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Cahyadi M, Mesinovic J, Chim ST, Ebeling P, Zengin A, Grech L. Medication and bone health in multiple sclerosis: A systematic review and meta-analysis. J Manag Care Spec Pharm 2023; 29:1331-1353. [PMID: 38058136 PMCID: PMC10776270 DOI: 10.18553/jmcp.2023.29.12.1331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND People with multiple sclerosis (MS) are often prescribed medications associated with adverse effects on bone health. However, it is unclear whether these medications incur decreases in areal bone mineral density (aBMD) and higher fracture risk in this population. OBJECTIVE To investigate the effects of commonly used medications on aBMD and fracture risk among people with MS. METHODS MEDLINE, Embase, Scopus, CINAHL, and Web of Science were searched from their inception until February 5, 2023. We included randomized controlled trials as well as cross-sectional, retrospective, and prospective studies investigating whether glucocorticoids, immunomodulators, antidepressants, anticonvulsants, anxiolytics, opioids, or antipsychotics influenced aBMD or fracture risk in people with MS. Data were pooled using random effects meta-analyses to determine hazard ratios (HRs) and 95% CIs. RESULTS We included 22 studies (n = 18,193). Six studies were included in the meta-analyses of glucocorticoid use and aBMD, whereas 2 studies were included in the medication use and fracture risk meta-analyses. No studies assessed the effect of antidepressants, anxiolytics, anticonvulsants, opioids, and antipsychotics on aBMD, and no studies assessed the effect of immunomodulators on fracture risk. Glucocorticoid use was significantly negatively associated with femoral neck aBMD (correlation = -0.21 [95% CI = -0.29 to -0.13]), but not with lumbar spine aBMD (correlation = -0.21 [95% CI = -0.50 to 0.12]). There were no differences in fracture risk between users of glucocorticoids (HR = 1.71 [95% CI = 0.04 to 76.47]), antidepressants (HR = 1.84 [95% CI = 0.09 to 38.49]), or anxiolytics (HR = 2.01 [95% CI = 0.06 to 64.22]), compared with nonusers. CONCLUSIONS The available evidence is insufficient to support a relationship between greater fracture risk for people with MS taking glucocorticoid, antidepressant, or anxiolytic medication, compared with nonusers, and it is unclear whether these medications are associated with bone loss in people with MS, beyond that in the general population. Additional high-quality studies with homogenous methodology exploring how medications influence aBMD and fracture risk in people with MS are required.
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Affiliation(s)
- Michael Cahyadi
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Jakub Mesinovic
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Sher Ting Chim
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Peter Ebeling
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Ayse Zengin
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Lisa Grech
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
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Heesen C, Magyari M, Stellmann JP, Lederer C, Giovannoni G, Scalfari A, Daumer M. The Sylvia Lawry Centre for Multiple Sclerosis Research (SLCMSR) – critical review facing the 20 anniversary. Mult Scler Relat Disord 2022; 63:103885. [DOI: 10.1016/j.msard.2022.103885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/31/2022] [Accepted: 05/13/2022] [Indexed: 11/26/2022]
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Koch MW, Sage K, Kaur S, Kim J, Cerchiaro G, Yong VW, Cutter GR, Metz LM. Repurposing Domperidone in Secondary Progressive Multiple Sclerosis: A Simon 2-Stage Phase 2 Futility Trial. Neurology 2021; 96:e2313-e2322. [PMID: 34038379 DOI: 10.1212/wnl.0000000000011863] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 02/02/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess whether treatment with the generic drug domperidone can reduce the progression of disability in secondary progressive multiple sclerosis (SPMS), we conducted a phase 2 futility trial following the Simon 2-stage design. METHODS We enrolled patients in an open-label, Simon 2-stage, single-center, phase 2, single-arm futility trial at the Calgary Multiple Sclerosis Clinic if they met the following criteria: age of 18 to 60 years, SPMS, screening Expanded Disability Status Scale score of 4.0 to 6.5, and screening timed 25-ft walk (T25FW) of ≥9 seconds. Patients received domperidone 10 mg 4 times daily for 1 year. The primary outcome was worsening of disability, defined as worsening of the T25FW performance by ≥20% at 12 months compared to baseline. This trial is registered with ClinicalTrials.gov (NCT02308137). RESULTS Between February 13, 2015, and January 3, 2020, 110 patients were screened, 81 received treatment, and 64 completed follow-up, of whom 62 were analyzed. The study did not meet its primary endpoint: 22 of 62 (35%) patients experienced significant worsening of disability, which is close to the expected proportion of 40% and above the predefined futility threshold. Patients with higher prolactin levels during the study had a significantly lower risk of disability progression, which may warrant further investigation. Domperidone treatment was reasonably well tolerated, but adverse events occurred in 84% and serious adverse events in 15% of patients. CONCLUSIONS Domperidone treatment could not reject futility in reducing disability progression in SPMS. The Simon 2-stage trial model may be a useful model for phase 2 studies in progressive MS. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02308137. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that in individuals with SPMS participating in a futility trial, domperidone treatment could not reject futility in reducing disability progression at 12 months.
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Affiliation(s)
- Marcus W Koch
- From the Departments of Clinical Neurosciences (M.W.K., K.S., S.K., J.K., G.C., V.W.Y., L.M.M.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham.
| | - Kayla Sage
- From the Departments of Clinical Neurosciences (M.W.K., K.S., S.K., J.K., G.C., V.W.Y., L.M.M.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - Sharanjit Kaur
- From the Departments of Clinical Neurosciences (M.W.K., K.S., S.K., J.K., G.C., V.W.Y., L.M.M.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - Janet Kim
- From the Departments of Clinical Neurosciences (M.W.K., K.S., S.K., J.K., G.C., V.W.Y., L.M.M.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - Graziela Cerchiaro
- From the Departments of Clinical Neurosciences (M.W.K., K.S., S.K., J.K., G.C., V.W.Y., L.M.M.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - V Wee Yong
- From the Departments of Clinical Neurosciences (M.W.K., K.S., S.K., J.K., G.C., V.W.Y., L.M.M.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - Gary R Cutter
- From the Departments of Clinical Neurosciences (M.W.K., K.S., S.K., J.K., G.C., V.W.Y., L.M.M.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - Luanne M Metz
- From the Departments of Clinical Neurosciences (M.W.K., K.S., S.K., J.K., G.C., V.W.Y., L.M.M.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
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Vignapiano R, Vicchio L, Favuzza E, Cennamo M, Mencucci R. Corneal Graft Rejection after Yellow Fever Vaccine: A Case Report. Ocul Immunol Inflamm 2021; 30:1207-1210. [PMID: 33507830 DOI: 10.1080/09273948.2020.1870146] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose: To report an unusual case of corneal graft rejection after yellow fever vaccine.Methods: Case report.Results: We have described the case of a 48-year-old man who developed a corneal graft rejection in the left eye 3 weeks after a yellow fever vaccination. The ophthalmic examination of the left eye revealed conjunctival hyperemia, corneal graft edema with Descemet folds, and fine keratic precipitates. No abnormalities were found in the right eye. The episode of graft rejection fully recovered after a short course of systemic and topical steroid treatment.Conclusions: This is the first case report of corneal transplant rejection temporally associated with yellow fever vaccination. Although the yellow fever vaccine is a very safe and efficacious vaccine, the occurrence of vaccine-related rejection may be more frequent than reported. Both patients and ophthalmologists should be aware of possible vaccine-related complications which may be potentially sight-threatening.
