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Jožef M, Locatelli I, Brecl Jakob G, Savšek L, Šurlan Popovič K, Špiclin Ž, Rot U, Kos M. Psychometric evaluation of the 5-item Medication Adherence Report Scale questionnaire in persons with multiple sclerosis. PLoS One 2024; 19:e0294116. [PMID: 38437197 PMCID: PMC10911604 DOI: 10.1371/journal.pone.0294116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/25/2023] [Indexed: 03/06/2024] Open
Abstract
The 5-item Medication Adherence Report Scale (MARS-5) is a reliable and valid questionnaire for evaluating adherence in patients with asthma, hypertension, and diabetes. Validity has not been determined in multiple sclerosis (MS). We aimed to establish criterion validity and reliability of the MARS-5 in persons with MS (PwMS). Our prospective study included PwMS on dimethyl fumarate (DMF). PwMS self-completed the MARS-5 on the same day before baseline and follow-up brain magnetic resonance imaging (MRI) 3 and 9 months after treatment initiation and were graded as highly and medium adherent upon the 24-cut-off score, established by receiver operator curve analysis. Health outcomes were represented by relapse occurrence from the 1st DMF dispense till follow-up brain MRI and radiological progression (new T2 MRI lesions and quantitative analysis) between baseline and follow-up MRI. Criterion validity was established by association with the Proportion of Days Covered (PDC), new T2 MRI lesions, and Beliefs in Medicines questionnaire (BMQ). The reliability evaluation included internal consistency and the test-retest method. We included 40 PwMS (age 37.6 ± 9.9 years, 75% women), 34 were treatment-naive. No relapses were seen during the follow-up period but quantitative MRI analysis showed new T2 lesions in 6 PwMS. The mean (SD) MARS-5 score was 23.1 (2.5), with 24 PwMS graded as highly adherent. The higher MARS-5 score was associated with higher PDC (b = 0.027, P<0.001, 95% CI: (0.0134-0.0403)) and lower medication concerns (b = -1.25, P<0.001, 95% CI: (-1.93-(-0,579)). Lower adherence was associated with increased number (P = 0.00148) and total volume of new T2 MRI lesions (P = 0.00149). The questionnaire showed acceptable internal consistency (Cronbach α = 0.72) and moderate test-retest reliability (r = 0.62, P < 0.0001, 95% CI: 0.33-0.79). The MARS-5 was found to be valid and reliable for estimating medication adherence and predicting medication concerns in persons with MS.
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Affiliation(s)
- Maj Jožef
- Chair of Social Pharmacy, Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Multiple Sclerosis Centre, Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Igor Locatelli
- Chair of Social Pharmacy, Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Gregor Brecl Jakob
- Multiple Sclerosis Centre, Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Lina Savšek
- Department of Neurology, General Hospital Celje, Celje, Slovenia
| | | | - Žiga Špiclin
- Laboratory for Imaging Technologies, Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
| | - Uroš Rot
- Multiple Sclerosis Centre, Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Chair of Neurology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Mitja Kos
- Chair of Social Pharmacy, Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
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Lee CY, Chan KH. Personalized Use of Disease-Modifying Therapies in Multiple Sclerosis. Pharmaceutics 2024; 16:120. [PMID: 38258130 PMCID: PMC10820407 DOI: 10.3390/pharmaceutics16010120] [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: 12/01/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Multiple sclerosis is an important neurological disease affecting millions of young patients globally. It is encouraging that more than ten disease-modifying drugs became available for use in the past two decades. These disease-modifying therapies (DMTs) have different levels of efficacy, routes of administration, adverse effect profiles and concerns for pregnancy. Much knowledge and caution are needed for their appropriate use in MS patients who are heterogeneous in clinical features and severity, lesion load on magnetic resonance imaging and response to DMT. We aim for an updated review of the concept of personalization in the use of DMT for relapsing MS patients. Shared decision making with consideration for the preference and expectation of patients who understand the potential efficacy/benefits and risks of DMT is advocated.
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Affiliation(s)
- Chi-Yan Lee
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, 405B, 4/F, Professorial Block, 102 Pokfulam Road, Hong Kong
- Neuroimmunology and Neuroinflammation Research Laboratory, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Koon-Ho Chan
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, 405B, 4/F, Professorial Block, 102 Pokfulam Road, Hong Kong
- Neuroimmunology and Neuroinflammation Research Laboratory, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
- Research Center of Heart, Brain, Hormone and Healthy Aging, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
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Roar M, Nielsen ARH, Berg JM, Sirakov G, Stilund M, Schäfer J, Ratzer R, Frederiksen J, Asgari N, Ashna SN, Jensen HB, Kant M, Theódorsdóttir Á, Illes Z, Sellebjerg F, Magyari M, Schlosser LM, Nordborg H, Wergeland S, Sejbaek T. Discontinuation of dimethyl fumarate in multiple sclerosis - a nationwide study. Mult Scler Relat Disord 2023; 80:105127. [PMID: 37956521 DOI: 10.1016/j.msard.2023.105127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/18/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Adherence is a prerequisite for the efficacy of any drug, and previous studies have shown that non-adherence is associated with disease activity and increased health care cost in multiple sclerosis (MS). The aim of this study was to investigate rates and reasons for discontinuation of dimethyl fumarate (DMF) among people with MS on a national level and differences between clinics in Denmark. METHODS This was a nationwide, registry and population study of patients treated with DMF. We calculated standard residuals (SR) demonstrate differences between clinics. For survival analysis regarding discontinuation rates and discontinuation due to specific AEs we used log-rank test Cox-proportional hazards and plotted Kaplan-Meier graphics. RESULTS We included 2,448 people with MS, treated with DMF from 2013 to 2020. Average treatment duration was 26 months (5,382 treatment years). 49.2 % of patients who initiated treatment with DMF (n = 1205) were continuously treated. Reasons for discontinuation were adverse events (54.5 %, n = 656), active disease (26.1 %, n = 315), pregnancy (9.4 %, n = 113) or other reasons (13.2 %, n = 159). We compared SR to the mean regarding reasons for discontinuation and found significant differences between sites regarding gastrointestinal adverse events, flushing and lymphopenia. Discontinuation due to all adverse events, flushing and lymphopenia were more frequent in female than male patients. CONCLUSION In this population-based study, we found major differences between the MS clinics in rates and reason for discontinuation of DMF. Our results suggest that management strategies during DMF treatment can reduce discontinuation rates.
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Affiliation(s)
- Malte Roar
- Department of Neurology, Aalborg University Hospital, Denmark
| | | | | | - Georgi Sirakov
- Department of Neurology and Physiotheraphy, Gødstrup Hospital, Herning, Denmark
| | - Morten Stilund
- Department of Neurology and Physiotheraphy, Gødstrup Hospital, Herning, Denmark; Department of Neurology, Aarhus University Hospitalt, Aarhus, Denmark
| | - Jakob Schäfer
- Department of Neurology, Aalborg University Hospital, Denmark
| | - Rikke Ratzer
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Jette Frederiksen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nasrin Asgari
- Department of Neurology, Slagelse and Institute of Regional Health Research, and Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Said Nasim Ashna
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark
| | - Henrik Boye Jensen
- Department of Neurology, Lillebaelt Hospital, Kolding, Denmark; The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway; BRIDGE, Brain Research - Inter Disciplinary Guided Excellence, Department of Regional Health Research, University of Southern Denmark
| | - Matthias Kant
- Department of Neurology, Hospital of Southern Jutland, Sønderborg, Denmark
| | | | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Louise Mose Schlosser
- Department of Neurology, Hospital Southwest Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Hilde Nordborg
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Stig Wergeland
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway; The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Tobias Sejbaek
- Department of Neurology, Hospital Southwest Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark; The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway; BRIDGE, Brain Research - Inter Disciplinary Guided Excellence, Department of Regional Health Research, University of Southern Denmark; MS Alliance of Southern Denmark, Denmark.
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Singer BA, Arnold DL, Drulovic J, Freedman MS, Gold R, Gudesblatt M, Jasinska E, LaGanke CC, Naismith RT, Negroski D, Oh J, Hernandez Perez MA, Selmaj K, Then Bergh F, Wundes A, Ziemssen T, Castro-Borrero W, Chen H, Levin S, Scaramozza M, Shankar SL, Wang T, Wray S. Diroximel fumarate in patients with relapsing-remitting multiple sclerosis: Final safety and efficacy results from the phase 3 EVOLVE-MS-1 study. Mult Scler 2023; 29:1795-1807. [PMID: 37905526 PMCID: PMC10687803 DOI: 10.1177/13524585231205708] [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: 05/12/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Diroximel fumarate (DRF) is approved for adults with relapsing-remitting multiple sclerosis (RRMS) in Europe and for relapsing forms of MS in the United States. DRF and dimethyl fumarate (DMF) yield bioequivalent exposure of the active metabolite monomethyl fumarate. Prior studies indicated fewer gastrointestinal (GI)-related adverse events (AEs) with DRF compared with DMF. OBJECTIVE To report final outcomes from EVOLVE-MS-1. METHODS EVOLVE-MS-1 was an open-label, 96-week, phase 3 study assessing DRF safety, tolerability, and efficacy in patients with RRMS. The primary endpoint was safety and tolerability; efficacy endpoints were exploratory. RESULTS Overall, 75.7% (800/1057) of patients completed the study; median exposure was 1.8 (range: 0.0-2.0) years. AEs occurred in 938 (88.7%) patients, mostly of mild (28.9%) or moderate (50.3%) severity. DRF was discontinued due to AEs in 85 (8.0%) patients, with < 2% discontinuing due to GI or flushing/flushing-related AEs. At Week 96, mean number of gadolinium-enhancing lesions was significantly reduced from baseline (72.7%; p < 0.0001); adjusted annualized relapse rate was 0.13 (95% confidence interval: 0.11-0.15). CONCLUSION DRF was generally well tolerated over 2 years, with few discontinuations due to AEs; radiological measures indicated decreased disease activity from baseline. These outcomes support DRF as a treatment option in patients with RRMS.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
- NeuroRx Research Inc., Montreal, QC, Canada
| | - Jelena Drulovic
- Clinic of Neurology, University of Belgrade, Belgrade, Serbia
| | - Mark S Freedman
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ralf Gold
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - Mark Gudesblatt
- NYU Langone South Shore Neurologic Associates, Patchogue, NY, USA
| | - Elzbieta Jasinska
- Collegium Medicum UJK, and Clinical Center, RESMEDICA, Kielce, Poland
| | | | | | | | - Jiwon Oh
- Division of Neurology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Krzysztof Selmaj
- Center of Neurology, Lodz, Poland
- Department of Neurology, University of Warmia and Mazury, Olsztyn, Poland
| | | | - Annette Wundes
- Department of Neurology, University of Washington Medical Center, Seattle, WA, USA
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, Dresden, Germany
| | | | | | | | | | | | | | - Sibyl Wray
- Hope Neurology MS Center, Knoxville, TN, USA
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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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Williams MJ, Amezcua L, Chinea A, Cohan S, Okai A, Okuda DT, Vargas W, Belviso N, Božin I, Jiang X, Lewin JB, Lyons J, Shen C, England SM, Grimes N. Real-World Safety and Effectiveness After 5 Years of Dimethyl Fumarate Treatment in Black and Hispanic Patients with Multiple Sclerosis in ESTEEM. Neurol Ther 2023; 12:1669-1682. [PMID: 37354276 PMCID: PMC10444730 DOI: 10.1007/s40120-023-00517-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/07/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION Multiple sclerosis (MS) clinical trials have included low numbers of patients from racial and ethnic minority populations; therefore, it is uncertain whether differences exist in response to disease-modifying therapies. We evaluated the real-world safety and effectiveness of dimethyl fumarate (DMF) treatment over 5 years in four patient cohorts: Black, non-Black, Hispanic, and non-Hispanic people with relapsing-remitting MS. METHODS ESTEEM is an ongoing, 5-year, multinational, prospective study evaluating the long-term safety and effectiveness of DMF in people with MS. The analysis included patients newly prescribed DMF in routine practice at 393 sites globally. RESULTS Overall, 5251 patients were analyzed (220 Black, 5031 non-Black; 105 Hispanic, 5146 non-Hispanic). Median (min-max) months of follow-up was 32 (0-72) for Black, 29 (1-77) for Hispanic, and 41 (0-85) for both the non-Black and non-Hispanic populations. In total, 39 (18%) Black and 29 (28%) Hispanic patients reported adverse events leading to treatment discontinuation versus 1126 (22%) non-Black and 1136 (22%) non-Hispanic patients; gastrointestinal disorders were the most common in all subgroups. Median lymphocyte counts decreased by 37% in Black, 40% in non-Black, 10% in Hispanic, and 39% in non-Hispanic patients in the first year, then remained stable and above the lower limit of normal in most patients. Annualized relapse rates (ARRs) (95% confidence intervals) up to 5 years were 0.054 (0.038-0.078) for Black, 0.077 (0.072-0.081) for non-Black, 0.069 (0.043-0.112) for Hispanic, and 0.076 (0.072-0.081) for non-Hispanic populations, representing reductions of 91-92% compared with ARR 12 months before study entry (all p < 0.0001). CONCLUSION The safety profile of DMF in these subgroups was consistent with the overall ESTEEM population. Relapse rates remained low in Black and Hispanic patients, and consistent with non-Black and non-Hispanic patients. These data demonstrate a comparable real-world treatment benefit of DMF in Black and Hispanic patients. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02047097.
