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Smets I, Versteegh M, Huygens S, Wokke B, Smolders J. Benefits of early highly effective versus escalation treatment strategies in relapsing multiple sclerosis estimated using a treatment-sequence model. Mult Scler 2024:13524585241258692. [PMID: 38859625 DOI: 10.1177/13524585241258692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
BACKGROUND Uncertainty about disproportionate impact on health care budgets limits implementation of early highly effective treatment (EHT) in multiple sclerosis (MS). OBJECTIVE To estimate cost-effectiveness of escalation versus EHT disease-modifying treatment (DMT) sequences. METHODS Using a health-economic approach, we analysed health benefits (relapse rate reduction, disability prevention), direct/indirect DMT and societal costs of escalation versus EHT DMT sequences. In scenario analyses, we allowed (1) earlier use of alemtuzumab (ALE) and (2) a single retreatment with cladribine (CLA). RESULTS In our model, we showed that the ratio between costs and quality-adjusted life years (QALYs) for the most cost-effective EHT and escalation sequence results into a similar net health benefit with higher costs and also higher QALYs associated with an EHT versus escalation strategy. Earlier use of ALE is more cost-effective than in later lines, even when aggravating the impact of its side-effects tenfold. Retreatment with CLA was more cost-effective in both escalation and EHT sequences. CONCLUSIONS Certain EHT sequences are equally cost-effective to escalation sequences and are likely to result in more health at uncertain additional costs. The favourable cost-benefit ratio of CLA and ALE suggests that a wider application of affordable highly effective therapies could promote the cost-effectiveness both EHT and escalation approaches.
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Affiliation(s)
- Ide Smets
- MS Center ErasMS, Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Beatrijs Wokke
- MS Center ErasMS, Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost Smolders
- MS Center ErasMS, Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS, Department of Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Neuroimmunology Research Group, Netherlands Institute for Neuroscience, Amsterdam, The Netherlands
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Singer BA, Feng J, Chiong-Rivero H. Early use of high-efficacy therapies in multiple sclerosis in the United States: benefits, barriers, and strategies for encouraging adoption. J Neurol 2024; 271:3116-3130. [PMID: 38615277 PMCID: PMC11136864 DOI: 10.1007/s00415-024-12305-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Multiple sclerosis (MS) is characterized by progressive neuroinflammation and neurodegeneration from disease onset that, if left untreated, can result in the accumulation of irreversible neurological disability. Early intervention with high-efficacy therapies (HETs) is increasingly recognized as the best strategy to delay or mitigate disease progression from the earliest stages of the disease and to prevent long-term neurodegeneration. Although there is growing clinical and real-world evidence supporting early HET intervention, foregoing this strategy in favor of a traditional escalation approach prioritizing lower-efficacy disease-modifying therapies remains a common approach in clinical practice. This review explores potential health care professional- and patient-related barriers to the early use of HETs in patients with MS in the United States. Barriers can include regulatory and reimbursement restrictions; knowledge gaps and long-term safety concerns among health care professionals; and various individual, cultural, and societal factors affecting patients. Potential strategies for overcoming these barriers and encouraging early HET use are proposed.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA.
| | - Jenny Feng
- Ochsner Medical Center, New Orleans, LA, USA
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Frahm N, Ellenberger D, Stahmann A, Fneish F, Lüftenegger D, Salmen HC, Schirduan K, Schaak TPA, Flachenecker P, Kleinschnitz C, Paul F, Krefting D, Zettl UK, Peters M, Warnke C. Treatment switches of disease-modifying therapies in people with multiple sclerosis: long-term experience from the German MS Registry. Ther Adv Neurol Disord 2024; 17:17562864241239740. [PMID: 38560408 PMCID: PMC10981260 DOI: 10.1177/17562864241239740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/14/2024] [Indexed: 04/04/2024] Open
Abstract
Background The spectrum of disease-modifying therapies (DMTs) for people with multiple sclerosis (PwMS) has expanded over years, but data on treatment strategies is largely lacking. DMT switches are common clinical practice. Objective To compare switchers and non-switchers, characterize the first DMT switch and identify reasons and predictors for switching the first DMT. Methods Data on 2722 PwMS from the German MS Registry were retrospectively analyzed regarding sociodemographic/clinical differences between 1361 switchers (PwMS discontinuing the first DMT) and non-switchers matched according to age, sex, and observation period. Frequencies of first and second DMTs were calculated and switch reasons identified. Predictors for DMT switches were revealed using univariable and multivariable regression models. Results Switchers and non-switchers differed significantly regarding time to first DMT, education, calendar period of the first DMT start (2014-2017 versus 2018-2021), first DMT class used [mild-to-moderate efficacy (MME) versus high-efficacy (HE) DMT], time on first DMT, and disease activity at first DMT start or cessation/last follow-up. The majority of PwMS started with MME DMTs (77.1%), with the most common being glatiramer acetate, dimethyl/diroximel fumarate, and beta-interferon variants. Switchers changed treatment more often to HE DMTs (39.6%), most commonly sphingosine-1-phosphate receptor modulators, anti-CD20 monoclonal antibodies, and natalizumab. Fewer PwMS switched to MME DMTs (35.9%), with the most common being dimethyl/diroximel fumarate, teriflunomide, or beta-interferon. Among 1045 PwMS with sufficient data (76.8% of 1361 switchers), the most frequent reasons for discontinuing the first DMT were disease activity despite DMT (63.1%), adverse events (17.1%), and patient request (8.3%). Predictors for the first DMT switch were MME DMT as initial treatment [odds ratio (OR) = 2.83 (1.76-4.61), p < 0.001; reference: HE DMT], first DMT initiation between 2014 and 2017 [OR = 11.55 (6.93-19.94), p < 0.001; reference: 2018-2021], and shorter time on first DMT [OR = 0.22 (0.18-0.27), p < 0.001]. Conclusion The initial use of MME DMTs was among the strongest predictors of DMT discontinuation in a large German retrospective MS cohort, arguing for the need for prospective treatment strategy trials, not only but also on the initial broad use of HE DMTs in PwMS.
