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Nistri R, Ianniello A, Pozzilli V, Giannì C, Pozzilli C. Advanced MRI Techniques: Diagnosis and Follow-Up of Multiple Sclerosis. Diagnostics (Basel) 2024; 14:1120. [PMID: 38893646 PMCID: PMC11171945 DOI: 10.3390/diagnostics14111120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/08/2024] [Accepted: 05/13/2024] [Indexed: 06/21/2024] Open
Abstract
Brain and spinal cord imaging plays a pivotal role in aiding clinicians with the diagnosis and monitoring of multiple sclerosis. Nevertheless, the significance of magnetic resonance imaging in MS extends beyond its clinical utility. Advanced imaging modalities have facilitated the in vivo detection of various components of MS pathogenesis, and, in recent years, MRI biomarkers have been utilized to assess the response of patients with relapsing-remitting MS to the available treatments. Similarly, MRI indicators of neurodegeneration demonstrate potential as primary and secondary endpoints in clinical trials targeting progressive phenotypes. This review aims to provide an overview of the latest advancements in brain and spinal cord neuroimaging in MS.
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Affiliation(s)
- Riccardo Nistri
- Department of Human Neuroscience, Sapienza University, 00185 Rome, Italy; (A.I.); (C.G.); (C.P.)
| | - Antonio Ianniello
- Department of Human Neuroscience, Sapienza University, 00185 Rome, Italy; (A.I.); (C.G.); (C.P.)
| | - Valeria Pozzilli
- Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Costanza Giannì
- Department of Human Neuroscience, Sapienza University, 00185 Rome, Italy; (A.I.); (C.G.); (C.P.)
- IRCCS Neuromed, 86077 Pozzilli, Italy
| | - Carlo Pozzilli
- Department of Human Neuroscience, Sapienza University, 00185 Rome, Italy; (A.I.); (C.G.); (C.P.)
- MS Center Sant’Andrea Hospital, 00189 Rome, Italy
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Chataway J, Williams T, Li V, Marrie RA, Ontaneda D, Fox RJ. Clinical trials for progressive multiple sclerosis: progress, new lessons learned, and remaining challenges. Lancet Neurol 2024; 23:277-301. [PMID: 38365380 DOI: 10.1016/s1474-4422(24)00027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/04/2023] [Accepted: 01/12/2024] [Indexed: 02/18/2024]
Abstract
Despite the success of disease-modifying treatments in relapsing multiple sclerosis, for many individuals living with multiple sclerosis, progressive disability continues to accrue. How to interrupt the complex pathological processes underlying progression remains a daunting and ongoing challenge. Since 2014, several immunomodulatory approaches that have modest but clinically meaningful effects have been approved for the management of progressive multiple sclerosis, primarily for people who have active inflammatory disease. The approval of these drugs required large phase 3 trials that were sufficiently powered to detect meaningful effects on disability. New classes of drug, such as Bruton tyrosine-kinase inhibitors, are coming to the end of their trial stages, several candidate neuroprotective compounds have been successful in phase 2 trials, and innovative approaches to remyelination are now also being explored in clinical trials. Work continues to define intermediate outcomes that can provide results in phase 2 trials more quickly than disability measures, and more efficient trial designs, such as multi-arm multi-stage and futility approaches, are increasingly being used. Collaborations between patient organisations, pharmaceutical companies, and academic researchers will be crucial to ensure that future trials maintain this momentum and generate results that are relevant for people living with progressive multiple sclerosis.