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Affiliation(s)
| | - Lilyana Amezcua
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Stanley Cohan
- Providence Portland Medical Center, Portland, OR, USA
| | - Annette Okai
- North Texas Institute of Neurology and Headache, Plano, TX, USA
| | - Darin T Okuda
- Neuroinnovation Program, UT Southwestern Medical Center, Dallas, TX, USA
| | - Wendy Vargas
- Columbia University Medical Center, New York City, NY, USA
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Sánchez-Sanz A, García-Martín S, Sabín-Muñoz J, Moreno-Torres I, Elvira V, Al-Shahrour F, García-Grande A, Ramil E, Rodríguez-De la Fuente O, Brea-Álvarez B, García-Hernández R, García-Merino A, Sánchez-López AJ. Dimethyl fumarate-related immune and transcriptional signature is associated with clinical response in multiple sclerosis-treated patients. Front Immunol 2023; 14:1209923. [PMID: 37483622 PMCID: PMC10360655 DOI: 10.3389/fimmu.2023.1209923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
Background and objective Dimethyl fumarate (DMF) is an immunomodulatory drug approved for the therapy of multiple sclerosis (MS). The identification of response biomarkers to DMF is a necessity in the clinical practice. With this aim, we studied the immunophenotypic and transcriptomic changes produced by DMF in peripheral blood mononuclear cells (PBMCs) and its association with clinical response. Material and methods PBMCs were obtained from 22 RRMS patients at baseline and 12 months of DMF treatment. Lymphocyte and monocyte subsets, and gene expression were assessed by flow cytometry and next-generation RNA sequencing, respectively. Clinical response was evaluated using the composite measure "no evidence of disease activity" NEDA-3 or "evidence of disease activity" EDA-3 at 2 years, classifying patients into responders (n=15) or non-responders (n=7), respectively. Results In the whole cohort, DMF produced a decrease in effector (TEM) and central (TCM) memory T cells in both the CD4+ and CD8+ compartments, followed by an increase in CD4+ naïve T cells. Responder patients presented a greater decrease in TEM lymphocytes. In addition, responder patients showed an increase in NK cells and were resistant to the decrease in the intermediate monocytes shown by non-responders. Responder patients also presented differences in 3 subpopulations (NK bright, NK dim and CD8 TCM) at baseline and 4 subpopulations (intermediate monocytes, regulatory T cells, CD4 TCM and CD4 TEMRA) at 12 months. DMF induced a mild transcriptional effect, with only 328 differentially expressed genes (DEGs) after 12 months of treatment. The overall effect was a downregulation of pro-inflammatory genes, chemokines, and activators of the NF-kB pathway. At baseline, no DEGs were found between responders and non-responders. During DMF treatment a differential transcriptomic response was observed, with responders presenting a higher number of DEGs (902 genes) compared to non-responders (189 genes). Conclusions Responder patients to DMF exhibit differences in monocyte and lymphocyte subpopulations and a distinguishable transcriptomic response compared to non-responders that should be further studied for the validation of biomarkers of treatment response to DMF.
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Affiliation(s)
- Alicia Sánchez-Sanz
- Neuroimmunology Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
- PhD Program in Molecular Biosciences, Doctoral School, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Julia Sabín-Muñoz
- Department of Neurology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Irene Moreno-Torres
- Demyelinating Diseases Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Víctor Elvira
- School of Mathematics, University of Edinburgh, Edinburgh, United Kingdom
| | - Fátima Al-Shahrour
- Bioinformatics Unit, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
| | - Aranzazu García-Grande
- Flow Cytometry Core Facility, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Elvira Ramil
- Sequencing Core Facility, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | | | - Beatriz Brea-Álvarez
- Radiodiagnostic Division, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Ruth García-Hernández
- Neuroimmunology Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Antonio García-Merino
- Neuroimmunology Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
- Department of Neurology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
- Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Antonio José Sánchez-López
- Neuroimmunology Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
- Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
- Biobank, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
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Zhang T, Alonzo I, Stubben C, Geng Y, Herdman C, Chandler N, Doane KP, Pluimer BR, Trauger SA, Peterson RT. A zebrafish model of combined saposin deficiency identifies acid sphingomyelinase as a potential therapeutic target. Dis Model Mech 2023; 16:dmm049995. [PMID: 37183607 PMCID: PMC10320721 DOI: 10.1242/dmm.049995] [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] [Received: 11/16/2022] [Accepted: 04/26/2023] [Indexed: 05/16/2023] Open
Abstract
Sphingolipidoses are a subcategory of lysosomal storage diseases (LSDs) caused by mutations in enzymes of the sphingolipid catabolic pathway. Like many LSDs, neurological involvement in sphingolipidoses leads to early mortality with limited treatment options. Given the role of myelin loss as a major contributor toward LSD-associated neurodegeneration, we investigated the pathways contributing to demyelination in a CRISPR-Cas9-generated zebrafish model of combined saposin (psap) deficiency. psap knockout (KO) zebrafish recapitulated major LSD pathologies, including reduced lifespan, reduced lipid storage, impaired locomotion and severe myelin loss; loss of myelin basic protein a (mbpa) mRNA was progressive, with no changes in additional markers of oligodendrocyte differentiation. Brain transcriptomics revealed dysregulated mTORC1 signaling and elevated neuroinflammation, where increased proinflammatory cytokine expression preceded and mTORC1 signaling changes followed mbpa loss. We examined pharmacological and genetic rescue strategies via water tank administration of the multiple sclerosis drug monomethylfumarate (MMF), and crossing the psap KO line into an acid sphingomyelinase (smpd1) deficiency model. smpd1 mutagenesis, but not MMF treatment, prolonged lifespan in psap KO zebrafish, highlighting the modulation of acid sphingomyelinase activity as a potential path toward sphingolipidosis treatment.
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Affiliation(s)
- Tejia Zhang
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
| | - Ivy Alonzo
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
| | - Chris Stubben
- Bioinformatic Analysis Shared Resource, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Yijie Geng
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
| | - Chelsea Herdman
- Department of Neurobiology and Molecular Medicine Program, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Nancy Chandler
- Electron Microscopy Core Laboratory, University of Utah, Salt Lake City, UT 84112, USA
| | - Kim P. Doane
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
| | - Brock R. Pluimer
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
| | - Sunia A. Trauger
- Harvard Center for Mass Spectrometry, Harvard University, Cambridge, MA 02138, USA
| | - Randall T. Peterson
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
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9
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Baeva ME, Metz LM, Greenfield J, Camara-Lemarroy CR. Simple Parameters from Complete Blood Count Predict Lymphopenia, Adverse Effects and Efficacy in People with MS treated with Dimethyl Fumarate. Mult Scler Relat Disord 2023; 74:104699. [PMID: 37031552 DOI: 10.1016/j.msard.2023.104699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/28/2023] [Accepted: 04/02/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Dimethyl fumarate (DMF) is a first-line oral therapy for relapsing-remitting multiple sclerosis (RRMS). This retrospective study aims to determine the utility of routine complete blood counts (CBC) in predicting lymphopenia, adverse effects and efficacy in a real-world clinical setting. METHODS The Calgary Multiple Sclerosis (MS) Clinic manages over 1800 people with MS on disease-modifying therapies (DMT). Data of patients with relapsing-remitting MS (pwMS) who initiated DMF between July 1, 2013 and December 31, 2014 were included. Patients were followed for one year. DMT use is carefully monitored and pwMS need a screening CBC and have regular CBCs done at follow-up. Demographic, clinical, MRI and relapse information are collected prospectively in a clinic database. We analyzed CBCs at baseline and month 3. RESULTS We identified 139 pwMS in the study period who started DMF. Median follow-up time on-drug was 12 (0.16-12) months. In our study, 15.8% of pwMS developed lymphopenia grade 2 or higher. Baseline lymphocyte counts and older age were significant predictors of lymphopenia. Higher baseline eosinophil counts predicted flushing/gastrointestinal adverse effects, and higher baseline monocyte counts were predictive of breakthrough disease activity. Neutrophil and platelet to lymphocyte ratios, markers that have been associated with overall mortality in the general population, were increased at month 3. CONCLUSIONS Routinely obtained CBCs during the screening and monitoring of people with MS starting DMF offer clinically useful information and generate interesting hypotheses. Age and baseline lymphocyte counts are reinforced as clinically useful predictors of lymphopenia. Our novel findings that baseline eosinophil and monocyte counts could offer insights into usual adverse effects and efficacy, respectively, should be further investigated as a potentially new set of biomarkers.
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10
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Jožef M, Locatelli I, Brecl Jakob G, Rot U, Kos M. Medication adherence and health outcomes in persons with multiple sclerosis treated with dimethyl fumarate. Mult Scler Relat Disord 2023; 72:104615. [PMID: 36933300 DOI: 10.1016/j.msard.2023.104615] [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: 01/09/2023] [Revised: 03/01/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system that particularly affects people in their 30s. Oral disease-modifying therapy (DMT) offers a simple dosage form, good efficacy and safety. Dimethyl fumarate (DMF) is a frequently prescribed oral DMT medication worldwide. The aim of this study was to evaluate the impact of medication adherence on health outcomes in Slovenian persons with MS treated with DMF. METHODS Our retrospective cohort study included persons with relapsing-remitting MS on DMF treatment. The medication adherence was evaluated by AdhereR software package using the proportion of days covered (PDC) measure. The threshold was set at 90%. Health outcomes after treatment initiation were represented by relapse occurrence, disability progression and occurrence of active (new T2 and T1/Gadolinium (Gd) enhancing) lesions between first two outpatient visits and first two brain magnetic resonance imaging (MRI), respectively. For each health outcome a separate multivariable regression model was built. RESULTS The study included 164 patients. Their mean age (SD) was 36.7 (8.8) years, and the majority of patients were women (114 or 70%). Eighty-one patients were treatment naive. The mean (SD) PDC value was 0.942 (0.08) and 82% of patients were considered adherent above the 90% threshold. Older age (OR 1.06 per one year, P = 0.017, 95% CI (1.01-1.11)) and treatment naivety (OR 3.93, P = 0.004, 95% CI (1.64-10.4)) were related to higher adherence. In the 6-year follow-up period after DMF treatment initiation, 33 patients experienced a relapse. Among those, 19 required an emergency visit. Sixteen patients had a 1-point disability progression on the Expanded Disability Status Scale (EDSS) score between two consecutive outpatient visits. Thirty-seven patients were found to have active lesions between first and second brain MRI. Medication adherence showed no impact on relapse occurrence or disability progression. Lower medication adherence (10% lower PDC) was associated with higher occurrence of active lesions (OR 1.25, P=0.038, 95% CI: 1.01-1.56). Higher disability prior to DMF initiation was related to a higher risk for relapse occurrence and EDSS progression. CONCLUSION Our study showed high medication adherence among Slovenian persons with relapse-remitting MS on DMF treatment. Higher adherence was associated with lower incidence of the radiological progression of MS. Interventions for improving medication adherence should be intended for younger patients with higher disability prior treatment with DMF and those switching from alternative DMTs.
