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Tramacere I, Virgili G, Perduca V, Lucenteforte E, Benedetti MD, Capobussi M, Castellini G, Frau S, Gonzalez-Lorenzo M, Featherstone R, Filippini G. Adverse effects of immunotherapies for multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2023; 11:CD012186. [PMID: 38032059 PMCID: PMC10687854 DOI: 10.1002/14651858.cd012186.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic disease of the central nervous system that affects mainly young adults (two to three times more frequently in women than in men) and causes significant disability after onset. Although it is accepted that immunotherapies for people with MS decrease disease activity, uncertainty regarding their relative safety remains. OBJECTIVES To compare adverse effects of immunotherapies for people with MS or clinically isolated syndrome (CIS), and to rank these treatments according to their relative risks of adverse effects through network meta-analyses (NMAs). SEARCH METHODS We searched CENTRAL, PubMed, Embase, two other databases and trials registers up to March 2022, together with reference checking and citation searching to identify additional studies. SELECTION CRITERIA We included participants 18 years of age or older with a diagnosis of MS or CIS, according to any accepted diagnostic criteria, who were included in randomized controlled trials (RCTs) that examined one or more of the agents used in MS or CIS, and compared them versus placebo or another active agent. We excluded RCTs in which a drug regimen was compared with a different regimen of the same drug without another active agent or placebo as a control arm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for data extraction and pairwise meta-analyses. For NMAs, we used the netmeta suite of commands in R to fit random-effects NMAs assuming a common between-study variance. We used the CINeMA platform to GRADE the certainty of the body of evidence in NMAs. We considered a relative risk (RR) of 1.5 as a non-inferiority safety threshold compared to placebo. We assessed the certainty of evidence for primary outcomes within the NMA according to GRADE, as very low, low, moderate or high. MAIN RESULTS This NMA included 123 trials with 57,682 participants. Serious adverse events (SAEs) Reporting of SAEs was available from 84 studies including 5696 (11%) events in 51,833 (89.9%) participants out of 57,682 participants in all studies. Based on the absolute frequency of SAEs, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 18 additional people would have a SAE compared to placebo. Low-certainty evidence suggested that three drugs may decrease SAEs compared to placebo (relative risk [RR], 95% confidence interval [CI]): interferon beta-1a (Avonex) (0.78, 0.66 to 0.94); dimethyl fumarate (0.79, 0.67 to 0.93), and glatiramer acetate (0.84, 0.72 to 0.98). Several drugs met our non-inferiority criterion versus placebo: moderate-certainty evidence for teriflunomide (1.08, 0.88 to 1.31); low-certainty evidence for ocrelizumab (0.85, 0.67 to 1.07), ozanimod (0.88, 0.59 to 1.33), interferon beta-1b (0.94, 0.78 to 1.12), interferon beta-1a (Rebif) (0.96, 0.80 to 1.15), natalizumab (0.97, 0.79 to 1.19), fingolimod (1.05, 0.92 to 1.20) and laquinimod (1.06, 0.83 to 1.34); very low-certainty evidence for daclizumab (0.83, 0.68 to 1.02). Non-inferiority with placebo was not met due to imprecision for the other drugs: low-certainty evidence for cladribine (1.10, 0.79 to 1.52), siponimod (1.20, 0.95 to 1.51), ofatumumab (1.26, 0.88 to 1.79) and rituximab (1.01, 0.67 to 1.52); very low-certainty evidence for immunoglobulins (1.05, 0.33 to 3.32), diroximel fumarate (1.05, 0.23 to 4.69), peg-interferon beta-1a (1.07, 0.66 to 1.74), alemtuzumab (1.16, 0.85 to 1.60), interferons (1.62, 0.21 to 12.72) and azathioprine (3.62, 0.76 to 17.19). Withdrawals due to adverse events Reporting of withdrawals due to AEs was available from 105 studies (85.4%) including 3537 (6.39%) events in 55,320 (95.9%) patients out of 57,682 patients in all studies. Based on the absolute frequency of withdrawals, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 31 additional people would withdraw compared to placebo. No drug reduced withdrawals due to adverse events when compared with placebo. There was very low-certainty evidence (meaning that estimates are not reliable) that two drugs met our non-inferiority criterion versus placebo, assuming an upper 95% CI RR limit of 1.5: diroximel fumarate (0.38, 0.11 to 1.27) and alemtuzumab (0.63, 0.33 to 1.19). Non-inferiority with placebo was not met due to imprecision for the following drugs: low-certainty evidence for ofatumumab (1.50, 0.87 to 2.59); very low-certainty evidence for methotrexate (0.94, 0.02 to 46.70), corticosteroids (1.05, 0.16 to 7.14), ozanimod (1.06, 0.58 to 1.93), natalizumab (1.20, 0.77 to 1.85), ocrelizumab (1.32, 0.81 to 2.14), dimethyl fumarate (1.34, 0.96 to 1.86), siponimod (1.63, 0.96 to 2.79), rituximab (1.63, 0.53 to 