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Hirt J, Dembowska K, Woelfle T, Axfors C, Granziera C, Kuhle J, Kappos L, Hemkens LG, Janiaud P. Clinical trial evidence of quality-of-life effects of disease-modifying therapies for multiple sclerosis: a systematic analysis. J Neurol 2024; 271:3131-3141. [PMID: 38625399 PMCID: PMC11136790 DOI: 10.1007/s00415-024-12366-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Increasingly, patients, clinicians, and regulators call for more evidence on the impact of innovative medicines on quality of life (QoL). We assessed the effects of disease-modifying therapies (DMTs) on QoL in people with multiple sclerosis (PwMS). METHODS Randomized trials assessing approved DMTs in PwMS with results for at least one outcome referred to as "quality of life" were searched in PubMed and ClinicalTrials.gov. RESULTS We identified 38 trials published between 1999 and 2023 with a median of 531 participants (interquartile range (IQR) 202 to 941; total 23,225). The evaluated DMTs were mostly interferon-beta (n = 10; 26%), fingolimod (n = 7; 18%), natalizumab (n = 5; 13%), and glatiramer acetate (n = 4; 11%). The 38 trials used 18 different QoL instruments, with up to 11 QoL subscale measures per trial (median 2; IQR 1-3). QoL was never the single primary outcome. We identified quantitative QoL results in 24 trials (63%), and narrative statements in 15 trials (39%). In 16 trials (42%), at least one of the multiple QoL results was statistically significant. The effect sizes of the significant quantitative QoL results were large (median Cohen's d 1.02; IQR 0.3-1.7; median Hedges' g 1.01; IQR 0.3-1.69) and ranged between d 0.14 and 2.91. CONCLUSIONS Certain DMTs have the potential to positively impact QoL of PwMS, and the assessment and reporting of QoL is suboptimal with a multitude of diverse instruments being used. There is an urgent need that design and reporting of clinical trials reflect the critical importance of QoL for PwMS.
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Affiliation(s)
- Julian Hirt
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, CH-4031, Basel, Switzerland
- Institute of Nursing Science, Department of Health, Eastern Switzerland University of Applied Sciences, St.Gallen, Switzerland
| | - Kinga Dembowska
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, CH-4031, Basel, Switzerland
| | - Tim Woelfle
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, CH-4031, Basel, Switzerland
- Department of Neurology and MS Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Cathrine Axfors
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, CH-4031, Basel, Switzerland
| | - Cristina Granziera
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, CH-4031, Basel, Switzerland
- Department of Neurology and MS Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jens Kuhle
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, CH-4031, Basel, Switzerland
- Department of Neurology and MS Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, CH-4031, Basel, Switzerland
| | - Lars G Hemkens
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, CH-4031, Basel, Switzerland
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Perrine Janiaud
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, CH-4031, Basel, Switzerland.
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA.
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Gonzalez-Lorenzo M, Ridley B, Minozzi S, Del Giovane C, Peryer G, Piggott T, Foschi M, Filippini G, Tramacere I, Baldin E, Nonino F. Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD011381. [PMID: 38174776 PMCID: PMC10765473 DOI: 10.1002/14651858.cd011381.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Different therapeutic strategies are available for the treatment of people with relapsing-remitting multiple sclerosis (RRMS), including immunomodulators, immunosuppressants and biological agents. Although each one of these therapies reduces relapse frequency and slows disability accumulation compared to no treatment, their relative benefit remains unclear. This is an update of a Cochrane review published in 2015. OBJECTIVES To compare the efficacy and safety, through network meta-analysis, of interferon beta-1b, interferon beta-1a, glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab, pegylated interferon beta-1a, daclizumab, laquinimod, azathioprine, immunoglobulins, cladribine, cyclophosphamide, diroximel fumarate, fludarabine, interferon beta 1-a and beta 1-b, leflunomide, methotrexate, minocycline, mycophenolate mofetil, ofatumumab, ozanimod, ponesimod, rituximab, siponimod and steroids for the treatment of people with RRMS. SEARCH METHODS CENTRAL, MEDLINE, Embase, and two trials registers were searched on 21 September 2021 together with reference checking, citation searching and contact with study authors to identify additional studies. A top-up search was conducted on 8 August 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) that studied one or more of the available immunomodulators and immunosuppressants as monotherapy in comparison to placebo or to another active agent, in adults with RRMS. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data. We considered both direct and indirect evidence and performed data synthesis by pairwise and network meta-analysis. Certainty of the evidence was assessed by the GRADE approach. MAIN RESULTS We included 50 studies involving 36,541 participants (68.6% female and 31.4% male). Median treatment duration was 24 months, and 25 (50%) studies were placebo-controlled. Considering the risk of bias, the most frequent concern was related to the role of the sponsor in the authorship of the study report or in data management and analysis, for which we judged 68% of the studies were at high risk of other bias. The other frequent concerns were performance bias (34% judged as having high risk) and attrition bias (32% judged as having high risk). Placebo was used as the common comparator for network analysis. Relapses over 12 months: data were provided in 18 studies (9310 participants). Natalizumab results in a large reduction of people with relapses at 12 months (RR 0.52, 95% CI 0.43 to 0.63; high-certainty evidence). Fingolimod (RR 0.48, 95% CI 0.39 to 0.57; moderate-certainty evidence), daclizumab (RR 0.55, 95% CI 0.42 to 0.73; moderate-certainty evidence), and immunoglobulins (RR 0.60, 95% CI 0.47 to 0.79; moderate-certainty evidence) probably result in a large reduction of people with relapses at 12 months. Relapses over 24 months: data were reported in 28 studies (19,869 participants). Cladribine (RR 0.53, 95% CI 0.44 to 0.64; high-certainty evidence), alemtuzumab (RR 0.57, 95% CI 0.47 to 0.68; high-certainty evidence) and natalizumab (RR 0.56, 95% CI 0.48 to 0.65; high-certainty evidence) result in a large decrease of people with relapses at 24 months. Fingolimod (RR 0.54, 95% CI 0.48 to 0.60; moderate-certainty evidence), dimethyl fumarate (RR 0.62, 95% CI 0.55 to 0.70; moderate-certainty evidence), and ponesimod (RR 0.58, 95% CI 0.48 to 0.70; moderate-certainty evidence) probably result in a large decrease of people with relapses at 24 months. Glatiramer acetate (RR 0.84, 95%, CI 0.76 to 0.93; moderate-certainty evidence) and interferon beta-1a (Avonex, Rebif) (RR 0.84, 95% CI 0.78 to 0.91; moderate-certainty evidence) probably moderately decrease people with relapses at 24 months. Relapses over 36 months findings were available from five studies (3087 participants). None of the treatments assessed showed moderate- or high-certainty evidence compared to placebo. Disability worsening over 24 months was assessed in 31 studies (24,303 participants). Natalizumab probably results in a large reduction of disability worsening (RR 0.59, 95% CI 0.46 to 0.75; moderate-certainty evidence) at 24 months. Disability worsening over 36 months was assessed in three studies (2684 participants) but none of the studies used placebo as the comparator. Treatment discontinuation due to adverse events data were available from 43 studies (35,410 participants). Alemtuzumab probably results in a slight reduction of treatment discontinuation due to adverse events (OR 0.39, 95% CI 0.19 to 0.79; moderate-certainty evidence). Daclizumab (OR 2.55, 95% CI 1.40 to 4.63; moderate-certainty evidence), fingolimod (OR 1.84, 95% CI 1.31 to 2.57; moderate-certainty evidence), teriflunomide (OR 1.82, 95% CI 1.19 to 2.79; moderate-certainty evidence), interferon beta-1a (OR 1.48, 95% CI 0.99 to 2.20; moderate-certainty evidence), laquinimod (OR 1.49, 95 % CI 1.00 to 2.15; moderate-certainty evidence), natalizumab (OR 1.57, 95% CI 0.81 to 3.05), and glatiramer acetate (OR 1.48, 95% CI 1.01 to 2.14; moderate-certainty evidence) probably result in a slight increase in the number of people who discontinue treatment due to adverse events. Serious adverse events (SAEs) were reported in 35 studies (33,998 participants). There was probably a trivial reduction in SAEs amongst people with RRMS treated with interferon beta-1b as compared to placebo (OR 0.92, 95% CI 0.55 to 1.54; moderate-certainty evidence). AUTHORS' CONCLUSIONS We are highly confident that, compared to placebo, two-year treatment with natalizumab, cladribine, or alemtuzumab decreases relapses more than with other DMTs. We are moderately confident that a two-year treatment with natalizumab may slow disability progression. Compared to those on placebo, people with RRMS treated with most of the assessed DMTs showed a higher frequency of treatment discontinuation due to AEs: we are moderately confident that this could happen with fingolimod, teriflunomide, interferon beta-1a, laquinimod, natalizumab and daclizumab, while our certainty with other DMTs is lower. We are also moderately certain that treatment with alemtuzumab is associated with fewer discontinuations due to adverse events than placebo, and moderately certain that interferon beta-1b probably results in a slight reduction in people who experience serious adverse events, but our certainty with regard to other DMTs is lower. Insufficient evidence is available to evaluate the efficacy and safety of DMTs in a longer term than two years, and this is a relevant issue for a chronic condition like MS that develops over decades. More than half of the included studies were sponsored by pharmaceutical companies and this may have influenced their results. Further studies should focus on direct comparison between active agents, with follow-up of at least three years, and assess other patient-relevant outcomes, such as quality of life and cognitive status, with particular focus on the impact of sex/gender on treatment effects.