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Affiliation(s)
- Maj Jožef
- University of Ljubljana, Faculty of Pharmacy, Aškerčeva cesta 7, Ljubljana 1000, Slovenia; University Medical Centre Ljubljana, Division of Neurology, Multiple Sclerosis Centre, Zaloška cesta 2, Ljubljana 1000, Slovenia
| | - Igor Locatelli
- University of Ljubljana, Faculty of Pharmacy, Aškerčeva cesta 7, Ljubljana 1000, Slovenia
| | - Gregor Brecl Jakob
- University Medical Centre Ljubljana, Division of Neurology, Multiple Sclerosis Centre, Zaloška cesta 2, Ljubljana 1000, Slovenia
| | - Uroš Rot
- University Medical Centre Ljubljana, Division of Neurology, Multiple Sclerosis Centre, Zaloška cesta 2, Ljubljana 1000, Slovenia; University of Ljubljana, Faculty of Medicine, Vrazov trg 2, Ljubljana 1000, Slovenia
| | - Mitja Kos
- University of Ljubljana, Faculty of Pharmacy, Aškerčeva cesta 7, Ljubljana 1000, Slovenia.
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11
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Lager B, Liseno J, Božin I, England SM, Shankar SL, Mendoza JP, Lewin JB. Real-World Analysis Affirms the High Persistence and Adherence Observed with Diroximel Fumarate in Patients with Multiple Sclerosis. Neurol Ther 2023; 12:145-159. [PMID: 36334241 PMCID: PMC9837354 DOI: 10.1007/s40120-022-00413-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Adherence to disease-modifying therapies is key for achieving optimal outcomes in multiple sclerosis (MS). Diroximel fumarate (DRF) is an oral fumarate approved for treatment of relapsing forms of MS. It has the same pharmacologically active metabolite as dimethyl fumarate (DMF) and similar efficacy and safety profiles, but with demonstrated fewer gastrointestinal (GI) related adverse events (AEs). There are limited data characterizing persistence and adherence to DRF in the real world. METHODS This retrospective analysis of the AcariaHealth Specialty Pharmacy Program included patients with MS initiating DRF from 1 December 2019 to 30 January 2021. This analysis evaluated persistence, measured as proportion of patients remaining on therapy; discontinuation rate due to GI AEs; and adherence measured by proportion of days covered (PDC). RESULTS Overall, 1143 patients were included; 433 (37.9%) patients had been treated with prior DMF and switched to DRF. Persistence was high in both groups: the estimated proportion of patients remaining on DRF at 16 months was 82.3% [95% confidence internal (CI) 77.2-86.3%], and 90.1% (95% CI 82.2-94.6%) in the DMF to DRF group. Fifty-two (4.5%) patients overall and 15 (3.5%) in the DMF switch subgroup discontinued DRF due to GI AEs. Mean PDC was 90.8% (95% CI 89.2-92.5%), and 85.4% (95% CI 83.3-87.4%) of patients achieved PDC ≥ 80% in the overall population. In the DMF to DRF group, mean PDC was 90.7% (95% CI 88.0-93.5%), and 84.8% (95% CI 81.4-88.1%) of patients achieved PDC ≥ 80%. CONCLUSION In this analysis of > 1000 patients treated with DRF in real-world clinical practice, overall persistence at 16 months was high, treatment discontinuation due to GI AEs was low, and patients were highly adherent to therapy. Of 433 patients who switched from DMF to DRF, most (> 90%) were able to tolerate and persist on DRF after switching. Graphical abstract available for this article.
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12
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Sánchez-Sanz A, Posada-Ayala M, Sabín-Muñoz J, Fernández-Miranda I, Aladro-Benito Y, Álvarez-Lafuente R, Royuela A, García-Hernández R, la Fuente ORD, Romero J, García-Merino A, Sánchez-López AJ. Endocannabinoid levels in peripheral blood mononuclear cells of multiple sclerosis patients treated with dimethyl fumarate. Sci Rep 2022; 12:20300. [PMID: 36434122 PMCID: PMC9700785 DOI: 10.1038/s41598-022-21807-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 10/04/2022] [Indexed: 11/27/2022] Open
Abstract
The endocannabinoid system (ECS), a signalling network with immunomodulatory properties, is a potential therapeutic target in multiple sclerosis (MS). Dimethyl fumarate (DMF) is an approved drug for MS whose mechanism of action has not been fully elucidated; the possibility exists that its therapeutic effects could imply the ECS. With the aim of studying if DMF can modulate the ECS, the endocannabinoids 2-arachidonoylglycerol (2-AG), anandamide (AEA), oleoylethanolamide (OEA) and palmitoylethanolamide (PEA) were determined by liquid chromatography-mass spectrometry in peripheral blood mononuclear cells from 21 healthy donors (HD) and 32 MS patients at baseline and after 12 and 24 months of DMF treatment. MS patients presented lower levels of 2-AG and PEA compared to HD. 2-AG increased at 24 months, reaching HD levels. AEA and PEA remained stable at 12 and 24 months. OEA increased at 12 months and returned to initial levels at 24 months. Patients who achieved no evidence of disease activity (NEDA3) presented the same modulation over time as EDA3 patients. PEA was modulated differentially between females and males. Our results show that the ECS is dysregulated in MS patients. The increase in 2-AG and OEA during DMF treatment suggests a possible role of DMF in ECS modulation.
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Affiliation(s)
- Alicia Sánchez-Sanz
- Neuroimmunology Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain ,grid.5515.40000000119578126PhD Program in Molecular Biosciences, Doctoral School, Universidad Autónoma de Madrid, Madrid, Spain
| | - María Posada-Ayala
- grid.449795.20000 0001 2193 453XFaculty of Experimental Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | - Julia Sabín-Muñoz
- grid.73221.350000 0004 1767 8416Department of Neurology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Ismael Fernández-Miranda
- grid.5515.40000000119578126PhD Program in Molecular Biosciences, Doctoral School, Universidad Autónoma de Madrid, Madrid, Spain ,Lymphoma Research Group, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Yolanda Aladro-Benito
- grid.411244.60000 0000 9691 6072Department of Neurology, Hospital Universitario de Getafe, Madrid, Spain
| | - Roberto Álvarez-Lafuente
- grid.414780.eGrupo de Investigación de Factores Ambientales en Enfermedades Degenerativas, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain ,grid.483890.e0000 0004 6095 7779Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Ana Royuela
- Clinical Biostatistics Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Ruth García-Hernández
- Neuroimmunology Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Ofir Rodríguez-De la Fuente
- grid.73221.350000 0004 1767 8416Department of Neurology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Julián Romero
- grid.449795.20000 0001 2193 453XFaculty of Experimental Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | - Antonio García-Merino
- Neuroimmunology Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain ,grid.73221.350000 0004 1767 8416Department of Neurology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain ,grid.483890.e0000 0004 6095 7779Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain ,grid.5515.40000000119578126Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Antonio José Sánchez-López
- Neuroimmunology Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain ,grid.483890.e0000 0004 6095 7779Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain ,Biobank, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
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13
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Hauer L, Sellner J. Diroximel Fumarate as a Novel Oral Immunomodulating Therapy for Relapsing Forms of Multiple Sclerosis: A Review on the Emerging Data. Drug Des Devel Ther 2022; 16:3915-3927. [PMID: 36388086 PMCID: PMC9663167 DOI: 10.2147/dddt.s236926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory, demyelinating and neurodegenerative disorder of the central nervous system. Disease-modifying drugs (DMDs) and subsequent adherence are crucial for preventing reversible episodes of neurological dysfunction and delayed onset of progressive accumulation of irreversible deficits. Yet, side effects may limit their usage in clinical practice. Gastrointestinal (GI) side effects are a significant limitation of the use of dimethyl fumarate (DMF), the most frequently prescribed oral DMD in MS worldwide. Diroximel fumarate (DRF) is a second-generation oral fumaric acid ester (FAE) that was developed as a formulation with better GI tolerability. The improved tolerability is assumed to be related to a lower synthesis of gut-irritating methanol. Other explanations for DRF’s lower extent of GI irritation include a more modest off-target activity due to its chemical structure. The superior GI tolerability of DRF compared to DMF could be proven in clinical trials and lead to approval of DRF for the treatment of relapsing forms of MS/relapsing-remitting MS (United States Food and Drug Administration and European Medicines Agency, respectively). Here, we summarize the mode of action of oral FAE and compare the chemical and physiological characteristics of DMF and DRF. Moreover, we discuss the adverse effects of FAE and introduce the emerging preclinical and trial data leading to the approval of DRF in MS. This article additionally reviews our current understanding of coronavirus disease 2019 (COVID-19) and the efficacy of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccination in people treated with FAE.
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Affiliation(s)
- Larissa Hauer
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Correspondence: Johann Sellner, Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstr. 67, Mistelbach, 2130, Austria, Tel +2572/9004-12850, Fax +2572/9004-49281, Email
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14
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Bollo L, Caputo F, Paolicelli D, Trojano M, Iaffaldano P. Interdisciplinary approach to opportunistic infections: staphylococcal meningitis in a patient with multiple sclerosis on treatment with dimethyl fumarate. Intern Emerg Med 2022; 17:1845-1847. [PMID: 35486330 PMCID: PMC9051806 DOI: 10.1007/s11739-022-02989-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Luca Bollo
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Francesca Caputo
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Pietro Iaffaldano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare, 11, 70124, Bari, Italy.
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15
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Rotstein D, Solomon JM, Sormani MP, Montalban X, Ye XY, Dababneh D, Muccilli A, Shah P. Association of No Evidence of Disease Activity With No Long-term Disability Progression in Multiple Sclerosis: A Systematic Review and Meta-analysis. Neurology 2022; 99:e209-e220. [PMID: 35473761 DOI: 10.1212/wnl.0000000000200549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 03/02/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We conducted a systematic review and meta-analysis to evaluate the relationship between no evidence of disease activity (NEDA) and no long-term disability progression on low- and high-efficacy therapy in relapsing-remitting multiple sclerosis (RRMS). METHODS MEDLINE, Embase, and the Cochrane Database were searched from January 1, 2006, to January 26, 2021. We selected studies that evaluated NEDA-3 (no relapse, new MRI lesion, or confirmed disability progression) at 1 or 2 years and had a minimum of 4 years of follow-up for determination of disability progression. Data were extracted by 2 independent reviewers and were meta-analyzed with a random-effects model. Primary outcome of no disability progression was defined as no confirmed progression on the Expanded Disability Status Scale during follow-up. We assessed the odds ratio (OR) for no disability progression with NEDA vs evidence of disease activity (EDA). Positive predictive value (PPV) of NEDA for no disability progression was summarized for studies with prevalence of no progression >80% vs ≤80% separately. RESULTS We included 29 studies in our qualitative synthesis, of which 27 (16 low efficacy, 11 high efficacy) were included in the meta-analysis (N = 10,935 participants). Median follow-up was 5.6 years (interquartile range 4.3-8.0 years). The pooled ORs for no progression with NEDA-3 vs EDA were 2.32 (95% CI 1.58-3.42; I 2 = 73%) for low-efficacy therapy and 3.19 (95% CI 1.86-5.47; I 2 = 86%) for high-efficacy therapy. Among studies with prevalence of no progression at follow-up >80%, the pooled PPV for low efficacy therapy was 91% (95% CI 89%-93%) and for high-efficacy therapy was 92% (95% CI 88%-94%). Among studies with prevalence of no progression ≤80%, the pooled PPV for low-efficacy therapy was 81% (95% CI 75%-86%) and for high-efficacy therapy was 86% (95% CI 80%-90%). DISCUSSION NEDA-3 is associated with no long-term disability progression in RRMS on both low- and high-efficacy therapies. Further studies of early composite outcome measures incorporating easily measurable biomarkers and longer follow-up may help to improve the prognostic value of NEDA-3 in RRMS. TRIAL REGISTRATION INFORMATION International Prospective Register of Systematic Reviews Identifier: CRD42020189316.