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Affiliation(s)
- Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK; Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK.
| | - Thomas Williams
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Vivien Li
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Ruth Ann Marrie
- Departments of Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Gurrea-Rubio M, Wang Q, Mills EA, Wu Q, Pitt D, Tsou PS, Fox DA, Mao-Draayer Y. Siponimod Attenuates Neuronal Cell Death Triggered by Neuroinflammation via NFκB and Mitochondrial Pathways. Int J Mol Sci 2024; 25:2454. [PMID: 38473703 PMCID: PMC10931690 DOI: 10.3390/ijms25052454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 03/14/2024] Open
Abstract
Multiple sclerosis (MS) is the most common autoimmune demyelinating disease of the central nervous system (CNS), consisting of heterogeneous clinical courses varying from relapsing-remitting MS (RRMS), in which disability is linked to bouts of inflammation, to progressive disease such as primary progressive MS (PPMS) and secondary progressive MS (SPMS), in which neurological disability is thought to be linked to neurodegeneration. As a result, successful therapeutics for progressive MS likely need to have both anti-inflammatory and direct neuroprotective properties. The modulation of sphingosine-1-phosphate (S1P) receptors has been implicated in neuroprotection in preclinical animal models. Siponimod/BAF312, the first oral treatment approved for SPMS, may have direct neuroprotective benefits mediated by its activity as a selective (S1P receptor 1) S1P1 and (S1P receptor 5) S1P5 modulator. We showed that S1P1 was mainly present in cortical neurons in lesioned areas of the MS brain. To gain a better understanding of the neuroprotective effects of siponimod in MS, we used both rat neurons and human-induced pluripotent stem cell (iPSC)-derived neurons treated with the neuroinflammatory cytokine tumor necrosis factor-alpha (TNF-α). Cell survival/apoptotic assays using flow cytometry and IncuCyte live cell analyses showed that siponimod decreased TNF-α induced neuronal cell apoptosis in both rat and human iPSCs. Importantly, a transcriptomic analysis revealed that mitochondrial oxidative phosphorylation, NFκB and cytokine signaling pathways contributed to siponimod's neuroprotective effects. Our data suggest that the neuroprotection of siponimod/BAF312 likely involves the relief of oxidative stress in neuronal cells. Further studies are needed to explore the molecular mechanisms of such interactions to determine the relationship between mitochondrial dysfunction and neuroinflammation/neurodegeneration.
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Affiliation(s)
- Mikel Gurrea-Rubio
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (M.G.-R.); (Q.W.); (P.-S.T.); (D.A.F.)
| | - Qin Wang
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; (Q.W.)
- Autoimmunity Center of Excellence, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Elizabeth A. Mills
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; (Q.W.)
| | - Qi Wu
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (M.G.-R.); (Q.W.); (P.-S.T.); (D.A.F.)
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; (Q.W.)
| | - David Pitt
- Department of Neurology, Yale Medicine, New Haven, CT 06473, USA;
| | - Pei-Suen Tsou
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (M.G.-R.); (Q.W.); (P.-S.T.); (D.A.F.)
- Autoimmunity Center of Excellence, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - David A. Fox
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (M.G.-R.); (Q.W.); (P.-S.T.); (D.A.F.)
- Autoimmunity Center of Excellence, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109, USA; (Q.W.)
- Autoimmunity Center of Excellence, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Multiple Sclerosis Center of Excellence, Oklahoma Medical Research Foundation, Oklahoma City, OK 73104, USA
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Gakis G, Angelopoulos I, Panagoulias I, Mouzaki A. Current knowledge on multiple sclerosis pathophysiology, disability progression assessment and treatment options, and the role of autologous hematopoietic stem cell transplantation. Autoimmun Rev 2024; 23:103480. [PMID: 38008300 DOI: 10.1016/j.autrev.2023.103480] [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: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) that affects nearly 2.8 million people each year. MS distinguishes three main types: relapsing-remitting MS (RRMS), secondary progressive MS (SPMS) and primary progressive MS (PPMS). RRMS is the most common type, with the majority of patients eventually progressing to SPMS, in which neurological development is constant, whereas PPMS is characterized by a progressive course from disease onset. New or additional insights into the role of effector and regulatory cells of the immune and CNS systems, Epstein-Barr virus (EBV) infection, and the microbiome in the pathophysiology of MS have emerged, which may lead to the development of more targeted therapies that can halt or reverse neurodegeneration. Depending on the type and severity of the disease, various disease-modifying therapies (DMTs) are currently used for RRMS/SPMS and PPMS. As a last resort, and especially in highly active RRMS that does not respond to DMTs, autologous hematopoietic stem cell transplantation (AHSCT) is performed and has shown good results in reducing neuroinflammation. Nevertheless, the question of its potential role in preventing disability progression remains open. The aim of this review is to provide a comprehensive update on MS pathophysiology, assessment of MS disability progression and current treatments, and to examine the potential role of AHSCT in preventing disability progression.