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Affiliation(s)
- Marien Gonzalez-Lorenzo
- Laboratorio di Metodologia delle revisioni sistematiche e produzione di Linee Guida, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ben Ridley
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Cochrane Italy, Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Guy Peryer
- School of Health Sciences, University of East Anglia (UEA), Norwich, UK
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, Queens University, Kingston, Ontario, Canada
| | - Matteo Foschi
- Department of Neuroscience, Multiple Sclerosis Center - Neurology Unit, S.Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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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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David OA, Predatu R, Cardoș RA. Effectiveness of the REThink therapeutic online video game in promoting mental health in children and adolescents. Internet Interv 2021; 25:100391. [PMID: 33996508 PMCID: PMC8099491 DOI: 10.1016/j.invent.2021.100391] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 12/22/2022] Open
Abstract
Although evidence-based interventions exist, estimates suggest that about 60% percent of children and adolescents with mental health disorders do not receive the treatment they need. In this context, one expanding strategy for increasing access to mental health care for children and adolescents is the use therapeutic, or serious, games. REThink is one such therapeutic game, developed to offer a CBT-based prevention that was documented in a controlled trial to develop psychological resilience in children and adolescents, aged between 10 and 16, helping them learn healthy strategies for coping with dysfunctional negative emotions such as anxiety, anger and depression. This study aims to test the effectiveness of the REThink therapeutic online video game in promoting emotional health in children and adolescents in a pilot study. Participants (N = 31), aged between 10 and 16 years, were recruited on a volunteer basis from a school. Emotional problems, irrational beliefs, negative automatic thoughts, rational beliefs, and problem solving abilities were assessed pre- and post-using the therapeutic game. We also measured participants' satisfaction with the game. Results obtained show improvements in terms of emotional problems of the youths, their irrational beliefs, negative automatic thoughts and high levels of intervention satisfaction. of this study are in support of the previous findings suggesting that the REThink online game can be a valuable tool for large-scale mental health efforts aimed at the prevention of emotional disorders in children and adolescents, in accordance with evidence-based prevention protocols.
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Affiliation(s)
- Oana A. David
- Department of Clinical Psychology and Psychotherapy, Babeş-Bolyai University, Romania,DATA Lab, The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babes-Bolyai University Cluj-Napoca, Romania,Corresponding authors at: Department of Clinical Psychology and Psychotherapy, Babeș-Bolyai University, 37 Republicii St., 400015 Cluj-Napoca, Romania.