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Affiliation(s)
- Dalia Rotstein
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada.
| | - Jacqueline Madeleine Solomon
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Maria Pia Sormani
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Xavier Montalban
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Xiang Y Ye
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Dina Dababneh
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Alexandra Muccilli
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Prakesh Shah
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
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16
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Ravn J, Jensen HB, Kant M, Andersen PB, Góra MK, Sejbæk T. Risk factors for development of lymphopenia in dimethyl fumarate-treated patients with multiple sclerosis. Mult Scler Relat Disord 2022; 67:104081. [DOI: 10.1016/j.msard.2022.104081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 04/30/2022] [Accepted: 07/28/2022] [Indexed: 10/31/2022]
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Marastoni D, Crescenzo F, Pisani AI, Zuco C, Schiavi G, Benedetti G, Ricciardi GK, Montemezzi S, Pizzini FB, Tamanti A, Calabrese M. Two years' effect of dimethyl fumarate on focal and diffuse gray matter pathology in multiple sclerosis. Mult Scler 2022; 28:2090-2098. [PMID: 35765211 DOI: 10.1177/13524585221104014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Data on the effect of dimethyl fumarate (DMF) on focal and diffuse gray matter (GM) damage, a relevant pathological substrate of multiple sclerosis (MS)-related disability are lacking. OBJECTIVE To evaluate the DMF effect on cortical lesions (CLs) accumulation and global and regional GM atrophy in subjects with relapsing-remitting MS. METHODS A total of 148 patients (mean age 38.1 ± 9.7 years) treated with DMF ended a 2-year longitudinal study. All underwent regular Expanded Disability Status Scale (EDSS assessment), and at least two 3T-magnetic resonance imaging (MRI) at 3 and 24 months after DMF initiation. CLs and changes in global and regional atrophy of several brain regions were compared with 47 untreated age and sex-matched patients. RESULTS DMF-treated patients showed lower CLs accumulation (median 0[0-3] vs 2[0-7], p < 0.001) with respect to controls. Global cortical thickness (p < 0.001) and regional thickness and volume were lower in treated group (cerebellum, hippocampus, caudate, and putamen: p < 0.001; thalamus p = 0.03). Lower relapse rate (14% vs 40%, p < 0.001), EDSS change (0.2 ± 0.4 vs 0.4 ± 0.9, p < 0.001), and new WM lesions (median 0[0-5] vs 2[0-6], p < 0.001) were reported. No severe adverse drug reactions occurred. CONCLUSIONS Beyond the well-known effect on disease activity, these results provide evidence of the effect of DMF through reduced progression of focal and diffuse GM damage.
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Affiliation(s)
- Damiano Marastoni
- Regional Multiple Sclerosis Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | | | - Anna I Pisani
- Regional Multiple Sclerosis Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Carmela Zuco
- Neurology Unit, "Carlo Poma" Hospital, ASST Mantua, Mantua, Italy
| | - Gianmarco Schiavi
- Regional Multiple Sclerosis Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Giulia Benedetti
- Regional Multiple Sclerosis Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Giuseppe K Ricciardi
- Neuroradiology & Radiology Units, Department of Diagnostic and Pathology, Integrated University Hospital of Verona, Verona, Italy
| | - Stefania Montemezzi
- Neuroradiology & Radiology Units, Department of Diagnostic and Pathology, Integrated University Hospital of Verona, Verona, Italy
| | - Francesca B Pizzini
- Radiology Unit, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Agnese Tamanti
- Regional Multiple Sclerosis Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Massimiliano Calabrese
- Regional Multiple Sclerosis Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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18
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Akaishi T, Ishii T, Aoki M, Nakashima I. Calculating and Comparing the Annualized Relapse Rate and Estimating the Confidence Interval in Relapsing Neurological Diseases. Front Neurol 2022; 13:875456. [PMID: 35756930 PMCID: PMC9226307 DOI: 10.3389/fneur.2022.875456] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
Calculating the crude or adjusted annualized relapse rate (ARR) and its confidence interval (CI) is often required in clinical studies to evaluate chronic relapsing diseases, such as multiple sclerosis and neuromyelitis optica spectrum disorders. However, accurately calculating ARR and estimating the 95% CI requires careful application of statistical approaches and basic familiarity with the exponential family of distributions. When the relapse rate can be regarded as constant over time or by individuals, the crude ARR can be calculated using the person-years method, which divides the number of all observed relapses among all participants by the total follow-up period of the study cohort. If the number of relapses can be modeled by the Poisson distribution, the 95% CI of ARR can be obtained by finding the 2.5% upper and lower critical values of the parameter λ as the mean. Basic familiarity with F-statistics is also required when comparing the ARR between two disease groups. It is necessary to distinguish the observed relapse rate ratio (RR) between two sample groups (sample RR) from the unobserved RR between their originating populations (population RR). The ratio of population RR to sample RR roughly follows the F distribution, with degrees of freedom obtained by doubling the number of observed relapses in the two sample groups. Based on this, a 95% CI of the population RR can be estimated. When the count data of the response variable is overdispersed, the negative binomial distribution would be a better fit than the Poisson. Adjusted ARR and the 95% CI can be obtained by using the generalized linear regression models after selecting appropriate error structures (e.g., Poisson, negative binomial, zero-inflated Poisson, and zero-inflated negative binomial) according to the overdispersion and zero-inflation in the response variable.
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Affiliation(s)
- Tetsuya Akaishi
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan.,Division of General Medicine, Tohoku University Hospital, Sendai, Japan.,Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tadashi Ishii
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan.,Division of General Medicine, Tohoku University Hospital, Sendai, Japan
| | - Masashi Aoki
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ichiro Nakashima
- Department of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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Bou-Fakhredin R, De Franceschi L, Motta I, Cappellini MD, Taher AT. Pharmacological Induction of Fetal Hemoglobin in β-Thalassemia and Sickle Cell Disease: An Updated Perspective. Pharmaceuticals (Basel) 2022; 15:ph15060753. [PMID: 35745672 PMCID: PMC9227505 DOI: 10.3390/ph15060753] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 12/04/2022] Open
Abstract
A significant amount of attention has recently been devoted to the mechanisms involved in hemoglobin (Hb) switching, as it has previously been established that the induction of fetal hemoglobin (HbF) production in significant amounts can reduce the severity of the clinical course in diseases such as β-thalassemia and sickle cell disease (SCD). While the induction of HbF using lentiviral and genome-editing strategies has been made possible, they present limitations. Meanwhile, progress in the use of pharmacologic agents for HbF induction and the identification of novel HbF-inducing strategies has been made possible as a result of a better understanding of γ-globin regulation. In this review, we will provide an update on all current pharmacological inducer agents of HbF in β-thalassemia and SCD in addition to the ongoing research into other novel, and potentially therapeutic, HbF-inducing agents.
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Affiliation(s)
- Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.B.-F.); (I.M.)
| | - Lucia De Franceschi
- Department of Medicine, University of Verona and Azienda Ospedaliera Universitaria Verona, 37128 Verona, Italy;
| | - Irene Motta
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.B.-F.); (I.M.)
- UOC General Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.B.-F.); (I.M.)
- UOC General Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence: (M.D.C.); (A.T.T.)
| | - Ali T. Taher
- Department of Internal Medicine, Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
- Correspondence: (M.D.C.); (A.T.T.)
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20
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Apóstolos SLP, Boaventura M, Mendes NT, Teixeira LS, Campana IG. How to choose initial treatment in multiple sclerosis patients: a case-based approach. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:159-172. [PMID: 35976318 PMCID: PMC9491420 DOI: 10.1590/0004-282x-anp-2022-s128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Immunotherapy dramatically changed the natural history of multiple sclerosis (MS), which was classically associated with severe disability. Treatment strategies advocate that early control of disease activity is crucial to avoid progressive disability, and the use of high efficacy drugs may be beneficial, but safety is a concern. Choosing the disease-modifying therapy is challenging in clinical practice and should be further discussed. OBJECTIVE To discuss the state of art of selecting the initial therapy for relapsing MS patients. METHODS We used a case-based approach followed by clinical discussion, exploring therapeutic options in different MS settings. RESULTS We presented clinical cases profile compatible with the use of MS therapies, classified into moderate and high efficacy. In the moderate efficacy group, we discussed interferons, glatiramer acetate, teriflunomide and dimethyl fumarate, while in the high efficacy group we discussed fingolimod, cladribine, natalizumab, ocrelizumab, alemtuzumab and ofatumumab. CONCLUSION Advances in MS treatment are remarkable. Strong evidence supports the use of early high efficacy therapy. However, biomarkers, clinical and radiologic prognostic factors, as well as patients' individual issues, should be valued and considered for a personalized treatment decision.
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Affiliation(s)
- Samira Luisa Pereira Apóstolos
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Mateus Boaventura
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Natalia Trombini Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Larissa Silva Teixeira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Igor Gusmão Campana
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
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Efficacy and Safety Outcomes with Diroximel Fumarate After Switching from Prior Therapies or Continuing on DRF: Results from the Phase 3 EVOLVE-MS-1 Study. Adv Ther 2022; 39:1810-1831. [PMID: 35211872 PMCID: PMC8870078 DOI: 10.1007/s12325-022-02068-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/07/2021] [Indexed: 02/06/2023]
Abstract
Introduction Diroximel fumarate (DRF) is an oral fumarate for relapsing multiple sclerosis (MS) with the same active metabolite as dimethyl fumarate (DMF). DRF has a safety/efficacy profile similar to DMF but with improved gastrointestinal (GI) tolerability and low (< 1%) treatment discontinuation due to GI adverse events (AEs). Efficacy and safety outcomes in patients who switched to DRF from other disease-modifying therapies (DMTs) have not been evaluated. Methods EVOLVE-MS-1 is an ongoing, 2-year, open-label, phase 3 study of DRF in adults with relapsing–remitting MS. Patients either entered as newly enrolled to DRF trials, or from the 5-week, randomized, head-to-head, phase 3 EVOLVE-MS-2 study of DRF and DMF. This analysis evaluated safety and GI tolerability in patients continuing on DRF (DRF-rollover) or switching from DMF (DMF-rollover) following EVOLVE-MS-2. Safety and efficacy were evaluated in a subset of newly enrolled patients who had received prior glatiramer acetate (GA; GA/DRF) or interferons (IFN; IFN/DRF) as their most recent DMT, prior to switching to DRF in EVOLVE-MS-1. Results As of September 1, 2020, 1057 patients were enrolled in EVOLVE-MS-1, including 166, 182, 239, and 225 patients in the GA/DRF, IFN/DRF, DRF-rollover, and DMF-rollover groups, respectively. Treatment discontinuation due to GI AEs was < 1% in all groups. GA/DRF and IFN/DRF patients experienced improvements from baseline in clinical and radiological efficacy outcomes, including significantly reduced annualized relapse rates. Rollover patients had low rates of new or recurrent GI AEs (DRF-rollover, 26.8%/4.2%; DMF-rollover, 27.1%/4.9%). Conclusion After 2 years of DRF exposure, patients with prior GA, IFN, or fumarate treatment had safety outcomes consistent with previous fumarate studies. Efficacy in patients with prior GA or IFN treatment was consistent with previous fumarate studies. The data suggest that transition to DRF from GA, IFN, or DMF is a reasonable treatment strategy, with low rates of discontinuation due to GI AEs. Trial Registration ClinicalTrials.gov (NCT02634307). Infographic ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02068-7.