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Affiliation(s)
- Niklas Frahm
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, Hannover, Niedersachsen 30171, Germany
| | - David Ellenberger
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Hannover, Germany
| | - Alexander Stahmann
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Hannover, Germany
| | - Firas Fneish
- German MS Registry, MS Forschungs- und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Hannover, Germany
| | | | | | | | | | | | - Christoph Kleinschnitz
- Department of Neurology and Center of Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Dagmar Krefting
- Department of Medical Informatics, University Medical Center Göttingen, Göttingen, Germany
| | - Uwe K. Zettl
- Department of Neurology, Neuroimmunological Section, University Medical Center of Rostock, Rostock, Germany
| | - Melanie Peters
- German MS Registry, Gesellschaft für Versorgungsforschung mbH (Society for Health Care Research [GfV]), Hannover, Germany
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University Hospital of Cologne, Cologne, Germany
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Papukchieva S, Stratil AS, Kahn M, Neß NH, Hollnagel-Schmitz M, Gerencser V, Rustemeier J, Eberl M, Friedrich B, Ziemssen T. Shifting from the treat-to-target to the early highly effective treatment approach in patients with multiple sclerosis - real-world evidence from Germany. Ther Adv Neurol Disord 2024; 17:17562864241237857. [PMID: 38525488 PMCID: PMC10960977 DOI: 10.1177/17562864241237857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/14/2024] [Indexed: 03/26/2024] Open
Abstract
Background While evidence highlights the effectiveness of initiating disease-modifying therapy with a high-efficacy medication for multiple sclerosis (MS) patients with poor prognostic factors, it remains unclear whether this approach has been adopted by a broad range of MS providers in Germany yet. Objective To assess the adoption of the early highly effective treatment (EHT) compared to the treat-to-target treatment approach with the option of escalating treatment efficacy over time in Germany based on real-world evidence data. Design Patient-level pharmacy dispensing data from the Permea platform were analysed from 2020 to 2022. Methods In total, 29,529 therapy beginners (>18 years) were included to analyse shifts in treatment approaches over time and switching behaviour. Medication classification adhered to the German Society of Neurology guidelines and designated fumarates, glatiramer acetate, teriflunomide and interferons as low-efficacy category 1 medications; cladribine and S1P-modulators as medium-efficacy category 2 medications; and alemtuzumab, natalizumab, ocrelizumab, ofatumumab and rituximab (off-label) as high-efficacy category 3 medications. Results Our results show that 70.0% of patients redeemed their first prescription for category 1 medication, 16.3% for category 2 and 13.7% for category 3 medications. The proportion of prescriptions filled shifted from 2020 to 2022 with a decrease of 14.7% for category 1 drugs and an increase of 12.5% for category 3 drugs. 93.2% of patients stayed on their initially prescribed medication category. 3.2% of category 1 and 3.7% of category 2 therapy beginners escalated to category 3 medication. 3.4% of category 3 medication users de-escalated their treatment to category 1 or category 2. Conclusion While most individuals started their treatment according to the treat-to-target approach and remained on their initially prescribed medication category, there has been a steadily increasing shift towards the EHT approach since 2020. These insights demonstrate that, while not officially recommended by German guidelines, MS providers increasingly adopt the EHT approach.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
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Deftereos SN, Vavougios GD, Bakirtzis C, Hadjigeorgiou G, Grigoriadis N. Effects of High Efficacy Multiple Sclerosis Disease Modifying Drugs on the Immune Synapse: A Systematic Review. Curr Pharm Des 2024; 30:536-551. [PMID: 38343058 DOI: 10.2174/0113816128288102240131053205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/11/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Co-signaling and adhesion molecules are important elements for creating immune synapses between T lymphocytes and antigen-presenting cells; they positively or negatively regulate the interaction between a T cell receptor with its cognate antigen, presented by the major histocompatibility complex. OBJECTIVES We conducted a systematic review on the effects of High Efficacy Disease Modifying Drugs (HEDMDs) for Multiple Sclerosis (MS) on the co-signaling and adhesion molecules that form the immune synapse. METHODS We searched EMBASE, MEDLINE, and other sources to identify clinical or preclinical reports on the effects of HEDMDs on co-signaling and adhesion molecules that participate in the formation of immune synapses in patients with MS or other autoimmune disorders. We included reports on cladribine tablets, anti- CD20 monoclonal antibodies, S1P modulators, inhibitors of Bruton's Tyrosine Kinase, and natalizumab. RESULTS In 56 eligible reports among 7340 total publications, limited relevant evidence was uncovered. Not all co-signaling and adhesion molecules have been studied in relation to every HEDMD, with more data being available on the anti-CD20 monoclonal antibodies (that affect CD80, CD86, GITR and TIGIT), cladribine tablets (affecting CD28, CD40, ICAM-1, LFA-1) and the S1P modulators (affecting CD86, ICAM-1 and LFA-1) and less on Natalizumab (affecting CD80, CD86, CD40, LFA-1, VLA-4) and Alemtuzumab (affecting GITR and CTLA-4). CONCLUSION The puzzle of HEDMD effects on the immune synapse is far from complete. The available evidence suggests that distinguishing differences exist between drugs and are worth pursuing further.
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Affiliation(s)
- Spyros N Deftereos
- Second Department of Neurology, Special Unit for Biomedical Research and Education (S.U.B.R.E.), School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Merck S.A., Greece, an Affiliate of Merck KGaA, Darmstadt, Germany
| | - George D Vavougios
- Department of Neurology, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Christos Bakirtzis
- Second Department of Neurology, Special Unit for Biomedical Research and Education (S.U.B.R.E.), School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Hadjigeorgiou
- Medical School, University of Cyprus, Nicosia, Cyprus
- Cyprus Academy of Sciences, Letters and Arts, Nicosia, Cyprus
| | - Nikolaos Grigoriadis
- Second Department of Neurology, Special Unit for Biomedical Research and Education (S.U.B.R.E.), School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Spelman T, Magyari M, Butzkueven H, Van Der Walt A, Vukusic S, Trojano M, Iaffaldano P, Horáková D, Drahota J, Pellegrini F, Hyde R, Duquette P, Lechner-Scott J, Sajedi SA, Lalive P, Shaygannejad V, Ozakbas S, Eichau S, Alroughani R, Terzi M, Girard M, Kalincik T, Grand'Maison F, Skibina O, Khoury SJ, Yamout B, Sa MJ, Gerlach O, Blanco Y, Karabudak R, Oreja-Guevara C, Altintas A, Hughes S, McCombe P, Ampapa R, de Gans K, McGuigan C, Soysal A, Prevost J, John N, Inshasi J, Stawiarz L, Manouchehrinia A, Forsberg L, Sellebjerg F, Glaser A, Pontieri L, Joensen H, Rasmussen PV, Sejbaek T, Poulsen MB, Christensen JR, Kant M, Stilund M, Mathiesen H, Hillert J. Predictors of treatment switching in the Big Multiple Sclerosis Data Network. Front Neurol 2023; 14:1274194. [PMID: 38187157 PMCID: PMC10771327 DOI: 10.3389/fneur.2023.1274194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Abstract
Background Treatment switching is a common challenge and opportunity in real-world clinical practice. Increasing diversity in disease-modifying treatments (DMTs) has generated interest in the identification of reliable and robust predictors of treatment switching across different countries, DMTs, and time periods. Objective The objective of this retrospective, observational study was to identify independent predictors of treatment switching in a population of relapsing-remitting MS (RRMS) patients in the Big Multiple Sclerosis Data Network of national clinical registries, including the Italian MS registry, the OFSEP of France, the Danish MS registry, the Swedish national MS registry, and the international MSBase Registry. Methods In this cohort study, we merged information on 269,822 treatment episodes in 110,326 patients from 1997 to 2018 from five clinical registries. Patients were included in the final pooled analysis set if they had initiated at least one DMT during the relapsing-remitting MS (RRMS) stage. Patients not diagnosed with RRMS or RRMS patients not initiating DMT therapy during the RRMS phase were excluded from the analysis. The primary study outcome was treatment switching. A multilevel mixed-effects shared frailty time-to-event model was used to identify independent predictors of treatment switching. The contributing MS registry was included in the pooled analysis as a random effect. Results Every one-point increase in the Expanded Disability Status Scale (EDSS) score at treatment start was associated with 1.08 times the rate of subsequent switching, adjusting for age, sex, and calendar year (adjusted hazard ratio [aHR] 1.08; 95% CI 1.07-1.08). Women were associated with 1.11 times the rate of switching relative to men (95% CI 1.08-1.14), whilst older age was also associated with an increased rate of treatment switching. DMTs started between 2007 and 2012 were associated with 2.48 times the rate of switching relative to DMTs that began between 1996 and 2006 (aHR 2.48; 95% CI 2.48-2.56). DMTs started from 2013 onwards were more likely to switch relative to the earlier treatment epoch (aHR 8.09; 95% CI 7.79-8.41; reference = 1996-2006). Conclusion Switching between DMTs is associated with female sex, age, and disability at baseline and has increased in frequency considerably in recent years as more treatment options have become available. Consideration of a patient's individual risk and tolerance profile needs to be taken into account when selecting the most appropriate switch therapy from an expanding array of treatment choices.