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Affiliation(s)
- Georgios Gakis
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece
| | - Ioannis Angelopoulos
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece
| | - Ioannis Panagoulias
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece
| | - Athanasia Mouzaki
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece.
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Hartung HP, Cree BA, Barnett M, Meuth SG, Bar-Or A, Steinman L. Bioavailable central nervous system disease-modifying therapies for multiple sclerosis. Front Immunol 2023; 14:1290666. [PMID: 38162670 PMCID: PMC10755740 DOI: 10.3389/fimmu.2023.1290666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/09/2023] [Indexed: 01/03/2024] Open
Abstract
Disease-modifying therapies for relapsing multiple sclerosis reduce relapse rates by suppressing peripheral immune cells but have limited efficacy in progressive forms of the disease where cells in the central nervous system play a critical role. To our knowledge, alemtuzumab, fumarates (dimethyl, diroximel, and monomethyl), glatiramer acetates, interferons, mitoxantrone, natalizumab, ocrelizumab, ofatumumab, and teriflunomide are either limited to the periphery or insufficiently studied to confirm direct central nervous system effects in participants with multiple sclerosis. In contrast, cladribine and sphingosine 1-phosphate receptor modulators (fingolimod, ozanimod, ponesimod, and siponimod) are central nervous system-penetrant and could have beneficial direct central nervous system properties.
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Affiliation(s)
- Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
- Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Palacký University Olomouc, Olomouc, Czechia
| | - Bruce A.C. Cree
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - Sven G. Meuth
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Lawrence Steinman
- Department of Neurology and Neurological Sciences, Beckman Center for Molecular Medicine, Stanford University Medical Center, Stanford, CA, United States
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Nakamura K, Zheng Y, Mahajan KR, Cohen JA, Fox RJ, Ontaneda D. Effect of ibudilast on thalamic magnetization transfer ratio and volume in progressive multiple sclerosis. Mult Scler 2023; 29:1257-1265. [PMID: 37537928 PMCID: PMC11130979 DOI: 10.1177/13524585231187289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND Thalamic volume (TV) is a sensitive biomarker of disease burden of injury in multiple sclerosis (MS) and appears to reflect overall lesion loads. Ibudilast showed significant treatment effect on brain atrophy and magnetization transfer ratio (MTR) of normal-appearing brain tissue but not in new/enlarging T2 lesion in the SPRINT-MS randomized clinical trial. OBJECTIVE To evaluate the effect of ibudilast on thalamic tissue integrity and volume in the SPRINT-MS. METHODS A total of 255 participants with progressive MS were randomized to oral ibudilast or placebo, and thalamic MTR and normalized TV over 96 weeks were quantified. Mixed-effect modeling assessed treatment effects on the thalamic MTR and TV, separately. Similarly, the measures were compared between the participants with confirmed disability progression (CDP). RESULTS Ibudilast's treatment effect was observed compared to placebo for thalamic MTR (p = 0.03) but not for TV (p = 0.68) while TV correlated with T2 lesion volume (p < 0.001). CDP associated with thalamic MTR (p = 0.04) but not with TV (p = 0.7). CONCLUSION Ibudilast showed an effect on thalamic MTR, which was associated with CDP, suggesting a clinically relevant effect on thalamic tissue integrity. However, the treatment effect was not observed in TV, suggesting that thalamic atrophy is more closely associated with global inflammatory activity than local tissue integrity. CLINICALTRIALS.GOV NCT01982942.