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Affiliation(s)
- Roberto Vignapiano
- Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), Eye Clinic, University of Florence, Florence, Italy
| | - Lidia Vicchio
- Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), Eye Clinic, University of Florence, Florence, Italy
| | - Eleonora Favuzza
- Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), Eye Clinic, University of Florence, Florence, Italy
| | - Michela Cennamo
- Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), Eye Clinic, University of Florence, Florence, Italy
| | - Rita Mencucci
- Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), Eye Clinic, University of Florence, Florence, Italy
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Comparing Plasma Exchange to Escalated Methyl Prednisolone in Refractory Multiple Sclerosis Relapses. J Clin Med 2019; 9:jcm9010035. [PMID: 31877873 PMCID: PMC7027010 DOI: 10.3390/jcm9010035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 12/19/2022] Open
Abstract
Intravenous methyl prednisolone (IVMPS) represents the standard of care for multiple sclerosis (MS) relapses, but fail to improve symptoms in one quarter of patients. In this regard, apart from extending steroid treatment to a higher dose, therapeutic plasma exchange (TPE) has been recognized as a treatment option. The aim of this retrospective, monocentric study was to investigate the efficacy of TPE versus escalated dosages of IVMPS in refractory MS relapses. An in-depth medical chart review was performed to identify patients from local databases. Relapse recovery was stratified as “good/full”, “average” and “worst/no” according to function score development. In total, 145 patients were analyzed. Good/average/worst recovery at discharge was observed in 60.9%/32.6%/6.5% of TPE versus 15.2%/14.1%/70.7% of IVMPS patients, respectively. A total of 53.5% of IVMPS patients received TPE as rescue treatment and 54.8% then responded satisfactorily. The multivariable odds ratio (OR) for worst/no recovery was 39.01 (95%–CI: 10.41–146.18; p ≤ 0.001), favoring administration of TPE as first escalation treatment. The effects were sustained at three-month follow-ups, as OR for further deterioration was 6.48 (95%–CI: 2.48–16.89; p ≤ 0.001), favoring TPE. In conclusion, TPE was superior over IVMPS in the amelioration of relapse symptoms at discharge and follow-up. This study provides class IV evidence supporting the administration of TPE as the first escalation treatment to steroid-refractory MS relapses.
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Rojas JI, Patrucco L, Cristiano E. An asymptomatic new lesion on MRI is a relapse and should be treated accordingly – Yes. Mult Scler 2019; 25:1842-1843. [DOI: 10.1177/1352458519855723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Juan Ignacio Rojas
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Liliana Patrucco
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Edgardo Cristiano
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
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Domperidone-induced elevation of serum prolactin levels and immune response in multiple sclerosis. J Neuroimmunol 2019; 334:576974. [PMID: 31174092 DOI: 10.1016/j.jneuroim.2019.576974] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/17/2019] [Accepted: 05/28/2019] [Indexed: 12/21/2022]
Abstract
Increasing systemic prolactin levels improves remyelination and neuronal survival in animal models of Multiple Sclerosis (MS), but it has been suggested that this therapeutic strategy may also increase inflammatory responses, and potentially harm patients. We analyzed serum prolactin and cytokine, chemokine and growth factor levels in sera from MS patients enrolled in two clinical trials who were treated with domperidone, a generic drug that increases systemic prolactin levels. In patients treated with domperidone, molecule levels changed little during follow up, while prolactin levels increased several-fold. We found no significant association between prolactin levels and radiological or clinical outcome.
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Brown KD, Farmer C, Freeman GM, Spartz EJ, Farhadian B, Thienemann M, Frankovich J. Effect of Early and Prophylactic Nonsteroidal Anti-Inflammatory Drugs on Flare Duration in Pediatric Acute-Onset Neuropsychiatric Syndrome: An Observational Study of Patients Followed by an Academic Community-Based Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic. J Child Adolesc Psychopharmacol 2017; 27:619-628. [PMID: 28696786 PMCID: PMC5749580 DOI: 10.1089/cap.2016.0193] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterized by the sudden onset of severe obsessive-compulsive symptoms and/or eating restriction along with at least two coinciding neuropsychiatric symptoms. When associated with group A Streptococcus, the syndrome is labeled Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections (PANDAS). An abnormal immune response to infection and subsequent neuroinflammation is postulated to play an etiologic role. We evaluated the impact of nonsteroidal anti-inflammatory drug (NSAID) treatment on flare duration in PANS/PANDAS. METHODS Patient inclusion criteria: Patients were included if they had at least one neuropsychiatric deterioration ("flare") that met strict PANS/PANDAS research criteria and for which flare duration could be assessed. Flare inclusion criteria: Any flare that started before October 15, 2016 was included and followed until the flare resolved or until the end of our data collection (November 1, 2016). Flare exclusion criteria: Flares were excluded if they were incompletely resolved, treated with aggressive immunomodulation, or treated with NSAIDs late (>30 days of flare onset). Ninety-five patients met study inclusion criteria and collectively experienced 390 flares that met flare criteria. Data were analyzed using multilevel linear models, adjusting for demographics, disease, and treatment covariates. RESULTS NSAID use was associated with a significantly shorter flare duration. Flares not treated with NSAIDs had a mean duration of approximately 12.2 weeks (95% CI: 9.3-15.1). Flares that occurred while the child was on NSAID maintenance therapy were approximately 4 weeks shorter than flares not managed with NSAIDs (95% CI: 1.85-6.24; p < 0.0001). Flares treated with NSAIDs within 30 days of flare onset were approximately 2.6 weeks shorter than flares not managed with NSAIDs (95% CI: 0.43-4.68; p = 0.02). Flares treated prophylactically and those treated early with NSAIDs did not differ in duration (p = 0.26). Among the flares that received NSAID treatment within the first 30 days, earlier intervention was modestly associated with shorter flare durations (i.e., for each day that NSAID treatment was delayed, flare duration increased by 0.18 weeks; 95% CI: 0.03-0.33; p = 0.02), though it was not statistically significant after controlling for covariates (p = 0.06). CONCLUSION NSAIDs given prophylactically or within 30 days of flare onset may shorten neuropsychiatric symptom duration in patients with new-onset and relapsing/remitting PANS and PANDAS. A randomized placebo-control clinical trial of NSAIDs in PANS is warranted to formally assess treatment efficacy.
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Affiliation(s)
- Kayla D. Brown
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Cristan Farmer
- Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - G. Mark Freeman
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Ellen J. Spartz
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Child & Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Frankovich
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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Abstract
Multiple sclerosis (MS) is the most common disabling neurologic disease of young adults. There are now 16 US Food and Drug Administration (FDA)-approved disease-modifying therapies for MS as well as a cohort of other agents commonly used in practice when conventional therapies prove inadequate. This article discusses approved FDA therapies as well as commonly used practice-based therapies for MS, as well as those therapies that can be used in patients attempting to become pregnant, or in patients with an established pregnancy, who require concomitant treatment secondary to recalcitrant disease activity.
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Binks S, Dobson R. Risk Factors, Epidemiology and Treatment Strategies for Metabolic Bone Disease in Patients with Neurological Disease. Curr Osteoporos Rep 2016; 14:199-210. [PMID: 27525980 DOI: 10.1007/s11914-016-0320-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Metabolic bone disease is a major public health concern, especially when it manifests as hip fracture which carries significant morbidity and mortality. Individuals with neurological disease are at higher risk of osteopenia, osteoporosis and fragility fracture compared to age-matched controls, yet this is under-appreciated by these patients. Clinician attention to this topic is therefore of importance and should address the bone health of men as well as women, a group in whom it may be an under-recognised problem. Evidence for optimal management of bone health in neurological disease remains to be defined, but a growing literature provides some useful guidance. This review focuses on two conditions, multiple sclerosis and Parkinson's disease, where research has been active over recent years. In neuroinflammation, shared immunological pathways between bone and brain are a current domain of interest and it will be intriguing to interrogate the action of emerging immunotherapies on these dual compartments.
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Affiliation(s)
- S Binks
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - R Dobson
- Blizard Institute, Queen Mary University, 4 Newark St, London, E1 2AT, UK.
- St Georges Hospital, Blackshaw Rd, London, SW17 0QT, UK.
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Joseph RM, Hunter AL, Ray DW, Dixon WG. Systemic glucocorticoid therapy and adrenal insufficiency in adults: A systematic review. Semin Arthritis Rheum 2016; 46:133-41. [PMID: 27105755 PMCID: PMC4987145 DOI: 10.1016/j.semarthrit.2016.03.001] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 03/04/2016] [Accepted: 03/07/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The aim of this systematic literature review was to summarize the current knowledge regarding the prevalence of, time to recovery from, and influence of glucocorticoid dose and duration on glucocorticoid-induced adrenal insufficiency (AI). METHODS Eligible studies were original research articles, which included adult patients with an indication for glucocorticoids and measured adrenal function following exposure to systemic glucocorticoids. Searches were performed in Web of Science and MEDLINE, with further articles identified from reference lists. Screening was performed in duplicate. Data were extracted for each group of glucocorticoid-exposed patients within eligible studies. The reported proportion of patients with AI was summarized as median and inter-quartile range. Results were then stratified by daily dose, cumulative dose, duration of exposure and time since last glucocorticoid use. The risk of bias within and across studies was considered: for randomised controlled trials risk of bias was assessed using the tool developed by the Cochrane Collaboration. RESULTS Overall, 73 eligible studies were identified out of 673 screened. The percentage of patients with AI ranged from 0% to 100% with a median (IQR) = 37.4% (13-63%). Studies were small-median (IQR) group size 16 (9-38)-and heterogeneous in methodology. AI persisted in 15% of patients retested 3 years after glucocorticoid withdrawal. Results remained widely distributed following stratification. AI was demonstrated at <5mg prednisolone equivalent dose/day, <4 weeks of exposure, cumulative dose <0.5g, and following tapered withdrawal. CONCLUSIONS The heterogeneity of studies and variability in results make it difficult to answer the research questions with confidence based on the current literature. There is evidence of AI following low doses and short durations of glucocorticoids. Hence, clinicians should be vigilant for adrenal insufficiency at all degrees of glucocorticoid exposure.