| | - Răzvan Predatu
- DATA Lab, The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babes-Bolyai University Cluj-Napoca, Romania,Doctoral School “Evidence-based assessment and psychological interventions”, Babeș-Bolyai University, Romania
| | - Roxana A.I. Cardoș
- Department of Clinical Psychology and Psychotherapy, Babeş-Bolyai University, Romania,DATA Lab, The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babes-Bolyai University Cluj-Napoca, Romania
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David OA, Cardoș RAI, Matu S. Is REThink therapeutic game effective in preventing emotional disorders in children and adolescents? Outcomes of a randomized clinical trial. Eur Child Adolesc Psychiatry 2019; 28:111-122. [PMID: 29992353 DOI: 10.1007/s00787-018-1192-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 07/02/2018] [Indexed: 11/28/2022]
Abstract
Therapeutic games represent a promising solution for addressing emotional difficulties in youths. The aim of the present study was to investigate the effectiveness of the REThink game, in helping children and adolescents, to develop psychological resilience. Therefore, 165 children aged between 10 and 16 years were randomly assigned in one of the three groups: 54 participants in the REThink condition, 55 participants in the Rational Emotive Behavior Education condition, and 56 participants in the waitlist condition. Results indicated that the REThink intervention had a significant impact on emotional symptoms (a moderate-effect size, d = 0.46) and on depressive mood (a large-effect size, d = 0.84). Furthermore, REThink had a significant impact on children's ability to regulate their emotions, with a significant effect on emotional awareness (d = 0.64), and on the ability for emotional control (d = 0.69). In conclusion, the implications of the REThink game are discussed in relationship with resiliency building programs designed for youths. TRIAL REGISTRATION: ClinicalTrials.gov NCT03308981.
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Affiliation(s)
- Oana A David
- Department of Clinical Psychology and Psychotherapy, The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeş-Bolyai University, No. 37, Republicii Street, 400015, Cluj-Napoca, Romania
| | - Roxana A I Cardoș
- Department of Clinical Psychology and Psychotherapy, The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeş-Bolyai University, No. 37, Republicii Street, 400015, Cluj-Napoca, Romania.
| | - Silviu Matu
- Department of Clinical Psychology and Psychotherapy, The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeş-Bolyai University, No. 37, Republicii Street, 400015, Cluj-Napoca, Romania
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Gerardi C, Bertele' V, Rossi S, Garattini S, Banzi R. Preapproval and postapproval evidence on drugs for multiple sclerosis. Neurology 2018; 90:964-973. [PMID: 29695598 DOI: 10.1212/wnl.0000000000005561] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/26/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review the evidence supporting the European Union marketing authorization of drugs for multiple sclerosis (MS) and assess how far postmarketing research addresses information gaps at the time of approval. METHODS Through its database, we identified drugs approved by the European Medicines Agency and gathered data on pivotal trials from the European Public Assessment Reports and corresponding publications. We searched Medline, Embase, Cochrane Library, and trial registries for postmarketing randomized controlled trials testing the drugs identified in any form of the disease. RESULTS Since approval of interferon and glatiramer up to 2017, the Agency has examined 10 drugs for the treatment of MS, and 8 were included in this study: alemtuzumab, daclizumab, dimethyl fumarate, fampridine, fingolimod, peginterferon-β-1a, natalizumab, and teriflunomide. We analyzed 16 pivotal trials enrolling almost 16,000 participants. Eleven compared new drugs to placebo, 5 to interferon-β-1a. Annualized relapse rate was the primary outcome in two-thirds and coprimary with disability progression in the 2 studies of alemtuzumab. Of the 52 postmarketing trials, 24 reported final results and 28 were ongoing, terminated, or completed but no results were available. None directly compared the approved drugs, thus leaving their respective therapeutic values unknown. Data on the prevention of disease progression were scarce: none of the disease-modifying drugs showed any effect on disability progression. CONCLUSION The lack of comparative evidence and data on clinical effectiveness hamper the assessment of therapeutic value and place in therapy of drugs approved for MS.