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Hua LH, Bar-Or A, Cohan SL, Lublin FD, Coyle PK, Cree BA, Meng X, Su W, Cox GM, Fox RJ. Effects of baseline age and disease duration on the efficacy and safety of siponimod in patients with active SPMS: Post hoc analyses from the EXPAND study. Mult Scler Relat Disord 2023; 75:104766. [PMID: 37245350 DOI: 10.1016/j.msard.2023.104766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Older age and longer disease duration (DD) may impact the effectiveness of disease-modifying therapies in patients with multiple sclerosis (MS). Siponimod is a sphingosine 1-phosphate receptor modulator approved for the treatment of active secondary progressive MS (SPMS) in many countries. The pivotal phase 3 EXPAND study examined siponimod versus placebo in a broad SPMS population with both active and non-active disease. In this population, siponimod demonstrated significant efficacy, including a reduction in the risk of 3-month confirmed disability progression (3mCDP) and 6-month confirmed disability progression (6mCDP). Benefits of siponimod were also observed across age and DD subgroups in the overall EXPAND population. Herein we sought to assess the clinical impact of siponimod across age and disease duration subgroups, specifically in participants with active SPMS. METHODS This study is a post hoc analysis of a subgroup of EXPAND participants with active SPMS (≥ 1 relapse in the 2 years before the study and/or ≥ 1 T1 gadolinium-enhancing magnetic resonance imaging lesion at baseline) receiving oral siponimod (2 mg/day) or placebo during EXPAND. Data were analyzed for participant subgroups stratified by age at baseline (primary cut-off: < 45 year ≥ 45 years; and secondary cut-off: < 50 years or ≥ 50 years) and by DD at baseline (< 16 years or ≥ 16 years). Efficacy endpoints were 3mCDP and 6mCDP. Safety assessments included adverse events (AEs), serious AEs, and AEs leading to treatment discontinuation. RESULTS Data from 779 participants with active SPMS were analyzed. All age and DD subgroups had 31-38% (3mCDP) and 27-43% (6mCDP) risk reductions with siponimod versus placebo. Compared with placebo, siponimod significantly reduced the risk of 3mCDP in participants aged ≥ 45 years (hazard ratio [HR]: 0.68; 95% confidence interval [CI]: 0.48-0.97), < 50 years (HR: 0.69; 95% CI: 0.49-0.98), ≥ 50 years (HR: 0.62; 95% CI: 0.40-0.96), and in participants with < 16 years DD (HR: 0.68; 95% CI: 0.47-0.98). The risk of 6mCDP was significantly reduced with siponimod versus placebo for participants aged < 45 years (HR: 0.60; 95% CI: 0.38-0.96), ≥ 45 years (HR: 0.67; 95% CI: 0.45-0.99), < 50 years (HR: 0.62; 95% CI: 0.43-0.90), and in participants with < 16 years DD (HR: 0.57; 95% CI: 0.38-0.87). Increasing age or longer MS duration did not appear to increase the risk of AEs, with an observed safety profile that remained consistent with the overall active SPMS and overall SPMS populations in EXPAND. CONCLUSIONS In participants with active SPMS, treatment with siponimod demonstrated a statistically significant reduction in the risk of 3mCDP and 6mCDP compared with placebo. Although not every outcome reached statistical significance in the subgroup analyses (possibly a consequence of small sample sizes), benefits of siponimod were seen across a spectrum of ages and DD. Siponimod was generally well tolerated by participants with active SPMS, regardless of baseline age and DD, and AE profiles were broadly similar to those observed in the overall EXPAND population.
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Affiliation(s)
- Le H Hua
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA.