5.00), cladribine (1.80, 0.89 to 3.62), mitoxantrone (2.11, 0.50 to 8.87), interferons (3.47, 0.95 to 12.72), and cyclophosphamide (3.86, 0.45 to 33.50). Eleven drugs may have increased withdrawals due to adverse events compared with placebo: low-certainty evidence for teriflunomide (1.37, 1.01 to 1.85), glatiramer acetate (1.76, 1.36 to 2.26), fingolimod (1.79, 1.40 to 2.28), interferon beta-1a (Rebif) (2.15, 1.58 to 2.93), daclizumab (2.19, 1.31 to 3.65) and interferon beta-1b (2.59, 1.87 to 3.77); very low-certainty evidence for laquinimod (1.42, 1.01 to 2.00), interferon beta-1a (Avonex) (1.54, 1.13 to 2.10), immunoglobulins (1.87, 1.01 to 3.45), peg-interferon beta-1a (3.46, 1.44 to 8.33) and azathioprine (6.95, 2.57 to 18.78); however, very low-certainty evidence is unreliable. Sensitivity analyses including only studies with low attrition bias, drug dose above the group median, or only patients with relapsing remitting MS or CIS, and subgroup analyses by prior disease-modifying treatments did not change these figures. Rankings No drug yielded consistent P scores in the upper quartile of the probability of being better than others for primary and secondary outcomes. AUTHORS' CONCLUSIONS We found mostly low and very low-certainty evidence that drugs used to treat MS may not increase SAEs, but may increase withdrawals compared with placebo. The results suggest that there is no important difference in the occurrence of SAEs between first- and second-line drugs and between oral, injectable, or infused drugs, compared with placebo. Our review, along with other work in the literature, confirms poor-quality reporting of adverse events from RCTs of interventions. At the least, future studies should follow the CONSORT recommendations about reporting harm-related issues. To address adverse effects, future systematic reviews should also include non-randomized studies.
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Affiliation(s)
- Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Ophthalmology, IRCCS - Fondazione Bietti, Rome, Italy
| | - Vittorio Perduca
- Université Paris Cité, CNRS, MAP5, F-75006 Paris, France
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Ersilia Lucenteforte
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Maria Donata Benedetti
- UOC Neurologia B - Policlinico Borgo Roma, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Capobussi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Greta Castellini
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | | | - Marien Gonzalez-Lorenzo
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Department of Oncology, Laboratory of Clinical Research Methodology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
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Vermersch P, Galazka A, Dangond F, Damian D, Wong SL, Jack D, Harty G. Efficacy of cladribine tablets in high disease activity patients with relapsing multiple sclerosis: post hoc analysis of subgroups with and without prior disease-modifying drug treatment. Curr Med Res Opin 2021; 37:459-464. [PMID: 33331183 DOI: 10.1080/03007995.2020.1865888] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Relapsing-remitting multiple sclerosis (RRMS) patients with high disease activity (HDA) experience more severe disease than those without HDA. This analysis describes the efficacy of cladribine tablets 3.5 mg/kg in HDA patient subgroups that were either treated with disease-modifying drugs (DMDs) prior to study entry or were treatment naïve. METHODS Post hoc analysis of the 96 week Cladribine Tablets Treating Multiple Sclerosis Orally (CLARITY) study compared cladribine tablets 3.5 mg/kg to placebo in subgroups of patients meeting the high relapse activity plus disease activity on treatment definition of HDA. Patients were categorized into either prior DMD treatment or DMD treatment-naïve subgroups. Endpoints included annualized relapse rate (ARR), time to first relapse, time to disability progression and magnetic resonance imaging (MRI) outcomes. No inferential statistical analyses were conducted between subgroups. RESULTS The DMD-naïve cohort (n = 187) was larger than the prior-DMD cohort (n = 102). In both the DMD-naïve and prior-DMD cohorts, cladribine tablets were associated with a reduction in ARR (rate ratio [RR]: 0.26; 95% confidence interval [CI]: 0.16-0.42; p < .0001 and RR: 0.55; 95% CI: 0.32-0.95; p = .0324, respectively). In both subgroups, cladribine tablets increased the time to relapse versus placebo (hazard ratio [HR]: 0.36; 95% CI: 0.21-0.62; p = .0002 for DMD-naïve cohort and HR: 0.50; 95% CI: 0.24-1.02; p = .0557 for prior-DMD cohort). Significant differences were observed for all assessed disability and MRI outcomes independently of previous treatment. CONCLUSION Post hoc evidence suggests consistent treatment benefits of cladribine tablets 3.5 mg/kg during the 96 week CLARITY study among HDA-RRMS patients who were either previously treated with DMDs or were treatment naïve.