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22
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Sainzde la Maza S, Muñoz JS, Pilode la Fuente B, Thuissard I, Andreu‑Vázquez C, Sánchez-Seco VG, Salgado-Cámara P, Costa-Frossard L, Monreal E, Ayuso-Peralta L, García-Vasco L, García‑Domínguez JM, Martínez-Ginés ML, Fernández CM, Díaz-Díaz J, Oreja-Guevara C, Gómez‑Moreno M, Martín H, Rubio-Flores L, Blasco MR, Villar-Guimerans LM, Aladro Y. Early predictive risk factors for dimethyl fumarate-associated lymphopenia in patients with multiple sclerosis. Mult Scler Relat Disord 2022; 59:103669. [DOI: 10.1016/j.msard.2022.103669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/16/2022] [Accepted: 02/03/2022] [Indexed: 11/16/2022]
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Salter A, Lancia S, Cutter G, Fox RJ, Marrie RA, Mendoza JP, Lewin JB. Characterizing Long-term Disability Progression and Employment in NARCOMS Registry Participants with Multiple Sclerosis Taking Dimethyl Fumarate. Int J MS Care 2022; 23:239-244. [PMID: 35035294 DOI: 10.7224/1537-2073.2020-109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Delayed-release dimethyl fumarate (DMF) is effective in relapsing-remitting multiple sclerosis (RRMS), but long-term effects of DMF on disability and disease progression in clinical settings are unknown. We evaluated disability and employment outcomes in persons with RRMS treated with DMF for up to 5 years. Methods This longitudinal study included US North American Research Committee on Multiple Sclerosis (NARCOMS) Registry participants with RRMS reporting DMF initiation in fall 2013 through spring 2018 with 1 year or more of follow-up. Time to 6-month confirmed disability progression (≥1-point increase in Patient-Determined Disease Steps [PDDS] score) and change in employment status were evaluated using Kaplan-Meier analysis. Participants were censored at last follow-up or at DMF discontinuation, whichever came first. Results During the study, 725 US participants with RRMS had at least 1 year of DMF follow-up data, of whom most were female and White. At year 5, 69.9% (95% CI, 65.4%-73.9%) of these participants were free from 6-month confirmed disability progression, and 84.7% (95% CI, 78.6%-89.2%) were free from conversion to secondary progressive MS. Of 116 participants with data at baseline and year 5, most had stable or improved PDDS and Performance Scales scores over 5 years. Of 322 participants 62 years and younger and employed at the index survey, 66.0% (95% CI, 57.6%-73.1%) were free from a negative change in employment type over 5 years. Conclusions Most US NARCOMS Registry participants treated up to 5 years with DMF remained free from 6-month confirmed disability progression and conversion to secondary progressive MS and had stable disability and employment status. These results support the long-term stability of disability and work-related outcomes with disease-modifying therapy.
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Affiliation(s)
- Amber Salter
- Division of Biostatistics, School of Medicine, Washington University in St Louis, St Louis, MO, USA (AS [now at UT Southwestern Medical Center], SL)
| | - Samantha Lancia
- Division of Biostatistics, School of Medicine, Washington University in St Louis, St Louis, MO, USA (AS [now at UT Southwestern Medical Center], SL)
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA (GC)
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA (RJF)
| | - Ruth Ann Marrie
- Department of Medicine and Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada (RAM)
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Kuchimanchi M, Bockbrader H, Dolphin N, Epling D, Quinlan L, Chapel S, Penner N. Development of a Population Pharmacokinetic Model for the Diroximel Fumarate Metabolites Monomethyl Fumarate and 2-Hydroxyethyl Succinimide Following Oral Administration of Diroximel Fumarate in Healthy Participants and Patients with Multiple Sclerosis. Neurol Ther 2022; 11:353-371. [PMID: 35041178 PMCID: PMC8857385 DOI: 10.1007/s40120-021-00316-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction Diroximel fumarate (DRF) is a next-generation oral fumarate that is indicated in the USA for relapsing forms of multiple sclerosis (MS). A joint population pharmacokinetic model was developed for the major active metabolite (monomethyl fumarate, MMF) and the major inactive metabolite (2-hydroxyethyl succinimide, HES) of DRF. Methods MMF and HES data were included from 341 healthy volunteers and 48 patients with MS across 11 phase I and III studies in which DRF was administered as single or multiple doses. Population modeling was performed with NONMEM version 7.3 with the first-order conditional estimation method. Results Estimated MMF clearance (CLMMF), volume of distribution, and absorption rate constant (Ka) were 13.5 L/h, 30.4 L, and 5.04 h−1, respectively. CLMMF and HES clearance (CLHES) increased with increasing body weight. CLHES decreased with decreasing renal function. CLMMF and CLHES were 28% and 12% lower in patients with MS than in healthy volunteers, respectively. Ka was reduced in the presence of low-, medium-, and high-fat meals by 37%, 51%, and 67%, respectively, for MMF; and by 34%, 49%, and 62%, respectively, for HES. Conclusions Age, sex, race, and baseline liver function parameters such as total bilirubin, albumin, and aspartate aminotransferase were not considered to be significant predictors of MMF or HES disposition. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-021-00316-6.
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Affiliation(s)
| | | | - Nancy Dolphin
- Ann Arbor Pharmacometrics Group (A2PG), Ann Arbor, MI, USA
| | - Daniel Epling
- Ann Arbor Pharmacometrics Group (A2PG), Ann Arbor, MI, USA
| | - Lauren Quinlan
- Ann Arbor Pharmacometrics Group (A2PG), Ann Arbor, MI, USA
| | - Sunny Chapel
- Ann Arbor Pharmacometrics Group (A2PG), Ann Arbor, MI, USA
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Health-Related Quality of Life with Diroximel Fumarate in Patients with Relapsing Forms of Multiple Sclerosis: Findings from Qualitative Research Using Patient Interviews. Adv Ther 2022; 39:3199-3213. [PMID: 35556227 PMCID: PMC9098785 DOI: 10.1007/s12325-022-02164-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/17/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Diroximel fumarate (DRF) is an oral fumarate for relapsing multiple sclerosis (MS). Clinical and real-world studies of DRF have demonstrated improved gastrointestinal (GI) tolerability and low (< 1%) GI-related treatment discontinuation versus dimethyl fumarate (DMF) and high rates of treatment adherence. Our aim was to conduct a concept elicitation study to identify treatment-related concepts most meaningful to patients and to evaluate how these concepts shape the patient perspective of DRF. METHODS In-depth qualitative interviews were conducted with patients from October to December 2020. US adults who had been prescribed DRF through routine clinical care and had taken DRF for ≥ 3 weeks in the past 6 months were eligible to participate. Semi-structured interviews explored patient perceptions on treatment selection and impact. RESULTS Seventeen patients participated in the study. Mean (SD) age was 49.3 (12.0) years. Sixteen patients reported prior disease-modifying therapy, while 10 (58.8%) had prior DMF. DRF treatment duration ranged from ~ 6 weeks to 10 months. Four key concepts emerged: (1) overall wellness and quality of life, (2) ease of administration, (3) minimal and manageable side effects, and (4) patient optimism due to MS treatments. Mode of administration (82.4%), no/mild side effects (70.6%), convenience over injectable/infusion medications (58.8%), and effectiveness (64.7%) were cited as positive aspects of DRF treatment. Frequent dosing (52.9%) and food requirements (41.2%) were cited as negative attributes; however, 94.1% had no dietary changes since starting treatment. CONCLUSION The patient perspective is a key aspect when considering a disease-modifying therapy for MS, given the multitude of options currently available. Overall wellness, ease of administration, and minimal and manageable side effects were DRF-related concepts most meaningful to patients on therapy. Acknowledging these patient perceptions in shared decision-making may lead to greater patient adherence and optimal treatment outcomes.
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Smets I, Giovannoni G. Derisking CD20-therapies for long-term use. Mult Scler Relat Disord 2021; 57:103418. [PMID: 34902761 DOI: 10.1016/j.msard.2021.103418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/15/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022]
Abstract
Anti-CD20 have quickly become the mainstay in the treatment of multiple sclerosis (MS) and other neuroinflammatory conditions. However, when they are used as a maintenance therapy the balance between risks and benefits changes. In this review, we suggested six steps to derisk anti-CD20. Firstly and secondly, adequate infectious screening followed by vaccinations before starting anti-CD20 are paramount. Third, family planning needs to be discussed upfront with every woman of childbearing age. Fourth, infusion reactions should be adequately managed to avoid treatment interruption. After repeated infusions, it becomes important to detect and prevent anti-CD20-related adverse events. Fifth, we recommended measuring immunoglobulin levels and reviewing vaccinations annually as well as counselling adequate fever management. For female patients, we emphasised the importance to engage with the local breast cancer screening programs. Sixth, to fundamentally derisk anti-CD20 therapies, we need evidence-based approaches to reduce dosing intervals and guide retreatment.
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Affiliation(s)
- Ide Smets
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Gavin Giovannoni
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom.
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27
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Chu L, Balusha A, Casserly C, Berger W, Morrow SA. Relationship between lymphopenia and disease activity in persons with multiple sclerosis treated with dimethyl fumarate. Mult Scler Relat Disord 2021; 57:103384. [DOI: 10.1016/j.msard.2021.103384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/02/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
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Moser T, Seiberl M, Feige J, Bieler L, Radlberger RF, O'Sullivan C, Pilz G, Harrer A, Schwenker K, Haschke-Becher E, Machegger L, Grimm J, Redlberger-Fritz M, Buchmann A, Khalil M, Kvas E, Trinka E, Wipfler P. Tetravalent Influenza Vaccine Is Not Associated With Neuroaxonal Damage in Multiple Sclerosis Patients. Front Immunol 2021; 12:718895. [PMID: 34512642 PMCID: PMC8428149 DOI: 10.3389/fimmu.2021.718895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background Efficacy of vaccines and disease activity linked to immunization are major concerns among people with multiple sclerosis (pwMS). Objective To assess antibody responses to seasonal influenza antigens and vaccine-associated neuroaxonal damage utilizing serum neurofilament light chain (sNfL) in pwMS receiving dimethyl fumarate (DMF). Methods In this prospective study, the 2020/2021 seasonal tetravalent influenza vaccine was administered to 20 pwMS treated with DMF and 15 healthy controls (HCs). The primary endpoints were responder rate of strain-specific antibody production (seroconversion or significant (4-fold) increase in influenza-antibody titers for ≥2/4 strains) at 30 days post-vaccination and changes in sNfL levels. Results All patients treated with DMF fulfilled the responder criteria for immunization compared with 53% of the controls. However, higher proportions of HCs already had influenza-antibody titers ≥1:40 at baseline (53% vs. 41%, p = 0.174). sNfL levels were comparable among both groups at baseline and did not increase 34 days after vaccination. In addition, no clinical or radiological disease reactivation was found. Conclusion DMF-treated patients mount an adequate humoral immune response to influenza vaccines. Within the limits of the small cohort investigated, our data suggest that influenza immunization is not associated with clinical or subclinical disease reactivation.
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Affiliation(s)
- Tobias Moser
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Michael Seiberl
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Julia Feige
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Lara Bieler
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Richard F Radlberger
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Ciara O'Sullivan
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Georg Pilz
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Andrea Harrer
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Kerstin Schwenker
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | | | - Lukas Machegger
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Jochen Grimm
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | | | | | - Michael Khalil
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria.,Neuroscience Institute, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Peter Wipfler
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
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Gold R, Arnold DL, Bar-Or A, Fox RJ, Kappos L, Mokliatchouk O, Jiang X, Lyons J, Kapadia S, Miller C. Long-term safety and efficacy of dimethyl fumarate for up to 13 years in patients with relapsing-remitting multiple sclerosis: Final ENDORSE study results. Mult Scler 2021; 28:801-816. [PMID: 34465252 PMCID: PMC8978463 DOI: 10.1177/13524585211037909] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dimethyl fumarate (DMF) demonstrated favorable benefit-risk in relapsing-remitting multiple sclerosis (RRMS) patients in phase-III DEFINE and CONFIRM trials, and ENDORSE extension. OBJECTIVE The main aim of this study is assessing DMF safety/efficacy up to 13 years in ENDORSE. METHODS Randomized patients received DMF 240 mg twice daily or placebo (PBO; Years 0-2), then DMF (Years 3-10; continuous DMF/DMF or PBO/DMF); maximum follow-up (combined studies), 13 years. RESULTS By January 2020, 1736 patients enrolled/dosed in ENDORSE (median follow-up 8.76 years (ENDORSE range: 0.04-10.98) in DEFINE/CONFIRM and ENDORSE); 52% treated in ENDORSE for ⩾6 years. Overall, 551 (32%) patients experienced serious adverse events (mostly multiple sclerosis (MS) relapse or fall; one progressive multifocal leukoencephalopathy); 243 (14%) discontinued treatment due to adverse events (4% gastrointestinal (GI) disorders). Rare opportunistic infections, malignancies, and serious herpes zoster occurred, irrespective of lymphocyte count. For DMF/DMF (n = 501), overall annualized relapse rate (ARR) remained low (0.143 (95% confidence interval (CI), 0.120-0.169)), while for PBO/DMF (n = 249), ARR decreased after initiating DMF and remained low throughout (ARR 0-2 years, 0.330 (95% CI, 0.266-0.408); overall ARR (ENDORSE, 0.151 (95% CI, 0.118-0.194)). Over 10 years, 72% DMF/DMF and 73% PBO/DMF had no 24-week confirmed disability worsening. CONCLUSION Sustained DMF safety/efficacy was observed in patients followed up to 13 years, supporting DMF's positive benefit/risk profile for long-term RRMS treatment.
