun
- Department of NeuroscienceUniversity Hospitals Coventry and WarwickshireCoventryUK
| | - Lauren Buckley
- Department of Neurology, Southmead HospitalNorth Bristol NHS TrustBristolUK
| | - Nikos Evangelou
- Nottingham Centre for Multiple Sclerosis and Neuroinflammation, Queen's Medical CentreUniversity Hospitals NHS TrustNottinghamUK
- University of NottinghamNottinghamUK
| | - Helen L. Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS TrustLeeds General InfirmaryLeedsUK
- Faculty of Medicine and HealthUniversity of LeedsLeedsUK
| | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Department of Neurology, Wessex Neurological CentreUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Sumi George
- Department of NeurologyUlster HospitalDundonaldUK
| | - Orla M. Gray
- Department of NeurologyUlster HospitalDundonaldUK
| | - Aimee M. Hibbert
- Nottingham Centre for Multiple Sclerosis and Neuroinflammation, Queen's Medical CentreUniversity Hospitals NHS TrustNottinghamUK
| | - Mo Hu
- Department of NeurologySwansea University Health BoardSwanseaUK
| | | | - Gillian Ingram
- Department of NeurologySwansea University Health BoardSwanseaUK
| | - Seema Kalra
- Neurology DepartmentUniversity Hospital North Midlands NHS TrustStoke‐on‐TrentUK
| | - Chia‐Hui E. Lim
- Department of Neurology, Wessex Neurological CentreUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK
| | | | | | - Naomi Mescall
- Queen Square Multiple Sclerosis Centre, Department of NeuroinflammationUniversity College LondonLondonUK
| | - Sam Norris
- Aneurin Bevan University Health Board, Department of NeurologyRoyal Gwent HospitalNewportUK
| | | | - Claire M. Rice
- Department of Neurology, Southmead HospitalNorth Bristol NHS TrustBristolUK
- Transplantation Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Melanie J. Russell
- Centre for Neurosciences, Leeds Teaching Hospitals NHS TrustLeeds General InfirmaryLeedsUK
| | - Marianne J. Shawe‐Taylor
- Queen Square Multiple Sclerosis Centre, Department of NeuroinflammationUniversity College LondonLondonUK
| | - Thomas E. Williams
- Queen Square Multiple Sclerosis Centre, Department of NeuroinflammationUniversity College LondonLondonUK
- Faculty of Brain Sciences, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Katharine E. Harding
- Aneurin Bevan University Health Board, Department of NeurologyRoyal Gwent HospitalNewportUK
| | - Neil P. Robertson
- Division of Psychological Medicine and Clinical NeurosciencesCardiff UniversityCardiffUK
- Department of NeurologyUniversity Hospital of WalesCardiffUK
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Roar M, Nielsen ARH, Berg JM, Sirakov G, Stilund M, Schäfer J, Ratzer R, Frederiksen J, Asgari N, Ashna SN, Jensen HB, Kant M, Theódorsdóttir Á, Illes Z, Sellebjerg F, Magyari M, Schlosser LM, Nordborg H, Wergeland S, Sejbaek T. Discontinuation of dimethyl fumarate in multiple sclerosis - a nationwide study. Mult Scler Relat Disord 2023; 80:105127. [PMID: 37956521 DOI: 10.1016/j.msard.2023.105127] [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: 03/01/2023] [Revised: 08/18/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Adherence is a prerequisite for the efficacy of any drug, and previous studies have shown that non-adherence is associated with disease activity and increased health care cost in multiple sclerosis (MS). The aim of this study was to investigate rates and reasons for discontinuation of dimethyl fumarate (DMF) among people with MS on a national level and differences between clinics in Denmark. METHODS This was a nationwide, registry and population study of patients treated with DMF. We calculated standard residuals (SR) demonstrate differences between clinics. For survival analysis regarding discontinuation rates and discontinuation due to specific AEs we used log-rank test Cox-proportional hazards and plotted Kaplan-Meier graphics. RESULTS We included 2,448 people with MS, treated with DMF from 2013 to 2020. Average treatment duration was 26 months (5,382 treatment years). 49.2 % of patients who initiated treatment with DMF (n = 1205) were continuously treated. Reasons for discontinuation were adverse events (54.5 %, n = 656), active disease (26.1 %, n = 315), pregnancy (9.4 %, n = 113) or other reasons (13.2 %, n = 159). We compared SR to the mean regarding reasons for discontinuation and found significant differences between sites regarding gastrointestinal adverse events, flushing and lymphopenia. Discontinuation due to all adverse events, flushing and lymphopenia were more frequent in female than male patients. CONCLUSION In this population-based study, we found major differences between the MS clinics in rates and reason for discontinuation of DMF. Our results suggest that management strategies during DMF treatment can reduce discontinuation rates.
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Affiliation(s)
- Malte Roar
- Department of Neurology, Aalborg University Hospital, Denmark
| | | | | | - Georgi Sirakov
- Department of Neurology and Physiotheraphy, Gødstrup Hospital, Herning, Denmark
| | - Morten Stilund
- Department of Neurology and Physiotheraphy, Gødstrup Hospital, Herning, Denmark; Department of Neurology, Aarhus University Hospitalt, Aarhus, Denmark
| | - Jakob Schäfer
- Department of Neurology, Aalborg University Hospital, Denmark
| | - Rikke Ratzer
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Jette Frederiksen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nasrin Asgari
- Department of Neurology, Slagelse and Institute of Regional Health Research, and Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Said Nasim Ashna
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark
| | - Henrik Boye Jensen
- Department of Neurology, Lillebaelt Hospital, Kolding, Denmark; The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway; BRIDGE, Brain Research - Inter Disciplinary Guided Excellence, Department of Regional Health Research, University of Southern Denmark
| | - Matthias Kant
- Department of Neurology, Hospital of Southern Jutland, Sønderborg, Denmark
| | | | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Louise Mose Schlosser
- Department of Neurology, Hospital Southwest Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Hilde Nordborg
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Stig Wergeland
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway; The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Tobias Sejbaek
- Department of Neurology, Hospital Southwest Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark; The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway; BRIDGE, Brain Research - Inter Disciplinary Guided Excellence, Department of Regional Health Research, University of Southern Denmark; MS Alliance of Southern Denmark, Denmark.
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3
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Boz C, Ozakbas S, Terzi M, Karabudak R, Sevim S, Turkoglu R, Soysal A, Balcı BP, Efendi H, Turan ÖF, Yüceyar N, Yetkin MF, Karahan SZ, Demirkıran M, Guler S, Agan K, Kıylıoğlu N, Baba C, Tuncer A, Köseoğlu M. The comparative effectiveness of fingolimod, natalizumab, and ocrelizumab in relapsing-remitting multiple sclerosis. Neurol Sci 2023; 44:2121-2129. [PMID: 36689010 DOI: 10.1007/s10072-023-06608-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 01/08/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Fingolimod, natalizumab, and ocrelizumab are commonly used in the second-line treatment of relapsing-remitting multiple sclerosis (RRMS). However, these have only been compared in observational studies, not in controlled trials, with limited and inconclusive results being reported. A comparison of their effect on relapse and disability in a real-world setting is therefore needed. OBJECTIVES The objective of this study was to compare the efficacy of fingolimod, natalizumab, and ocrelizumab in reducing disease activity in RRMS. METHODS This multicenter, retrospective observational study was carried out with prospectively collected data from 16 centers. All consecutive RRMS patients treated with fingolimod, natalizumab, and ocrelizumab were included. Data for relapses, Expanded Disability Status Scale (EDSS) scores, and brain magnetic resonance imaging (MRI) scans were collected. Patients were matched using propensity scores. Annualized relapse rates (ARR), time to first relapse, and disability accumulation were compared. RESULTS Propensity score matching retained 736 patients in the fingolimod versus 370 in the natalizumab groups, 762 in the fingolimod versus 434 in the ocrelizumab groups, and 310 in the natalizumab versus 310 in the ocrelizumab groups for final analyses. Mean ARR decreased markedly from baseline after treatment in all three treatment groups. Mean on-treatment ARR was lower in natalizumab-treated patients (0.09, 95% confidence interval (CI), 0.07-0.12) than in those treated with fingolimod (0.17, 0.15-0.19, p<0.001), ocrelizumab (0.08, 0.06-0.11), and fingolimod (0.14, 0.12-0.16, p=0.001). No significant difference was observed in mean on-treatment ARR between patients treated with natalizumab (0.08, 0.06-0.11) and ocrelizumab (0.09, 0.07-0.12, p=0.54). Compared to fingolimod, the natalizumab and ocrelizumab groups exhibited a higher percentage of relapse-free patients and a lower percentage of MRI-active patients at year 1. No significance differences in disability accumulation were determined between the therapies. CONCLUSION Natalizumab and ocrelizumab exhibited similar effects on relapse control, and both were associated with better relapse control than fingolimod. The effects of the three therapies on disability outcomes were similar.