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Affiliation(s)
- Patrick Vermersch
- Inserm U1172, CHU Lille, FHU Imminent, University of Lille, Lille, France
| | - Andrew Galazka
- Ares Trading S.A., Eysins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Fernando Dangond
- EMD Serono Research & Development Institute Inc., Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
| | - Doris Damian
- EMD Serono Research & Development Institute Inc., Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
| | - Schiffon L Wong
- EMD Serono Research & Development Institute Inc., Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
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Tafazzoli A, Chavan A, Harty G, Moller J, Wong SL. Efficiency Model of Cladribine Tablets Versus Infusion-Based Disease-Modifying Drugs for Patients with Relapsing-Remitting Multiple Sclerosis. Adv Ther 2020; 37:3791-3806. [PMID: 32647909 DOI: 10.1007/s12325-020-01426-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION To develop a simulation model assessing the efficiency of using cladribine tablets versus infusion-based disease-modifying drugs (DMDs) for the treatment of relapsing-remitting multiple sclerosis (RRMS) from a facility perspective in the UK. METHODS A scheduling algorithm was developed to simulate day-case admissions and calculate the mean changes to resource use and time burden for patients in a facility that transitions from infusion-based treatments to cladribine tablets over 1 year. Model inputs and assumptions were based on previous research and expert opinion. Model validation and quality checks were performed and additional scenario analyses were also conducted. RESULTS The model successfully scheduled all infusion treatments in the base case and no patients were left off the schedule as a result of lack of capacity. Modeled base-case outcomes increased in future scenarios owing to a 35% increase in demand. The introduction of cladribine tablets reduced these impacts. Specifically, the difference in mean daily utilization was reduced in the future scenario from 13% to 3% as 8% of patients moved to cladribine tablets; annual administration costs decreased by 96% and annual time burden decreased by 90%. Results from additional scenarios showed the largest benefits from switching current infusion patients to cladribine tablets were realized in facilities having moderate to high resource utilization. CONCLUSIONS This model provides facility decision-makers the ability to assess the efficiency of using cladribine tablets rather than an infusion-based DMD. The simulation quantified the benefits gained from reducing the burden on facility resources by switching some patients with RRMS from infusion-based DMDs to cladribine tablets. Overall, modeled outcomes increased in future scenarios owing to an increase in demand, although the introduction of cladribine tablets reduced this impact.
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Affiliation(s)
- Ali Tafazzoli
- Evidence Synthesis, Modeling and Communication, Evidera, Bethesda, MD, USA
| | - Ameya Chavan
- Evidence Synthesis, Modeling and Communication, Evidera, Bethesda, MD, USA
| | - Gerard Harty
- Global Evidence and Value Development, Global Research and Development, EMD Serono, Inc, Billerica, MA, USA.
| | - Jorgen Moller
- Evidence Synthesis, Modeling and Communication, Evidera, London, UK
| | - Schiffon L Wong
- Global Evidence and Value Development, Global Research and Development, EMD Serono, Inc, Billerica, MA, USA
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Desirability and acceptability of a treatment-sequencing model in relapsing-remitting multiple sclerosis: A health technology assessment perspective. Int J Technol Assess Health Care 2020; 36:162-166. [PMID: 32423521 DOI: 10.1017/s0266462320000112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Gather health technology assessment (HTA) experts' insights on the desirability and acceptability of treatment-sequencing models applied to relapsing-remitting multiple sclerosis (RRMS). DATA SOURCE/STUDY SETTING Primary data. STUDY DESIGN In-depth double-blind semi-structured telephone interviews. DATA COLLECTION/EXTRACTION METHODS General themes were extracted from qualitative interviews. PRINCIPAL FINDINGS Although experts confirmed the importance of evaluating the clinical and cost-effectiveness of treatments as part of a sequence, the current HTA decision making framework is not conducive to this. Developing an RRMS treatment-sequencing model that meets HTA requirements is difficult, in particular due to scarcity of effectiveness data in later treatment lines. CONCLUSIONS At present, a treatment-sequencing model for RRMS may be desirable yet not requested by HTA bodies for their decision making. However, there could be other areas where a treatment-sequencing model for RRMS is of use.
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van Eijndhoven E, Brauer M, Kee R, MacEwan J, Mucha L, Wong SL, Durand A, Shafrin J. Modeling the impact of patient treatment preference on health outcomes in relapsing-remitting multiple sclerosis. J Med Econ 2020; 23:474-483. [PMID: 31903813 DOI: 10.1080/13696998.2019.1711100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Aims: Model how moving from current disease-modifying drug (DMD) prescribing patterns for relapsing-remitting multiple sclerosis (RRMS) observed in the United Kingdom (UK) to prescribing patterns based on patient preferences would impact health outcomes over time.Materials and methods: A cohort-based Markov model was used to measure the effect of DMDs on long-term health outcomes for individuals with RRMS. Data from a discrete choice experiment were used to estimate the market shares of DMDs based on patient preferences (i.e. preference shares). These preference shares and real-world UK market shares were used to calculate the effect of prescribing behavior on relapses, disability progression, and quality-adjusted life-years (QALYs). The incremental benefit of patient-centered prescribing over current practices for the UK RRMS population was then estimated; scenario and sensitivity analyses were also conducted.Results: Compared to current prescribing practices, when UK patients with RRMS were treated following patient preferences, health outcomes were improved. This population was expected to experience 501,690 relapses and gain 1,003,263 discounted QALYs over 50 years under patient-centered prescribing practices compared to 538,417 relapses and 958,792 discounted QALYs under current practices (-6.8% and +4.6%, respectively). Additionally, less disability progression was observed when prescribed treatment was based on patient preferences. In a scenario analysis where only oral treatments were considered, the results were similar, although the magnitude of benefit was smaller. Number of relapses was most sensitive to how the annualized relapse rate was modeled; disability progression was most sensitive to mortality rate assumptions.Limitations: Treatment efficacy estimates applied to various models in this study were based on data derived from clinical trials, rather than real-world data; the impact of patient-centered prescribing on treatment adherence and/or switching was not modeled.Conclusions: The population of UK RRMS patients may experience overall health gains if patient preferences are better incorporated into prescribing practices.