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Affiliation(s)
- Rebecca M Joseph
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ann Louise Hunter
- Manchester Centre for Endocrinology and Diabetes, Institute of Human Development, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David W Ray
- Manchester Centre for Endocrinology and Diabetes, Institute of Human Development, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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Sethi V, Nair G, Absinta M, Sati P, Venkataraman A, Ohayon J, Wu T, Yang K, Shea C, Dewey BE, Cortese IC, Reich DS. Slowly eroding lesions in multiple sclerosis. Mult Scler 2016; 23:464-472. [PMID: 27339071 DOI: 10.1177/1352458516655403] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND At autopsy, 20%-40% of chronic multiple sclerosis (MS) lesions are labeled "slowly expanding" and feature myelin phagocytosis at the lesion edge. As pathological lesion classification relies on a single, terminal time point, the rate of lesion expansion cannot be directly measured. OBJECTIVE To study long-term volume changes in individual MS lesions. METHODS Volumes of individual lesions on proton density magnetic resonance imaging (MRI) acquired between 1992 and 2015 were measured in 22 individuals (one lesion per person). After correction for acquisition protocol, a mixed model evaluated lesion volume changes. RESULTS The mean (standard deviation) lesion volume at baseline was 142 (82) mL, falling to 74 (51) mL after 16 (3) years. All lesions shrank over time. Change in lesion volume did not correlate with change in supratentorial brain volume ( p = 0.33). In simulations, the results could be explained by a process of slow radial expansion superimposed on substantially more rapid resorption of damaged tissue. CONCLUSION We noted sustained radiological contraction of MS lesions, a surprising result given that fresh myelin breakdown products within chronic active lesions are observed relatively frequently at autopsy. Therefore, the primary pathological process in chronic lesions, even those described as "slowly expanding," is likely to be tissue loss.
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Affiliation(s)
- Varun Sethi
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Govind Nair
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Martina Absinta
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Pascal Sati
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Arun Venkataraman
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Joan Ohayon
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Tianxia Wu
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Kelly Yang
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Colin Shea
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Blake E Dewey
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Irene Cm Cortese
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Daniel S Reich
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
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Larouche V, Correa JA, Cassidy P, Beauregard C, Garfield N, Rivera J. Prevalence of autoimmune disease in patients with prolactinomas and non-functioning pituitary adenomas. Pituitary 2016; 19:202-9. [PMID: 26700946 DOI: 10.1007/s11102-015-0699-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Prolactin can affect autoimmune response and evidence suggests that hyperprolactinemia can primarily precipitate autoimmunity. We postulate that patients with prolactinomas are more prone to autoimmune disease (AID). METHODS We conducted a retrospective case-control study comparing prevalence of AID in 100 prolactinoma patients (PRL-P, cases) and 100 age- and gender-matched non-functioning pituitary adenoma patients (NFPA-P, controls) assessed at the Neuroendocrine Clinics of the McGill University Health Centre between January 2005 and December 2014. Comparisons were done using a conditional logistic regression (CLR) analysis. Multiple imputation was used to account for missing data values. RESULTS Sixty-eight women and 32 men were in each group. Median age was 37 years for PRL-P and 46 years for NFPA-P. AID was diagnosed in 28/100 cases and 16/100 controls. Autoimmune thyroid disease was the most common AID reported in both groups, representing 70 and 61% of the AID diagnoses respectively. CLR analysis revealed a multiplicative interaction effect between AID prevalence and age (p 0.004). Odds ratios for AID in PRL-P compared to NFPA-P increase with age and become significant at age 43, reaching 4.17 (95% CI 1.26, 13.82) at age 45 and 8.09 (95% CI 1.96, 33.43) at age 50 (p 0.05). CONCLUSION Our data showed a higher prevalence of AID in both PRL-P and NFPA-P than in a reference population. In both groups, prevalence of AID increased with age, given a multiplicative interaction effect. A significant higher prevalence of autoimmunity in PRL-P compared with NFPA-P occurs after age 43. These associations may have significant implications for the management of prolactinoma patients.
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Affiliation(s)
- V Larouche
- Internal Medicine Residency Training Program, Department of Medicine, McGill University, Montreal, QC, Canada.
| | - J A Correa
- Department of Mathematics and Statistics, McGill University, Montreal, QC, Canada
| | - P Cassidy
- Department of Pharmacology, Université de Montréal, Montreal, QC, Canada
| | - C Beauregard
- Division of Endocrinology, McGill University Health Centre, Montreal, QC, Canada
| | - N Garfield
- Division of Endocrinology, McGill University Health Centre, Montreal, QC, Canada
| | - J Rivera
- Division of Endocrinology, McGill University Health Centre, Montreal, QC, Canada
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Etemadifar M, Najafi MA, Najafi MR, Alavi A, Nasr Z, Farokhi M, Rezaei A. Multiple sclerosis and hyperprolactinemia: a case-control study. Acta Neurol Belg 2015; 115:253-7. [PMID: 25501283 DOI: 10.1007/s13760-014-0403-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 12/03/2014] [Indexed: 11/30/2022]
Abstract
UNLABELLED Multiple sclerosis (MS) is an autoimmune disease of central nervous system which is characterized with demyelination. Prolactin, synthesized in the anterior pituitary cells, has a role in maturation of immune cells, suggesting its possible implication in autoreactivity. The aim of the current study is to investigate the role of hyperprolactinemia in MS. Twenty-two MS patients with hyperprolactinemia diagnosed with pituitary adenoma and 66 MS patients without hyperprolactinemia were enrolled in our case-control study. They were matched with regard to age, gender, and MS subtypes. Patients with other concomitant autoimmune diseases and pregnancy were excluded. Statistical analyses were carried out using SPSS (SPSS statistic package, version 21.0.0) statistical software. The Pearson Chi-square test and the t test were used to determine whether there were any significant differences. The level of significance was set at p < 0.05. Greater value of relapse rate among hyperprolactinemic MS patients in comparison to non-hyperprolactinemic MS patients was statistically significant (p < 0.001). Statistically significant difference between the two groups in terms of EDSS was observed (case group vs. CONTROL 1.3 vs. 1.9; p = 0.007). The correlation between MS duration and duration of hyperprolactinemia was significant in the case group (p < 0.05, R = 0.752). No statistically significant difference was found between two groups regarding duration of MS. This study suggested a protective role of prolactin in demyelinating procedure of MS.
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Affiliation(s)
- Masoud Etemadifar
- Department of Neurology, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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15
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Relationship between Prolactin Plasma Levels and White Matter Volume in Women with Multiple Sclerosis. Mediators Inflamm 2015; 2015:732539. [PMID: 26236110 PMCID: PMC4510259 DOI: 10.1155/2015/732539] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 06/17/2015] [Accepted: 06/22/2015] [Indexed: 11/28/2022] Open
Abstract
Background. The role of prolactin (PRL) on tissue injury and repair mechanisms in multiple
sclerosis (MS) remains unclear. The aim of this work was to investigate the relationship between PRL plasma levels and brain damage as measured by magnetic resonance imaging (MRI). Methods. We employed a chemiluminescence immunoassay for measuring plasma levels of PRL. We used a 1.5 T scanner to acquire images and Jim 4.0 and SIENAX software to analyse them. Results. We included 106 women with relapsing remitting (RR) MS and stable disease in the last
two months. There was no difference in PRL plasma levels between patients with and without gadolinium enhancement on MRI. PRL plasma levels correlated with white matter volume (WMV) (rho = 0.284, p = 0.014) but not with grey matter volume (GMV). Moreover, PRL levels predicted changes in WMV (Beta: 984, p = 0.034). Conclusions. Our data of a positive association between PRL serum levels and WMV support the role of PRL in promoting myelin repair as documented in animal models of demyelination. The lack of an increase of PRL in the presence of gadolinium enhancement, contrasts with the view considering this hormone as an immune-stimulating and detrimental factor in the inflammatory process associated with MS.