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Affiliation(s)
- Cavit Boz
- Department of Neurology, Karadeniz Technical University Medical Faculty, 61080, Trabzon, Turkey.
| | - Serkan Ozakbas
- Department of Neurology, Dokuz Eylul University, Izmir, Turkey
| | - Murat Terzi
- Department of Neurology, Ondokuz Mayis University, Samsun, Turkey
| | - Rana Karabudak
- Department of Neurology, Hacettepe University, Ankara, Turkey
| | - Serhan Sevim
- Department of Neurology, Mersin University, Mersin, Turkey
| | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | - Belgin Petek Balcı
- Department of Neurology, Haseki Educational and Research Center, Istanbul, Turkey
| | - Hüsnü Efendi
- Department of Neurology, Kocaeli University, Izmit, Turkey
| | | | - Nur Yüceyar
- Department of Neurology, Ege University, Izmir, Turkey
| | | | - Serap Zengin Karahan
- Department of Neurology, Karadeniz Technical University Medical Faculty, 61080, Trabzon, Turkey
| | | | - Sibel Guler
- Department of Neurology, Trakya University, Edirne, Turkey
| | - Kadriye Agan
- Department of Neurology, Marmara University, Istanbul, Turkey
| | - Nefati Kıylıoğlu
- Department of Neurology, Aydın Adnan Menderes University, Aydin, Turkey
| | - Cavid Baba
- Department of Neurology, Dokuz Eylul University, Izmir, Turkey
| | - Asli Tuncer
- Department of Neurology, Hacettepe University, Ankara, Turkey
| | - Mesrure Köseoğlu
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
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4
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Papeix C, Castelnovo G, Leray E, Coustans M, Levy P, Visy JM, Kobelt G, Lamy F, Allaf B, Heintzmann F, Chouette I, Raponi E, Durand B, Grevat E, Kamar D, Debouverie M, Lebrun-Frenay C. Long-Term Effectiveness, Safety and Tolerability of Fingolimod in Patients with Multiple Sclerosis in Real-World Treatment Settings in France: The VIRGILE Study. Neurol Ther 2022; 11:633-658. [PMID: 35147904 PMCID: PMC9095796 DOI: 10.1007/s40120-022-00334-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 01/28/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction It is important to confirm the effectiveness and tolerability of disease-modifying treatments for relapsing–remitting multiple sclerosis (RRMS) in real-world treatment settings. This prospective observational cohort study (VIRGILE) was performed at the request of the French health authorities. The primary objective was to evaluate the effectiveness of fingolimod 0.5 mg in reducing the annualised relapse rate (ARR) in patients with RRMS. Methods Participating neurologists enrolled all adult patients with RRMS starting fingolimod treatment between 2014 and 2016, who were followed for 3 years. Follow-up consultations took place at the investigator’s discretion. The primary outcome measure was the change in ARR at month 24 after fingolimod initiation. Relapses and adverse events were documented at each consultation; disability assessment (EDSS) and magnetic resonance imagery were performed at the investigator’s discretion. Results Of 1055 eligible patients, 633 patients were assessable at month 36; 405 (64.0%) were treated continuously with fingolimod for 3 years. The ARR decreased from 0.92 ± 0.92 at inclusion to 0.31 ± 0.51 at month 24, a significant reduction of 0.58 [95% CI − 0.51 to − 0.65] relapses/year (p < 0.001). Since starting fingolimod, 461 patients (60.9%) remained relapse-free at month 24 and 366 patients (55.5%) at month 36. In multivariate analysis, no previous disease-modifying treatment, number of relapses in the previous year and lower EDSS score at inclusion were associated with a greater on-treatment reduction in ARR. The mean EDSS score remained stable over the course of the study. Sixty-one out of 289 (21.1%) patients presented new radiological signs of disease activity. Treatment-related serious adverse events were lymphopenia (N = 21), bradycardia (N = 19), elevated transaminases (N = 9) and macular oedema (N = 9). Conclusions The effectiveness and tolerability of fingolimod in everyday clinical practice are consistent with findings of previous phase III studies. Our study highlights the utility of fingolimod for the long-term management of patients with multiple sclerosis. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00334-y.
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Affiliation(s)
- Caroline Papeix
- Département de Neurologie, Hôpital de la Pitié Salpêtrière, APHP 6, 83 Boulevard de l'Hôpital, 75013, Paris, France.
| | | | | | - Marc Coustans
- Service de Neurologie, Hôpital Laënnec, Quimper, France
| | - Pierre Levy
- LEDa, LEGOS, Université Paris-Dauphine, PSL Research University, Paris, France
| | | | | | | | | | | | | | - Eric Raponi
- Novartis Pharma S.A.S., Rueil-Malmaison, France
| | | | | | - Driss Kamar
- Ividata Life Science, Levallois-Perret, France
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Long-term real-world effectiveness and safety of fingolimod over 5 years in Germany. J Neurol 2022; 269:3276-3285. [PMID: 34982201 PMCID: PMC9120082 DOI: 10.1007/s00415-021-10931-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/03/2022]
Abstract
Objective To evaluate the 5-year real-world benefit–risk profile of fingolimod in patients with relapsing–remitting MS (RRMS) in Germany. Methods Post-Authorization Non-interventional German sAfety study of GilEnyA (PANGAEA) is a non-interventional real-world study to prospectively assess the effectiveness and safety of fingolimod in routine clinical practice in Germany. The follow-up period comprised 5 years. Patients were included if they had been diagnosed with RRMS and had been prescribed fingolimod as part of clinical routine. There were no exclusion criteria except the contraindications for fingolimod as defined in the European label. The effectiveness and safety analysis set comprised 4032 and 4067 RRMS patients, respectively. Results At the time of the 5-year follow-up of PANGAEA, 66.57% of patients still continued fingolimod therapy. Annualized relapse rates decreased from baseline 1.5 ± 1.15 to 0.42 ± 0.734 at year 1 and 0.21 ± 0.483 at year 5, and the disability status remained stable, as demonstrated by the Expanded Disability Status Scale mean change from baseline (0.1 ± 2.51), the decrease of the Multiple Sclerosis Severity Score from 5.1 ± 2.59 at baseline to 3.9 ± 2.31 at the 60-months follow-up, and the percentage of patients with ‘no change’ in the Clinical Global Impression scale at the 60-months follow-up (78.11%). Adverse events (AE) occurring in 75.04% of patients were in line with the known safety profile of fingolimod and were mostly non-serious AE (33.62%) and non-serious adverse drug reactions (50.59%; serious AE 4.98%; serious ADR 10.82%). Conclusions PANGAEA demonstrated the sustained beneficial effectiveness and safety of fingolimod in the long-term real-world treatment of patients with RRMS. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10931-w.
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Burkill S, Smith KA, Stridh P, Kockum I, Hillert J, Lindahl H, Alfredsson L, Olsson T, Piehl F, Montgomery S, Bahmanyar S. The DQB1 *03:02 Genotype and Treatment for Pain in People With and Without Multiple Sclerosis. Front Neurol 2020; 11:993. [PMID: 33013655 PMCID: PMC7500133 DOI: 10.3389/fneur.2020.00993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 07/29/2020] [Indexed: 11/13/2022] Open
Abstract
Murine models have demonstrated that the major histocompatibility complex (MHC) is associated with pain-like behavior in peripheral nerve injury, however, the same association has not been shown when considering injury to the central nervous system (CNS), which more closely mimics the damage to the CNS experienced by MS patients. Previous research has indicated the DQB1*03:02 allele of the class II HLA genes as being associated with development of neuropathic pain in persons undergoing inguinal hernia surgery or with lumbar spinal disk herniation. Whether this HLA allele plays a part in susceptibility to pain, has not, as far as we are aware, been previously investigated. This study utilizes information on DQB1*03:02 alleles as part of the EIMS, GEMS, and IMSE studies in Sweden. It also uses register data for 3,877 MS patients, and 4,548 matched comparators without MS, to assess whether the DQB1*03:02 allele is associated with prescribed pain medication use, and whether associations with this genotype differ depending on MS status. Our results showed no association between the DQB1*03:02 genotype and pain medication in MS patients, with an adjusted odds ratio (OR) of 1.02 (95% CI 0.85-1.24). In contrast, there was a statistically significant association of low magnitude in individuals without MS [adjusted OR 1.18 (95% CI 1.03-1.35)], which provides support for HLA influence on susceptibility to pain in the general population. Additionally, the effect of zygosity was evident for the non-MS cohort, but not among MS patients, suggesting the DQB1*03:02 allele effect is modified by the presence of MS.