| | - Amit Bar-Or
- Department of Neurology and the Center for Neuroinflammation and Experimental Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stanley L Cohan
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, Portland, OR, USA
| | - Fred D Lublin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patricia K Coyle
- Department of Neurology, Stony Brook University, Stony Brook, NY, USA
| | - Bruce Ac Cree
- UCSF, Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Xiangyi Meng
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Wendy Su
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research Neurological Institute Cleveland Clinic, Cleveland, OH, USA
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Klotz L, Antel J, Kuhlmann T. Inflammation in multiple sclerosis: consequences for remyelination and disease progression. Nat Rev Neurol 2023; 19:305-320. [PMID: 37059811 DOI: 10.1038/s41582-023-00801-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 04/16/2023]
Abstract
Despite the large number of immunomodulatory or immunosuppressive treatments available to treat relapsing-remitting multiple sclerosis (MS), treatment of the progressive phase of the disease has not yet been achieved. This lack of successful treatment approaches is caused by our poor understanding of the mechanisms driving disease progression. Emerging concepts suggest that a combination of persisting focal and diffuse inflammation within the CNS and a gradual failure of compensatory mechanisms, including remyelination, result in disease progression. Therefore, promotion of remyelination presents a promising intervention approach. However, despite our increasing knowledge regarding the cellular and molecular mechanisms regulating remyelination in animal models, therapeutic increases in remyelination remain an unmet need in MS, which suggests that mechanisms of remyelination and remyelination failure differ fundamentally between humans and demyelinating animal models. New and emerging technologies now allow us to investigate the cellular and molecular mechanisms underlying remyelination failure in human tissue samples in an unprecedented way. The aim of this Review is to summarize our current knowledge regarding mechanisms of remyelination and remyelination failure in MS and in animal models of the disease, identify open questions, challenge existing concepts, and discuss strategies to overcome the translational roadblock in the field of remyelination-promoting therapies.
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Affiliation(s)
- Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Jack Antel
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Québec, Canada
| | - Tanja Kuhlmann
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Québec, Canada.
- Institute of Neuropathology, University Hospital Münster, Münster, Germany.
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Jakimovski D, Silva D, Dwyer MG, Weinstock-Guttman B, Benedict RH, Riolo J, Zivadinov R. Therapy effect on AI-derived thalamic atrophy using clinical routine MRI protocol: A longitudinal, multi-center, propensity-matched multiple sclerosis study. Mult Scler Relat Disord 2023; 74:104708. [PMID: 37084495 DOI: 10.1016/j.msard.2023.104708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/27/2023] [Accepted: 04/06/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND The effect of disease modifying therapies (DMTs) on brain atrophy in persons with multiple sclerosis (pwMS) is typically investigated in highly standardized clinical trial settings or single-center academic institutions. We aimed at utilizing artificial intelligence (AI)-based volumetric analysis on routine unstandardized T2-FLAIR scans in determining the effect of DMTs on lateral ventricular volume (LVV) and thalamic volume (TV) changes in pwMS. METHODS The DeepGRAI (Deep Gray Rating via Artificial Intelligence) registry is a multi-center, longitudinal, observational, real-word study with a convenience sample of 1002 relapsing-remitting (RR) pwMS from 30 United States sites. Brain MRI exams acquired as part of the routine clinical management were collected at baseline and on average at 2.6-years follow-up. The MRI scans were acquired either on 1.5T or 3T scanners with no prior harmonization. TV was determined using the DeepGRAI tool and lateral ventricular volume LVV was measured using NeuroSTREAM software. RESULTS After propensity matching based on baseline age, disability and time of follow-up, untreated pwRRMS had significantly greater TV change when compared to treated pwRRMS (-1.2% vs. -0.3%, p = 0.044). PwRRMS treated with high-efficacy DMTs had significant and two-fold lower% LVV change when compared to pwRRMS treated on moderate-efficacy DMTs (3.5% vs. 7.0%, p = 0.001). PwRRMS who stopped DMT during the follow-up had significantly greater annualized% TV change compared to pwRRMS who remained on their DMT (-0.73% vs. -0.14%, p = 0.012) and significantly greater annualized% LVV change (3.4% vs. 1.7%, p = 0.047). These findings were also observed in a propensity analysis that additionally incorporated matching for scanner model at both baseline and follow-up visits. CONCLUSIONS LVV and TV measured on T2-FLAIR scans can detect treatment-induced short-term neurodegenerative changes measured in a real-word unstandardized, multicenter, clinical routine setting.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine, and Biomedical Sciences, University at Buffalo, State University of New York, NY, USA
| | | | - Michael G Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine, and Biomedical Sciences, University at Buffalo, State University of New York, NY, USA; Center for Biomedical Imaging at Clinical and Translational Science Institute, University of Buffalo, State University of New York, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, NY, USA
| | - Ralph Hb Benedict
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, NY, USA
| | - Jon Riolo
- Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine, and Biomedical Sciences, University at Buffalo, State University of New York, NY, USA; Center for Biomedical Imaging at Clinical and Translational Science Institute, University of Buffalo, State University of New York, NY, USA.