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Affiliation(s)
| | | | - Rebecca Kee
- Precision Health Economics, Los Angeles, CA, USA
| | | | - Lisa Mucha
- Global Evidence & Value Development, Global Research & Development, EMD Serono Inc, Billerica, MA, USA
| | - Schiffon L Wong
- Global Evidence & Value Development, Global Research & Development, EMD Serono Inc, Billerica, MA, USA
| | - Adeline Durand
- Global Evidence & Value Development, Global Research & Development, EMD Serono Inc, Billerica, MA, USA
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Siddiqui MK, Singh B, Attri S, Veraart C, Harty G, Wong SL. Use of rituximab in adults with relapsing-remitting multiple sclerosis: a systematic literature review. Curr Med Res Opin 2020; 36:809-826. [PMID: 32129684 DOI: 10.1080/03007995.2020.1739009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Rituximab is used as an off-label treatment for relapsing-remitting multiple sclerosis (RRMS); however, the comparative efficacy and safety of rituximab versus currently licensed disease-modifying drugs (DMDs) for RRMS is unknown. A systematic literature review was conducted to evaluate the available data pertaining to efficacy and safety of rituximab in adult patients with RRMS and highly active relapsing multiple sclerosis (HA-RMS); data quality was critically assessed via risk of bias (RoB) assessment.Methods: Biomedical literature databases were searched until mid-2018 and key proceedings were searched from 2016 to 2018. Critical appraisal of non-randomized studies was conducted using the Cochrane RoB assessment tool; randomized controlled trials (RCTs) were appraised using comprehensive assessment criteria based on the NICE guidelines.Results: Thirty-eight unique studies based on 49 publications were identified: 25 RRMS studies (one RCT) and 13 HA-RMS studies (no RCTs). The evidence among patients with RRMS generally favored rituximab in comparison to placebo (relapse rate) and interferons/glatiramer acetate (relapse rate and disability progression), although much of the non-randomized data were descriptive and/or not statistically significant. In comparison to placebo, rituximab was associated with a greater risk of adverse events. Two-thirds of the non-randomized RRMS studies were associated with critical/serious RoB; the single RCT was associated with low RoB. Furthermore, all of the non-randomized HA-RMS studies were associated with critical/serious RoB.Conclusions: Available evidence of off-label rituximab use for the treatment of patients with RRMS suggests generally favorable efficacy versus placebo and interferons/glatiramer acetate; however, the poor quality of the included studies limits any robust conclusions.
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Scoring disease in an animal model of multiple sclerosis using a novel infrared-based automated activity-monitoring system. Sci Rep 2019; 9:19194. [PMID: 31844134 PMCID: PMC6915774 DOI: 10.1038/s41598-019-55713-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/20/2019] [Indexed: 01/06/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic demyelinating disorder of the central nervous system (CNS). Its corresponding animal model, experimental autoimmune encephalomyelitis (EAE), is widely used to understand disease pathogenesis and test novel therapeutic agents. However, existing methods to score EAE disease severity are subjective and often vary between individual researchers, making it difficult to translate findings across different studies. An enhanced automated method of disease scoring would eliminate subjectivity and reduce operator-dependent errors. Here, we used an Infra-Red Activity Monitoring System (IRAMS) to measure murine locomotor activity as a surrogate measure of disease severity and compared it to standard EAE scoring methods. In mice immunized with CNS-specific myelin antigens, we observed an inverse correlation between disease severity and mouse activity, with the IRAMS showing enhanced disease scoring compared to standard EAE scoring methods. Relative to standard EAE scoring methods, IRAMS showed comparable measurement of disease relapses and remissions in the SJL/J-relapsing-remitting model of EAE, and could comparably assess the therapeutic efficiency of the MS drug, Copaxone (Glatiramer acetate-GA). Thus, the IRAMS is a method to measure disease severity in EAE without subjective bias and is a tool to consistently assess the efficacy of novel therapeutic agents for MS.
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Salas PAO, Parra CO, Florez CEP, Goez LM, Velez-van-Meerbeke A, Rodriguez JH. Safety liver profile of teriflunomide versus interferon β in multiple sclerosis: Systematic review and indirect comparison meta-analysis. Mult Scler Relat Disord 2018; 26:192-200. [PMID: 30268040 DOI: 10.1016/j.msard.2018.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/12/2018] [Accepted: 09/12/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare the liver safety profile of interferon β (IFN β) and teriflunomide in patients with multiple sclerosis. METHODS A network meta-analysis was carried out following the Cochrane Collaboration methodology. All trials comparing all types of IFN β with teriflunomide, or disease-modifying drugs, or placebo in RRMS were included. An indirect comparison network meta-analysis within a Bayesian framework with STATA (version 13.0) was done for this study. RESULTS The database searches yielded 284 titles, with 15 records as duplicates. One study was identified by manually searching. Thirteen articles were included in the systematic review. Twelve studies compared IFN β (4203 patients) vs another DMT. Four studies evaluated the effectiveness and safety of teriflunomide (906 patients) vs another DMT. Six studies reported drug-induced liver injury as per the Hy's Law. However, only one study had a direct comparison and reported no cases of liver toxicity in either group, so it was not possible to estimate the OR. The indirect comparisons metanalysis shows that there was no statistically-significant difference between teriflunomide and IFN β (OR 1.09, 95% CI 0.02-2.16). CONCLUSIONS There were no significant difference when comparing IFN β and teriflunomide in terms of liver failure or elevation of transaminases.