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Affiliation(s)
- Sarah Burkill
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Solna, Sweden.,Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Solna, Sweden.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Kelsi A Smith
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Solna, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Solna, Sweden
| | - Pernilla Stridh
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.,Centre for Molecular Medicine, Karolinska University Hospital Solna, Solna, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.,Centre for Molecular Medicine, Karolinska University Hospital Solna, Solna, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
| | - Hannes Lindahl
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.,Centre for Molecular Medicine, Karolinska University Hospital Solna, Solna, Sweden
| | - Lars Alfredsson
- Institute of Environmental Medicine, Karolinska Institutet, Solna, Sweden.,Centre for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.,Centre for Molecular Medicine, Karolinska University Hospital Solna, Solna, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.,Centre for Molecular Medicine, Karolinska University Hospital Solna, Solna, Sweden
| | - Scott Montgomery
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Solna, Sweden.,Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Shahram Bahmanyar
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Solna, Sweden.,Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Solna, Sweden
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7
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Nicholas JA, Edwards NC, Edwards RA, Dellarole A, Grosso M, Phillips AL. Real-world adherence to, and persistence with, once- and twice-daily oral disease-modifying drugs in patients with multiple sclerosis: a systematic review and meta-analysis. BMC Neurol 2020; 20:281. [PMID: 32664928 PMCID: PMC7371467 DOI: 10.1186/s12883-020-01830-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/12/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Nonadherence to disease-modifying drugs (DMDs) for multiple sclerosis (MS) is associated with poorer clinical outcomes, including higher rates of relapse and disease progression, and higher medical resource use. A systematic review and quantification of adherence and persistence with oral DMDs would help clarify the extent of nonadherence and nonpersistence in patients with MS to help prescribers make informed treatment plans and optimize patient care. The objectives were to: 1) conduct a systematic literature review to assess the availability and variability of oral DMD adherence and/or persistence rates across 'real-world' data sources; and 2) conduct meta-analyses of the rates of adherence and persistence for once- and twice-daily oral DMDs in patients with MS using real-world data. METHODS A systematic review of studies published between January 2010 and April 2018 in the PubMed database was performed. Only studies assessing once- and twice-daily oral DMDs were available for inclusion in the analysis. Study quality was evaluated using a modified version of the Newcastle-Ottawa Scale, a tool for assessing quality of observational studies. The random effects model evaluated pooled summary estimates of nonadherence. RESULTS From 510 abstracts, 31 studies comprising 16,398 patients with MS treated with daily oral DMDs were included. Overall 1-year mean medication possession ratio (MPR; n = 4 studies) was 83.3% (95% confidence interval [CI] 74.5-92.1%) and proportion of days covered (PDC; n = 4 studies) was 76.5% (95% CI 72.0-81.1%). Pooled 1-year MPR ≥80% adherence (n = 6) was 78.5% (95% CI 63.5-88.5%) and PDC ≥80% (n = 5 studies) was 71.8% (95% CI 59.1-81.9%). Pooled 1-year discontinuation (n = 20) was 25.4% (95% CI 21.6-29.7%). CONCLUSIONS Approximately one in five patients with MS do not adhere to, and one in four discontinue, daily oral DMDs before 1 year. Opportunities to improve adherence and ultimately patient outcomes, such as patient education, medication support/reminders, simplified dosing regimens, and reducing administration or monitoring requirements, remain. Implementation of efforts to improve adherence are essential to improving care of patients with MS.
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Affiliation(s)
| | | | | | | | - Megan Grosso
- EMD Serono, Inc. (an affiliate of Merck KGaA, Darmstadt, Germany), Rockland, MA, USA
| | - Amy L Phillips
- EMD Serono, Inc. (an affiliate of Merck KGaA, Darmstadt, Germany), Rockland, MA, USA
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8
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Manouchehrinia A, Stridh P, Khademi M, Leppert D, Barro C, Michalak Z, Benkert P, Lycke J, Alfredsson L, Kappos L, Piehl F, Olsson T, Kuhle J, Kockum I. Plasma neurofilament light levels are associated with risk of disability in multiple sclerosis. Neurology 2020; 94:e2457-e2467. [PMID: 32434867 PMCID: PMC7455371 DOI: 10.1212/wnl.0000000000009571] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 12/27/2019] [Indexed: 12/31/2022] Open
Abstract
Objective To investigate the association between plasma neurofilament light chain (pNfL) levels and the risk of developing sustained disability worsening. Methods Concentrations of pNfL were determined in 4,385 persons with multiple sclerosis (MS) and 1,026 randomly selected population-based sex- and age-matched controls using the highly sensitive Single Molecule Array (SimoaTM) NF-Light Advantage Kit. We assessed the impact of age-stratified pNfL levels above the 80th, 95th, and 99th percentiles among controls on the risk of Expanded Disability Status Scale (EDSS) worsening within the following year and reaching sustained EDSS scores of 3.0, 4.0, and 6.0 and conversion to secondary progressive multiple sclerosis (SPMS). Results The median (interquartile range [IQR]) pNfL was 7.5 (4.1) pg/mL in controls and 11.4 (9.6) pg/mL in MS (p < 0.001). The median (IQR) duration of follow-up was 5 (5.1) years. High pNfL was associated with increased adjusted rates of EDSS worsening ranging between 1.4 (95% confidence intervals [CIs]: 1.1–1.8) and 1.7 (95% CI: 1.4–2.3). High pNfL was also associated with the risk of reaching a sustained EDSS score of 3.0, with adjusted rates ranging between 1.5 (95% CI: 1.2–1.8) and 1.55 (95% CI: 1.3–1.8) over all percentile cutoffs (all p < 0.001). Similar increases were observed for the risk of sustained EDSS score 4.0. In contrast, the risk of reaching sustained EDSS score 6.0 and conversion to SPMS was not consistently significant. Conclusions Elevated pNfL levels at early stages of MS are associated with an increased risk of reaching sustained disability worsening. Hence, pNfL may serve as a prognostic tool to assess the risk of developing permanent disability in MS.
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Affiliation(s)
- Ali Manouchehrinia
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden.
| | - Pernilla Stridh
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Mohsen Khademi
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - David Leppert
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Christian Barro
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Zuzanna Michalak
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Pascal Benkert
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Jan Lycke
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Lars Alfredsson
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Ludwig Kappos
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Fredrik Piehl
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Tomas Olsson
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Jens Kuhle
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
| | - Ingrid Kockum
- From the Department of Clinical Neuroscience (A.M., P.S., M.K., F.P., T.O., I.K.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Karolinska Institutet; Centre for Molecular Medicine (A.M., P.S., M.K., F.P., T.O., I.K.), Karolinska University Hospital, Stockholm, Sweden; Departments of Medicine, Biomedicine, and Clinical Research (D.L., C.B., Z.M., L.K., J.K.), Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Switzerland; Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Gothenburg; Institute of Environmental Medicine (L.A.), Karolinska Institutet, Stockholm; and Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Sweden
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Barrero F, Mallada-Frechin J, Martínez-Ginés ML, Marzo ME, Meca-Lallana V, Izquierdo G, Ara JR, Oreja-Guevara C, Meca-Lallana J, Forero L, Sánchez-Vera I, Moreno MJ. Spanish real-world experience with fingolimod in relapsing-remitting multiple sclerosis patients: MS NEXT study. PLoS One 2020; 15:e0230846. [PMID: 32240213 PMCID: PMC7117743 DOI: 10.1371/journal.pone.0230846] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/10/2020] [Indexed: 11/18/2022] Open
Abstract
Purpose The objective of this study was to characterize the demographic and clinical profile of RRMS patients receiving fingolimod in Spain, and to evaluate drug effectiveness and safety in clinical practice. Methods This observational, retrospective, multicentre, nationwide study was performed at 56 Spanish hospitals and involved 804 RRMS patients who received oral fingolimod (0.5 mg) since November 2011, with a minimum follow-up of 12 months. Results The mean annualized relapse rate (ARR) in the year before fingolimod was 1.08 and the median EDSS was 3; patients were exposed to fingolimod for 2.2 years as average; regarding magnetic resonance imaging (MRI) activity, more than half of the patients had >20 lesions at baseline. Patients were previously treated with first-line injectable DMTs (60.3%), or natalizumab (31.3%), and 8.3% were naïve patients. Overall, the ARR significantly decreased to 0.28, 0.22 and 0.17 (74.1%, 79.7% and 83.5% of relative reduction, respectively) after 12, 24 and 36 months of treatment, P<0.001. The ARR of patients who switched from natalizumab to fingolimod was stable over the study. Most of the patients (88.7%) were free from confirmed disability and MRI activity (67.3%) after 24 months. The persistence after 12 months on fingolimod was 93.9%. Conclusions The subgroups of patients analysed showed differential baseline demographic and clinical characteristics. The analysis of patients who received fingolimod in routine clinical practice confirmed adequate efficacy and safety, even for long-term treatment. The present data also confirmed the positive benefit/risk balance with fingolimod in real-world clinical practice setting.