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Dumitrescu L, Papathanasiou A, Coclitu C, Garjani A, Evangelou N, Constantinescu CS, Popescu BO, Tanasescu R. An update on the use of sphingosine 1-phosphate receptor modulators for the treatment of relapsing multiple sclerosis. Expert Opin Pharmacother 2023; 24:495-509. [PMID: 36946625 PMCID: PMC10069376 DOI: 10.1080/14656566.2023.2178898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an immune-mediated disorder of the CNS manifested by recurrent attacks of neurological symptoms (related to focal inflammation) and gradual disability accrual (related to progressive neurodegeneration and neuroinflammation). Sphingosine-1-phosphate-receptor (S1PR) modulators are a class of oral disease-modifying therapies (DMTs) for relapsing MS. The first S1PR modulator developed and approved for MS was fingolimod, followed by siponimod, ozanimod, and ponesimod. All are S1P analogues with different S1PR-subtype selectivity. They restrain the S1P-dependent lymphocyte egress from lymph nodes by binding the lymphocytic S1P-subtype-1-receptor. Depending on their pharmacodynamics and pharmacokinetics, they can also interfere with other biological functions. AREAS COVERED Our narrative review covers the PubMed English literature on S1PR modulators in MS until August 2022. We discuss their pharmacology, efficacy, safety profile, and risk management recommendations based on the results of phase II and III clinical trials. We briefly address their impact on the risk of infections and vaccines efficacy. EXPERT OPINION S1PR modulators decrease relapse rate and may modestly delay disease progression in people with relapsing MS. Aside their established benefit, their place and timing within the long-term DMT strategy in MS, as well as their immunological effects in the new and evolving context of the post-COVID-19 pandemic and vaccination campaigns warrant further study.
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Affiliation(s)
- Laura Dumitrescu
- Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania
| | - Athanasios Papathanasiou
- Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, UK
| | - Catalina Coclitu
- Department of Multiple Sclerosis and Neuroimmunology, CHU Grenoble, Grenoble, France
| | - Afagh Garjani
- Academic Clinical Neurology, Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nikos Evangelou
- Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, UK
- Academic Clinical Neurology, Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Cris S Constantinescu
- Academic Clinical Neurology, Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Neurology, Cooper Neurological Institute, Camden, NJ, USA
| | - Bogdan Ovidiu Popescu
- Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania
| | - Radu Tanasescu
- Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, UK
- Academic Clinical Neurology, Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
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Regner-Nelke L, Pawlitzki M, Willison A, Rolfes L, Oezalp SH, Nelke C, Kölsche T, Korsen M, Grothe M, Groppa S, Luessi F, Engel S, Nelles G, Bonmann E, Roick H, Friedrich A, Knorn P, Landefeld H, Biro Z, Ernst M, Bayas A, Menacher M, Akgün K, Kleinschnitz C, Ruck T, Ziemssen T, Pul R, Meuth SG. Real-world evidence on siponimod treatment in patients with secondary progressive multiple sclerosis. Neurol Res Pract 2022; 4:55. [PMID: 36336685 PMCID: PMC9639325 DOI: 10.1186/s42466-022-00219-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Background Therapeutic options targeting inflammation in multiple sclerosis (MS) have evolved rapidly for relapsing–remitting MS, whereas few therapies are available for progressive forms of MS, in particular secondary progressive MS (SPMS). The approval of siponimod for SPMS has allowed for optimism in the otherwise discouraging therapeutic landscape.