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Affiliation(s)
- Tim Spelman
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- MSBase Foundation, Melbourne, VIC, Australia
| | - Melinda Magyari
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Helmut Butzkueven
- MSBase Foundation, Melbourne, VIC, Australia
- MS and Neuroimmunology Research, Central Clinical School, Alfred and Box Hill Hospitals, Monash University, Melbourne, VIC, Australia
| | - Anneke Van Der Walt
- MSBase Foundation, Melbourne, VIC, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Sandra Vukusic
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- Centre des Neurosciences de Lyon, L'Institut national de la santé et de la recherche médicale 1028 et Centre national de la recherche scientifique joint research units5292, Lyon, France
- Faculté de Médicine Lyon-Est, Université Claude Bernard Lyon 1, Villeurbanne, Auvergne-Rhône-Alpes, France
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Pietro Iaffaldano
- Department of Translational Biomedicine and Neuroscience, DiBraiN, University of Bari Aldo Moro, Bari, Italy
| | - Dana Horáková
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Jirí Drahota
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Fabio Pellegrini
- Biogen International GmbH, Zug, Switzerland
- Biogen Digital Health, Biogen Spain, Madrid, Spain
| | | | - Pierre Duquette
- University of Montreal Hospital Research Centre and Universite de Montreal, Montreal, QC, Canada
| | - Jeannette Lechner-Scott
- University Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, Hunter New England Health, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Seyed Aidin Sajedi
- Department of Neurology, Neuroscience Research Center, Golestan University of Medical Sciences, Gogan, Iran
| | - Patrice Lalive
- Faculty of Medicine, Division of Neurology, Geneva University Hospital, Geneva, Switzerland
| | | | | | - Sara Eichau
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Murat Terzi
- Medical Faculty, 19 Mayis University, Samsun, Türkiye
| | - Marc Girard
- University of Montreal Hospital Research Centre and Universite de Montreal, Montreal, QC, Canada
| | - Tomas Kalincik
- Clinical Outcomes Research Unit, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | | | - Olga Skibina
- MS and Neuroimmunology Research, Central Clinical School, Alfred and Box Hill Hospitals, Monash University, Melbourne, VIC, Australia
| | - Samia J. Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bassem Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maria Jose Sa
- Department of Neurology, Faculty of Health Sciences, University Fernando Pessoa, Porto, Portugal
| | - Oliver Gerlach
- Academic MS Center Zuyderland, Department of Neurology, Zuyderland Medical Center, Sittard-Geleen, Netherlands
| | - Yolanda Blanco
- Center of Neuroimmunology, Service of Neurology, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | | | - Ayse Altintas
- Department of Neurology, School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Türkiye
| | | | | | | | | | | | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Türkiye
| | | | - Nevin John
- Monash Health, Melbourne, VIC, Australia
| | | | - Leszek Stawiarz
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Ali Manouchehrinia
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Lars Forsberg
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Anna Glaser
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Luigi Pontieri
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Hanna Joensen
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | | | - Tobias Sejbaek
- Department of Neurology, Southwest Jutland Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Mai Bang Poulsen
- Department of Neurology, Nordsjællands Hospital, Hillerød, Denmark
| | - Jeppe Romme Christensen
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Matthias Kant
- Department of Neurology, Hospital of Southern Jutland, University of Southern Denmark, Aabenraa, Denmark
| | - Morten Stilund
- Department of Neurology, Physiotherapy and Occupational Therapy, Gødstrup Hospital, Herning, Denmark
- NIDO | Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Henrik Mathiesen
- Department of Neurology, Copenhagen University Hospital Herlev and Gentofte, København, Denmark
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Deleu D, Garcia Canibano B, Elalamy O, Sayed Abdelmoneim M, Boshra A. Practical Guidance on the Use of Cladribine Tablets in the Management or Relapsing Multiple Sclerosis: Expert Opinion from Qatar. Degener Neurol Neuromuscul Dis 2023; 13:81-88. [PMID: 38105885 PMCID: PMC10725680 DOI: 10.2147/dnnd.s433459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
The increasing availability of high-efficacy disease-modifying therapies (DMT) for the management of relapsing multiple sclerosis (RMS) has increased the potential for individualised patient management but has added complexity to the design of treatment regimens. The long-term application of immune reconstitution therapy (IRT) is supported by an increasing database of real world studies that have added important information on the long-term safety and efficacy of this approach. Cladribine tablets (CladT) is an IRT given as two annual short courses of treatment, following which a majority of patients then demonstrate no significant MS disease activity over a period of years. Whether, and how, to treat patients beyond the first two years of treatment remains a matter for debate, as clinical evidence accumulates. We, a group of neurologists who manage people with RMS in Qatar, provide our expert consensus recommendations on the application and long-term management of CladT therapy based on our experience with treatment in the last 5 years. These include pragmatic recommendations for people with MS disease activity in years 3 and 4 (ie up to four years following first dose of CladT), and for people with or without MS disease activity in subsequent years. We believe our recommendations will help to ensure the optimal application of CladT-based IRT, with the potential benefit for the patient of achieving prolonged periods free of both MS disease symptoms and the burden of regular applications of immunosuppressive DMT.
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Affiliation(s)
- Dirk Deleu
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Osama Elalamy
- Department of Neurology (Neurosciences Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Amir Boshra
- Merck Serono Middle East FZ-Ltd., Dubai, UAE, an affiliate of Merck KGaA, Dubai, United Arab Emirates
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8
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Brownlee W, Amin A, Ashton L, Herbert A. Real-world use of cladribine tablets (completion rates and treatment persistence) in patients with multiple sclerosis in England: The CLARENCE study. Mult Scler Relat Disord 2023; 79:104951. [PMID: 37639781 DOI: 10.1016/j.msard.2023.104951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/28/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Treatment with cladribine tablets, a high-efficacy disease-modifying therapy (DMT), has been available in England since 2017 for patients with highly active relapsing multiple sclerosis (MS). Real-world data on treatment completion, persistence and switching in patients treated with cladribine tablets are beginning to emerge, but only small single and multicentre cohorts have reported so far. This longitudinal retrospective observational study (CLARENCE) evaluated a large cohort (>1900) of patients with highly active relapsing MS, receiving cladribine tablets across England, to determine rates of treatment completion, persistence and switching in the real world. METHODS Using data obtained from Blueteq® forms, a compulsory requirement for DMT reimbursement in England, we evaluated rates of treatment completion (defined as the proportion of patients who received the full 2-year course of cladribine tablets), treatment persistence (defined as the proportion of patients who did not switch and/or discontinue treatment before receiving the full 2-year course) and treatment switch (defined as the proportion of patients who switched treatment from cladribine tablets to another DMT at any point after their first course). The change in Expanded Disability Status Scale (EDSS) score between Years 1 and 2 of treatment was also determined. All data were analysed descriptively. RESULTS Blueteq® forms were completed for 1934 MS patients treated with cladribine tablets; of these patients, 691 (36%) were treatment naïve. The median EDSS score (range) at treatment initiation with cladribine tablets was 2.5 (0, 8.5). At time of analysis (September 2021, last follow-up point), a total of 1020 (53%) patients had completed the full 2-year course of cladribine tablets. At the same time point, 1762 (91%) patients were considered as treatment persistent (i.e., the patient had completed either 1 course of tablets with <18 months of follow-up data or the full 2-year course of cladribine tablets). Overall, 78 (4%) patients switched to another DMT at any point after their first course, which included 33 (1.7%) patients who switched after completing the full 2-year course. In terms of their disability, 469 (84%) patients had stable EDSS scores between Years 1 and 2 of treatment. CONCLUSION In this large real-world study of patients receiving cladribine tablets across England, high rates of treatment persistence and low rates of switching were observed, with only 1.7% of patients receiving the full 2-year course and switching treatment. The majority (84%) of evaluable patients showed stable disability between Years 1 and 2 of treatment. These findings complement earlier data from clinical trials and real-world studies, confirming the effectiveness of cladribine tablets for patients with highly active relapsing MS.
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Affiliation(s)
- Wallace Brownlee
- Queen Square MS Centre, UCL Institute of Neurology and NIHR UCL Hospitals Biomedical Research Centre, London, UK.