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Affiliation(s)
- Chiara Gerardi
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Vittorio Bertele'
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvia Rossi
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvio Garattini
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Rita Banzi
- From IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri" (C.G., V.B., S.G., R.B.); and Neuroimmunology and Neuromuscular Diseases Unit (S.R.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
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Hamidi V, Couto E, Ringerike T, Klemp M. A Multiple Treatment Comparison of Eleven Disease-Modifying Drugs Used for Multiple Sclerosis. J Clin Med Res 2018; 10:88-105. [PMID: 29317954 PMCID: PMC5755648 DOI: 10.14740/jocmr3168w] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 09/05/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Several disease-modifying drug therapies are available for the treatment of multiple sclerosis (MS). To ensure the most appropriate MS management, we assessed the effectiveness and cost-effectiveness of the disease-modifying medicines used for MS. METHODS We conducted a systematic review including 11 disease-modifying drugs used for treatment of adult patients diagnosed with relapsing-remitting MS. We performed a network meta-analysis using both direct and indirect evidence. We examined the endpoints, annual relapse, disability progression, mortality, serious adverse events and withdrawal from the study due to adverse events. Cost-effectiveness was assessed by developing a decision model. The model calculated costs and quality-adjusted life years (QALYs) with different treatment strategies. Uncertainties in the parameter values were explored with a probabilistic sensitivity analysis and several scenario analyses. RESULTS Alemtuzumab 12 mg was the most effective against annual relapse (high quality evidence). For disability progression, dimethyl fumarate 240 mg and fingolimod 0.5 mg and 1.25 mg were more effective treatment alternatives (high quality evidence). For withdrawal due to adverse events, the conclusion is unclear due to the low quality of the available evidence. Peg-interferon beta-1a was associated with more adverse events (than the other treatments). None of the examined treatments had an effect on overall mortality compared to placebo. The economic analysis indicated that alemtuzumab was more effective in terms of QALYs and less costly than the other treatment alternatives. Discarding alemtuzumab, three treatment alternatives (interferon beta-1b (Extavia), peg-interferon beta-1a and natalizumab) could be considered cost-effective depending on the willingness-to-pay (WTP) threshold. Assuming a WTP below EUR 111,690 per QALY, interferon beta-1b (Extavia) was approximately 36% likely to be the most cost-effective treatment, followed by peg-interferon beta-1a (approximately 34% likely). CONCLUSIONS Our results showed that alemtuzumab can be considered as more effective and less costly than the other treatment alternatives. There is a substantial potential cost saving if more patients start on the more effective and less costly treatment alternatives.
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Affiliation(s)
- Vida Hamidi
- Norwegian Institute of Public Health, Norway
| | | | | | - Marianne Klemp
- Norwegian Institute of Public Health, Norway
- Department of Pharmacology, University of Oslo, Norway
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Gerber B, Cowling T, Chen G, Yeung M, Duquette P, Haddad P. The impact of treatment adherence on clinical and economic outcomes in multiple sclerosis: Real world evidence from Alberta, Canada. Mult Scler Relat Disord 2017; 18:218-224. [DOI: 10.1016/j.msard.2017.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/29/2017] [Accepted: 10/04/2017] [Indexed: 12/15/2022]
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Munsell M, Frean M, Menzin J, Phillips AL. An evaluation of adherence in patients with multiple sclerosis newly initiating treatment with a self-injectable or an oral disease-modifying drug. Patient Prefer Adherence 2017; 11:55-62. [PMID: 28115831 PMCID: PMC5221550 DOI: 10.2147/ppa.s118107] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE As the multiple sclerosis (MS) disease-modifying drug (DMD) treatment options have expanded to include oral therapies, it is important to understand whether route of administration is associated with DMD adherence. The objective of this study was to compare adherence to DMDs in patients with MS newly initiating treatment with a self-injectable versus an oral DMD. METHODS This retrospective database study used IMS Health Real World Data Adjudicated Claims - US data between July 1, 2010 and June 30, 2014. Adherence was measured by medication possession ratio (MPR), calculated as the total number of treated days divided by the total number of days from the first treated day until the end of 12-month follow-up. A binary measure representing adherence (MPR ≥0.8) versus nonadherence (MPR <0.8) to therapy was used. Logistic regression evaluated the likelihood of adherence to index DMD type (self-injectable vs oral). Covariates included patient baseline characteristics (ie, age, sex, comorbidities) and index DMD type. RESULTS The analysis included 7,207 self-injectable and 1,175 oral DMD-treated patients with MS. In unadjusted analyses, the proportion of patients adherent to therapy (MPR ≥0.8) did not differ significantly between the self-injectable (54.1%) and the oral DMD cohorts (53.0%; P=0.5075). After controlling for covariates, index DMD type was not a significant predictor of adherence (odds ratio [OR] 1.062; 95% confidence interval [CI]: 0.937-1.202; P=0.3473). Higher likelihood of adherence was associated with male sex (OR 1.20; 95% CI: 1.085-1.335; P=0.0005) and age groups older than 18-34 years (ORs 1.220-1.331; P<0.01). Depression was associated with a lower likelihood of adherence (OR 0.618; 95% CI: 0.511-0.747; P<0.0001). CONCLUSION Male sex and age older than 18-34 years were significantly associated with a higher likelihood of adherence, while depression was associated with a lower likelihood of adherence. Index DMD type, stratified by the route of administration (self-injectable vs oral DMD), was not a significant predictor of DMD adherence.