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Affiliation(s)
- Paola Andrea Ortiz Salas
- Fundación Cardioinfantil, Instituto de Cardiologia, Bogotá, Colombia; Grupo de investigación en neurociencias NeURos, School of medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia.
| | | | | | - Lina Maria Goez
- Fundación Cardioinfantil, Instituto de Cardiologia, Bogotá, Colombia
| | - Alberto Velez-van-Meerbeke
- Grupo de investigación en neurociencias NeURos, School of medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Jesus Hernan Rodriguez
- Fundación Cardioinfantil, Instituto de Cardiologia, Bogotá, Colombia; Grupo de investigación en neurociencias NeURos, School of medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia; Hospital Universitario Mederi, Bogotá, Colombia
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Gold R, Schlegel E, Elias-Hamp B, Albert C, Schmidt S, Tackenberg B, Xiao J, Schaak T, Salmen HC. Incidence and mitigation of gastrointestinal events in patients with relapsing-remitting multiple sclerosis receiving delayed-release dimethyl fumarate: a German phase IV study (TOLERATE). Ther Adv Neurol Disord 2018; 11:1756286418768775. [PMID: 29707040 PMCID: PMC5912264 DOI: 10.1177/1756286418768775] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/26/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Gastrointestinal (GI) events are common adverse events (AEs) associated with delayed-release dimethyl fumarate (DMF), an approved treatment for relapsing–remitting multiple sclerosis (RRMS). The objective of the TOLERATE study was to evaluate GI tolerability and GI mitigation via symptomatic therapies in patients initiating DMF in a real-world clinical setting in Germany. Methods: TOLERATE was a multicentre, open-label, single-arm study performed at 25 German sites. Endpoints were frequency, severity, duration (all primary) and mitigation of GI-related events (secondary). Patients were instructed to take DMF according to the prescribing information for up to 12 weeks and to document GI events and intake of GI-symptomatic therapy on numerical rating scales, using eDiaries. Results: A total of 211 patients were included in the safety population (71% female; mean age 40 ± 11 years). Of these, 185 patients (87.7%) reported GI-related events, out of which nearly half received GI-symptomatic therapy (84/185; 45.4%). The most frequently reported GI events were upper abdominal pain, flatulence and nausea. GI-related events peaked during the first 3 weeks of therapy and rapidly decreased thereafter. The severity of GI events over 12 weeks according to the Modified Overall Gastrointestinal Symptom Scale were mild to moderate in the majority of patients reporting GI-related events and taking symptomatic GI medication (53.6%). Only 10% of all patients discontinued study treatment due to AEs in general, while 6.6% discontinued due to GI-related events. The severity of GI-related events decreased over time in patients who received symptomatic treatment with one or more medications (e.g. acid secretion blockers, antidiarrhoeals or antiemetics). Conclusion: Gastrointestinal events associated with delayed-release DMF were mainly mild to moderate in severity. Prevalence of GI events peaked during the first 3 weeks of therapy and rapidly faded thereafter. Although 44.9% of patients experiencing GI events used common GI symptomatic therapies, only 6.6% of patients discontinued DMF because of GI events, suggesting that GI events could be managed well with common symptomatic therapy.
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Affiliation(s)
- Ralf Gold
- Katholisches Klinikum Bochum St. Josef-Hospital, Neurological Clinic, Bochum University, Gudrunstraße 56, 44791 Bochum, Germany
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Perspectives from the Patient and the Healthcare Professional in Multiple Sclerosis: Social Media and Patient Education. Neurol Ther 2017; 7:23-36. [PMID: 29243028 PMCID: PMC5990508 DOI: 10.1007/s40120-017-0087-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Indexed: 11/20/2022] Open
Abstract
A diagnosis of multiple sclerosis (MS) is life-altering. Because the course of MS is heterogeneous, patients may face uncertainty in terms of long-term physical and cognitive challenges, potential loss of employment, and the risk of social isolation. Patients often turn to the Internet and social media for information about MS and its management, and to seek out fellow patients and support groups. Here, we examine the use of social media and the Internet among patients with MS, considering its impact on patient education. We consider the access that these conduits provide not only to other patients with MS but also to a wealth of disease-related information online. These themes are further illustrated with first-hand experiences of the patient author and her physician. We also explore the impact of the Internet and social media on the education and support of patients with MS from the healthcare professional’s (HCP’s) perspective, including opportunities for HCPs to promote disease education among their patients, and the advantages that arise from patients being better informed about their disease. The rise of the Internet and social media has changed the patient experience, helping patients to support each other, to educate themselves proactively about their condition, and to participate more actively in decisions relating to disease management than perhaps was the case historically. Funding Novartis Pharmaceuticals Corporation.