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Affiliation(s)
- Francisco Barrero
- Neurology Department, Hospital Uniersitario San Cecilio de Granada, Granada, Spain
| | | | | | | | | | - Guillermo Izquierdo
- Neurology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - José Ramón Ara
- Neurology Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Celia Oreja-Guevara
- Neurology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | - Lucía Forero
- Neurology Department, Hospital Universitario Puerta del Mar, Cádiz, Spain
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10
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Meca-Lallana J, Ayuso T, Martínez-Yelamos S, Durán C, Contreras Martín Y, Herrera Navarro N, Pérez Sempere A, Álvarez-Cermeño JC, Millán Pascual J, Meca-Lallana V, Romero Sevilla R, Ricart J. Effectiveness of Fingolimod versus Natalizumab as Second-Line Therapy for Relapsing-Remitting Multiple Sclerosis in Spain: Second-Line GATE Study. Eur Neurol 2020; 83:25-33. [PMID: 32187609 DOI: 10.1159/000505778] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is a lack of head-to-head studies comparing the efficacy of fingolimod (FIN) and natalizumab (NTZ) as second-line therapy for relapsing-remitting multiple sclerosis (RRMS). METHODS Multicenter, observational study, in which, information of 388 patients randomly selected and treated with FIN or NTZ in routine clinical practice was retrospectively collected with the main objective of comparing the annualized relapse rate (ARR) over the first year, after FIN or NTZ treatment initiation. RESULTS Mean ARR during the first year of treatment was 0.28 in FIN group and 0.12 in NTZ group (p = 0.0064); nevertheless, the difference between groups lost statistical significance when the propensity score analysis was performed. Time to disability -progression was similar in both treatment groups (12.3 ± 6.7 months in FIN, and 12.8 ± 0.1 months in NTZ; p = 0.4654). Treatment persistence after the first year of treatment was higher in patients treated with FIN (95%) than in those treated with NTZ (84%; p = 0.0014). CONCLUSIONS After 12 months of treatment, both FIN and NTZ reduced the ARR, but ARR percent reduction was significantly higher with NTZ. Treatment persistence was higher in patients receiving FIN.
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Affiliation(s)
- José Meca-Lallana
- Unidad de Esclerosis Múltiple, Servicio de Neurología, Hospital Clínico Universitario "Virgen de la Arrixaca" (IMIB-ARRIXACA), Murcia, Spain, .,Cátedra de Neuroinmunología Clínica y Esclerosis Múltiple, UCAM, Universidad Católica San Antonio, Murcia, Spain,
| | | | | | - Carmen Durán
- Hospital Universitario Infanta Cristina, Badajoz, Spain
| | | | | | | | | | | | - Virginia Meca-Lallana
- Unidad de Enfermedades Desmielinizantes, Hospital Universitario de la Princesa, Madrid, Spain
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11
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A Retrospective Analysis of Real-World Discontinuation Rates with Delayed-Release Dimethyl Fumarate in Patients with Relapsing-Remitting Multiple Sclerosis. Neurol Ther 2019; 9:85-92. [PMID: 31834566 PMCID: PMC7229102 DOI: 10.1007/s40120-019-00174-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Indexed: 12/13/2022] Open
Abstract
Introduction The main objective of this study was to examine discontinuation rates associated with delayed-release dimethyl fumarate (DMF) when used for the treatment of relapsing multiple sclerosis (MS) in a real-world, clinical practice setting. Methods Data were collected retrospectively from charts of adult patients with relapsing–remitting MS treated at a single large institution in Australia, who completed at least 6 months of continuous therapy, either with DMF or another MS medication administered following DMF discontinuation. The primary endpoint was overall discontinuation rate. Secondary endpoints included discontinuation rate 6 months after initiation of DMF therapy; incidence of adverse events, particularly gastrointestinal events; discontinuation rate because of adverse events; and use of concomitant medications by patients during administration of DMF. Results A total of 100 patients initially prescribed DMF between October 1, 2013 and June 30, 2014 were included in the analysis. The mean age of the patients was 43 years and 80% were female. The overall discontinuation rate was 13%, with 9% discontinuing because of gastrointestinal tolerability issues, within the first 6 months. Dose changes as a result of adverse events occurred in 15% of patients, and none of the adverse events reported were serious. Only one patient discontinued owing to lack of efficacy. Conclusion This study, conducted shortly after the approval of DMF in Australia when first-hand clinical experience was still limited, demonstrated that DMF has an acceptable tolerability profile in the real-world setting that is similar to that demonstrated in clinical trials.
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Granqvist M, Boremalm M, Poorghobad A, Svenningsson A, Salzer J, Frisell T, Piehl F. Comparative Effectiveness of Rituximab and Other Initial Treatment Choices for Multiple Sclerosis. JAMA Neurol 2019; 75:320-327. [PMID: 29309484 DOI: 10.1001/jamaneurol.2017.4011] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Comparative real-world effectiveness studies of initial disease-modifying treatment (DMT) choices for relapsing-remitting multiple sclerosis (RRMS) that include rituximab are lacking. Objective To assess the effectiveness and drug discontinuation rates of rituximab among patients with newly diagnosed RRMS compared with injectable DMTs, dimethyl fumarate, fingolimod, or natalizumab. Design, Setting, and Patients This retrospective cohort study used prospectively collected data to examine specialized care of 2 Swedish county-based community samples of patients with RRMS. Patients with RRMS who received diagnoses from January 1, 2012, to October 31, 2015, who resided in Stockholm or Västerbotten Counties were identified from a Swedish multiple sclerosis registry. Main Outcomes and Measures All reasons for drug discontinuation of initial treatment choice (main outcome) and specific reasons for switching (secondary outcomes) were analyzed with multivariable Cox regression, including propensity scores. Results Among 494 patients (median [interquartile range] age, 34.4 [27.4-43.4] years; 158 men [32.0%]), 215 received an injectable DMT (43.5%); 86 (17.4%), dimethyl fumarate; 17 (3.4%), fingolimod; 50 (10.1%), natalizumab; 120 (24.3%), rituximab; and 6 (1.2%), other DMT. Regional preferences were pronounced, with 42 of 52 (81%) and 78 of 442 (18%) receiving rituximab in Västerbotten and Stockholm, respectively. The annual discontinuation rate for rituximab, injectable DMTs, dimethyl fumarate, fingolimod, and natalizumab were 0.03, 0.53, 0.32, 0.38, and 0.29, respectively. Continued disease activity was the main reason for discontinuation of injectable DMTs, dimethyl fumarate, and fingolimod; positive John Cunningham virus serology results were the main reason for discontinuation of natalizumab. Rate of clinical relapses and/or neuroradiologic disease activity were significantly lower for rituximab compared with injectable DMTs and dimethyl fumarate, with a tendency for lower relapse rates also compared with natalizumab and fingolimod. The annual discontinuation rate of initial treatment choice was significantly lower in Västerbotten compared with Stockholm (0.09 and 0.37, respectively). Conclusions and Relevance Rituximab was superior to all other DMT in terms of drug discontinuation and displayed better clinical efficacy compared with injectable DMTs and dimethyl fumarate with borderline significance compared with natalizumab and fingolimod. The county where rituximab constituted the main initial treatment choice displayed better outcomes in most measured variables. Collectively, our findings suggest that rituximab performs better than other commonly used DMTs in patients with newly diagnosed RRMS.