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Affiliation(s)
- Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Douglas L Arnold
- Montreal Neurological Institute-Hospital, McGill University and NeuroRx Research, Montreal, QC, Canada
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
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Wiendl H, Gold R, Berger T, Derfuss T, Linker R, Mäurer M, Aktas O, Baum K, Berghoff M, Bittner S, Chan A, Czaplinski A, Deisenhammer F, Di Pauli F, Du Pasquier R, Enzinger C, Fertl E, Gass A, Gehring K, Gobbi C, Goebels N, Guger M, Haghikia A, Hartung HP, Heidenreich F, Hoffmann O, Kallmann B, Kleinschnitz C, Klotz L, Leussink VI, Leutmezer F, Limmroth V, Lünemann JD, Lutterotti A, Meuth SG, Meyding-Lamadé U, Platten M, Rieckmann P, Schmidt S, Tumani H, Weber F, Weber MS, Zettl UK, Ziemssen T, Zipp F. Multiple Sclerosis Therapy Consensus Group (MSTCG): position statement on disease-modifying therapies for multiple sclerosis (white paper). Ther Adv Neurol Disord 2021; 14:17562864211039648. [PMID: 34422112 PMCID: PMC8377320 DOI: 10.1177/17562864211039648] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/28/2021] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis is a complex, autoimmune-mediated disease of the central nervous system characterized by inflammatory demyelination and axonal/neuronal damage. The approval of various disease-modifying therapies and our increased understanding of disease mechanisms and evolution in recent years have significantly changed the prognosis and course of the disease. This update of the Multiple Sclerosis Therapy Consensus Group treatment recommendation focuses on the most important recommendations for disease-modifying therapies of multiple sclerosis in 2021. Our recommendations are based on current scientific evidence and apply to those medications approved in wide parts of Europe, particularly German-speaking countries (Germany, Austria, and Switzerland).
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Affiliation(s)
- Heinz Wiendl
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster
| | - Ralf Gold
- Neurologie, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Gudrunstraße 56, 44791 Bochum, Germany
| | - Thomas Berger
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Wien, Austria
| | - Tobias Derfuss
- Neurologische Klinik und Poliklinik, Universitätsspital Basel, Basel, Switzerland
| | - Ralf Linker
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Mathias Mäurer
- Neurologie und Neurologische Frührehabilitation, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, Würzburg, Germany
| | - Orhan Aktas
- Neurologische Klinik, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Karl Baum
- Neurologie, Klinik Hennigsdorf, Hennigsdorf, Germany
| | | | - Stefan Bittner
- Klinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew Chan
- Neurologie, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | | | | | | | | | - Christian Enzinger
- Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz, Austria
| | - Elisabeth Fertl
- Wiener Gesundheitsverbund, Neurologische Abteilung, Wien, Austria
| | - Achim Gass
- Neurologische Klinik, Universitätsmedizin Mannheim/Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Klaus Gehring
- Berufsverband Deutscher Nervenärzte (BVDN), Neurozentrum am Klosterforst, Itzehoe, Germany
| | | | - Norbert Goebels
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Guger
- Klinik für Neurologie 2, Kepler Universitätsklinikum, Linz, Austria
| | | | - Hans-Peter Hartung
- Klinik für Neurologie, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany; Klinik für Neurologie, Medizinische Universität Wien, Wien, Austria
| | - Fedor Heidenreich
- Diakovere Krankenhaus, Henriettenstift, Klinik für Neurologie und klinische Neurophysiologie, Hannover, Germany
| | - Olaf Hoffmann
- Klinik für Neurologie, Alexianer St. Josefs-Krankenhaus Potsdam, Potsdam, Germany; NeuroCure, Charité-Universitätsmedizin Berlin, Berlin, Germany; Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Germany
| | - Boris Kallmann
- Kallmann Neurologie, Multiple Sklerose Zentrum Bamberg, Bamberg, Germany
| | | | - Luisa Klotz
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Münster, Germany
| | | | - Fritz Leutmezer
- Neurologie, Universitäts-Klinik für Neurologie Wien, Wien, Austria
| | - Volker Limmroth
- Klinik für Neurologie, Krankenhaus Köln-Merheim, Köln, Germany
| | - Jan D Lünemann
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Münster, Germany
| | | | - Sven G Meuth
- Neurologische Klinik, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Michael Platten
- Neurologische Klinik, Universitätsmedizin Mannheim/Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Peter Rieckmann
- Medical Park, Fachklinik für Neurologie, Zentrum für Klinische Neuroplastizität, Bischofswiesen, Germany
| | - Stephan Schmidt
- Neurologie, Gesundheitszentrum St. Johannes Hospital, Bonn, Germany
| | - Hayrettin Tumani
- Fachklinik für Neurologie Dietenbronn, Akademisches Krankenhaus der Universität Ulm, Ulm, Germany
| | - Frank Weber
- Neurologie, Sana Kliniken, Cham, Switzerland
| | - Martin S Weber
- Institut für Neuropathologie, Neurologische Klinik, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Uwe K Zettl
- Klinik und Poliklinik für Neurologie, Zentrum für Nervenheilkunde, Universitätsmedizin Rostock, Rostock, Germany
| | - Tjalf Ziemssen
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Frauke Zipp
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
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31
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Wiendl H, Gold R, Berger T, Derfuss T, Linker R, Mäurer M, Stangel M, Aktas O, Baum K, Berghoff M, Bittner S, Chan A, Czaplinski A, Deisenhammer F, Di Pauli F, Du Pasquier R, Enzinger C, Fertl E, Gass A, Gehring K, Gobbi C, Goebels N, Guger M, Haghikia A, Hartung HP, Heidenreich F, Hoffmann O, Hunter ZR, Kallmann B, Kleinschnitz C, Klotz L, Leussink V, Leutmezer F, Limmroth V, Lünemann JD, Lutterotti A, Meuth SG, Meyding-Lamadé U, Platten M, Rieckmann P, Schmidt S, Tumani H, Weber MS, Weber F, Zettl UK, Ziemssen T, Zipp F. [Multiple sclerosis treatment consensus group (MSTCG): position paper on disease-modifying treatment of multiple sclerosis 2021 (white paper)]. DER NERVENARZT 2021; 92:773-801. [PMID: 34297142 PMCID: PMC8300076 DOI: 10.1007/s00115-021-01157-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 12/16/2022]
Abstract
Die Multiple Sklerose ist eine komplexe, autoimmun vermittelte Erkrankung des zentralen Nervensystems, charakterisiert durch inflammatorische Demyelinisierung sowie axonalen/neuronalen Schaden. Die Zulassung verschiedener verlaufsmodifizierender Therapien und unser verbessertes Verständnis der Krankheitsmechanismen und -entwicklung in den letzten Jahren haben die Prognose und den Verlauf der Erkrankung deutlich verändert. Diese Aktualisierung der Behandlungsempfehlung der Multiple Sklerose Therapie Konsensus Gruppe konzentriert sich auf die wichtigsten Empfehlungen für verlaufsmodifizierende Therapien der Multiplen Sklerose im Jahr 2021. Unsere Empfehlungen basieren auf aktuellen wissenschaftlichen Erkenntnissen und gelten für diejenigen Medikamente, die in weiten Teilen Europas, insbesondere in den deutschsprachigen Ländern (Deutschland, Österreich, Schweiz), zugelassen sind.
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Affiliation(s)
- Heinz Wiendl
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Westfälische Wilhelms-Universität Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland. .,Steuerungsgruppe der MSTKG, Münster, Deutschland. .,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.
| | - Ralf Gold
- Steuerungsgruppe der MSTKG, Münster, Deutschland. .,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland. .,Neurologie, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland.
| | - Thomas Berger
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Universitätsklinik für Neurologie, Medizinische Universität Wien, Wien, Österreich
| | - Tobias Derfuss
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Neurologische Klinik und Poliklinik, Universitätsspital Basel, Basel, Schweiz
| | - Ralf Linker
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Klinik und Poliklinik für Neurologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Mathias Mäurer
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Neurologie und Neurologische Frührehabilitation, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, Würzburg, Deutschland
| | - Martin Stangel
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Klinische Neuroimmunologie und Neurochemie, Klinik für Neurologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Orhan Aktas
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Karl Baum
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Martin Berghoff
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Stefan Bittner
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Andrew Chan
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Adam Czaplinski
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | | | - Franziska Di Pauli
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Renaud Du Pasquier
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Christian Enzinger
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Elisabeth Fertl
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Achim Gass
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Klaus Gehring
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Claudio Gobbi
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Norbert Goebels
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Michael Guger
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Aiden Haghikia
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Hans-Peter Hartung
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Fedor Heidenreich
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Olaf Hoffmann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Zoë R Hunter
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Boris Kallmann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | | | - Luisa Klotz
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Verena Leussink
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Fritz Leutmezer
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Volker Limmroth
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Jan D Lünemann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Andreas Lutterotti
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Sven G Meuth
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Uta Meyding-Lamadé
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Michael Platten
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Peter Rieckmann
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Stephan Schmidt
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Hayrettin Tumani
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Martin S Weber
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Frank Weber
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Uwe K Zettl
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Tjalf Ziemssen
- Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland
| | - Frauke Zipp
- Steuerungsgruppe der MSTKG, Münster, Deutschland.,Multiple Sklerose Therapie Konsensus Gruppe (MSTKG), Münster, Deutschland.,Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
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Callegari I, Derfuss T, Galli E. Update on treatment in multiple sclerosis. Presse Med 2021; 50:104068. [PMID: 34033862 DOI: 10.1016/j.lpm.2021.104068] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/29/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. In recent years, many disease-modifying therapies (DMT) have been approved for MS treatment. For this reason, a profound knowledge of the characteristics and indications of the available compounds is required to tailor the therapeutic strategy to the individual patient characteristics. This should include the mechanism of action and pharmacokinetic of the drug, the safety and efficacy profile provided by clinical trials, as well as the understanding of possible side effects. Moreover, the evolving knowledge of the disease is paving the way to new and innovative therapeutic approaches, as well as the development of new biomarkers to monitor the therapeutic response and to guide the clinician's therapeutic choices. In this review we provide a comprehensive overview on currently approved therapies in MS and the emerging evidence-based strategies to adopt for initiating, monitoring, and eventually adapting a therapeutic regimen with DMT.
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Affiliation(s)
- Ilaria Callegari
- Department of Biomedicine, University Hospital Basel, University of Basel, Hebelstrasse 20, 4031 Basel, Switzerland
| | - Tobias Derfuss
- Department of Biomedicine, University Hospital Basel, University of Basel, Hebelstrasse 20, 4031 Basel, Switzerland; Department of Neurology, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland.
| | - Edoardo Galli
- Department of Biomedicine, University Hospital Basel, University of Basel, Hebelstrasse 20, 4031 Basel, Switzerland; Department of Neurology, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
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Berger AA, Sottosanti ER, Winnick A, Izygon J, Berardino K, Cornett EM, Kaye AD, Varrassi G, Viswanath O, Urits I. Monomethyl Fumarate (MMF, Bafiertam) for the Treatment of Relapsing Forms of Multiple Sclerosis (MS). Neurol Int 2021; 13:207-223. [PMID: 34069538 PMCID: PMC8162564 DOI: 10.3390/neurolint13020022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/18/2021] [Accepted: 04/15/2021] [Indexed: 01/29/2023] Open
Abstract
Multiple sclerosis (MS) is a prevalent neurologic autoimmune disorder affecting two million people worldwide. Symptoms include gait abnormalities, perception and sensory losses, cranial nerve pathologies, pain, cognitive dysfunction, and emotional aberrancies. Traditional therapy includes corticosteroids for the suppression of relapses and injectable interferons. Recently, several modern therapies-including antibody therapy and oral agents-were approved as disease-modifying agents. Monomethyl fumarate (MMF, Bafiertam) is a recent addition to the arsenal available in the fight against MS and appears to be well-tolerated, safe, and effective. In this paper, we review the evidence available regarding the use of monomethyl fumarate (Bafiertam) in the treatment of relapsing-remitting MS.