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16
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Kümpfel T, Schwan M, Weber F, Holsboer F, Trenkwalder C, Then Bergh F. Hypothalamo-pituitary-adrenal axis activity evolves differentially in untreated versus treated multiple sclerosis. Psychoneuroendocrinology 2014; 45:87-95. [PMID: 24845180 DOI: 10.1016/j.psyneuen.2014.03.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 03/05/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Heterogeneous hypothalamo-pituitary-adrenal (HPA) system dysregulation has been shown in multiple sclerosis (MS), and cross-sectional studies suggested increasing hyperactivity with longer, progressing disease. Longitudinal studies to confirm this hypothesis and to study the impact of disease modifying treatment (DMT) have not been performed. OBJECTIVE/METHOD In order to determine the longitudinal evolution of HPA system activity in patients with MS, we performed an open follow-up evaluation of sixty patients with definite MS. Patients were untreated at baseline; at follow-up, 40 received DMT. From the combined dexamethasone/CRH test, performed at baseline and follow-up, we derived neuroendocrine indicators (maximum, maximum rise, mean location and area under the curve) for cortisol, ACTH and ACTH/cortisol ratio. RESULTS In 20 patients who remained untreated (test-retest interval 28.8 ± 5.4 months), ACTH/cortisol ratios decreased significantly, driven by both mild increase in cortisol and reduction of ACTH secretion. In 40 patients with DMT (test-retest interval 15.5 ± 2.5 months), secretion of cortisol, ACTH and ACTH/cortisol ratios did not change significantly. There was significant, moderate correlation between baseline and follow-up tests for cortisol, but not for ACTH indicators. In untreated, but not in treated patients, change in ACTH/cortisol ratios showed moderate inverse correlation to the time interval between tests (Pearson: beta -0.52 to -0.56, p<0.05); the relation to progression of neurological disability was not significant. CONCLUSIONS HPA axis activation in untreated MS drifts from hypothalamo-pituitary to more adrenal activation, consistent with adrenal sensitization or hypertrophy due to chronic HPA axis activation. HPA system regulation remains more stable in MS patients on DMT.
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Affiliation(s)
- Tania Kümpfel
- Max Planck Institute of Psychiatry, Section of Neurology, Kraepelinstrasse 10, 80804 München, Germany
| | - Michaela Schwan
- Max Planck Institute of Psychiatry, Section of Neurology, Kraepelinstrasse 10, 80804 München, Germany
| | - Frank Weber
- Max Planck Institute of Psychiatry, Section of Neurology, Kraepelinstrasse 10, 80804 München, Germany
| | - Florian Holsboer
- Max Planck Institute of Psychiatry, Section of Neurology, Kraepelinstrasse 10, 80804 München, Germany
| | - Claudia Trenkwalder
- Max Planck Institute of Psychiatry, Section of Neurology, Kraepelinstrasse 10, 80804 München, Germany
| | - Florian Then Bergh
- Max Planck Institute of Psychiatry, Section of Neurology, Kraepelinstrasse 10, 80804 München, Germany.
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17
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Krieger S, Sorrells SF, Nickerson M, Pace TWW. Mechanistic insights into corticosteroids in multiple sclerosis: war horse or chameleon? Clin Neurol Neurosurg 2014; 119:6-16. [PMID: 24635918 DOI: 10.1016/j.clineuro.2013.12.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 11/19/2013] [Accepted: 12/27/2013] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Relapse management is a crucial component of multiple sclerosis (MS) care. High-dose corticosteroids (CSs) are used to dampen inflammation, which is thought to hasten the recovery of MS relapse. A diversity of mechanisms drive the heterogeneous clinical response to exogenous CSs in patients with MS. Preclinical research is beginning to provide important insights into how CSs work, both in terms of intended and unintended effects. In this article we discuss cellular, systemic, and clinical characteristics that might contribute to intended and unintended CS effects when utilizing supraphysiological doses in clinical practice. The goal of this article is to consider recent insights about CS mechanisms of action in the context of MS. METHODS We reviewed relevant preclinical and clinical studies on the desirable and undesirable effects of high-dose corticosteroids used in MS care. RESULTS Preclinical studies reviewed suggest that corticosteroids may act in unpredictable ways in the context of autoimmune conditions. The precise timing, dosage, duration, cellular exposure, and background CS milieu likely contribute to their clinical heterogeneity. CONCLUSION It is difficult to predict when patients will respond favorably to CSs, both in terms of therapeutic response and tolerability profile. There are specific cellular, systemic, and clinical characteristics that might merit further consideration when utilizing CSs in clinical practice, and these should be explored in a translational setting.
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Affiliation(s)
- Stephen Krieger
- Corinne Goldsmith Dickinson Center for MS, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shawn F Sorrells
- Department of Neurosurgery, The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, California, USA
| | | | - Thaddeus W W Pace
- College of Nursing and College of Medicine (Department of Psychiatry), University of Arizona, Tucson, Arizona, USA.
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18
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Abstract
Glucorticorticoids have both anti-inflammatory and immunosuppressive properties and both synthetic and natural glucocorticoid medications have been used to treat a number of inflammatory and autoimmune conditions, including the management of acute multiple sclerosis (MS) attacks. Many of the studies supporting the use of this approach to MS treatment have important limitations. Nevertheless, on balance, the data seem to support the notion that a brief glucocorticoid treatment regimen (~2 weeks) hastens recovery from an acute MS flare and that this treatment, in general, is well tolerated. However, such treatment does not seem to alter the final degree of recovery from the MS attack. Among the practice community, even within MS centers, there seems to be a general belief that the selection of the optimal agent, route of administration, and the duration of therapy can be made on the basis of personal experience and/or theoretic considerations. As a result, currently, there are a variety of idiosyncratic regimens (often vigorously defended), which are commonly used to treat patients. Nevertheless, it is important to recognize that the best route of administration, the optimal dose and duration of treatment, and the preferred agent or agents have yet to be firmly established. Moreover, although it may well turn out that some of these factors are more important than others, the best current evidence for the efficacy of glucocorticoid treatment in MS, by far, comes from the optic neuritis treatment trial, which used high-dose intravenous methylprednisolone for the first 3 days followed by an 11-day course of low-dose oral prednisone.
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Affiliation(s)
- Douglas S Goodin
- Department of Neurology, University of California, San Francisco, USA.
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19
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Neuroendocrine immunoregulation in multiple sclerosis. Clin Dev Immunol 2013; 2013:705232. [PMID: 24382974 PMCID: PMC3870621 DOI: 10.1155/2013/705232] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 09/29/2013] [Accepted: 09/30/2013] [Indexed: 12/03/2022]
Abstract
Currently, it is generally accepted that multiple sclerosis (MS) is a complex multifactorial disease involving genetic and environmental factors affecting the autoreactive immune responses that lead to damage of myelin. In this respect, intrinsic or extrinsic factors such as emotional, psychological, traumatic, or inflammatory stress as well as a variety of other lifestyle interventions can influence the neuroendocrine system. On its turn, it has been demonstrated that the neuroendocrine system has immunomodulatory potential. Moreover, the neuroendocrine and immune systems communicate bidirectionally via shared receptors and shared messenger molecules, variously called hormones, neurotransmitters, or cytokines. Discrepancies at any level can therefore lead to changes in susceptibility and to severity of several autoimmune and inflammatory diseases. Here we provide an overview of the complex system of crosstalk between the neuroendocrine and immune system as well as reported dysfunctions involved in the pathogenesis of autoimmunity, including MS. Finally, possible strategies to intervene with the neuroendocrine-immune system for MS patient management will be discussed. Ultimately, a better understanding of the interactions between the neuroendocrine system and the immune system can open up new therapeutic approaches for the treatment of MS as well as other autoimmune diseases.