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Affiliation(s)
| | - Molly Frean
- Boston Health Economics, Inc., Waltham, MA, USA
| | - Joseph Menzin
- Boston Health Economics, Inc., Waltham, MA, USA
- Correspondence: Joseph Menzin, Boston Health Economics, Inc., 20 Fox Road, Waltham, MA 02451, USA, Tel +1 781 290 0808, Fax +1 781 290 0029, Email
| | - Amy L Phillips
- Health Economics & Outcomes Research, EMD Serono Inc., Rockland, MA, USA
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Al‐Jabi SW, Zyoud SH, Sweileh WM, Wildali AH, Saleem HM, Aysa HA, Badwan MA, Awang R. Relationship of treatment satisfaction to health-related quality of life: findings from a cross-sectional survey among hypertensive patients in Palestine. Health Expect 2015; 18:3336-48. [PMID: 25484002 PMCID: PMC5810714 DOI: 10.1111/hex.12324] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2014] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Evaluation of the association between treatment satisfaction and health-related quality of life (HRQoL) may enable health-care providers to understand the issues that influence quality of life and to recognize the aspects of hypertension treatment that need improvement to enhance the long-term treatment outcomes. OBJECTIVE The aim of this study was to determine the relationship between HRQoL and treatment satisfaction in a sample of Palestinian hypertensive patients. METHODS A cross-sectional study was conducted, adopting the Treatment Satisfaction Questionnaire for Medication (TSQM 1.4) for the assessment of treatment satisfaction and using the European Quality of Life scale (EQ-5D-5L) for the assessment of HRQoL. Descriptive and comparative statistics were used to describe socio-demographic and disease-related characteristics of the patients. All analyses were performed using SPSS v 15.0. RESULTS Four hundred and ten hypertensive patients were enrolled in the study. This study findings indicate a positive correlation between all satisfaction domains and HRQoL. Significant differences were observed between this study variables (P < 0.001). After adjustment for covariates using multiple linear regression, an increase of one point in the global satisfaction scale was associated with a 0.16 increase in EQ-5D index scores (r = 0.16; P < 0.001). CONCLUSIONS Patients with reportedly higher satisfaction scores have reported relatively higher EQ-5D-5L index values. These study findings could be helpful in clinical practice, mainly in the early treatment of hypertensive patients, at a point where improving treatment satisfaction and HRQoL is still possible.
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Affiliation(s)
- Samah W. Al‐Jabi
- Department of Clinical and CommunityPharmacy College of Medicine and Health SciencesAn‐Najah National UniversityNablusPalestine
| | - Sa'ed H. Zyoud
- Department of Clinical and CommunityPharmacy College of Medicine and Health SciencesAn‐Najah National UniversityNablusPalestine
- Poison Control and Drug Information Center (PCDIC)College of Medicine and Health SciencesAn‐Najah National UniversityNablusPalestine
- WHO Collaborating Centre for Drug InformationNational Poison CentreUniversiti Sains Malaysia (USM)PenangMalaysia
| | - Waleed M. Sweileh
- Department of Pharmacology and ToxicologyCollege of Medicine and Health SciencesAn‐Najah National UniversityNablusPalestine
| | - Aysha H. Wildali
- PharmD ProgramCollege of Medicine and Health SciencesAn‐Najah National UniversityNablusPalestine
| | - Hanan M. Saleem
- PharmD ProgramCollege of Medicine and Health SciencesAn‐Najah National UniversityNablusPalestine
| | - Hayat A. Aysa
- PharmD ProgramCollege of Medicine and Health SciencesAn‐Najah National UniversityNablusPalestine
| | - Mohammad A. Badwan
- PharmD ProgramCollege of Medicine and Health SciencesAn‐Najah National UniversityNablusPalestine
| | - Rahmat Awang
- WHO Collaborating Centre for Drug InformationNational Poison CentreUniversiti Sains Malaysia (USM)PenangMalaysia
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