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Bell C, Anderson J, Ganguly T, Prescott J, Capila I, Lansing JC, Sachleben R, Iyer M, Fier I, Roach J, Storey K, Miller P, Hall S, Kantor D, Greenberg BM, Nair K, Glajch J. Development of Glatopa® (Glatiramer Acetate): The First FDA-Approved Generic Disease-Modifying Therapy for Relapsing Forms of Multiple Sclerosis. J Pharm Pract 2017. [PMID: 28847230 DOI: 10.1177/0897190017725984.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The multiple sclerosis (MS) treatment landscape in the United States has changed dramatically over the past decade. While many disease-modifying therapies (DMTs) have been approved by the US Food and Drug Administration (FDA) for the treatment of relapsing forms of MS, DMT costs continue to rise. The availability of generics and biosimilars in the MS-treatment landscape is unlikely to have a major impact on clinical benefit. However, their availability will provide alternative treatment options and potentially lower costs through competition, thus increasing the affordability of and access to these drugs. In April 2015, the first generic version of the complex drug glatiramer acetate (Glatopa® 20 mg/mL) injection was approved in the United States as a fully substitutable generic for all approved indications of the 20 mg/mL branded glatiramer acetate (Copaxone®) dosage form. Despite glatiramer acetate's complex nature-being a chemically synthesized (ie, nonbiologic) mixture of peptides-the approval occurred without conducting any clinical trials. Rather, extensive structural and functional characterization was performed to demonstrate therapeutic equivalence to the innovator drug. The approval of Glatopa signifies an important milestone in the US MS-treatment landscape, with the hope that the introduction of generic DMTs and eventually biosimilar DMTs will lead to future improvements in the affordability and access of these much-needed treatments for MS.
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Affiliation(s)
- Christine Bell
- 1 Analytical Development, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - James Anderson
- 2 Pharmaceutical Sciences, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Tanmoy Ganguly
- 3 Research and Development, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - James Prescott
- 4 Analytical Chemistry, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Ishan Capila
- 5 Research, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | | | - Richard Sachleben
- 6 Complex Generics Manufacturing, Technical Operations, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Mani Iyer
- 7 Chemical Development and Manufacturing, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Ian Fier
- 8 Program and Project Management, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - James Roach
- 9 Clinical Development and Regulatory Affairs, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Kristina Storey
- 10 Regulatory Affairs, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Paul Miller
- 11 Medical Affairs and Communications, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Steven Hall
- 12 Medical Affairs, Sandoz, Inc, a Novartis Division, Princeton, NJ, USA
| | - Daniel Kantor
- 13 Division of Neurology, Florida Atlantic University, Boca Raton, FL, USA
| | - Benjamin M Greenberg
- 14 Neurology and Neurotherapeutics, Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kavita Nair
- 15 Department of Clinical Pharmacy, University of Colorado School of Pharmacy, Aurora, CO, USA
| | - Joseph Glajch
- 1 Analytical Development, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
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12
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Bell C, Anderson J, Ganguly T, Prescott J, Capila I, Lansing JC, Sachleben R, Iyer M, Fier I, Roach J, Storey K, Miller P, Hall S, Kantor D, Greenberg BM, Nair K, Glajch J. Development of Glatopa® (Glatiramer Acetate): The First FDA-Approved Generic Disease-Modifying Therapy for Relapsing Forms of Multiple Sclerosis. J Pharm Pract 2017; 31:481-488. [PMID: 28847230 PMCID: PMC6144347 DOI: 10.1177/0897190017725984] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The multiple sclerosis (MS) treatment landscape in the United States has changed dramatically over the past decade. While many disease-modifying therapies (DMTs) have been approved by the US Food and Drug Administration (FDA) for the treatment of relapsing forms of MS, DMT costs continue to rise. The availability of generics and biosimilars in the MS-treatment landscape is unlikely to have a major impact on clinical benefit. However, their availability will provide alternative treatment options and potentially lower costs through competition, thus increasing the affordability of and access to these drugs. In April 2015, the first generic version of the complex drug glatiramer acetate (Glatopa® 20 mg/mL) injection was approved in the United States as a fully substitutable generic for all approved indications of the 20 mg/mL branded glatiramer acetate (Copaxone®) dosage form. Despite glatiramer acetate's complex nature-being a chemically synthesized (ie, nonbiologic) mixture of peptides-the approval occurred without conducting any clinical trials. Rather, extensive structural and functional characterization was performed to demonstrate therapeutic equivalence to the innovator drug. The approval of Glatopa signifies an important milestone in the US MS-treatment landscape, with the hope that the introduction of generic DMTs and eventually biosimilar DMTs will lead to future improvements in the affordability and access of these much-needed treatments for MS.