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Affiliation(s)
- Amnon A. Berger
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA 02115, USA;
- Correspondence: (A.A.B.); (E.M.C.); Tel.: +1-(617)-667-7000 (A.A.B.); Fax: +1-(617)-667-5050 (A.A.B.)
| | - Emily R. Sottosanti
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA 02115, USA;
| | - Ariel Winnick
- Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva 8400100, Israel; (A.W.); (J.I.)
- School of Optometry, University of California, Berkeley, CA 94720, USA
| | - Jonathan Izygon
- Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva 8400100, Israel; (A.W.); (J.I.)
| | - Kevin Berardino
- School of Medicine, Georgetown University, Washington, DC 20007, USA;
| | - Elyse M. Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
- Correspondence: (A.A.B.); (E.M.C.); Tel.: +1-(617)-667-7000 (A.A.B.); Fax: +1-(617)-667-5050 (A.A.B.)
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
| | | | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ 85004, USA
- Valley Anesthesiology and Pain Consultants—Envision Physician Services, Phoenix, AZ 85001, USA
- Department of Anesthesiology, School of Medicine, Creighton University, Omaha, NE 68124, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
- Southcoast Health, Southcoast Health Physician Group Pain Medicine, North Dartmouth, MA 02747, USA
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Yu J, Li Y, Li Z, Li H, Chen Y, Chen X, Su W, Liang D. Subconjunctival injections of dimethyl fumarate inhibit lymphangiogenesis and allograft rejection in the rat cornea. Int Immunopharmacol 2021; 96:107580. [PMID: 33823430 DOI: 10.1016/j.intimp.2021.107580] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/09/2021] [Accepted: 03/08/2021] [Indexed: 11/26/2022]
Abstract
Corneal lymphangiogenesis induced by macrophages played a critical role in corneal allograft rejection (CGR). However, there are few Food and Drug Administration (FDA)-approved drugs that target lymphangiogenesis. The aim of our study is to evaluate the effects of dimethyl fumarate (DMF) on corneal allograft survival in rats. Penetrating corneal transplantation was performed in rats. Subconjunctival injections of dimethyl fumarate (20 µg) were administered at the end of the operation and postoperative day 3 to day 11. The clinical signs of corneal allografts were evaluated. Immunohistochemistry, quantitative real-time PCR (qPCR), flow cytometry and western blot were performed respectively. The effects and mechanism of DMF on RAW264.7 cells were determined by qPCR, enzyme-linked immunosorbent assay (ELISA), and western blot in vitro. The results showed that subconjunctival injections of DMF could significantly inhibit corneal lymphangiogenesis and CGR with decreased corneal macrophage infiltration compared with the vehicle group. Moreover, DMF could reduce the mRNA expression of monocyte chemoattractant protein 1 (MCP-1), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-1β (IL-1β), and vascular endothelial growth factor-C (VEGF-C) in the corneal grafts and RAW264.7 macrophages by inhibiting NF-κB activation. Furthermore, compared with the vehicle group, the number of dendritic cells in the ipsilateral cervical lymph nodes of the DMF-treated group was decreased significantly. Collectively, our findings showed that DMF could suppress CGR by inhibiting the macrophage-induced corneal lymphoangiogenesis.
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Affiliation(s)
- Jianfeng Yu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China; Eye Institute, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China; Medical School, Nantong University, Nantong, Jiangsu Province, China
| | - Yingqi Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China; Department of Ophthalmology, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Zhuang Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - He Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yuxi Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiaoqing Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Wenru Su
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.
| | - Dan Liang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.
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Diem L, Chan A. Persisting lymphopenia and dimethyl fumarate: A clinical commentary. Mult Scler 2021; 27:1309-1310. [PMID: 33620267 DOI: 10.1177/1352458521996698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Severe prolonged lymphopenia as rare side-effect of dimethyl fumarate is mostly reversible. Caldito et al. report a case of persistent severe lymphopenia over 5 years after discontinuation of dimethyl fumarate. We discuss several clinical implications. Safe withdrawal of disease modifying therapies in terms of reoccurrence of disease activity and drug related adverse events need further attention as our treatment armamentarium continues to grow.
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Affiliation(s)
- Lara Diem
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Caldito NG, O'Leary S, Stuve O. Persistent severe lymphopenia 5 years after dimethyl fumarate discontinuation. Mult Scler 2021; 27:1306-1308. [PMID: 33620273 DOI: 10.1177/1352458520988149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
One known adverse event associated with dimethyl fumarate (DMF) is grade III lymphopenia which usually resolves within 2-3 months upon DMF discontinuation. Here, we report a case of a 50-year-old woman with MS who developed grade III lymphopenia within 6 months of DMF initiation, and despite treatment cessation within the next 6 months, she has continued to have severe persistent lymphopenia for over 5 years. Our observation suggests prolonged and possibly irreversible lymphopenia as a possible adverse event of DMF, and it emphasizes the need for monitoring lymphocyte numbers, and to cease dosing promptly after onset of grade III lymphopenia.
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Affiliation(s)
- Natalia Gonzalez Caldito
- Department of Neurology & Neurotherapeutics, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Shirley O'Leary
- Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
| | - Olaf Stuve
- Department of Neurology & Neurotherapeutics, University of Texas Southwestern Medical School, Dallas, TX, USA/Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
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Lucchini M, Prosperini L, Buscarinu MC, Centonze D, Conte A, Cortese A, Elia G, Fantozzi R, Ferraro E, Gasperini C, Ianniello A, Landi D, Marfia GA, Nociti V, Pozzilli C, Salvetti M, Tortorella C, Mirabella M. Predictors of lymphocyte count recovery after dimethyl fumarate-induced lymphopenia in people with multiple sclerosis. J Neurol 2021; 268:2238-2245. [PMID: 33496861 PMCID: PMC8179888 DOI: 10.1007/s00415-021-10412-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dimethyl fumarate (DMF) is an oral drug approved for Relapsing Multiple Sclerosis (RMS) patients. Grade III lymphopenia is reported in 5-10% DMF-treated patients. Data on lymphocyte count (ALC) recovery after DMF withdrawal following prolonged lymphopenia are still scarce. OBJECTIVES To characterize ALC recovery and to identify predictors of slower recovery after DMF interruption. METHODS Multicenter data from RMS patients who started DMF and developed lymphopenia during treatment were collected. In patients with grade II-III lymphopenia, ALCs were evaluated from DMF withdrawal until reaching lymphocyte counts > 800/mm3. RESULTS Among 1034 patients who started DMF, we found 198 (19.1%) patients with lymphopenia and 65 patients (6.3%) who discontinued DMF due to persistent grade II-III lymphopenia. Complete data were available for 51 patients. All patients recovered to ALC > 800 cells/mm3 with a median time of 3.4 months. Lower ALCs at DMF suspension (HR 0.98; p = 0.005), longer disease duration (HR 1.29; p = 0.014) and prior exposure to MS treatments (HR 0.03; p = 0.025) were found predictive of delayed ALC recovery. CONCLUSION ALC recovery after DMF withdrawal is usually rapid, nevertheless it may require longer time in patients with lower ALC count at DMF interruption, longer disease duration and previous exposure to MS treatments, potentially leading to delayed initiation of a new therapy.
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Affiliation(s)
- Matteo Lucchini
- Multiple Sclerosis Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
- Università Cattolica del Sacro Cuore, Rome, Italy.
| | | | | | - Diego Centonze
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Antonella Conte
- IRCCS Neuromed, Pozzilli, Isernia, Italy
- Department of Human Neurosciences, Sapienza University, Rome, Italy
| | - Antonio Cortese
- Department of Human Neurosciences, Sapienza University, Rome, Italy
- San Filippo Neri Hospital, Rome, Italy
| | - Giorgia Elia
- Multiple Sclerosis Center, Ospedale S. Andrea, Rome, Italy
| | | | | | | | | | - Doriana Landi
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, Rome, Italy
| | - Girolama Alessandra Marfia
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- IRCCS Neuromed, Pozzilli, Isernia, Italy
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, Rome, Italy
| | - Viviana Nociti
- Multiple Sclerosis Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carlo Pozzilli
- Multiple Sclerosis Center, Ospedale S. Andrea, Rome, Italy
- Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Marco Salvetti
- Center for Experimental Neurological Therapies, NESMOS, S. Andrea Hospital, Rome, Italy
- IRCCS Neuromed, Pozzilli, Isernia, Italy
| | | | - Massimiliano Mirabella
- Multiple Sclerosis Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Gómez-Moreno M, Sánchez-Seco VG, Moreno-García S, Cámara PS, Sabin-Muñoz J, Ayuso-Peralta L, Oreja-Guevara C, Díaz-Díaz J, Sainz de la Maza S, Costa-Frossard L, Pilo de la Fuente B, Aladro-Benito Y. Cancer diagnosis in a Spanish cohort of multiple sclerosis patients under dimethylfumarate treatment. Mult Scler Relat Disord 2021; 49:102747. [PMID: 33524928 DOI: 10.1016/j.msard.2021.102747] [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: 12/30/2020] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Potential increase of cancer incidence is one of the main safety concerns of the disease-modifying therapies employed in Multiple Sclerosis (MS). OBJECTIVE Detailed description of patients who developed cancer among a prospective cohort of Spanish MS patients on dimethyl fumarate (DMF) treatment. METHODS We describe patients who developed cancer among a cohort of 886 MS patients on DMF treatment (2681 patient-years), with a median time of exposure of 39.5 months (IQR 23-51.5), who participated in a multicentre and prospective real-world study conducted in 16 Spanish National Health System hospitals from February 2014 to May 2019. Local researchers were periodically contacted by the investigation team to monitor safety issues. Cancer histories were collected from the medical records and the information was updated at July 30th 2020. RESULTS Eight Caucasian women developed cancer, which accounts for 0.9% and an accumulated malignancy rate of 298.39 cases per 100,000 patient-years of DMF exposure. At the time of cancer diagnosis, age was between 33 to 67 years and median time on DMF treatment 16.5 months (range 1-53). Two patients had familiar history of cancer. No specific cancer lines were found (breast cancer in 2 cases, thyroid in 3, urothelial carcinoma, cervix and a progression to leiomyosarcoma from a mitotically active leiomyoma). DMF was withdrawn during cancer treatment in 6 patients and reintroduced later. All cancers except one are in complete remission. The patient with leiomyosarcoma died by cancer progression. CONCLUSION A relationship between cancers and DMF is unlikely because the malignancy rate was similar to that of the age-and sex-matched general population, and because of the absence of specific tumour cell lines. Nevertheless, as with other immunosuppressive DMTs, clinicians treating MS should be aware of any potential cancer symptom and demand proper testing.
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Affiliation(s)
- Mayra Gómez-Moreno
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este, 80, 28031 Madrid, Spain
| | - Victoria Galán Sánchez-Seco
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Doce de Octubre, Av. de Córdoba, s/n, 28041 Madrid, Spain
| | - Sara Moreno-García
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Doce de Octubre, Av. de Córdoba, s/n, 28041 Madrid, Spain
| | - Paula Salgado Cámara
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Doce de Octubre, Av. de Córdoba, s/n, 28041 Madrid, Spain
| | - Julia Sabin-Muñoz
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Puerta de Hierro, Calle Joaquín Rodrigo, 1, 28222 Majadahonda, Madrid, Spain
| | - Lucia Ayuso-Peralta
- Department of Neurology, Hospital Universitario Príncipe de Asturias, Carr. de Alcalá, s/n, 28805 Meco, Madrid, Spain
| | - Celia Oreja-Guevara
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Clínico San Carlos, Calle del Prof Martín Lagos, s/n, 28040 Madrid, Spain
| | - Judit Díaz-Díaz
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Clínico San Carlos, Calle del Prof Martín Lagos, s/n, 28040 Madrid, Spain
| | - Susana Sainz de la Maza
- Multiple Sclerosis Unit, Department of Neurology,Hospital Universitario Ramón y Cajal, M-607, km. 9, 100, 28034 Madrid, Spain
| | - Lucienne Costa-Frossard
- Multiple Sclerosis Unit, Department of Neurology,Hospital Universitario Ramón y Cajal, M-607, km. 9, 100, 28034 Madrid, Spain
| | - Belén Pilo de la Fuente
- Multiple Sclerosis Unit, Department of Neurology,Hospital Universitario Getafe, Carr. Madrid - Toledo, Km 12,500, 28905 Getafe, Madrid, Spain
| | - Yolanda Aladro-Benito
- Multiple Sclerosis Unit, Department of Neurology,Hospital Universitario Getafe, Carr. Madrid - Toledo, Km 12,500, 28905 Getafe, Madrid, Spain.