Methods We conducted a retrospective, multicenter, non-interventional study analyzing the efficacy and safety of siponimod under real-world conditions in 227 SPMS patients. According to the retrospective study framework, data was acquired at prespecified time points. Clinical readouts were assessed every three months. Disease progression was determined as increase in expanded disability status scale (EDSS), radiological progression, or the occurrence of new relapses under treatment. For safety analyses, adverse events (AE) and reasons for discontinuation were documented. The collected data points were analyzed at baseline and after 6, 12 and 18 months. However, data were predominately collected at the 6- and 12-month time points as many patients were lost to follow-up. In a group consisting of 41 patients, a more detailed investigation regarding disease progression was conducted, including data from measurement of cognitive and motoric functions. Results Under siponimod therapy, 64.8% of patients experienced sustained clinical disease stability at 12 months. Out of the stable patients 21.4% of patients improved. Of the remaining patients, 31.5% experienced EDSS progression, 3.7% worsened without meeting the threshold for progression. Relapses occurred in 7.4%. Radiological disease activity was detected in 24.1% of patients after six months of treatment and in 29.6% of patients at 12 months follow-up. The in-depth cohort consisting of 41 patients demonstrated no substantial changes in cognitive abilities measured by Paced Auditory Serial Addition Test and Symbol Digit Modalities Test or motoric functions measured with Timed 25-Foot Walk, 100-m timed test, and 9-Hole Peg Test throughout the 12-month study period. Radiological assessment showed a stable volume of white and grey matter, as well as a stable lesion count at 12 months follow-up. AE were observed in nearly half of the included patients, with lymphopenia being the most common. Due to disease progression or AE, 31.2% of patients discontinued therapy. Conclusion Treatment with siponimod had an overall stabilizing effect regarding clinical and radiological outcome measures. However, there is a need for more intensive treatment management and monitoring to identify disease progression and AE. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-022-00219-3.
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Affiliation(s)
- Liesa Regner-Nelke
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marc Pawlitzki
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Alice Willison
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Leoni Rolfes
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Sinem-Hilal Oezalp
- Department of Neurology, University Medicine Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Christopher Nelke
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tristan Kölsche
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Melanie Korsen
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Matthias Grothe
- Department of Neurology, University Hospital Greifswald, Greifswald, Germany
| | - Sergiu Groppa
- Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Felix Luessi
- Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Sinah Engel
- Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | | | - Holger Roick
- E/M/S/A Center for Neurology / Psychiatry / Neuroradiology, Singen, Germany
| | | | | | | | - Zoltan Biro
- Clinic for Neurology Selzer, Baiersbronn, Germany
| | - Michael Ernst
- Center for Neurology, Psychiatry and Psychotherapy, Sinsheim, Germany
| | - Antonios Bayas
- Department of Neurology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Martina Menacher
- Department of Neurology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Katja Akgün
- Center of Clinical Neurosciences, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, University Medicine Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neurosciences, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Refik Pul
- Department of Neurology, University Medicine Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany. .,Department of Neurology, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
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Gold R, Piani-Meier D, Kappos L, Bar-Or A, Vermersch P, Giovannoni G, Fox RJ, Arnold DL, Benedict RHB, Penner IK, Rouyrre N, Kilaru A, Karlsson G, Ritter S, Dahlke F, Hach T, Cree BAC. Siponimod vs placebo in active secondary progressive multiple sclerosis: a post hoc analysis from the phase 3 EXPAND study. J Neurol 2022; 269:5093-5104. [PMID: 35639197 PMCID: PMC9363350 DOI: 10.1007/s00415-022-11166-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 04/29/2022] [Accepted: 05/01/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Siponimod is a sphingosine 1-phosphate receptor modulator approved for active secondary progressive multiple sclerosis (aSPMS) in most countries; however, phase 3 EXPAND study data are from