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Affiliation(s)
- Christine Bell
- 1 Analytical Development, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - James Anderson
- 2 Pharmaceutical Sciences, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Tanmoy Ganguly
- 3 Research and Development, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - James Prescott
- 4 Analytical Chemistry, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Ishan Capila
- 5 Research, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | | | - Richard Sachleben
- 6 Complex Generics Manufacturing, Technical Operations, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Mani Iyer
- 7 Chemical Development and Manufacturing, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Ian Fier
- 8 Program and Project Management, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - James Roach
- 9 Clinical Development and Regulatory Affairs, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Kristina Storey
- 10 Regulatory Affairs, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Paul Miller
- 11 Medical Affairs and Communications, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Steven Hall
- 12 Medical Affairs, Sandoz, Inc, a Novartis Division, Princeton, NJ, USA
| | - Daniel Kantor
- 13 Division of Neurology, Florida Atlantic University, Boca Raton, FL, USA
| | - Benjamin M Greenberg
- 14 Neurology and Neurotherapeutics, Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kavita Nair
- 15 Department of Clinical Pharmacy, University of Colorado School of Pharmacy, Aurora, CO, USA
| | - Joseph Glajch
- 1 Analytical Development, Momenta Pharmaceuticals, Inc, Cambridge, MA, USA
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13
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Weinstock-Guttman B, Nair KV, Glajch JL, Ganguly TC, Kantor D. Two decades of glatiramer acetate: From initial discovery to the current development of generics. J Neurol Sci 2017; 376:255-259. [DOI: 10.1016/j.jns.2017.03.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/10/2017] [Accepted: 03/20/2017] [Indexed: 11/16/2022]
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14
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Deleu D, Mesraoua B, El Khider H, Canibano B, Melikyan G, Al Hail H, Mhjob N, Bhagat A, Ibrahim F, Hanssens Y. Optimization and stratification of multiple sclerosis treatment in fast developing economic countries: a perspective from Qatar. Curr Med Res Opin 2017; 33:439-458. [PMID: 27892723 DOI: 10.1080/03007995.2016.1261818] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The introduction of disease-modifying therapies (DMTs) - with varying degrees of efficacy for reducing annual relapse rate and disability progression - has considerably transformed the therapeutic landscape of relapsing-remitting multiple sclerosis (RRMS). We aim to develop rational evidence-based treatment recommendations and algorithms for the management of clinically isolated syndrome (CIS) and RRMS that conform to the healthcare system in a fast-developing economic country such as Qatar. RESEARCH DESIGN AND METHODS We conducted a systematic review using a comprehensive search of MEDLINE, PubMed, and Cochrane Database of Systematic Reviews (1 January 1990 through 30 September 2016). Additional searches of the American Academy of Neurology and European Committee for Treatment and Research in Multiple Sclerosis abstracts from 2012 through 2016 were performed, in addition to searches of the Food and Drug Administration and European Medicines Agency websites to obtain relevant safety information on these DMTs. RESULTS For each of the DMTs, the mode of action, efficacy, safety and tolerability are briefly discussed. To facilitate the interpretation, the efficacy data of the pivotal phase III trials are expressed by their most clinically useful measure of therapeutic efficacy, the number needed to treat (NNT). In addition, an overview of head-to-head trials in RRMS is provided as well as a summary of the several different RRMS management strategies (lateral switching, escalation, induction, maintenance and combination therapy) and the potential role of each DMT. Finally, algorithms were developed for CIS, active and highly active or rapidly evolving RRMS and subsequent breakthrough disease or suboptimal treatment response while on DMTs. The benefit-to-risk profiles of the DMTs, taking into account patient preference, allowed the provision of rational and safe patient-tailored treatment algorithms. CONCLUSIONS Recommendations and algorithms for the management of CIS and RRMS have been developed relevant to the healthcare system of this fast-developing economic country.
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Affiliation(s)
- Dirk Deleu
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Boulenouar Mesraoua
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Hisham El Khider
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Beatriz Canibano
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Gayane Melikyan
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Hassan Al Hail
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Noha Mhjob
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Anjushri Bhagat
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Faiza Ibrahim
- a Department of Neurology , Neuroscience Institute, Hamad Medical Corporation , Doha , State of Qatar
| | - Yolande Hanssens
- b Department of Clinical Services Unit , Pharmacy, Hamad Medical Corporation , Doha , State of Qatar
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15
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Jones E, Pike J, Marshall T, Ye X. Quantifying the relationship between increased disability and health care resource utilization, quality of life, work productivity, health care costs in patients with multiple sclerosis in the US. BMC Health Serv Res 2016; 16:294. [PMID: 27443278 PMCID: PMC4957342 DOI: 10.1186/s12913-016-1532-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 07/07/2016] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic progressive condition affecting the central nervous system. Progression of MS results in increased level of disability and most patients will eventually experience some degree of functional impairment and impaired mobility. Costs and burdens escalate as MS disability increases. However, there is a lack of recent data on the impact of MS disability on the cost and burden among patients in the US. METHODS Data for this study were drawn from a real world, cross-sectional survey undertaken between 2013 and 2014. Neurologists completed detailed patient report forms (PRF) for the most recent consulting patients with MS (age >18 years). Patient's perceptions of their diagnosis and health-related quality of life (HRQoL) were collected through a patient self-completion questionnaire (PSC). Regression analysis was used to evaluate the relationship between disability (determined by latest Expanded Disability Status Scale [EDSS] score) and current relapse and health care resource utilization, health care costs, HRQoL and work productivity. RESULTS PRF data were collected for 715 patients (335 also completed a PSC). Patients with higher disability scores (EDSS 3-5 and >5 vs <3 points) and current relapse (vs no current relapse) reported significantly greater health resource utilization for physician visits (p < 0.05) and hospitalizations (p < 0.05) in the preceding 12 months. In addition, they had poorer HRQoL (p < 0.05), were significantly more likely to be unemployed (p < 0.05) and to have had to stop working due to MS (p < 0.05). They also incurred significantly higher health care related costs, including costs for physician consultations, hospitalizations and therapy (p < 0.05). The total costs of care were $51,825, $57,889 and $67,116 for EDSS < 3, EDSS 3-5 and EDSS > 5 groups, respectively; $51,692 and $58,648 for non-relapse and relapse groups, respectively. CONCLUSIONS For MS patients in the US, health resource utilization and healthcare care costs increase with progression of disability. As the disability worsens, patients also exhibit diminished HRQoL and lower work productivity. There is a need for treatments that slow down or delay disability progression among MS patients.