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9
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Park SY, Kwon YN, Kim S, Kim SH, Kim JK, Kim JS, Nam TS, Min YG, Park KS, Park JS, Seok JM, Sung JJ, Sohn E, Shin KJ, Shin JH, Shin HY, Oh SI, Oh J, Yoon BA, Lee S, Lee JM, Lee HL, Choi K, Huh SY, Jang MJ, Min JH, Kim BJ, Kim SM. Early rituximab treatment reduces long-term disability in aquaporin-4 antibody-positive neuromyelitis optica spectrum. J Neurol Neurosurg Psychiatry 2023; 94:800-805. [PMID: 37268404 DOI: 10.1136/jnnp-2022-330714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/12/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) causes relapsing inflammatory attacks in the central nervous system, leading to disability. As rituximab, a B-lymphocyte-depleting monoclonal antibody, is an effective in preventing NMOSD relapses, we hypothesised that earlier initiation of rituximab can also reduce long-term disability of patients with NMOSD. METHODS This multicentre retrospective study involving 19 South Korean referral centres included patients with NMOSD with aquaporin-4 antibodies receiving rituximab treatment. Factors associated with the long-term Expanded Disability Status Scale (EDSS) were assessed using multivariable regression analysis. RESULTS In total, 145 patients with rituximab treatment (mean age of onset, 39.5 years; 88.3% female; 98.6% on immunosuppressants/oral steroids before rituximab treatment; mean disease duration of 121 months) were included. Multivariable analysis revealed that the EDSS at the last follow-up was associated with time to rituximab initiation (interval from first symptom onset to initiation of rituximab treatment). EDSS at the last follow-up was also associated with maximum EDSS before rituximab treatment. In subgroup analysis, the time to initiation of rituximab was associated with EDSS at last follow-up in patients aged less than 50 years, female and those with a maximum EDSS score ≥6 before rituximab treatment. CONCLUSIONS Earlier initiation of rituximab treatment may prevent long-term disability worsening in patients with NMOSD, especially among those with early to middle-age onset, female sex and severe attacks.
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Affiliation(s)
- Su Yeon Park
- Department of Neurology, Korea Cancer Center Hospital, Seoul, Korea (the Republic of)
| | - Young Nam Kwon
- Department of Neurology, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Sunyoung Kim
- Department of Neurology, Ulsan University Hospital College of Medicine, Ulsan, Korea (the Republic of)
| | - Seung-Hyun Kim
- Department of Neurology, Hanyang University College of Medicine, Seoul, Korea (the Republic of)
| | - Jong Kuk Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea (the Republic of)
| | - Jun-Soon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Tai-Seung Nam
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea (the Republic of)
| | - Young Gi Min
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Jin-Sung Park
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea (the Republic of)
| | - Jin Myoung Seok
- Department of Neurology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea (the Republic of)
| | - Jung-Joon Sung
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Eunhee Sohn
- Department of Neurology, Chungnam National University, College of Medicine, Daejeon, Korea (the Republic of)
| | - Kyong Jin Shin
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Korea (the Republic of)
| | - Jin-Hong Shin
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Seong-Il Oh
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea (the Republic of)
| | - Jeeyoung Oh
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea (the Republic of)
| | - Byeol-A Yoon
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea (the Republic of)
| | - Sanggon Lee
- Department of Neurology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea (the Republic of)
| | - Jong-Mok Lee
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea (the Republic of)
| | - Hye Lim Lee
- Department of Neurology, Korea University College of Medicine, Seoul, Korea (the Republic of)
| | - Kyomin Choi
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea (the Republic of)
| | - So-Young Huh
- Department of Neurology, Kosin University College of Medicine, Busan, Korea (the Republic of)
| | - Myoung-Jin Jang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Ju-Hong Min
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of)
| | - Byoung Joon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of)
| | - Sung-Min Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
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Greenberg B, Giovannoni G. A place for biosimilars in the changing multiple sclerosis treatment landscape. Mult Scler Relat Disord 2023; 77:104841. [PMID: 37467536 DOI: 10.1016/j.msard.2023.104841] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/02/2023] [Accepted: 06/16/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The treatment paradigm for multiple sclerosis (MS), particularly relapsing-remitting MS, is heavily reliant on biologic disease-modifying therapies (DMTs). However, the current cost of treatment acts as a significant barrier to access for patients. Over the next few years exclusivity periods for key biologic medicines used in MS are likely to end, opening the door for biosimilar medicines to enter the market. METHODS In this review, we discuss what biosimilar medicines are, and how the existing experience with biosimilar medicines across multiple therapy areas can inform the assimilation of biosimilar medicines into the MS treatment landscape in Europe and the US. RESULTS There is currently a lack of knowledge and awareness around the distinctions and similarities between small molecules, non-biological complex drugs, and biological medicines, as well as the different categories of follow-on successor medicines. These include biosimilar medicines that offer a matching efficacy and safety profile to the reference biologic. Understanding and recognition of the stringency of the approval pathways required for drug categories such as biosimilars are key in building confidence in treatment outcomes. For example, biosimilar medicines are sometimes perceived only as 'copies' of their reference biologic despite undergoing an extensive approval process requiring that no clinically meaningful differences are observed between the biosimilar medicine and the reference medicine. For MS, introduction of biosimilar medicines in the future will enable more people with MS to receive effective treatment, and also expand access to biologic DMTs in MS. Experiences from the use of biosimilars in multiple therapy areas have shown us that this can result in cost-saving benefits for a healthcare system. Introduction of biosimilar medicines in other therapy areas has also demonstrated the importance of appropriate, accurate education and information for their successful integration into clinical practice. CONCLUSION In order to realize optimized treatment outcomes in MS in coming years and to find the appropriate place for biosimilar medicines in the changing MS landscape, it is essential that clinicians and people with MS understand the fundamentals of biosimilars, their potential benefits and consistency of treatment provided by a biosimilar medicine, given the matching efficacy and safety profile to its reference medicine. As evidenced in other therapy areas, biosimilar medicines may reduce key barriers to access by providing a cost-effective alternative to the MS treatment arsenal, while providing the same treatment outcomes as reference biologics.
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Affiliation(s)
- Benjamin Greenberg
- Department of Neurology and Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Rd, Bethnal Green, London E1 4NS, United Kingdom
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Hrnciarova T, Drahota J, Spelman T, Hillert J, Lycke J, Kubala Havrdova E, Recmanova E, Adamkova J, Mares J, Libertinova J, Pavelek Z, Hradilek P, Ampapa R, Stetkarova I, Peterka M, Martinkova A, Stourac P, Grunermelova M, Vachova M, Dufek M, Horakova D. Does initial high efficacy therapy in multiple sclerosis surpass escalation treatment strategy? A comparison of patients with relapsing-remitting multiple sclerosis in the Czech and Swedish national multiple sclerosis registries. Mult Scler Relat Disord 2023; 76:104803. [PMID: 37329786 DOI: 10.1016/j.msard.2023.104803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/23/2023] [Accepted: 06/05/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND In relapsing-remitting multiple sclerosis (RRMS) the most common treatment strategy has been to start with low-moderate efficacy disease modifying therapy (LE-DMT) and to escalate to more efficacious treatments in cases of breakthrough disease activity. However, recent evidence suggests a better outcome in patients commencing with moderate-high efficacy DMT (HE-DMT) immediately after clinical onset. OBJECTIVE The aim of this study is to compare disease activity and disability outcomes in patients treated with the two alternative strategies using the Swedish and Czech national multiple sclerosis registries, taking advantage of the fact that the relative frequency of each strategy differs markedly between these two countries. METHODS Adult RRMS patients who initiated their first-ever DMT between 2013 and 2016 and were included in the Swedish MS register were compared with a similar cohort from the MS register of the Czech Republic using propensity score overlap weighting as a balancing method. The main outcomes of interest were time to confirmed disability worsening (CDW), time to achieve an expanded disability status scale (EDSS) value of 4, time to relapse, and time to confirmed disability improvement (CDI). To support the results, a sensitivity analysis focusing solely on patients from Sweden starting with HE-DMT and patients from the Czech Republic starting with LE-DMT was performed. RESULTS In the Swedish cohort, 42% of patients received HE-DMT as initial therapy compared to 3.8% of patients in the Czech cohort. The time to CDW was not significantly different between the Swedish and Czech cohorts (p-value 0.2764), with hazard ratio (HR) of 0.89 and a 95% confidence interval (CI) of 0.77-1.03. Patients from the Swedish cohort exhibited better outcomes for all remaining variables. The risk of reaching EDSS 4 was reduced by 26% (HR 0.74, 95%CI 0.6-0.91, p-value 0.0327), the risk of relapse was reduced by 66% (HR 0.34, 95%CI 0.3-0.39, p-value <0.001), and the probability of CDI was three times higher (HR 3.04, 95%CI 2.37-3.9, p-value <0.001). CONCLUSION The analysis of the Czech and the Swedish RRMS cohorts confirmed a better prognosis for patients in Sweden, where a significant proportion of patients received HE-DMT as initial treatment.