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Affiliation(s)
- Mathias Granqvist
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Malin Boremalm
- Department of Pharmacology and Clinical Neuroscience, Section for Neurology, Umeå University, Umeå, Sweden
| | - Amyar Poorghobad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jonatan Salzer
- Department of Pharmacology and Clinical Neuroscience, Section for Neurology, Umeå University, Umeå, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Bedri SK, Nilsson OB, Fink K, Månberg A, Hamsten C, Ayoglu B, Manouchehrinia A, Nilsson P, Olsson T, Hillert J, Grönlund H, Glaser A. Plasma protein profiling reveals candidate biomarkers for multiple sclerosis treatment. PLoS One 2019; 14:e0217208. [PMID: 31141529 PMCID: PMC6541274 DOI: 10.1371/journal.pone.0217208] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 05/07/2019] [Indexed: 12/14/2022] Open
Abstract
Multiple sclerosis (MS) treatment options have improved significantly over the past decades, but the consequences of MS can still be devastating and the needs for monitoring treatment surveillance are considerable. In the current study we used affinity proteomics technology to identify potential biomarkers which could ultimately be used to as facilitate treatment decisions. We profiled the intra-individual changes in the levels of 59 target proteins using an antibody suspension bead array in serial plasma samples from 44 MS patients during treatment with natalizumab followed by fingolimod. Nine proteins showed decreasing plasma levels during natalizumab treatment, with PEBP1 and RTN3 displaying the most significant changes. Protein levels remained stable during fingolimod treatment for both proteins. The decreasing PEBP1 levels during natalizumab treatment could be validated using ELISA and replicated in an independent cohort. These results support the use of this technology as a high throughput method of identifying potentially useful biomarkers of MS treatment.
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Affiliation(s)
- Sahl Khalid Bedri
- Department of Clinical Neuroscience and Centrum for Molecular Medicine at Karolinska, Institutet, Stockholm, Sweden
- * E-mail:
| | - Ola B. Nilsson
- Department of Clinical Neuroscience and Centrum for Molecular Medicine at Karolinska, Institutet, Stockholm, Sweden
- TCER AB, c/o Advice Företagsassistans i Stockholm AB, Stockholm, Sweden
| | - Katharina Fink
- Department of Clinical Neuroscience and Centrum for Molecular Medicine at Karolinska, Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Månberg
- Affinity Proteomics, SciLifeLab, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH-Royal Institute of Technology, Stockholm, Sweden
| | - Carl Hamsten
- Immunology and Allergy unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Burcu Ayoglu
- Affinity Proteomics, SciLifeLab, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH-Royal Institute of Technology, Stockholm, Sweden
| | - Ali Manouchehrinia
- Department of Clinical Neuroscience and Centrum for Molecular Medicine at Karolinska, Institutet, Stockholm, Sweden
| | - Peter Nilsson
- Affinity Proteomics, SciLifeLab, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH-Royal Institute of Technology, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience and Centrum for Molecular Medicine at Karolinska, Institutet, Stockholm, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience and Centrum for Molecular Medicine at Karolinska, Institutet, Stockholm, Sweden
| | - Hans Grönlund
- Department of Clinical Neuroscience and Centrum for Molecular Medicine at Karolinska, Institutet, Stockholm, Sweden
| | - Anna Glaser
- Department of Clinical Neuroscience and Centrum for Molecular Medicine at Karolinska, Institutet, Stockholm, Sweden
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Ziemssen T, Lang M, Tackenberg B, Schmidt S, Albrecht H, Klotz L, Haas J, Lassek C, Couto CAM, Findlay JA, Cornelissen C. Real-world persistence and benefit-risk profile of fingolimod over 36 months in Germany. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e548. [PMID: 30882022 PMCID: PMC6410931 DOI: 10.1212/nxi.0000000000000548] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/08/2019] [Indexed: 11/15/2022]
Abstract
Objective To assess the long-term real-world benefit-risk profile of fingolimod in patients with relapsing MS in Germany. Methods This analysis used data from the noninterventional real-world study, Post-Authorization Non-interventional German sAfety study of GilEnyA (PANGAEA), to assess prospectively the persistence, effectiveness, and safety of fingolimod over 36 months (±90 days) in Germany. For inclusion in the effectiveness analysis (n = 2,537), patients were required to have received fingolimod for the first time in PANGAEA, to have at least 12 months of data, and to have completed each 12-month follow-up period. For the safety analysis (n = 3,266), patients were additionally allowed to have received fingolimod before enrollment. Results At baseline, 94.7% of patients in the effectiveness analysis had received a previous disease-modifying therapy. After 36 months, 70.4% of patients were still receiving fingolimod. Over this period, annualized relapse rates decreased to 0.265 (95% CI: 0.244-0.286) from 1.79 (95% CI: 1.75-1.83), and mean Expanded Disability Status Scale scores remained stable (mean change from baseline: +0.049 [95% CI: -0.015 to +0.114]). In total, 16% of patients had 6-month confirmed disability improvement, 12.5% had 6-month confirmed disability worsening, and 52.4% were free from relapses and 6-month confirmed disability worsening. Adverse events (AEs) and serious AEs were experienced by up to 23.4% and 3.9% of patients, respectively, during any of the 12-month follow-up periods. The frequency and nature of AEs were in line with previous findings. Conclusions Using systematically collected data from PANGAEA, this analysis demonstrates the sustained effectiveness, high persistence, and manageable safety profile of fingolimod over 36 months.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - Michael Lang
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - Björn Tackenberg
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - Stephan Schmidt
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - Holger Albrecht
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - Luisa Klotz
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - Judith Haas
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - Christoph Lassek
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - C Anne-Marie Couto
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - John A Findlay
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
| | - Christian Cornelissen
- Center of Clinical Neuroscience (T.Z.), Neurological University Clinic Carl Gustav Carus, University of Technology, Dresden; NeuroPoint Patient Academy and Neurological Practice (M.L.), Ulm; Department of Neurology (B.T.), Center of Neuroimmunology, Philipps-University, Marburg; Bonn Neurological Practice (S.S.); Neurological Practice (H.A.), Munich; Department of Neurology (L.K.), University Hospital Münster, Münster; Centre for Multiple Sclerosis (J.H.), Jewish Hospital Berlin; Kassel and Vellmar Neurology Practice (C.L.), Vellmar, Germany; Oxford PharmaGenesis (C.A-M.C.); Oxford PharmaGenesis (J.A.F.), United Kingdom; and Novartis Pharma GmbH (C.C.), Nuremberg, Germany
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Kavaliunas A, Tinghög P, Friberg E, Olsson T, Alexanderson K, Hillert J, Karrenbauer VD. Cognitive function predicts work disability among multiple sclerosis patients. Mult Scler J Exp Transl Clin 2019; 5:2055217318822134. [PMID: 30729025 PMCID: PMC6350142 DOI: 10.1177/2055217318822134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 11/08/2018] [Accepted: 11/22/2018] [Indexed: 11/16/2022] Open
Abstract
Background In multiple sclerosis various aspects of cognitive function can be detrimentally affected. More than that, patients´ employment and social functioning is likely to be impacted. Objective To determine whether work disability among multiple sclerosis patients could be predicted by the symbol digit modalities test. Methods A register-based cohort study was conducted. Individual data on work disability, operationalised as annual net days of sickness absence and/or disability pension were retrieved at baseline, when the symbol digit modalities test was performed, after one-year and 3-year follow-up for 903 multiple sclerosis patients. The incidence rate ratios for work disability were calculated with general estimating equations using a negative binomial distribution and were adjusted for gender, age, educational level, family composition, type of living area and physical disability. Results After one year of follow-up, the patients in the lowest symbol digit modalities test quartile were estimated to have a 73% higher rate of work disability when compared to the patients in the highest symbol digit modalities test quartile (incidence rate ratio 1.73, 95% confidence interval 1.42‒2.10). This estimate after 3-year follow-up was similar (incidence rate ratio 1.68, 95% confidence interval 1.40‒2.02). Conclusion Cognitive function is to a high extent associated with multiple sclerosis patients' future work disability, even after adjusting for other factors.