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Alroughani R, Huppke P, Mazurkiewicz-Beldzinska M, Blaschek A, Valis M, Aaen G, Pultz J, Peng X, Beynon V. Delayed-Release Dimethyl Fumarate Safety and Efficacy in Pediatric Patients With Relapsing-Remitting Multiple Sclerosis. Front Neurol 2021; 11:606418. [PMID: 33473248 PMCID: PMC7812971 DOI: 10.3389/fneur.2020.606418] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/26/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Pediatric multiple sclerosis (MS) is rare: only 1.5-5% of MS cases are diagnosed before 18 years of age, and data on disease-modifying therapies (DMTs) for pediatric MS are limited. The CONNECTED study assessed the long-term safety and efficacy of treatment with delayed-release dimethyl fumarate (DMF), an oral MS DMT, in pediatric patients with MS. Methods: CONNECTED is the 96-week extension to FOCUS, a 24-week phase 2 study of patients aged 13-17 years; participants received DMF 240 mg twice daily. Endpoints included (primary) incidence of adverse events (AEs), serious AEs, and DMF discontinuations due to an AE, and (secondary) T2 hyperintense lesion incidence by magnetic resonance imaging and annualized relapse rate (ARR). Results: Twenty participants [median (range) age, 17 (14-18) years; 65% female] who completed FOCUS enrolled into CONNECTED; 17 (85%) completed CONNECTED. Eighteen participants (90%) experienced AEs: the most frequent was flushing (25%). None experienced infections or fever related to low lymphocyte counts. Three participants experienced four serious AEs; none led to DMF discontinuation. Twelve of 17 participants (71%) had no new/newly enlarged T2 lesions from weeks 16-24, two (12%) had one, and one each (6%) had two, three, or five or more lesions [median (range), 0 (0-6)]. Over the full 120-week treatment period, ARR was 0.2, an 84.5% relative reduction (n = 20; 95% confidence interval: 66.8-92.8; p < 0.0001) vs. the year before DMF initiation. Conclusions: The long-term safety and efficacy observed in CONNECTED was consistent with adults, suggesting pediatric and adolescent patients with MS might benefit from DMF treatment.
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Affiliation(s)
- Raed Alroughani
- Dasman Diabetes Institute, Dasman, Kuwait and Amiri Hospital, Sharq, Kuwait
| | - Peter Huppke
- Department of Pediatrics and Pediatric Neurology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Astrid Blaschek
- Department of Pediatric Neurology and Developmental Medicine, Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Martin Valis
- Neurologicka klinika, Fakultni nemocnice Hradec Kralove, Hradec Kralove, Czechia
| | - Gregory Aaen
- Loma Linda University Children's Health, Loma Linda, CA, United States
| | - Joe Pultz
- Biogen, Cambridge, MA, United States
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Comi G, Dalla Costa G, Moiola L. Newly approved agents for relapsing remitting multiple sclerosis: how real-world evidence compares with randomized clinical trials? Expert Rev Neurother 2020; 21:21-34. [PMID: 33043718 DOI: 10.1080/14737175.2021.1829478] [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: 01/06/2023]
Abstract
INTRODUCTION In recent years, many treatment options have become available for relapsing remitting MS. Randomized clinical trials and real-world studies are complementary sources of information, and together have the potential to offer a comprehensive understanding of the safety and efficacy profiles of each drug, a critical factor for a personalized management of the disease. AREAS COVERED In this review, the authors provide an up-to-date review of both RCTs and real-world studies assessing the safety and efficacy profiles of recently developed disease-modifying drugs for relapsing remitting MS. These include fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab and ocrelizumab. EXPERT OPINION From the authors' review of the literature, the efficacy profiles resulted from RCTs were confirmed by observational studies with regard to the disease-modifying drugs considered. The magnitude of the effects on annualized relapse rates and MRI active lesions was generally even larger in the observational studies compared to RCTs. From the safety point of view, observational studies revealed new adverse events, mostly in the area of bacterial and opportunistic infections, not seen in the relative registration programme. This is a very important gain because it allows to elaborate appropriate strategies to prevent and handle the risks.
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Affiliation(s)
- Giancarlo Comi
- Institute of Experimental Neurology of San Raffaele Hospital , Milan, Italy
| | - Gloria Dalla Costa
- Institute of Experimental Neurology of San Raffaele Hospital , Milan, Italy.,Vita-Salute San Raffaele University , Milan, Italy
| | - Lucia Moiola
- Institute of Experimental Neurology of San Raffaele Hospital , Milan, Italy.,Neurology Unit and MS Center, San Raffaele Hospital , Milan, Italy
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Jakimovski D, Vaughn CB, Eckert S, Zivadinov R, Weinstock-Guttman B. Long-term drug treatment in multiple sclerosis: safety success and concerns. Expert Opin Drug Saf 2020; 19:1121-1142. [PMID: 32744073 DOI: 10.1080/14740338.2020.1805430] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The portfolio of multiple sclerosis (MS) disease modifying treatments (DMTs) has significantly expanded over the past two decades. Given the lifelong use of MS pharmacotherapy, understanding their long-term safety profiles is essential in determining suitable and personalized treatment. AREAS COVERED In this narrative review, we summarize the short-, mid-, and long-term safety profile of currently available MS DMTs categories. In addition to the initial trial findings, safety outcomes derived from long-term extension studies (≥5-20 years) and safety-based prescription programs have been reviewed. In order to better understand the risk-benefit ratio for each particular DMT group, a short description of the DMT-based efficacy outcomes has been included. EXPERT OPINION Long-term extension trials, large observational studies and real-world databases allow detection of rare and potentially serious adverse events. Two-year-long trials are unable to fully capture the positive and negative effects of immune system modulation and reconstitution. DMT-based monitoring programs can provide greater insights regarding safe use of MS medications in different patient populations and clinical settings. During the process of shared DMT decision, both MS care providers and their patients should be aware of an ever-expanding number of drug-based adverse events and their influence on the risk-benefit analysis.
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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 , Buffalo, NY, USA
| | - Caila B Vaughn
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
| | - Svetlana Eckert
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, 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 , Buffalo, NY, USA.,Translational Imaging Center at Clinical Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Stat37$e University of New York , Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
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Jonasson E, Sejbaek T. Diroximel fumarate in the treatment of multiple sclerosis. Neurodegener Dis Manag 2020; 10:267-276. [PMID: 32686599 DOI: 10.2217/nmt-2020-0025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Diroximel fumarate (DRF) is a new emerging therapy for patients with multiple sclerosis. The levels of its active metabolite, monomethyl fumarate, are bioequivalent to the levels generated from dimethyl fumarate (DMF) treatment. The efficacy and safety profiles of DRF are expected to be similar to the well-established profiles of DMF. The metabolism of DRF leads to lower concentration of methanol in the small intestine than with DMF and thus reduced severity and frequency of gastrointestinal adverse events. DRF seems a promising alternative to DMF and other first-line therapies for multiple sclerosis. The current review is based on the two existing Phase III trials of DRF: the interim analysis of the EVOLVE-MS-1 trial and the completed EVOLVE-MS-2 trial.
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Affiliation(s)
- Elise Jonasson
- Department of Neurology, Hospital South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Tobias Sejbaek
- Department of Neurology, Hospital South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark.,BRIDGE, Brain Research - Inter-Disciplinary Guided Excellence, Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark.,MS Alliance of Southern Denmark, Esbjerg, Denmark
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Scuderi SA, Ardizzone A, Paterniti I, Esposito E, Campolo M. Antioxidant and Anti-inflammatory Effect of Nrf2 Inducer Dimethyl Fumarate in Neurodegenerative Diseases. Antioxidants (Basel) 2020; 9:antiox9070630. [PMID: 32708926 PMCID: PMC7402174 DOI: 10.3390/antiox9070630] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022] Open
Abstract
Neurodegenerative diseases (NDs) represents debilitating conditions characterized by degeneration of neuronal cells in specific brain areas, causing disability and death in patients. In the pathophysiology of NDs, oxidative stress, apoptosis and neuroinflammation have a key role, as demonstrated by in vivo and in vitro models. Therefore, the use of molecules with antioxidant and anti-inflammatory activities represents a possible strategy for the treatment of NDs. Many studies demonstrated the beneficial effects of fumaric acid esters (FAEs) to counteract neuroinflammation and oxidative stress. Among these molecules, dimethyl fumarate (DMF) showed a valid therapeutic approach to slow down neurodegeneration and relieve symptoms in patients with NDs. DMF is a methyl ester of fumaric acid and acts as modulator of the nuclear factor erythroid 2-related factor 2 (Nrf2) pathway as well as nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) translocation. Therefore, this review aims to examine the potential beneficial effects of DMF to counteract oxidative stress and inflammation in patients with NDs.
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Mantero V, Abate L, Basilico P, Balgera R, Salmaggi A, Nourbakhsh B, Cordano C. COVID-19 in dimethyl fumarate-treated patients with multiple sclerosis. J Neurol 2020; 268:2023-2025. [PMID: 32588182 PMCID: PMC7314911 DOI: 10.1007/s00415-020-10015-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Vittorio Mantero
- Department of Neurology, MS Center, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy.
| | - Lucia Abate
- Department of Neurology, MS center, ASST Lariana, Como, Italy
| | - Paola Basilico
- Department of Neurology, MS Center, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Roberto Balgera
- Department of Neurology, MS Center, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Andrea Salmaggi
- Department of Neurology, MS Center, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Bardia Nourbakhsh
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Christian Cordano
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, USA
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Wagener FADTG, Pickkers P, Peterson SJ, Immenschuh S, Abraham NG. Targeting the Heme-Heme Oxygenase System to Prevent Severe Complications Following COVID-19 Infections. Antioxidants (Basel) 2020; 9:E540. [PMID: 32575554 PMCID: PMC7346191 DOI: 10.3390/antiox9060540] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 01/08/2023] Open
Abstract
SARS-CoV-2 is causing a pandemic resulting in high morbidity and mortality. COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) are often critically ill and show lung injury and hemolysis. Heme is a prosthetic moiety crucial for the function of a wide variety of heme-proteins, including hemoglobin and cytochromes. However, injury-derived free heme promotes adhesion molecule expression, leukocyte recruitment, vascular permeabilization, platelet activation, complement activation, thrombosis, and fibrosis. Heme can be degraded by the anti-inflammatory enzyme heme oxygenase (HO) generating biliverdin/bilirubin, iron/ferritin, and carbon monoxide. We therefore postulate that free heme contributes to many of the inflammatory phenomena witnessed in critically ill COVID-19 patients, whilst induction of HO-1 or harnessing heme may provide protection. HO-activity not only degrades injurious heme, but its effector molecules possess also potent salutary anti-oxidative and anti-inflammatory properties. Until a vaccine against SARS-CoV-2 becomes available, we need to explore novel strategies to attenuate the pro-inflammatory, pro-thrombotic, and pro-fibrotic consequences of SARS-CoV-2 leading to morbidity and mortality. The heme-HO system represents an interesting target for novel "proof of concept" studies in the context of COVID-19.
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Affiliation(s)
- Frank A. D. T. G. Wagener
- Department of Dentistry-Orthodontics and Craniofacial Biology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Philips van Leydenlaan 25, 6525EX Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6500HB Nijmegen, The Netherlands;
| | | | - Stephan Immenschuh
- Institute for Transfusion Medicine, Hannover Medical School, 30625 Hannover, Germany;
| | - Nader G. Abraham
- Departments of Medicine and Pharmacology, New York Medical College, Valhalla, NY 10595, USA;
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