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Affiliation(s)
- Tereza Hrnciarova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic; Department of Epidemiology and Biostatistics, Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jiri Drahota
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic; IMPULS Endowment Fund, Prague, Czech Republic
| | - Tim Spelman
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Kubala Havrdova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | | | - Jana Adamkova
- Department of Neurology, Hospital České Budějovice, České Budějovice, Czech Republic
| | - Jan Mares
- Department of Neurology and Centre of Clinical Neuroscience, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jana Libertinova
- Department of Neurology, Second Faculty of Medicine and Motol University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Zbysek Pavelek
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czech Republic
| | - Pavel Hradilek
- Department of Clinical Neuroscience, Medical Faculty, Ostrava University and Department of Neurology, University Hospital, Ostrava, Czech Republic
| | - Radek Ampapa
- Department of Neurology, Hospital Jihlava, Jihlava, Czech Republic
| | - Ivana Stetkarova
- Department of Neurology, Third Faculty of Medicine, Charles University in Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Marek Peterka
- Department of Neurology, Faculty of Medicine in Pilsen and University Hospital Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Alena Martinkova
- Department of Neurology, Hospital Pardubice, Pardubice, Czech Republic
| | - Pavel Stourac
- Department of Neurology, University Hospital Brno, Brno, Czech Republic
| | | | - Marta Vachova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic; Department of Neurology, KZ a.s., Hospital Teplice, Teplice, Czech Republic
| | - Michal Dufek
- First Department of Neurology, Masaryk University, St. Anne's University Hospital, Brno, Czech Republic
| | - Dana Horakova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic.
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12
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Tayyab M, Metz LM, Li DKB, Kolind S, Carruthers R, Traboulsee A, Tam RC. Accounting for uncertainty in training data to improve machine learning performance in predicting new disease activity in early multiple sclerosis. Front Neurol 2023; 14:1165267. [PMID: 37305756 PMCID: PMC10251494 DOI: 10.3389/fneur.2023.1165267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction Machine learning (ML) has great potential for using health data to predict clinical outcomes in individual patients. Missing data are a common challenge in training ML algorithms, such as when subjects withdraw from a clinical study, leaving some samples with missing outcome labels. In this study, we have compared three ML models to determine whether accounting for label uncertainty can improve a model's predictions. Methods We used a dataset from a completed phase-III clinical trial that evaluated the efficacy of minocycline for delaying the conversion from clinically isolated syndrome to multiple sclerosis (MS), using the McDonald 2005 diagnostic criteria. There were a total of 142 participants, and at the 2-year follow-up 81 had converted to MS, 29 remained stable, and 32 had uncertain outcomes. In a stratified 7-fold cross-validation, we trained three random forest (RF) ML models using MRI volumetric features and clinical variables to predict the conversion outcome, which represented new disease activity within 2 years of a first clinical demyelinating event. One RF was trained using subjects with the uncertain labels excluded (RFexclude), another RF was trained using the entire dataset but with assumed labels for the uncertain group (RFnaive), and a third, a probabilistic RF (PRF, a type of RF that can model label uncertainty) was trained on the entire dataset, with probabilistic labels assigned to the uncertain group. Results Probabilistic random forest outperformed both the RF models with the highest AUC (0.76, compared to 0.69 for RFexclude and 0.71 for RFnaive) and F1-score (86.6% compared to 82.6% for RFexclude and 76.8% for RFnaive). Conclusion Machine learning algorithms capable of modeling label uncertainty can improve predictive performance in datasets in which a substantial number of subjects have unknown outcomes.
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Affiliation(s)
- Maryam Tayyab
- School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Luanne M Metz
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David K B Li
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shannon Kolind
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robert Carruthers
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anthony Traboulsee
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Roger C Tam
- School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Benefits of early treatment with natalizumab: a real-world study. Mult Scler Relat Disord 2022; 68:104216. [PMID: 36288658 DOI: 10.1016/j.msard.2022.104216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 08/19/2022] [Accepted: 10/02/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The impact of early versus later high-efficacy disease-modifying therapy (DMT) in patients with multiple sclerosis (MS) is uncertain. This study reported the association of early versus later natalizumab treatment with real-world clinical outcomes in MS patients. METHODS The study included 661 participants diagnosed with MS in 1994 or later from 7 US centers participating in the MS Partners Advancing Technology for Health Solutions (MS PATHS) network. Time to natalizumab treatment between diagnosis and first infusion (TTNT) was determined from the Tysabri Outreach: Unified Commitment to Health (TOUCH) registry. Clinical outcomes were defined using neuroperformance tests included in the Multiple Sclerosis Performance Test. Associations were tested using TTNT as a categorical and continuous variable. Linear mixed models addressed within-subject and within-site clustering. RESULTS TTNT varied from 0.1 to 19.8 years (median [interquartile range] 4.2 [1.8, 9.0] years). A significant association between later natalizumab use and worse outcomes was demonstrated for walking speed (p < 0.001), processing speed (p < 0.001), manual dexterity (p < 0.001), brain atrophy (p = 0.001), and T2 lesion volume (p = 0.02). Covariate-adjusted modelling of a sensitivity population diagnosed with MS in 2006 or later (n = 424) demonstrated significant associations between longer TTNT and worse walking speed (p < 0.05), processing speed (p < 0.001), and manual dexterity (p < 0.001). CONCLUSION Later initiation of natalizumab was associated with worse clinical and radiologic imaging outcomes. Thus, high-efficacy DMT may have greater benefit when started earlier in MS patients. These results provide a rationale for randomized controlled trials to further assess the impact of early highly-effective DMT use versus later escalation of therapy.
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14
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Shosha E, Burton JM. Discussing the potential for progression with patients newly diagnosed with multiple sclerosis: When, how, and why? Mult Scler Relat Disord 2022; 68:104230. [PMID: 36240704 DOI: 10.1016/j.msard.2022.104230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 10/02/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022]
Abstract
Despite convergent evidence that upwards of 50% of patients with MS transition from a relapsing to progressive phase within 20 years of disease onset, and the recent acknowledgement of the commonality of progression independent of relapses, there remains no consensus regarding the nature and timing of a discussion about the possibility of a secondary progressive phase with relapsing-remitting MS patients. Some neurologists prefer to conduct this at the inaugural visit to provide more information about disease behaviour and potential planning that might entail, while others may defer any discussion about this phase, as there is no clear consensus for it and it can be a sensitive topic, with concern that too early a discussion could worsen anxiety and discourage or delay decisions regarding disease modifying treatments. Furthermore, it is unknown at onset which patients will transition to a progressive phenotype. This review and opinion paper will outline some of the opportunities and challenges associated with such a disclosure, and attempt to provide a balanced, patient-centred approach to address this delicate topic.
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Affiliation(s)
- Eslam Shosha
- Neurology division, Department of Medicine, McMaster University, Hamilton Health Science Center, 237 Barton st, E, Room 436, Hamilton, ON L8L 2X2, Canada.
| | - Jodie M Burton
- Department of clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Canada
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Craner M, Al Malik Y, Babtain FA, Alshamrani F, Alkhawajah MM, Alfugham N, Al-Yafeai RH, Aljarallah S, Makkawi S, Qureshi S, Ziehn M, Wahba H. Unmet Needs and Treatment of Relapsing-Remitting Multiple Sclerosis in Saudi Arabia: Focus on the Role of Ofatumumab. Neurol Ther 2022; 11:1457-1473. [PMID: 36048334 PMCID: PMC9434517 DOI: 10.1007/s40120-022-00401-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/17/2022] [Indexed: 12/13/2022] Open
Abstract
Treatment-pattern data suggest that some patients with multiple sclerosis (MS) in the Kingdom of Saudi Arabia (KSA) may not be receiving optimal treatment. A virtual meeting of ten expert Saudi neurologists, held on October 23, 2020, discussed unmet needs in relapsing-remitting MS (RRMS), and the role of ofatumumab as a suitable treatment in the KSA. Multiple unmet needs were identified: poor quality of life, with high rates of depression and anxiety; a negative impact of MS on work ability; treatment choices that may compromise efficacy for safety or vice versa; inconvenient or complex dosage regimens; and limited access to patient education and support. Early use of highly effective disease-modifying treatments (DMTs) results in better patient outcomes than starting with less effective treatments and downstream escalation, but this strategy may be underutilized in the KSA. B cells are important in MS pathogenesis, and treatments targeting these may improve clinical outcomes. Ofatumumab differs from other B cell-depleting therapies, being a fully human monoclonal antibody that binds to CD20 at a completely separate site from the epitope bound by ocrelizumab, and being administered by subcutaneous injection. When compared with teriflunomide in two randomized, phase 3 clinical trials in patients with RRMS, ofatumumab was associated with significant reductions in annualized relapse rates, rates of confirmed disability worsening, and active lesions on magnetic resonance imaging. The incidence of adverse events, including serious infections, was similar with the two treatments. Ofatumumab is a valuable first- or second-line treatment option for RRMS in the KSA, particularly for patients who would benefit from highly effective DMTs early in the disease course, and for those who prefer the convenience of self-injection. Future research will clarify the position of ofatumumab in RRMS treatment, and comparative cost data may support the broad inclusion of ofatumumab in formularies across the KSA.