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Affiliation(s)
| | - Petter Tinghög
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden.,Red Cross University College, Sweden
| | - Emilie Friberg
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden.,Center for Molecular Medicine, Karolinska University Hospital, Sweden
| | | | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden.,Center for Molecular Medicine, Karolinska University Hospital, Sweden.,Department of Neurology, Karolinska University Hospital, Sweden
| | - Virginija Danylaite Karrenbauer
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden.,Department of Neurology, Karolinska University Hospital, Sweden
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Ziemssen T, Rothenbacher D, Kuhle J, Berger T. [Real-world evidence : Benefits and limitations in multiple sclerosis research]. DER NERVENARZT 2019; 88:1153-1158. [PMID: 28776214 DOI: 10.1007/s00115-017-0387-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Real-world evidence (RWE) expands the data obtained in randomized clinical trials (RCTs), which are based on both homogeneous selected patient groups and limited study durations, to long-term experiences in clinical routine. In particular, chronic diseases such as multiple sclerosis (MS) with both heterogeneous pathologies and a growing number of therapeutic options require a careful RWE-based assessment of long-term efficacy and safety parameters. OBJECTIVE This review presents RWE data sources applied in MS research and discusses potential quality standards. MATERIAL AND METHODS This article is based on the results of an expert meeting of the authors held in October 2015 and a selective literature search. RESULTS The RWE data sources include the reporting system of drug safety monitoring, non-interventional studies, MS-specific registries, administrative health databases, and electronic medical records. These data sources have different objectives and are subject to specific limitations with respect to the disease and therapy-relevant analytical options. The combination of different sources into an integrative approach might improve the validity of RWE in MS research; however, this objective requires the standardization of data collection and processing as well as the definition of uniform and transnational quality standards. CONCLUSION There is still a need for high-quality, comprehensive, and valid RWE data as these data cover additional aspects of patient care and expand the data available by complementary information. Further development of an integrative RWE approach requires cooperation at various levels with the aim of the best possible standardization and harmonization of clinical MS data.
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Affiliation(s)
- T Ziemssen
- Zentrum für klinische Neurowissenschaften, Klinik für Neurologie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - D Rothenbacher
- Institut für Epidemiologie und Medizinische Biometrie, Universität Ulm, Ulm, Deutschland
| | - J Kuhle
- Neurologie, Departement für Medizin, Biomedizin und Klinische Forschung, Universitätskliniken Basel, Basel, Schweiz
| | - T Berger
- Universitätsklinik für Neurologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
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17
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Real-world persistence with fingolimod for the treatment of multiple sclerosis: A systematic review and meta-analysis. J Neurol Sci 2018; 388:168-174. [PMID: 29627016 DOI: 10.1016/j.jns.2018.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 02/16/2018] [Accepted: 03/09/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To systematically review reports of fingolimod persistence in the treatment of relapsing-remitting multiple sclerosis (RRMS) across data sources and practice settings, and to develop a consensus estimate of the 1-year real-world persistence rate. METHODS A systematic literature review was conducted (MEDLINE, EMBASE, and abstracts from selected conferences [2013-2015]) to identify observational studies reporting 1-year fingolimod persistence among adult patients with RRMS (sample size ≥50). A random-effects meta-analysis was performed to estimate a synthesized 1-year persistence rate and to assess heterogeneity across studies. RESULTS Of 527 publications identified, 25 real-world studies reporting 1-year fingolimod persistence rates were included. The studies included patients from different data sources (e.g., administrative claims, electronic medical records, or registries), used different definitions of persistence (e.g., based on prescriptions refills, patient report, or prescription orders), and spanned multiple geographic regions. Reported 1-year persistence rates ranged from 72%-100%, and exhibited statistical evidence of heterogeneity (I2 = 93% of the variability due to heterogeneity across studies). The consensus estimate of the 1-year persistence rate was 82% (95% confidence interval: 79%-85%). CONCLUSIONS Across heterogeneous study designs and patient populations found in real-world studies, the consensus 1-year fingolimod persistence rate exceeded 80%, consistent with persistence rates identified in the recently-completed trial, PREFERMS.
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18
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Effectiveness and baseline factors associated to fingolimod response in a real-world study on multiple sclerosis patients. J Neurol 2018; 265:896-905. [PMID: 29435643 DOI: 10.1007/s00415-018-8791-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Treatment choice in multiple sclerosis (MS) is crucial for optimizing risk-benefit profile. OBJECTIVE To assess fingolimod (FTY) effectiveness and identify baseline features associated to disease activity in a large Italian cohort of Relapsing-Remitting (RR) MS patients. METHODS Three-hundred sixty-seven RRMS patients starting FTY treatment at San Raffaele Hospital (Milan-Italy) underwent clinical and MRI evaluations for 2 years. Treatment response was assessed considering the proportion of patients with no evidence of disease activity (NEDA) and recording the time to first relapse. Primary analyses were performed stratifying for Natalizumab (NTZ) treatment in the year before (NO_NTZ vs NTZ group), to account for post-NTZ reactivation. RESULTS Almost half of patients were NEDA after 2 years, 53.4% in the NO_NTZ group and 36.2% in the NTZ group. Despite an opposite trend during the first 6-12 months, at 2-year follow-up the two groups were comparable for relapses and number of new/enlarging T2 and Gd-enhancing lesions. Baseline parameters of higher disease activity (ARR, Gd enhancing lesions and age at onset) were associated with increased likelihood of failing NEDA criteria or with shorter time to relapse (p < 0.05). CONCLUSIONS Our data strengthen FTY effectiveness in everyday clinical practice, even in patients switching from NTZ treatment. Baseline parameters of inflammatory activity are the most important prognostic factors for mid-term disease reactivation also during second-line treatment with FTY, providing hints on how to select therapies towards a more personalized management.
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Guger M, Enzinger C, Leutmezer F, Kraus J, Kalcher S, Kvas E, Berger T. Real-life clinical use of natalizumab and fingolimod in Austria. Acta Neurol Scand 2018; 137:181-187. [PMID: 29159801 DOI: 10.1111/ane.12864] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To compare the efficacy of natalizumab or fingolimod in a nationwide observational cohort using prospectively collected data. MATERIALS AND METHODS We included all patients starting treatment with natalizumab or fingolimod documented in the Austrian MS Treatment Registry (AMSTR) from 2011 and staying on therapy for at least 24 months. We used propensity scores for several matching methods and as a covariate in multivariate models to correct for the bias of this non-randomized registry study. RESULTS The study cohort includes 588 patients with RRMS. Ten patients did not produce a propensity score in the common support region, thus leaving 578 cases for final analyses, 332 in the fingolimod and 246 in the natalizumab group. Mean annualized relapse rates (ARR) during the 24 months observation period were 0.19 under fingolimod and 0.12 under natalizumab treatment (P = .005). No statistical significant differences were found analysing the log-transformed ARR, probability for experiencing a relapse, EDSS progression and EDSS regression. The hazard ratio for switching treatment from fingolimod comparing with natalizumab was 0.36 (95% CI: 0.247-0.523), P < .001. CONCLUSIONS The generalized linear model (GLM) for relapse count as Poisson distributed dependent variable and propensity score as covariate showed a statistically significant reduction for the mean relapse count in the natalizumab group compared with fingolimod. This effect was smaller in the analyses of log-transformed ARR with propensity score matching, loosing statistical significance although showing the same direction for the effect. We assume that the GLM was the more sensitive model analysing this question.
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Affiliation(s)
- M. Guger
- Clinic for Neurology 2, Med Campus III. Kepler University Clinic Linz Austria
| | - C. Enzinger
- Department of Neurology Medical University of Graz Graz Austria
| | - F. Leutmezer
- Department of Neurology Medical University of Vienna Vienna Austria
| | - J. Kraus
- Department of Laboratory Medicine Paracelsus Medical University and Salzburger Landeskliniken Salzburg Austria
- Department of Neurology Medical Faculty Heinrich‐Heine‐University Düsseldorf Germany
| | | | - E. Kvas
- Hermesoft Statistics Graz Austria
| | - T. Berger
- Clinical Department of Neurology Medical University of Innsbruck Innsbruck Austria
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Kavaliunas A, Danylaite Karrenbauer V, Gyllensten H, Manouchehrinia A, Glaser A, Olsson T, Alexanderson K, Hillert J. Cognitive function is a major determinant of income among multiple sclerosis patients in Sweden acting independently from physical disability. Mult Scler 2017; 25:104-112. [PMID: 29143553 DOI: 10.1177/1352458517740212] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In multiple sclerosis (MS), various aspects of cognitive function can be detrimentally affected, thus patients' employment and social functioning is commonly impacted. OBJECTIVE To analyse income among MS patients in relation to cognitive function, assessed with the Symbol Digit Modalities Test (SDMT). METHODS A cross-sectional study including 2080 MS patients was conducted linking national register-based data. Descriptive statistics and a two-part model were used to estimate differences in earnings and social benefits. RESULTS MS patients in the highest SDMT score quartile earned more than twice annually compared to patients in the lowest quartile, whereas patients in the lowest quartile received three times more income through social benefits. The difference in earnings and benefits across the SDMT performance quartiles remained statistically significant after adjusting for various clinical and socio-demographic variables, including physical disability. The corrected prevalence ratios for MS patients in the highest quartile for having income from earnings and benefits were 1.40 (95% confidence interval (CI): 1.29-1.49) and 0.81 (95% CI: 0.71-0.90), respectively, when compared to the patients in the lowest quartile. CONCLUSION Cognitive function affects the financial situation of MS patients negatively and independently of physical disability. This warrants cognitive testing as a routine measure in health care services for MS patients.