an SPMS population with/without disease activity. A need exists to characterize efficacy/safety of siponimod in aSPMS. METHODS Post hoc analysis of participants with aSPMS (≥ 1 relapse in 2 years before study and/or ≥ 1 T1 gadolinium-enhancing [Gd +] magnetic resonance imaging [MRI] lesions at baseline) receiving oral siponimod (2 mg/day) or placebo for up to 3 years in EXPAND. ENDPOINTS 3-month/6-month confirmed disability progression (3mCDP/6mCDP); 3-month confirmed ≥ 20% worsening in Timed 25-Foot Walk (T25FW); 6-month confirmed improvement/worsening in Symbol Digit Modalities Test (SDMT) scores (≥ 4-point change); T2 lesion volume (T2LV) change from baseline; number of T1 Gd + lesions baseline-month 24; number of new/enlarging (N/E) T2 lesions over all visits. RESULTS Data from 779 participants with aSPMS were analysed. Siponimod reduced risk of 3mCDP/6mCDP vs placebo (by 31%/37%, respectively; p < 0.01); there was no significant effect on T25FW. Siponimod increased likelihood of 6-month confirmed SDMT improvement vs placebo (by 62%; p = 0.007) and reduced risk of 6-month confirmed SDMT worsening (by 27%; p = 0.060). Siponimod was associated with less increase in T2LV (1316.3 vs 13.3 mm3; p < 0.0001), and fewer T1 Gd + and N/E T2 lesions than placebo (85% and 80% reductions, respectively; p < 0.0001). CONCLUSIONS In aSPMS, siponimod reduced risk of disability progression and was associated with benefits on cognition and MRI outcomes vs placebo. TRIAL REGISTRATION ClinicalTrials.gov number: NCT01665144.
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Affiliation(s)
- Ralf Gold
- Department of Neurology, St. Josef Hospital and Ruhr University of Bochum, Bochum, Germany.
| | | | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB) and Multiple Sclerosis Center, Departments of Head, Spine and Neuromedicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick Vermersch
- University of Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas L Arnold
- NeuroRx Research, Montreal, QC, Canada and Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | | | - Iris-Katharina Penner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | | | | | | | | | - Bruce A C Cree
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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Cohan SL, Benedict RHB, Cree BAC, DeLuca J, Hua LH, Chun J. The Two Sides of Siponimod: Evidence for Brain and Immune Mechanisms in Multiple Sclerosis. CNS Drugs 2022; 36:703-719. [PMID: 35725892 PMCID: PMC9259525 DOI: 10.1007/s40263-022-00927-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 12/13/2022]
Abstract
Siponimod is a selective sphingosine 1-phosphate receptor subtype 1 (S1P1) and 5 (S1P5) modulator approved in the United States and the European Union as an oral treatment for adults with relapsing forms of multiple sclerosis (RMS), including active secondary progressive multiple sclerosis (SPMS). Preclinical and clinical studies provide support for a dual mechanism of action of siponimod, targeting peripherally mediated inflammation and exerting direct central effects. As an S1P1 receptor modulator, siponimod reduces lymphocyte egress from lymph nodes, thus inhibiting their migration from the periphery to the central nervous system. As a result of its peripheral immunomodulatory effects, siponimod reduces both magnetic resonance imaging (MRI) lesion (gadolinium-enhancing and new/enlarging T2 hyperintense) and relapse activity compared with placebo. Independent of these effects, siponimod can penetrate the blood-brain barrier and, by binding to S1P1 and S1P5 receptors on a variety of brain cells, including astrocytes, oligodendrocytes, neurons, and microglia, exert effects to modulate neural inflammation and neurodegeneration. Clinical data in patients with SPMS have shown that, compared with placebo, siponimod treatment is associated with reductions in levels of neurofilament light chain (a marker of neuroaxonal damage) and thalamic and cortical gray matter atrophy, with smaller reductions in MRI magnetization transfer ratio and reduced confirmed disability progression. This review examines the preclinical and clinical data supporting the dual mechanism of action of siponimod in RMS.
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Affiliation(s)
- Stanley L Cohan
- Providence Multiple Sclerosis Center, Providence Brain Institute, 9135 SW Barnes Rd Suite 461, Portland, OR, 97225, USA.
| | | | - Bruce A C Cree
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Le H Hua
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Jerold Chun
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
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Prakhova L, Ilves A. The first russian experience of use of siponimod in real clinical practice. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:138-141. [DOI: 10.17116/jnevro2022122071138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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