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Affiliation(s)
- Matthew Craner
- grid.4991.50000 0004 1936 8948Neurosciences Department, University of Oxford, Oxford, UK
| | - Yaser Al Malik
- grid.412149.b0000 0004 0608 0662College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,grid.452607.20000 0004 0580 0891King Abdullah International Medical Research Center, Riyadh, Saudi Arabia ,grid.415254.30000 0004 1790 7311Division of Neurology, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Fawzi A. Babtain
- grid.415310.20000 0001 2191 4301King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Foziah Alshamrani
- grid.411975.f0000 0004 0607 035XDepartment of Neurology, College of Medicine, Imam Abdulrahman bin Faisal University, Al Khobar, Saudi Arabia
| | - Mona M. Alkhawajah
- grid.415310.20000 0001 2191 4301King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Nora Alfugham
- grid.415310.20000 0001 2191 4301King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Salman Aljarallah
- grid.56302.320000 0004 1773 5396College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Seraj Makkawi
- grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia ,grid.452607.20000 0004 0580 0891King Abdullah International Medical Research Centre, Jeddah, Saudi Arabia ,Department of Medicine, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
| | | | - Marina Ziehn
- grid.419481.10000 0001 1515 9979Global Medical Affairs, Novartis AG, Basel, Switzerland
| | - Hazem Wahba
- Medical Affairs/Real World Evidence, Novartis, Saudi Arabia ,Novartis Saudi Ltd., SERVCORP Laysen Valley, Building No. 13, Intersection King Khalid and Orouba Road, Riyadh, Saudi Arabia
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The Brave New World of Early Treatment of Multiple Sclerosis: Using the Molecular Biomarkers CXCL13 and Neurofilament Light to Optimize Immunotherapy. Biomedicines 2022; 10:biomedicines10092099. [PMID: 36140203 PMCID: PMC9495360 DOI: 10.3390/biomedicines10092099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
Multiple sclerosis (MS) is a highly heterogeneous disease involving a combination of inflammation, demyelination, and CNS injury. It is the leading cause of non-traumatic neurological disability in younger people. There is no cure, but treatments in the form of immunomodulatory drugs (IMDs) are available. Experience over the last 30 years has shown that IMDs, also sometimes called disease-modifying therapies, are effective in downregulating neuroinflammatory activity. However, there are a number of negatives in IMD therapy, including potential for significant side-effects and adverse events, uncertainty about long-term benefits regarding disability outcomes, and very high and increasing financial costs. The two dozen currently available FDA-approved IMDs also are heterogeneous with respect to efficacy and safety, especially long-term safety, and determining an IMD treatment strategy is therefore challenging for the clinician. Decisions about optimal therapy have been particularly difficult in early MS, at the time of the initial clinical demyelinating event (ICDE), at a time when early, aggressive treatment would best be initiated on patients destined to have a highly inflammatory course. However, given the fact that the majority of ICDE patients have a more benign course, aggressive immunosuppression, with its attendant risks, should not be administered to this group, and should only be reserved for patients with a more neuroinflammatory course, a decision that can only be made in retrospect, months to years after the ICDE. This quandary of moderate vs. aggressive therapy facing clinicians would best be resolved by the use of biomarkers that are predictive of future neuroinflammation. Unfortunately, biomarkers, especially molecular biomarkers, have not thus far been particularly useful in assisting clinicians in predicting the likelihood of future neuroinflammation, and thus guiding therapy. However, the last decade has seen the emergence of two highly promising molecular biomarkers to guide therapy in early MS: the CXCL13 index and neurofilament light. This paper will review the immunological and neuroscientific underpinnings of these biomarkers and the data supporting their use in early MS and will propose how they will likely be used to maximize benefit and minimize risk of IMDs in MS patients.
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Rotstein D, Solomon JM, Sormani MP, Montalban X, Ye XY, Dababneh D, Muccilli A, Shah P. Association of No Evidence of Disease Activity With No Long-term Disability Progression in Multiple Sclerosis: A Systematic Review and Meta-analysis. Neurology 2022; 99:e209-e220. [PMID: 35473761 DOI: 10.1212/wnl.0000000000200549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 03/02/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We conducted a systematic review and meta-analysis to evaluate the relationship between no evidence of disease activity (NEDA) and no long-term disability progression on low- and high-efficacy therapy in relapsing-remitting multiple sclerosis (RRMS). METHODS MEDLINE, Embase, and the Cochrane Database were searched from January 1, 2006, to January 26, 2021. We selected studies that evaluated NEDA-3 (no relapse, new MRI lesion, or confirmed disability progression) at 1 or 2 years and had a minimum of 4 years of follow-up for determination of disability progression. Data were extracted by 2 independent reviewers and were meta-analyzed with a random-effects model. Primary outcome of no disability progression was defined as no confirmed progression on the Expanded Disability Status Scale during follow-up. We assessed the odds ratio (OR) for no disability progression with NEDA vs evidence of disease activity (EDA). Positive predictive value (PPV) of NEDA for no disability progression was summarized for studies with prevalence of no progression >80% vs ≤80% separately. RESULTS We included 29 studies in our qualitative synthesis, of which 27 (16 low efficacy, 11 high efficacy) were included in the meta-analysis (N = 10,935 participants). Median follow-up was 5.6 years (interquartile range 4.3-8.0 years). The pooled ORs for no progression with NEDA-3 vs EDA were 2.32 (95% CI 1.58-3.42; I 2 = 73%) for low-efficacy therapy and 3.19 (95% CI 1.86-5.47; I 2 = 86%) for high-efficacy therapy. Among studies with prevalence of no progression at follow-up >80%, the pooled PPV for low efficacy therapy was 91% (95% CI 89%-93%) and for high-efficacy therapy was 92% (95% CI 88%-94%). Among studies with prevalence of no progression ≤80%, the pooled PPV for low-efficacy therapy was 81% (95% CI 75%-86%) and for high-efficacy therapy was 86% (95% CI 80%-90%). DISCUSSION NEDA-3 is associated with no long-term disability progression in RRMS on both low- and high-efficacy therapies. Further studies of early composite outcome measures incorporating easily measurable biomarkers and longer follow-up may help to improve the prognostic value of NEDA-3 in RRMS. TRIAL REGISTRATION INFORMATION International Prospective Register of Systematic Reviews Identifier: CRD42020189316.