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20
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Zendedel A, Beyer C, Kipp M. Cuprizone-induced demyelination as a tool to study remyelination and axonal protection. J Mol Neurosci 2013; 51:567-72. [PMID: 23666824 DOI: 10.1007/s12031-013-0026-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 04/30/2013] [Indexed: 12/22/2022]
Abstract
In the brain of multiple sclerosis (MS) patients, the conduction block of axons due to demyelination and inflammation underlies early neurological symptoms, whereas axonal transection accounts for permanent deficits occurring during later disease stages. The beneficial function of myelin for the protection of the axonal compartment and network stability between neurons has been shown in numerous studies. Thus, rapid and adequate remyelination is an important factor for axonal patronage during neuroinflammatory conditions. In this review article, we discuss frequently used experimental in vivo and in vitro animal models to examine remyelination and repair in MS. The focus of the discussion is the relevance of the toxin model 'cuprizone' to study the pathology of demyelination and the physiology of remyelination. This also includes recent findings in this animal model which implicate that axonal damage is an ongoing process independent of the initiation of endogenous remyelination.
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Affiliation(s)
- Adib Zendedel
- Institute of Neuroanatomy, Faculty of Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
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21
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McPherson RC, Anderton SM. Adaptive immune responses in CNS autoimmune disease: mechanisms and therapeutic opportunities. J Neuroimmune Pharmacol 2013; 8:774-90. [PMID: 23568718 DOI: 10.1007/s11481-013-9453-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 03/13/2013] [Indexed: 01/20/2023]
Abstract
The processes underlying autoimmune CNS inflammation are complex, but key roles for autoimmune lymphocytes seem inevitable, based on clinical investigations in multiple sclerosis (MS) and related diseases such as neuromyelitis optica, together with the known pathogenic activity of T cells in experimental autoimmune encephalomyelitis (EAE) models. Despite intense investigation, the details of etiopathology in these diseases have been elusive. Here we describe recent advances in the rodent models that begin to allow a map of pathogenic and protective immunity to be drawn. This map might illuminate previous successful and unsuccessful therapeutic strategies targeting particular pathways, whilst also providing better opportunities for the future, leading to tailored intervention based on understanding the quality of each individual's autoimmune response.
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Affiliation(s)
- Rhoanne C McPherson
- Centre for Inflammation Research and Centre for Multiple Sclerosis Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK
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22
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Ross AP, Ben-Zacharia A, Harris C, Smrtka J. Multiple sclerosis, relapses, and the mechanism of action of adrenocorticotropic hormone. Front Neurol 2013; 4:21. [PMID: 23482896 PMCID: PMC3591751 DOI: 10.3389/fneur.2013.00021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 02/13/2013] [Indexed: 12/27/2022] Open
Abstract
Relapses in multiple sclerosis (MS) are disruptive and frequently disabling for patients, and their treatment is often a challenge to clinicians. Despite progress in the understanding of the pathophysiology of MS and development of new treatments for long-term management of MS, options for treating relapses have not changed substantially over the past few decades. Corticosteroids, a component of the hypothalamic-pituitary-adrenal axis that modulate immune responses and reduce inflammation, are currently the mainstay of relapse treatment. Adrenocorticotropic hormone (ACTH) gel is another treatment option. Although it has long been assumed that the efficacy of ACTH in treating relapses depends on the peptide’s ability to increase endogenous corticosteroid production, evidence from research on the melanocortin system suggests that steroidogenesis may only partly account for ACTH influences. Indeed, the melanocortin peptides [ACTH and α-, β-, γ-melanocyte-stimulating hormones (MSH)] and their receptors (Melanocortin receptors, MCRs) exert multiple actions, including modulation of inflammatory and immune mediator production. MCRs are widely distributed within the central nervous system and in peripheral tissues including immune cells (e.g., macrophages). This suggests that the mechanism of action of ACTH includes not only steroid-mediated indirect effects, but also direct anti-inflammatory and immune-modulating actions via the melanocortin system. An increased understanding of the role of the melanocortin system, particularly ACTH, in the immune and inflammatory processes underlying relapses may help to improve relapse management.
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Affiliation(s)
- Amy Perrin Ross
- Department of Neurosciences, Loyola University Chicago Chicago, IL, USA
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23
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Abstract
Multiple sclerosis (MS) is more common among women than men. MS often goes into remission during pregnancy, when prolactin (PRL) levels are known to be high. In an animal model of demyelination, PRL promoted myelin repair, suggesting it has potential as a remyelinating therapy in MS. In this systematic review, we examined the known associations between PRL and MS, in order to elucidate its potential role in the pathophysiology and treatment of MS. A systematic search was performed in the electronic databases PubMed and EMBASE, using the keywords "prolactin" AND “multiple sclerosis.” The inclusion criteria were met by 23 studies. These studies suggested to us that elevated PRL may be more common in MS patients than in controls. Hyperprolactinemia may also be associated with clinical relapse in MS, especially among patients with hypothalamic lesions or optic neuritis; however, it is unknown if this is a cause or consequence of a relapse. Overall, most people with MS have normal PRL levels. The impact of PRL on MS outcomes remains unclear.
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Affiliation(s)
- Simon Zhornitsky
- Multiple Sclerosis Program, Department of Clinical Neurosciences, University of Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - V Wee Yong
- Multiple Sclerosis Program, Department of Clinical Neurosciences, University of Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Samuel Weiss
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Luanne M Metz
- Multiple Sclerosis Program, Department of Clinical Neurosciences, University of Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
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24
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Zikán V, Týblová M, Raška I, Havrdová E, Luchavová M, Michalská D, Kuběna AA. Bone mineral density and body composition in men with multiple sclerosis chronically treated with low-dose glucocorticoids. Physiol Res 2012; 61:405-17. [PMID: 22670701 DOI: 10.33549/physiolres.932299] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The aim of the study was to compare the bone mineral density (BMD) and body composition between ambulatory male MS patients and control subjects and to evaluate the relationships among body composition, motor disability, glucocorticoids (GC) use, and bone health. Body composition and BMD were measured by dual-energy X-ray absorptiometry in 104 ambulatory men with MS (mean age: 45.2 years) chronically treated with low-dose GC and in 54 healthy age-matched men. Compared to age-matched controls, MS patients had a significantly lower total body bone mineral content (TBBMC) and BMD at all measured sites except for the radius. Sixty five male MS patients (62.5 %) met the criteria for osteopenia and twenty six of them (25 %) for osteoporosis. The multivariate analysis showed a consistent dependence of bone measures (except whole body BMD) on BMI. The total leg lean mass % was as an independent predictor of TBBMC. The Expanded Disability Status Scale (EDSS), cumulative GC dose and age were independent determinants for BMD of the proximal femur. We conclude that decreasing mobility in male MS patients is associated with an increasing degree of osteoporosis and muscle wasting in the lower extremities. The chronic low-dose GC treatment further contributes to bone loss.
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Affiliation(s)
- V Zikán
- Third Department of Medicine, Department of Endocrinology and Metabolism, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic.
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25
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Abstract
Pediatric onset multiple sclerosis (MS) may be seen in 2-5% of patients with MS. It is characterized by high disease burden. As such, early treatment with preventative therapies should be considered. Although randomized controlled trials have not been conducted on therapies for pediatric MS, there is a growing body of literature suggesting safety of first-line agents approved for use in adult MS, including interferons and glatiramer acetate. The use of second-line therapies, such as natalizumab, cyclophosphamide, and mitoxantrone has been described in a small number of pediatric MS cases. These case series suggest benefit of these agents after limited follow-up. Little information on long-term effects of therapies such as cyclophosphamide, mitoxantrone, or natalizumab is available for this population, although concerns of increased risk for opportunistic infections (progressive multifocal leukoencephalopathy with natalizumab) and secondary hematologic cancers (with mitoxantrone) exist. Finally, although fatigue, motor, cognitive, and psychosocial difficulties are common in this population, no trials have been conducted on pharmacologic or non-pharmacologic interventions for the management of these problems. Therapies for spasticity, including baclofen (including the baclofen pump), diazepam, and botulinum toxin have been evaluated in children with cerebral palsy and may be used safely in children. Psychiatric intervention is often necessary for affective disorders. Interventions for fatigue have not been studied, although evidence in the adult MS literature suggests possible benefit of exercise and modafinil. This article provides a practical guide to the diagnosis and treatment of multiple sclerosis in pediatric patients.
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Affiliation(s)
- E Ann Yeh
- Department of Pediatrics (Neurology), University of Toronto, ON, Canada.