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Affiliation(s)
- E Jones
- Adelphi Real World, Adelphi Mill, Bollington, Macclesfield, Cheshire, SK10 5JB, UK.
| | - J Pike
- Adelphi Real World, Adelphi Mill, Bollington, Macclesfield, Cheshire, SK10 5JB, UK
| | - T Marshall
- Abbvie Inc., 26525 Riverwoods Blvd., Mettawa, IL, 60060, USA
| | - X Ye
- Abbvie Inc., 26525 Riverwoods Blvd., Mettawa, IL, 60060, USA
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16
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Wang Q, Meng J, Dong A, Yu JZ, Zhang GX, Ma CG. The Pharmacological Effects and Mechanism ofTripterygium wilfordiiHook F in Central Nervous System Autoimmunity. J Altern Complement Med 2016; 22:496-502. [DOI: 10.1089/acm.2016.0004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Qing Wang
- 2011 Collaborative Innovation Center/Research Center of Neurobiology, Shanxi University of Traditional Chinese Medicine, Shanxi Province, People's Republic of China
| | - Jian Meng
- Institute of Brain Science, Shanxi Datong University, Datong, People's Republic of China
| | - Aiguo Dong
- 2011 Collaborative Innovation Center/Research Center of Neurobiology, Shanxi University of Traditional Chinese Medicine, Shanxi Province, People's Republic of China
| | - Jie-zhong Yu
- Institute of Brain Science, Shanxi Datong University, Datong, People's Republic of China
| | - Guang-Xian Zhang
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA
| | - Cun-Gen Ma
- 2011 Collaborative Innovation Center/Research Center of Neurobiology, Shanxi University of Traditional Chinese Medicine, Shanxi Province, People's Republic of China
- Institute of Brain Science, Shanxi Datong University, Datong, People's Republic of China
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17
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Tramacere I, Benedetti MD, Capobussi M, Castellini G, Citterio A, Del Giovane C, Frau S, Gonzalez-Lorenzo M, La Mantia L, Moja L, Nuzzo S, Filippini G. Adverse effects of immunotherapies for multiple sclerosis: a network meta-analysis. Hippokratia 2016. [DOI: 10.1002/14651858.cd012186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Irene Tramacere
- Fondazione IRCCS Istituto Neurologico Carlo Besta; Neuroepidemiology Unit; Via Giovanni Celoria, 11 Milan Italy 20133
| | - Maria Donata Benedetti
- Azienda Ospedaliera Universitaria Integrata; UOC Neurologia B - Policlinico Borgo Roma; Piazzale La Scuro , 10 Verona Verona Italy 37135
| | - Matteo Capobussi
- University of Milan; Department of Biomedical Sciences for Health; Via Pascal, 36 Milan Italy 20100
| | - Greta Castellini
- University of Milan; Department of Biomedical Sciences for Health; Via Pascal, 36 Milan Italy 20100
- IRCCS Galeazzi Orthopaedic Institute; Unit of Clinical Epidemiology; Milan Italy
| | - Antonietta Citterio
- IRCCS National Neurological Institute C. Mondino; Scientific Direction; Via Mondino 2 Pavia Italy 27100
| | - Cinzia Del Giovane
- University of Modena and Reggio Emilia; Italian Cochrane Centre, Department of Diagnostic, Clinical and Public Health Medicine; Modena Italy
| | | | - Marien Gonzalez-Lorenzo
- University of Milan; Department of Biomedical Sciences for Health; Via Pascal, 36 Milan Italy 20100
| | - Loredana La Mantia
- IRCCS. Santa Maria Nascente - Fondazione Don Gnocchi; Unit of Neurorehabilitation - Multiple Sclerosis Center; Via Capecelatro, 66 Milan Italy 20148
| | - Lorenzo Moja
- University of Milan; Department of Biomedical Sciences for Health; Via Pascal, 36 Milan Italy 20100
- IRCCS Galeazzi Orthopaedic Institute; Clinical Epidemiology Unit; Milan Italy
| | - Sara Nuzzo
- Fondazione IRCCS. Istituto Neurologico Carlo Besta; Via Celoria, 11 Milan Italy 20133
| | - Graziella Filippini
- Fondazione IRCCS. Istituto Neurologico Carlo Besta; Scientific Direction; via Celoria, 11 Milan Italy 20133
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