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Affiliation(s)
- Andrius Kavaliunas
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Virginija Danylaite Karrenbauer
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden/Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Hanna Gyllensten
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden/Centre for Person-centred Care (GPCC), Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ali Manouchehrinia
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Glaser
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden/Centre for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden/Department of Neurology, Karolinska University Hospital, Stockholm, Sweden/Centre for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
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Bedri SK, Fink K, Manouchehrinia A, Lundström W, Kockum I, Olsson T, Hillert J, Glaser A. Multiple sclerosis treatment effects on plasma cytokine receptor levels. Clin Immunol 2017; 187:15-25. [PMID: 28941836 DOI: 10.1016/j.clim.2017.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/24/2017] [Accepted: 08/27/2017] [Indexed: 01/04/2023]
Abstract
Genetic variants within some cytokine receptor genes have been associated with MS susceptibility, including IL7RA and IL2RA. As these genes are expressed by cells targeted by immune-modulatory drugs, we explored the potential role of their gene products as biomarkers in monitoring MS treatment. We assessed the impact of natalizumab followed by fingolimod on the intra-individual changes of plasma protein levels of sIL-7Rα, sIL-2Rα and also sIL-6R and sgp130 in MS patients. During natalizumab treatment we observed a decline in sgp130 and sIL-7Rα levels, while subsequent fingolimod treatment lead to increased sgp130 and sIL-7Rα and decreased sIL-2Rα levels. In addition, during fingolimod treatment sIL-7Rα levels were increasing significantly more in patients homozygous for the MS risk genotype of rs6897932. We also observed an effect of the MS associated rs71624119 on sgp130 levels. These results may elucidate the pharmacodynamics of treatments and help identify biomarkers for MS outcomes.
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Affiliation(s)
- Sahl Khalid Bedri
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Katharina Fink
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ali Manouchehrinia
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Wangko Lundström
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anna Glaser
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.
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Thomas K, Proschmann U, Ziemssen T. Fingolimod hydrochloride for the treatment of relapsing remitting multiple sclerosis. Expert Opin Pharmacother 2017; 18:1649-1660. [PMID: 28844164 DOI: 10.1080/14656566.2017.1373093] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Fingolimod was the first oral and the first in class disease modifying treatment in multiple sclerosis that acts as sphingosine-1-phospathe receptor agonist. Since approval in 2010 there is a growing experience with fingolimod use in clinical practice, but also next-generation sphingosin-1-receptor agonists in ongoing clinical trials. Growing evidence demonstrates additional effects beyond impact on lymphocyte circulation, highlighting further promising targets in multiple sclerosis therapy. Areas covered: Here we present a systematic review using PubMed database searching and expert opinion on fingolimod use in clinical practice. Long-term data of initial clinical trials and post-marketing evaluations including long-term efficacy, safety, tolerability and management especially within growing disease modifying treatment options and pre-treatment constellation in multiple sclerosis patients are critically discussed. Furthermore novel findings in mechanism of actions and prospective on additional use in progressive forms in multiple sclerosis are presented. Expert opinion: There is an extensive long-term experience on fingolimod use in clinical practice demonstrating the favorable benefit-risk of this drug. Using a defined risk management approach experienced MS clinicians should apply fingolimod after critical choice of patients and review of clinical aspects. Further studies are essential to discuss additional benefit in progressive forms in multiple sclerosis.
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Affiliation(s)
- Katja Thomas
- a Center of Clinical Neuroscience , University Hospital, Dresden , Dresden , Germany
| | - Undine Proschmann
- a Center of Clinical Neuroscience , University Hospital, Dresden , Dresden , Germany
| | - Tjalf Ziemssen
- a Center of Clinical Neuroscience , University Hospital, Dresden , Dresden , Germany
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23
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Lanzillo R, Carotenuto A, Moccia M, Saccà F, Russo CV, Massarelli M, De Rosa A, Brescia Morra V. A longitudinal real-life comparison study of natalizumab and fingolimod. Acta Neurol Scand 2017; 136:217-222. [PMID: 27976804 DOI: 10.1111/ane.12718] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Different retrospective studies compared natalizumab and fingolimod in relapsing-remitting multiple sclerosis (RRMS), with conflicting results. We aimed to explore the prescriptive attitude and the clinical outcome of the two therapies. METHODS We retrospectively included all RRMS patients treated with natalizumab (n=101) or fingolimod (n=78) as their first second-line therapy with at least 24-month follow-up. Demographic and clinical features were recorded to calculate the propensity score (PS). Outcomes of interest were annualized relapse rate (ARR), risk of relapse, and change in the EDSS RESULTS: At baseline, natalizumab patients were younger and had a shorter disease duration, a higher number of relapse in 1 year (1yR) and 2 years (2yR) and overall (ARR-PT) pretherapy, compared to fingolimod patients. On therapy, the proportion of relapsing patients and the mean RR were similar in the two groups. However, the change in the ARR was higher in natalizumab than in fingolimod group (P<.002), but, using PS as a covariate, it was comparable (P=.960). Similarly, the change in EDSS was significantly different for the two groups (P<.004), but not after adjusting for the PS (P=.321). CONCLUSION We observed a comparable efficacy on ARR reduction and on EDSS progression with natalizumab and fingolimod correcting through PS, suggesting that the efficacy difference observed before correction might derive from the clinical attitude in prescribing natalizumab in more active MS patients in real life.
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Affiliation(s)
- R. Lanzillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Multiple Sclerosis Clinical Care and Research Centre; Federico II University; Naples Italy
| | - A. Carotenuto
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Multiple Sclerosis Clinical Care and Research Centre; Federico II University; Naples Italy
| | - M. Moccia
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Multiple Sclerosis Clinical Care and Research Centre; Federico II University; Naples Italy
| | - F. Saccà
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Multiple Sclerosis Clinical Care and Research Centre; Federico II University; Naples Italy
| | - C. V. Russo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Multiple Sclerosis Clinical Care and Research Centre; Federico II University; Naples Italy
| | - M. Massarelli
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Multiple Sclerosis Clinical Care and Research Centre; Federico II University; Naples Italy
| | - A. De Rosa
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Multiple Sclerosis Clinical Care and Research Centre; Federico II University; Naples Italy
| | - V. Brescia Morra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Multiple Sclerosis Clinical Care and Research Centre; Federico II University; Naples Italy
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Ziemssen T, Medin J, Couto CAM, Mitchell CR. Multiple sclerosis in the real world: A systematic review of fingolimod as a case study. Autoimmun Rev 2017; 16:355-376. [DOI: 10.1016/j.autrev.2017.02.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/20/2016] [Indexed: 02/02/2023]
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Comparative Effectiveness Research of Disease-Modifying Therapies for the Management of Multiple Sclerosis: Analysis of a Large Health Insurance Claims Database. Neurol Ther 2017; 6:91-102. [PMID: 28211024 PMCID: PMC5447557 DOI: 10.1007/s40120-017-0064-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Limited data are available on the real-world effectiveness of newer oral disease-modifying therapies (DMTs) in multiple sclerosis. The purpose of this study was to retrospectively compare the real-world effectiveness of dimethyl fumarate (DMF), fingolimod, teriflunomide, and injectable DMTs in routine clinical practice based on US claims data. METHODS Patients newly-initiating DMF, interferon beta (IFNβ), glatiramer acetate (GA), teriflunomide, or fingolimod in 2013 were identified in the Truven MarketScan Commercial Claims Databases (N = 6372). Relapse episodes were identified based on a published claim-based algorithm and used to determine the annualized relapse rate (ARR) for the year before and after initiating therapy. Poisson and negative binomial regression was used to determine the adjusted incidence rate ratio (IRR) for each therapy relative to DMF. RESULTS Significant ARR reductions in the year after initiating therapy were reported for DMF and fingolimod (P < 0.0001). Compared with DMF, the adjusted IRR (95% CI) for relapse in the year after initiating therapy was 1.27 (1.10-1.46) for IFNβ, 1.34 (1.17-1.53) for GA, 1.23 (1.05-1.45) for teriflunomide, and 1.03 (0.88-1.21) for fingolimod. Results were consistent across subgroup and sensitivity analyses. CONCLUSION These real-world data suggest DMF and fingolimod have similar effectiveness and demonstrate superior effectiveness to IFNβ, GA, and teriflunomide. FUNDING Biogen, Cambridge, MA, USA.