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26
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Abstract
Sex hormones, especially estrogen and prolactin (PRL), have an important role in modulating the immune response. PRL is secreted from the pituitary gland as well as other organs and cells particularly lymphocytes. PRL has an immune stimulatory effect and promotes autoimmunity. PRL interferes specifically with B cell tolerance induction, enhances proliferative response to antigens and mitogens and increases the production of immune globulins, cytokines and autoantibodies. Hyperprolactinemia (HPRL) in women present with clinical manifestations of galactorrhea, primary or secondary amenorrhea, delayed menarche or a change in the menses either in the amount or in the regularity. Furthermore in the last 2 decades multi-organ and organ specific autoimmune diseases like systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Sjogren's syndrome (SS), Hashimoto's thyroiditis (HT), multiple sclerosis (MS), psoriasis, hepatitis C patients, Behçet's disease, peripartum cardiomyopathy (PPCM) and active celiac disease were discussed to be associated with HPRL. There is data showing correlation between PRL level and diseases activity in few diseases. Genetic factors may have a role in humans as in animal models. The PRL isoforms based on the differences in the amino acid sequence and size of the cytoplasmic domain have an important effect on the bioactivity on prolactin receptors (PRL-Rs).
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Affiliation(s)
- Shahar Shelly
- Department of Medicine B, Wolfson Medical Center, Holon, Israel
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27
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Abstract
People who are disabled with multiple sclerosis (MS) may be at increased risk of osteoporosis. This review discusses issues relevant to bone health in MS and makes practical recommendations regarding prevention and screening for osteoporosis and fracture risk in MS. A search of the literature up until 5 April 2011 was performed using key search terms, and articles pertinent to bone health in MS were analysed. Bone mineral density (BMD) is reduced at the lumbar spine, hip and total body in MS, with the degree of reduction being greatest at the hip. A strong relationship exists between the disability level, measured by the Expanded Disability Status Score, and BMD at the lumbar spine and femoral neck, particularly the latter. The rate of loss of BMD also correlates with the level of disability. Pulsed corticosteroids for acute episodes of MS, even with a high cumulative steroid dose, do not significantly affect BMD, but an effect on fracture risk is yet to be elucidated. There appears to be no correlation between vitamin D levels and BMD, and the relationship between disability and vitamin D levels remains unclear. Falls and fractures are more common than in healthy controls, and the risk rises with increasing levels of disability. The principal factor resulting in low BMD and increased fracture risk in MS is immobility. Antiresorptive therapy with bisphosphonates and optimising vitamin D levels are likely to be effective interventions although there are no randomised studies of this therapy.
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Affiliation(s)
- J C Gibson
- Level 2, Department of Rehabilitation Medicine, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK.
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28
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Abstract
Optic neuritis is an inflammatory condition of the optic nerve characterized by a sudden onset of unilateral visual loss, usually affecting young females. Demyelination associated with multiple sclerosis (MS) is the most common cause in regions where MS is prevalent; while in other places, there are a substantial proportion of cases where infective or autoimmune causes are seen. Optic Neuritis Treatment Trial (ONTT) was the first major study that provided information on the natural history, role of steroids in treatment and risk of development of MS. Subsequently, numerous clinical trials have evaluated different modalities of management of optic neuritis and MS. The Controlled High-Risk Subjects Avonex Multiple Sclerosis Prevention Study (CHAMPS); the Prevention of Relapses and Disability by Interferon β-1a Subcutaneously in Multiple Sclerosis (PRISMS) Trial; and, most recently, the Betaferon in Newly Emerging Multiple Sclerosis for Initial Treatment (BENEFIT) Study have provided large amount of information on the natural history of optic neuritis and management options available. However, due to the low prevalence of MS reported in Asian studies, high cost of therapy and indefinite time period of treatment, it may not be cost effective to start interferon therapy in most cases.
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Affiliation(s)
- Vimla Menon
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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29
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Yeh EA, Weinstock-Guttman B. Fingolimod: an oral disease-modifying therapy for relapsing multiple sclerosis. Adv Ther 2011; 28:270-8. [PMID: 21394595 DOI: 10.1007/s12325-011-0004-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Indexed: 10/18/2022]
Abstract
This paper presents a summary of the current knowledge of the mechanism of action of fingolimod (FTY720; Gilenya®; Novartis Pharma Stein AG, Stein, Switzerland) and the phase 2 and 3 studies that have been performed on the drug. This study will discuss specific safety issues that should be considered when initiating this therapy. Multiple sclerosis (MS), an inflammatory disease of the central nervous system, is considered to be a leading cause of neurologic disability in young adults, and predominantly affects young women. The past two decades have seen significant growth in therapeutic options for relapsing forms of MS, including FTY720. Fingolimod (FTY720) is a sphingosine-1-phosphate receptor modulator, and currently the approved dosage is 0.5 mg daily. Notable side effects include bradycardia in the first hours after administration and macular edema. There may be an increased risk of herpetic infections (varicella zoster virus and herpes simplex virus) associated with this medication. This oral therapy has been shown to be effective in double-blind, placebo-controlled studies, and in trials comparing it to weekly interferon beta-1a therapy. However, the long-term efficacy and safety of this oral medication in relapsing MS, including the effect on reduction of disability progression and cognitive decline, remains to be established.
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Yeh EA. Diagnosis and treatment of multiple sclerosis in pediatric and adolescent patients: current status and future therapies. Adolesc Health Med Ther 2010; 1:61-71. [PMID: 24600262 PMCID: PMC3916074 DOI: 10.2147/ahmt.s8130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric-onset multiple sclerosis (MS) comprises approximately 3%-5% of cases of MS in North America. Recent years have seen significant advances in the diagnosis and treatment of this condition, including the introduction of proposed diagnostic criteria for pediatric demyelinating disorders, and a growing body of knowledge regarding treatment options. This article reviews current approaches to the diagnosis and management of pediatric MS.
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Affiliation(s)
- E Ann Yeh
- Department of Neurology, Pediatric MS Center of the JNI, SUNY Buffalo, Buffalo, NY, USA
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Multiple sclerosis attacks triggered by hyperprolactinemia. J Neurooncol 2009; 98:407-9. [DOI: 10.1007/s11060-009-0076-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 11/16/2009] [Indexed: 12/12/2022]
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Abstract
BACKGROUND Multiple sclerosis (MS) is an immune-mediated inflammatory disease of the central nervous system (CNS) that usually is clinically characterized by repeated subacute relapses followed by remissions. Therapeutic strategies include corticosteroid treatment of relapses and immunomodulatory- or immunosuppressive treatment to prevent new relapses and progression of disability. OBJECTIVES To review the evidences for the use of corticosteroids in the treatment of relapses in MS as well as its possible disease modifying potential. MATERIALS & METHODS Available literature from PubMed search and personal experiences on corticosteroid treatment in multiple sclerosis were reviewed. RESULTS High dose short-term oral or intravenous methylprednisolone for 3-5 days speed up recovery from relapses, but the treatment has no influence on the occurrence of new relapses or long-term disability. There is also some evidence that pulsed treatment with methylprednisolone have beneficial long-term effects in multiple sclerosis. CONCLUSION Relapses with moderate to serious disability should be treated with high dose intravenous or oral methylprednisolone. More data is needed to determine long-term disease modifying effects of corticosteroids.
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Affiliation(s)
- K M Myhr
- Norwegian Multiple Sclerosis National Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway.
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Brandes DW, Callender T, Lathi E, O'Leary S. A review of disease-modifying therapies for MS: maximizing adherence and minimizing adverse events. Curr Med Res Opin 2009; 25:77-92. [PMID: 19210141 DOI: 10.1185/03007990802569455] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In a chronic disabling disorder such as multiple sclerosis (MS), adherence to treatment is of critical importance in maximizing benefits of therapy over the long term. Adverse events (AEs) are often cited by patients who discontinue therapy. METHODS Databases including Medline, CINAHL, and International Pharmaceutical Abstracts were searched for literature pertaining to adherence and AEs in MS published between January 1970 and August 2008. Clinical studies and case reports of AEs were included, as were papers that outlined factors that influence adherence. An advisory board with extensive experience in managing patients with MS developed guidelines to assist healthcare providers in maximizing adherence to disease-modifying therapy. DISCUSSION Internally based factors such as self-image, and externally based factors such as AEs, may influence patients' willingness and ability to adhere to therapy. Management of AEs associated with disease-modifying therapies and other therapies is reviewed, including intramuscular and subcutaneous interferon beta (IFNbeta)-1a, IFNbeta-1b, glatiramer acetate, natalizumab, methylprednisolone, mitoxantrone, cyclophosphamide, methotrexate, azathioprine, and intravenous immunoglobulin. CONCLUSIONS Effective management of MS is an ongoing, dynamic process that can enhance patients' adherence to therapy. Healthcare practitioners may address factors influencing adherence among patients with MS by managing treatment expectations, maintaining good communication with the patient, and managing AEs of treatment. Although the guidelines proposed herein originate from a single advisory board, it seems clear that by addressing patient concerns, healthcare practitioners can work with patients to enhance their ability to continue to adhere to their therapies and thereby gain the benefits of their treatment over the long term.