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Affiliation(s)
- Dalia Rotstein
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada.
| | - Jacqueline Madeleine Solomon
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Maria Pia Sormani
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Xavier Montalban
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Xiang Y Ye
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Dina Dababneh
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Alexandra Muccilli
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
| | - Prakesh Shah
- From the Department of Medicine (D.R., A.M.), University of Toronto; St. Michael's Hospital (D.R., A.M.), Toronto; Department of Medicine (J.M.S.), McMaster University, Hamilton, Ontario, Canada; Section of Biostatistics (M.P.S.), Department of Health Sciences, University of Genova; IRCCS Ospedale Policlinico San Martino (M.P.S.), Genova, Italy; Department of Neurology (X.M.), Cemcat, Hospital Universitari Vall d-Hebron, Universitat Autonoma de Barcelona, Spain; Department of Pediatrics (X.Y.Y., P.S.), Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Neurology (D.D.), Columbia University Irving Medical Center; New York Presbyterian Hospital (D.D.), New York City; and Institute of Health, Policy, Management and Evaluation (P.S.), University of Toronto, Ontario, Canada
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A Targeted Literature Search and Phenomenological Review of Perspectives of People with Multiple Sclerosis and Healthcare Professionals of the Immunology of Disease-Modifying Therapies. Neurol Ther 2022; 11:955-979. [PMID: 35608740 PMCID: PMC9127487 DOI: 10.1007/s40120-022-00349-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/25/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction The mechanisms of action of disease-modifying therapies (DMTs) for multiple sclerosis (MS) are complex and involve an interplay of immune system components. People with MS (PwMS) may lack a clear understanding of the immunological pathways involved in MS and its treatment; effective communication between healthcare professionals (HCPs) and PwMS is needed to facilitate shared decision-making when discussing the disease and selecting DMTs and is particularly important in the coronavirus disease 2019 (COVID-19) era. Methods In this patient-authored two-part review, we performed a targeted literature search to assess the need for better communication between HCPs and PwMS regarding treatment selection, and also conducted a qualitative survey of four patient and care-partner authors to obtain insights regarding their understanding of and preferences for the treatment and management of MS. Results Following a search of the Embase and MEDLINE databases using Ovid in June 2020, an analysis of 40 journal articles and conference abstracts relating to patient empowerment and decision-making in DMT selection for MS showed a preference for safety and efficacy of treatments, followed by autonomy and convenience of administration. A need for better communication between HCPs and PwMS during treatment selection to improve patient satisfaction was also identified. The open survey responses from the patient authors revealed a need for greater involvement in decision-making processes and desire for improved communication and information tools. Conclusions This targeted literature search and phenomenological review confirms PwMS preferences for empowered decision-making in disease management and treatment selection, to optimize independence, safety, and efficacy. It also identifies an unmet need for improved communication and information tools that convey MS information in a relatable manner. Furthermore, this review seeks to address this unmet need by providing plain language figures and descriptions of MS immune mechanisms that can be used to facilitate discussions between HCPs and PwMS. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00349-5. In multiple sclerosis (MS), there are different cells in the immune system that contribute to the disease. The main cells in the immune system are T and B cells. People with MS (PwMS) might not be familiar with details about the immune system, and healthcare professionals might not always communicate details about how treatments work clearly to PwMS when choosing treatments with them. It is important for PwMS to have all the information they need to help make decisions about treatments. This information needs to be given in a way they can understand. This is especially important during the coronavirus disease 2019 (COVID-19) pandemic. In this paper, we first looked at what research has already been published about what is most important to PwMS when making treatment decisions. The existing research says that safety and effectiveness are the most important things and that PwMS prefer treatments that they can take themselves. PwMS also need better communication and information from doctors to make decisions and to help explain how MS treatments work in the body. Next, we gave a survey to the patients who are authors of this paper to ask about what is important to them when making treatment decisions. Their answers were very similar to the existing research. Overall, PwMS need better communication from healthcare professionals about the immune system. This paper also includes plain language descriptions and figures to help healthcare professionals explain and discuss the importance of the immune system in MS with PwMS.
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Zhang Y, Cofield S, Cutter G, Krieger S, Wolinsky JS, Lublin F. Predictors of Disease Activity and Worsening in Relapsing-Remitting Multiple Sclerosis. Neurol Clin Pract 2022; 12:e58-e65. [DOI: 10.1212/cpj.0000000000001177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives:Disease activity in multiple sclerosis (MS) is highly variable, and there are limited prospective studies on predictors of disease outcomes. The goal of the study is to identify and assess patient characteristics in MS that predict disease activity and worsening.Methods:The study population consisted of a prospective cohort of 1,008 participants with relapsing-remitting (RR) onset MS enrolled in the CombiRx trial. Cox regression analysis was used to determine hazard ratio (HR) associations between baseline (BL) demographics, clinical history, MRI metrics, and treatment; with outcomes of time to first new disease activity over up to 7-years of follow-up including relapse, MRI activity, and disease worsening.Results:1,008 participants were randomized, with 959 eligible for assessment of disease activity and worsening on follow-up. In the multivariable models, risk of relapse was higher in participants younger than 38 at BL vs. older (HR range 1.36-1.43), with presence of Gd+ lesions at baseline (HR 1.38, [95%CI: 1.14, 1.67]), and with BL EDSS ≥3.5 vs. <3.5 (HR range 1.63-1.67). Risk of new MRI activity was higher in younger participants (HR range 1.58-1.84), with higher preexisting lesion counts greater than the median lesion count with ≥71 T2 hyperintense lesions vs. <71 (HR 1.50, [95%CI 1.27, 1.77]), with presence of BL Gd+ lesions (HR 1.75, [95%CI: 1.49, 2.06]), and higher baseline T2 lesion volume (HR 1.02 for every unit increase in baseline volume, [95% CI 1.01, 1.03]). Risk of new MRI activity was lower in those receiving combination therapy compared to either GA (HR range 0.67-0.68) or IFN (HR range 0.68-0.70). Risk of disease worsening was higher for those with higher T2 volume (HR for 1 unit increase in volume 1.01, 95% CI 1.004, 1.03) and BL EDSS <2 (HR range 2.79-2.96). There were no associations between sex, race, and disease duration on relapse, MRI activity, or disease worsening in multivariable analysis.Conclusion:Prospective data from a large clinical trial cohort shows that younger MS patients with high baseline relapses and MRI lesion burden have the highest risk of subsequent disease activity.CombiRx was registered at ClinicalTrials.gov (NCT00211887) on September 21, 2005. Study enrollment began in January 2005.