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Trojano M, Tintore M, Montalban X, Hillert J, Kalincik T, Iaffaldano P, Spelman T, Sormani MP, Butzkueven H. Treatment decisions in multiple sclerosis — insights from real-world observational studies. Nat Rev Neurol 2017; 13:105-118. [DOI: 10.1038/nrneurol.2016.188] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Salzer J, Svenningsson R, Alping P, Novakova L, Björck A, Fink K, Islam-Jakobsson P, Malmeström C, Axelsson M, Vågberg M, Sundström P, Lycke J, Piehl F, Svenningsson A. Rituximab in multiple sclerosis: A retrospective observational study on safety and efficacy. Neurology 2016; 87:2074-2081. [PMID: 27760868 PMCID: PMC5109942 DOI: 10.1212/wnl.0000000000003331] [Citation(s) in RCA: 257] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 06/02/2016] [Indexed: 11/29/2022] Open
Abstract
Objective: To investigate the safety and efficacy of rituximab in multiple sclerosis (MS). Methods: In this retrospective uncontrolled observational multicenter study, off-label rituximab-treated patients with MS were identified through the Swedish MS register. Outcome data were collected from the MS register and medical charts. Adverse events (AEs) grades 2–5 according to the Common Terminology Criteria for Adverse Events were recorded. Results: A total of 822 rituximab-treated patients with MS were identified: 557 relapsing-remitting MS (RRMS), 198 secondary progressive MS (SPMS), and 67 primary progressive MS (PPMS). At baseline, 26.2% had contrast-enhancing lesions (CELs). Patients were treated with 500 or 1,000 mg rituximab IV every 6–12 months, during a mean 21.8 (SD 14.3) months. During treatment, the annualized relapse rates were 0.044 (RRMS), 0.038 (SPMS), and 0.015 (PPMS), and 4.6% of patients displayed CELs. Median Expanded Disability Status Scale remained unchanged in RRMS (p = 0.42) and increased by 0.5 and 1.0 in SPMS and PPMS, respectively (p = 0.10 and 0.25). Infusion-related AEs occurred during 7.8% of infusions and most were mild. A total of 89 AEs grades ≥2 (of which 76 infections) were recorded in 72 patients. No case of progressive multifocal leukoencephalopathy was detected. Conclusions: This is the largest cohort of patients with MS treated with rituximab reported so far. The safety, clinical, and MRI findings in this heterogeneous real-world cohort treated with different doses of rituximab were similar to those reported in previous randomized controlled trials on B-cell depletion therapy in MS. Classification of evidence: This study provides Class IV evidence that for patients with MS, rituximab is safe and effective.
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Affiliation(s)
- Jonatan Salzer
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Rasmus Svenningsson
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Peter Alping
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Lenka Novakova
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Anna Björck
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Katharina Fink
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Protik Islam-Jakobsson
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Clas Malmeström
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Markus Axelsson
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mattias Vågberg
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Peter Sundström
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Jan Lycke
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Fredrik Piehl
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Anders Svenningsson
- From the Department of Pharmacology and Clinical Neuroscience (J.S., R.S., P.I.-J., M.V., P.S., A.S.), Umeå University; Departments of Clinical Neuroscience (R.S., P.A., A.B., K.F., F.P.) and Clinical Sciences, Danderyd Hospital (A.S.), Karolinska Institutet, Stockholm; and Department of Clinical Neuroscience (L.N., C.M., M.A., J.L.), Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
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Tsivgoulis G, Katsanos AH, Mavridis D, Grigoriadis N, Dardiotis E, Heliopoulos I, Papathanasopoulos P, Karapanayiotides T, Kilidireas C, Hadjigeorgiou GM, Voumvourakis K. The Efficacy of Natalizumab versus Fingolimod for Patients with Relapsing-Remitting Multiple Sclerosis: A Systematic Review, Indirect Evidence from Randomized Placebo-Controlled Trials and Meta-Analysis of Observational Head-to-Head Trials. PLoS One 2016; 11:e0163296. [PMID: 27684943 PMCID: PMC5042498 DOI: 10.1371/journal.pone.0163296] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/05/2016] [Indexed: 12/14/2022] Open
Abstract
Background Although Fingolimod (FGD) and Natalizumab (NTZ) appear to be effective in relapsing-remitting multiple sclerosis (RRMS), they have never been directly compared in a randomized clinical trial (RCT). Methods and Findings We evaluated the comparative efficacy of FGD vs. NTZ using a meta-analytical approach. Data from placebo-controlled RCTs was used for indirect comparisons and observational data was utilized for head-to-head comparisons. We identified 3 RCTs (2498 patients) and 5 observational studies (2576 patients). NTZ was associated with a greater reduction in the 2-year annualized relapse rate (ARR; SMDindirect = -0.24;95% CI: from -0.44 to -0.04; p = 0.005) and with the probability of no disease activity at 2 years (ORindirect:1.82, 95% CI: from 1.05 to 3.15) compared to FGD, while no differences between the two therapies were found in the proportion of patients who remained relapse-free (ORindirect = 1.20;95% CI: from 0.84 to 1.71) and those with disability progression (ORindirect = 0.76;95% CI: from 0.48 to 1.21) at 2 years. In the analysis of observational data, we found no significant differences between NTZ and FGD in the 2-year ARR (SMD = -0.05; 95% CI: from -0.26 to 0.16), and 2-year disability progression (OR:1.08;95% CI: from 0.77 to 1.52). However, NTZ-treated patients were more likely to remain relapse-free at 2-years compared to FGD (OR: 2.19;95% CI: from 1.15 to 4.18; p = z0.020). Conclusions Indirect analyses of RCT data and head-to-head comparisons of observational findings indicate that NTZ may be more effective than FGD in terms of disease activity reduction in patients with RRMS. However, head-to-head RCTs are required to independently confirm this preliminary observation.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” Hospital, School of Medicine, University of Athens, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital in Brno, Brno, Czech Republic
- * E-mail:
| | - Aristeidis H. Katsanos
- Second Department of Neurology, “Attikon” Hospital, School of Medicine, University of Athens, Athens, Greece
- Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
- Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Nikolaos Grigoriadis
- Second Department of Neurology, “AHEPA” University Hospital, Aristotelion University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - Efthymios Dardiotis
- Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Ioannis Heliopoulos
- Department of Neurology, Alexandroupolis University Hospital, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Theodoros Karapanayiotides
- Second Department of Neurology, “AHEPA” University Hospital, Aristotelion University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - Constantinos Kilidireas
- First Department of Neurology, “Eginition” Hospital, School of Medicine, University of Athens, Athens, Greece
| | | | - Konstantinos Voumvourakis
- Second Department of Neurology, “Attikon” Hospital, School of Medicine, University of Athens, Athens, Greece
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Ziemssen T, Hillert J, Butzkueven H. The importance of collecting structured clinical information on multiple sclerosis. BMC Med 2016; 14:81. [PMID: 27246898 PMCID: PMC4888646 DOI: 10.1186/s12916-016-0627-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 05/18/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) are the 'gold standard' in the generation of drug efficacy and safety evidence. However, enrolment criteria, timelines and atypical comparators of RCTs limit their relevance to standard clinical practice. DISCUSSION Real-world data (RWD) provide longitudinal information on the comparative effectiveness and tolerability of drugs, as well as their impact on resource use, medical costs, and pharmacoeconomic and patient-reported outcomes. This is particularly important in multiple sclerosis (MS), where economic treatment benefits of long-term disability reduction are a cornerstone of payer drug approvals - these are typically not examined in the RCT itself but modelled using real-world datasets. Importantly, surrogate markers used in RCTs to predict the prevention of long-term disability progression can only truly be assessed through RWD methodologies. We discuss the differences between RCTs and RWD studies, describe how RWD complements the evidence base from RCTs in MS, summarize the different methods of RWD collection, and explain the importance of structuring data analysis to avoid bias. Guidance on performing and identifying high-quality real-world evidence studies is also provided.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, MS Center Dresden, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Jan Hillert
- Department of Clinical Neuroscience and Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
| | - Helmut Butzkueven
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
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