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Favorable effect of immunomodulator therapy on bone mineral density in multiple sclerosis. Ir J Med Sci 2008; 178:43-5. [PMID: 19002746 DOI: 10.1007/s11845-008-0253-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2008] [Accepted: 10/08/2008] [Indexed: 01/16/2023]
Abstract
BACKGROUND Osteoporosis is a complication of multiple sclerosis (MS), especially if corticosteroid therapy is given. Little is known about the effect on bone of immunomodulatory therapy (IMT) for MS. AIM We sought to evaluate bone mass in patients with MS on IMT. METHODS We measured bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA) in 37 patients with MS who received IMT. Different IMTs were administered: interferon beta-1a in 70%, interferon beta-1b in 27% and Glatiramer in 3%. High-dose pulse corticosteroid therapy (intravenous methylprednisolone 500 mg) was given to 81% ranging from 1 to 17 courses. RESULTS Both mean BMD Z-score at spine of 0.53 (CI, 0.15-0.92; P = 0.0084) and mean BMD Z-score at femur of 0.72 (CI, 0.42-1.01; P < 0.0001) were significantly greater than zero. CONCLUSIONS IMT may have a favorable effect on bone in patients with MS even in the presence of pulse steroid therapy.
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Acute inflammatory demyelinating optic neuritis: evidence-based visual and neurological considerations. Neurologist 2008; 14:207-23. [PMID: 18617847 DOI: 10.1097/nrl.0b013e31816f27fe] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optic neuritis (ON) is an acute inflammatory demyelinating disorder of the optic nerve that occurs most often in young adults. It can be a monophasic or polyphasic disease isolated to the optic nerve(s) or can be associated with a more widespread demyelinating disorder of the central nervous system such as multiple sclerosis (MS) or neuromyelitis optica. Advances in therapeutics that modify the risk of progression to MS have emphasized accurate diagnosis and risk assessment of patients with ON. REVIEW SUMMARY ON usually presents with acute unilateral visual loss associated with ocular pain exacerbated by eye movements. Similar to results found in studies assessing corticosteroid used in MS relapses, intravenous methylprednisolone accelerates visual recovery from ON but has no impact on long-term visual outcome. A clinically isolated syndrome (CIS), such as ON, is a clinical demyelinating event that is often the initial attack of relapsing-remitting MS. Disease modifying drugs, in particular interferons-beta, have been shown to reduce the risk of MS conversion in high-risk patients presenting with a CIS. The exact timing and patient selection for the initiation of treatment remain controversial. CONCLUSION ON is the best studied CIS. The visual prognosis is excellent in most cases regardless of whether the patient is treated with corticosteroids or not. Three recently completed prospective, randomized, double-blinded, placebo-controlled studies have shown that starting a disease-modifying drug at the time of a CIS can reduce the rate of development of MS. However, better diagnostic tools are needed to precisely predict the conversion to MS and the factors influencing disease severity to determine the most appropriate therapeutic paradigm and avoid unnecessary treatment.
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Moses H, Brandes DW. Managing adverse effects of disease-modifying agents used for treatment of multiple sclerosis. Curr Med Res Opin 2008; 24:2679-90. [PMID: 18694542 DOI: 10.1185/03007990802329959] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND First-line agents approved in the United States for treatment of relapsing multiple sclerosis (MS) include intramuscular interferon beta (IFNbeta)-1a, subcutaneous (SC) IFNbeta-1a, SC IFNbeta-1b, and SC glatiramer acetate. Intravenous mitoxantrone is the only agent approved for secondary progressive MS, progressive relapsing MS, and worsening relapsing MS. Intravenous natalizumab is approved for relapsing forms of MS generally in patients who have an inadequate response to, or are unable to tolerate, first-line therapies. Corticosteroids are commonly used to treat relapses. This paper reviews the incidence and management of common adverse events (AEs) associated with these treatments. METHODS MEDLINE and EMBASE were searched for clinical trials and other publications between 1985 and 2007 reporting AEs associated with MS therapies, using these search terms: multiple sclerosis, interferon, Avonex, Betaseron, Rebif, glatiramer, copolymer 1, Copaxone, mitoxantrone, natalizumab, adverse events. RESULTS A class-specific flu-like syndrome associated with IFNbeta can be managed through initial dose escalation and administration of analgesics and antipyretics, prophylactically or symptomatically. Injection-site reactions can occur in patients receiving injectable therapies, particularly SC IFNbeta or glatiramer acetate. The greatest risk to patients receiving mitoxantrone is cardiotoxicity; thus, the cumulative dose is limited. Allergic reactions occur rarely with natalizumab, and there is a potential risk of progressive multifocal leukoencephalopathy. AEs associated with short-term pulse corticosteroid therapy are usually transient and largely resolve after treatment is completed. CONCLUSIONS To improve adherence to therapy, it is important to educate patients regarding AEs and to manage AEs proactively.
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Affiliation(s)
- Harold Moses
- Vanderbilt Stallworth Rehabilitation Hospital, Vanderbilt University Medical Center, Nashville, TN 37212, USA.
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Daumer M, Held U, Ickstadt K, Heinz M, Schach S, Ebers G. Reducing the probability of false positive research findings by pre-publication validation - experience with a large multiple sclerosis database. BMC Med Res Methodol 2008; 8:18. [PMID: 18402689 PMCID: PMC2358908 DOI: 10.1186/1471-2288-8-18] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Accepted: 04/10/2008] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Published false positive research findings are a major problem in the process of scientific discovery. There is a high rate of lack of replication of results in clinical research in general, multiple sclerosis research being no exception. Our aim was to develop and implement a policy that reduces the probability of publishing false positive research findings. We have assessed the utility to work with a pre-publication validation policy after several years of research in the context of a large multiple sclerosis database. METHODS The large database of the Sylvia Lawry Centre for Multiple Sclerosis Research was split in two parts: one for hypothesis generation and a validation part for confirmation of selected results. We present case studies from 5 finalized projects that have used the validation policy and results from a simulation study. RESULTS In one project, the "relapse and disability" project as described in section II (example 3), findings could not be confirmed in the validation part of the database. The simulation study showed that the percentage of false positive findings can exceed 20% depending on variable selection. CONCLUSION We conclude that the validation policy has prevented the publication of at least one research finding that could not be validated in an independent data set (and probably would have been a "true" false-positive finding) over the past three years, and has led to improved data analysis, statistical programming, and selection of hypotheses. The advantages outweigh the lost statistical power inherent in the process.
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Affiliation(s)
- Martin Daumer
- Sylvia Lawry Centre for MS Research, Hohenlindener Str. 1, 81677 Munich, Germany
| | - Ulrike Held
- Sylvia Lawry Centre for MS Research, Hohenlindener Str. 1, 81677 Munich, Germany
| | - Katja Ickstadt
- Department of Statistics, University of Dortmund, 44221 Dortmund, Germany
| | - Moritz Heinz
- Institute for Medical Biometry, Epidemiology and Computer Science, Clinic of Gutenberg's University Mainz, Germany
| | - Siegfried Schach
- Department of Statistics, University of Dortmund, 44221 Dortmund, Germany
| | - George Ebers
- University Dept of Clinical Neurology, Oxford University, UK
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Paul F, Waiczies S, Wuerfel J, Bellmann-Strobl J, Dörr J, Waiczies H, Haertle M, Wernecke KD, Volk HD, Aktas O, Zipp F. Oral high-dose atorvastatin treatment in relapsing-remitting multiple sclerosis. PLoS One 2008; 3:e1928. [PMID: 18398457 PMCID: PMC2276246 DOI: 10.1371/journal.pone.0001928] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 02/19/2008] [Indexed: 11/21/2022] Open
Abstract
Background Recent data from animal models of multiple sclerosis (MS) and from a pilot study indicated a possible beneficial impact of statins on MS. Methodology/Principal Findings Safety, tolerability and effects on disease activity of atorvastatin given alone or in combination with interferon-beta (IFN-β) were assessed in a phase II open-label baseline-to-treatment trial in relapsing-remitting MS (RRMS). Patients with at least one gadolinium-enhancing lesion (CEL) at screening by magnetic resonance imaging (MRI) were eligible for the study. After a baseline period of 3 monthly MRI scans (months −2 to 0), patients followed a 9-month treatment period on 80 mg atorvastatin daily. The number of CEL in treatment months 6 to 9 compared to baseline served as the primary endpoint. Other MRI-based parameters as well as changes in clinical scores and immune responses served as secondary endpoints. Of 80 RRMS patients screened, 41 were included, among them 16 with IFN-β comedication. The high dose of 80 mg atorvastatin was well tolerated in the majority of patients, regardless of IFN-β comedication. Atorvastatin treatment led to a substantial reduction in the number and volume of CEL in two-sided multivariate analysis (p = 0.003 and p = 0.008). A trend towards a significant decrease in number and volume of CEL was also detected in patients with IFN-β comedication (p = 0.060 and p = 0.062), in contrast to patients without IFN-β comedication (p = 0.170 and p = 0.140). Immunological investigations showed no suppression in T cell response but a significant increase in IL-10 production. Conclusions/Significance Our data suggest that high-dose atorvastatin treatment in RRMS is safe and well tolerated. Moreover, MRI analysis indicates a possible beneficial effect of atorvastatin, alone or in combination with IFN-β, on the development of new CEL. Thus, our findings provide a rationale for phase II/III trials, including combination of atorvastatin with already approved immunomodulatory therapy regimens. Trial Registration ClinicalTrials.gov NCT00616187
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Affiliation(s)
- Friedemann Paul
- Cecilie Vogt Clinic for Neurology in the HELIOS Clinic Berlin-Buch, Charité – University Medicine Berlin and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Sonia Waiczies
- Cecilie Vogt Clinic for Neurology in the HELIOS Clinic Berlin-Buch, Charité – University Medicine Berlin and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Jens Wuerfel
- Cecilie Vogt Clinic for Neurology in the HELIOS Clinic Berlin-Buch, Charité – University Medicine Berlin and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Judith Bellmann-Strobl
- Cecilie Vogt Clinic for Neurology in the HELIOS Clinic Berlin-Buch, Charité – University Medicine Berlin and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Jan Dörr
- Cecilie Vogt Clinic for Neurology in the HELIOS Clinic Berlin-Buch, Charité – University Medicine Berlin and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
- Department of Neurology in the HELIOS Clinic Berlin-Buch, Berlin, Germany
| | - Helmar Waiczies
- Cecilie Vogt Clinic for Neurology in the HELIOS Clinic Berlin-Buch, Charité – University Medicine Berlin and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Mareile Haertle
- Cecilie Vogt Clinic for Neurology in the HELIOS Clinic Berlin-Buch, Charité – University Medicine Berlin and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | | | - Hans-Dieter Volk
- Institute of Immunology, Charité – University Medicine Berlin, Berlin, Germany
| | - Orhan Aktas
- Cecilie Vogt Clinic for Neurology in the HELIOS Clinic Berlin-Buch, Charité – University Medicine Berlin and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Frauke Zipp
- Cecilie Vogt Clinic for Neurology in the HELIOS Clinic Berlin-Buch, Charité – University Medicine Berlin and Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
- * E-mail:
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Ciccone A, Beretta S, Brusaferri F, Galea I, Protti A, Spreafico C. Corticosteroids for the long-term treatment in multiple sclerosis. Cochrane Database Syst Rev 2008:CD006264. [PMID: 18254098 DOI: 10.1002/14651858.cd006264.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Short term high dose corticosteroid treatment improves symptoms and short term disability after an acute exacerbation of multiple sclerosis (MS) but it is unknown whether its long-term use can reduce the accumulation of disability. OBJECTIVES To determine the efficacy and safety of long-term corticosteroid use in MS. SEARCH STRATEGY We searched the following bibliographic databases: CENTRAL (Issue 1, 2007), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007). In an effort to identify further published, unpublished and ongoing trials we searched reference lists and contacted trial authors and one pharmaceutical company. SELECTION CRITERIA We considered controlled, randomised trials (RCTs), with or without blinding, of long term treatment (i.e. longer than 6 months) of any type of corticosteroid in MS, irrespective of disease course. DATA COLLECTION AND ANALYSIS Reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS Three trials, all classified at high risk of bias, contributed to this review (Miller 1961; BPSM 1995; Zivadinov 2001) resulting in a total of 183 participants (91 treated). Corticosteroid therapy did not reduce the risk of being worse at the end of follow-up (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.26 to 1.02) but there was a substantial heterogeneity between studies (I(2): 78.4%). I. v. periodic high dose methylprednisolone (MP) was associated with a significant reduction in the risk of disability progression at 5 years in relapsing-remitting (RR) MS (OR 0.26, 95% CI 0.10 to 0.66), while oral continuous low dose prednisolone was not associated with any risk reduction in disability progression at 18 months (OR 1.23, 95% CI 0.43 to 3.56). Risk of experiencing at least one exacerbation at end of follow-up was not significantly reduced with corticosteroid treatment (OR 0.36; 95% CI 0.10 to 1.25). Only one study recorded adverse events: in one patient i. v. MP was discontinued after the fourth pulse when he developed acute glomerulonephritis; a second patient was removed from the study after the fifth i. v. MP pulse because of severe osteoporosis. AUTHORS' CONCLUSIONS There is no enough evidence that long-term corticosteroid treatment delays progression of long term disability in patients with MS. Since one study at high risk of bias showed that the administration of pulsed high dose i. v. MP is associated with a significant reduction in the risk of long term disability progression in patients with RR MS, an adequately powered, high quality RCT is needed to investigate this finding.
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Affiliation(s)
- A Ciccone
- Azienda Ospedale Niguarda Ca' Granda, Department of Neurology, Piazza Ospedale Maggiore 3, Milano, Italy, 20162.
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Naismith RT, Cross AH. MAGNETIC RESONANCE IMAGING OF MULTIPLE SCLEROSIS. Continuum (Minneap Minn) 2007. [DOI: 10.1212/01.con.0000293643.43858.9a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Orbach H, Shoenfeld Y. Hyperprolactinemia and autoimmune diseases. Autoimmun Rev 2007; 6:537-42. [PMID: 17854745 DOI: 10.1016/j.autrev.2006.10.005] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Accepted: 10/26/2006] [Indexed: 11/24/2022]
Abstract
The autoimmune diseases are more common in females. The sex hormones have an important role in this gender bias, mainly estrogen and prolactin (PRL) which modulate the immune response. PRL is secreted from the pituitary gland and other organs and cells mainly the lymphocytes. PRL has an immunostimulatory effect and promotes autoimmunity: PRL impairs the negative selection of autoreactive B lymphocytes occurring during B cell maturation into fully functional B cells. PRL has an anti-apoptotic effect, enhances proliferative response to antigens and mitogens and enhances the production of immunoglobulins and autoantibodies. Hyperprolactinemia (HPRL) is observed in multi-organ and organ specific autoimmune diseases like systemic lupus erythematosus (SLE) rheumatoid arthritis (RA), Sjogren's syndrome (SS), Hashimoto's thyroiditis (HT) and multiple sclerosis (MS). There is no consistent correlation between PRL levels and disease activity. Murine models and small studies in SLE patients suggest some role of dopamine agonists in the therapy of those diseases. The genetic factor may have a role in humans as in animal models. The PRL isoform has an important effect on the bioactivity on prolactin receptors (PRL-Rs).
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Affiliation(s)
- Hedi Orbach
- Department of Medicine B, Wolfson Medical Center, Holon, Israel
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Then Bergh F. The clock keeps ticking for intravenous methylprednisolone. J Neurol Neurosurg Psychiatry 2007; 78:788. [PMID: 17635976 PMCID: PMC2117721 DOI: 10.1136/jnnp.2006.109272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Patients with multiple sclerosis may benefit more from night‐time rather than daytime infusion
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