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20
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Ziemssen T, Arnold DL, Alvarez E, Cross AH, Willi R, Li B, Kukkaro P, Kropshofer H, Ramanathan K, Merschhemke M, Kieseier B, Su W, Häring DA, Hauser SL, Kappos L, Kuhle J. Prognostic Value of Serum Neurofilament Light Chain for Disease Activity and Worsening in Patients With Relapsing Multiple Sclerosis: Results From the Phase 3 ASCLEPIOS I and II Trials. Front Immunol 2022; 13:852563. [PMID: 35432382 PMCID: PMC9009385 DOI: 10.3389/fimmu.2022.852563] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/07/2022] [Indexed: 11/27/2022] Open
Abstract
Objective This study aims to confirm the prognostic value of baseline serum neurofilament light chain (sNfL) for on-study disease activity and worsening in patients with relapsing MS (RMS). Background Previous post-hoc studies suggested that sNfL could be a prognostic biomarker in RMS. In the phase 3 ASCLEPIOS I/II trials in which ofatumumab demonstrated better efficacy outcomes than teriflunomide, treatment with ofatumumab also led to significantly reduced sNfL levels compared to teriflunomide treatment. Design/Methods In this study, we report protocol-planned analyses from the pooled ASCLEPIOS I/II trials (N=1882). Per protocol, patients were stratified by median baseline sNfL levels (9.3 pg/ml) into high (>median) and low (≤median) categories to prognosticate: annualized rate of new/enlarging T2 (neT2) lesions in year 1 and 2, annualized relapse rate, annual percentage change in whole brain (WB) and regional brain volume [thalamus, white matter (WM), cortical gray matter (cGM)], and disability outcomes. Similar analyses were performed for the recently diagnosed (within 3 years), treatment-naive patients (no prior disease-modifying therapy) subgroup. Results High versus low sNfL at baseline was prognostic of increased on-study T2 lesion formation at year 1 (relative increase: ofatumumab +158%; teriflunomide +69%, both p<0.001), which persisted in year 2 (+65%, p=0.124; +46%, p=0.003); of higher annual percentage change of WB volume (ofatumumab, −0.32% vs. −0.24%, p=0.044, and teriflunomide, −0.43% vs. −0.29%, p=0.002), thalamic volume (−0.56% vs. −0.31%, p=0.047 and −0.94% vs. −0.49%, p<0.001), and WM volume (−0.30% vs. −0.19%, p=0.083 and −0.38% vs. −0.18%, p=0.003) but not of cGM volume (−0.39% vs. −0.32%, p=0.337 and −0.49% vs. −0.46%, p=0.563). A single sNfL assessment at baseline was not prognostic for on-study relapses or disability worsening. Results were similar in the subgroup of recently diagnosed, treatment-naive patients. Conclusion This study confirms that baseline sNfL levels are prognostic of future on-study lesion formation and whole brain and regional atrophy in all RMS patients, including recently diagnosed, treatment-naive patients.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Clinic Carl-Gustav Carus, Dresden, Germany
- *Correspondence: Tjalf Ziemssen,
| | - Douglas L. Arnold
- Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
- NeuroRx Research, Montreal, QC, Canada
| | - Enrique Alvarez
- Department of Neurology, Rocky Mountain MS Center at the University of Colorado, Aurora, CO, United States
| | - Anne H. Cross
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, United States
| | | | - Bingbing Li
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | | | | | | | | | | | - Wendy Su
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | | | - Stephen L. Hauser
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic and MS Center, Department of Head, Spine and Neuromedicine, University Hospital Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Jens Kuhle
- Neurologic Clinic and Policlinic and MS Center, Department of Head, Spine and Neuromedicine, University Hospital Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
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Massey J, Jackson K, Singh M, Hughes B, Withers B, Ford C, Khoo M, Hendrawan K, Zaunders J, Charmeteau-De Muylder B, Cheynier R, Luciani F, Ma D, Moore J, Sutton I. Haematopoietic Stem Cell Transplantation Results in Extensive Remodelling of the Clonal T Cell Repertoire in Multiple Sclerosis. Front Immunol 2022; 13:798300. [PMID: 35197974 PMCID: PMC8859174 DOI: 10.3389/fimmu.2022.798300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/13/2022] [Indexed: 12/29/2022] Open
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is a vital therapeutic option for patients with highly active multiple sclerosis (MS). Rates of remission suggest AHSCT is the most effective form of immunotherapy in controlling the disease. Despite an evolving understanding of the biology of immune reconstitution following AHSCT, the mechanism by which AHSCT enables sustained disease remission beyond the period of lymphopenia remains to be elucidated. Auto-reactive T cells are considered central to MS pathogenesis. Here, we analyse T cell reconstitution for 36 months following AHSCT in a cohort of highly active MS patients. Through longitudinal analysis of sorted naïve and memory T cell clones, we establish that AHSCT induces profound changes in the dominant T cell landscape of both CD4+ and CD8+ memory T cell clones. Lymphopenia induced homeostatic proliferation is followed by clonal attrition; with only 19% of dominant CD4 (p <0.025) and 13% of dominant CD8 (p <0.005) clones from the pre-transplant repertoire detected at 36 months. Recovery of a thymically-derived CD4 naïve T cell repertoire occurs at 12 months and is ongoing at 36 months, however diversity of the naïve populations is not increased from baseline suggesting the principal mechanism of durable remission from MS after AHSCT relates to depletion of putative auto-reactive clones. In a cohort of MS patients expressing the MS risk allele HLA DRB1*15:01, public clones are probed as potential biomarkers of disease. AHSCT appears to induce sustained periods of disease remission with dynamic changes in the clonal T cell repertoire out to 36 months post-transplant.
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Affiliation(s)
- Jennifer Massey
- Department of Haematology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Department of Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Blood Stem Cell and Cancer Research Group, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
- St. Vincent’s Clinical School, Faculty of Medicine, University of New South Wales (UNSW), Darlinghurst, NSW, Australia
- *Correspondence: Jennifer Massey,
| | - Katherine Jackson
- Immunogenomics Lab, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Mandeep Singh
- St. Vincent’s Clinical School, Faculty of Medicine, University of New South Wales (UNSW), Darlinghurst, NSW, Australia
- Immunogenomics Lab, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Brendan Hughes
- School of Medical Sciences and Kirby Institute for Infection and Immunity, University of New South Wales (UNSW), Kensington, NSW, Australia
| | - Barbara Withers
- Department of Haematology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Blood Stem Cell and Cancer Research Group, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
- St. Vincent’s Clinical School, Faculty of Medicine, University of New South Wales (UNSW), Darlinghurst, NSW, Australia
| | - Carole Ford
- Blood Stem Cell and Cancer Research Group, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Melissa Khoo
- Blood Stem Cell and Cancer Research Group, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Kevin Hendrawan
- Blood Stem Cell and Cancer Research Group, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - John Zaunders
- Immunology Laboratory, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | | | - Rémi Cheynier
- Université de Paris, INSERM, CNRS, Institut Cochin, Paris, France
| | - Fabio Luciani
- School of Medical Sciences and Kirby Institute for Infection and Immunity, University of New South Wales (UNSW), Kensington, NSW, Australia
| | - David Ma
- Department of Haematology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Blood Stem Cell and Cancer Research Group, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
- St. Vincent’s Clinical School, Faculty of Medicine, University of New South Wales (UNSW), Darlinghurst, NSW, Australia
| | - John Moore
- Department of Haematology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Blood Stem Cell and Cancer Research Group, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
- St. Vincent’s Clinical School, Faculty of Medicine, University of New South Wales (UNSW), Darlinghurst, NSW, Australia
| | - Ian Sutton
- St. Vincent’s Clinical School, Faculty of Medicine, University of New South Wales (UNSW), Darlinghurst, NSW, Australia
- Department of Neurology, St Vincent’s Clinic, Darlinghurst, NSW, Australia
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Casanova B, Quintanilla-Bordás C, Gascón F. Escalation vs. Early Intense Therapy in Multiple Sclerosis. J Pers Med 2022; 12:jpm12010119. [PMID: 35055434 PMCID: PMC8778390 DOI: 10.3390/jpm12010119] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/28/2021] [Accepted: 01/01/2022] [Indexed: 02/01/2023] Open
Abstract
The treatment strategy of multiple sclerosis (MS) is a highly controversial debate. Currently, there are up to 19 drugs approved. However, there is no clear evidence to guide fundamental decisions such as what treatment should be chosen in first place, when treatment failure or suboptimal response should be considered, or what treatment should be considered in these cases. The “escalation strategy” consists of starting treatment with drugs of low side-effect profile and low efficacy, and “escalating” to drugs of higher efficacy—with more potential side-effects—if necessary. This strategy has prevailed over the years. However, the evidence supporting this strategy is based on short-term studies, in hope that the benefits will stand in the long term. These studies usually do not consider the heterogeneity of the disease and the limited effect that relapses have on the long-term. On the other hand, “early intense therapy” strategy refers to starting treatment with drugs of higher efficacy from the beginning, despite having a less favorable side-effect profile. This approach takes advantage of the so-called “window of opportunity” in hope to maximize the clinical benefits in the long-term. At present, the debate remains open. In this review, we will critically review both strategies. We provide a summary of the current evidence for each strategy without aiming to reach a definite conclusion.
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Affiliation(s)
- Bonaventura Casanova
- Unitat de Neuroimmunologia, Hospital Universitari i Politècnic La Fe. València, la Universitat de València, 46026 Valencia, Spain;
- Correspondence:
| | - Carlos Quintanilla-Bordás
- Unitat de Neuroimmunologia, Hospital Universitari i Politècnic La Fe. València, la Universitat de València, 46026 Valencia, Spain;
| | - Francisco Gascón
- Unitat de Neuroimmunologia, Hospital Clínic Universitari de València, 46010 Valencia, Spain;
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Experiences in treatment of multiple sclerosis with natalizumab from a real-life cohort over 15 years. Sci Rep 2021; 11:23317. [PMID: 34857795 PMCID: PMC8639988 DOI: 10.1038/s41598-021-02665-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/16/2021] [Indexed: 11/29/2022] Open
Abstract
Natalizumab (NTZ) has been used for treatment of highly active relapsing–remitting multiple sclerosis (MS). When stopping NTZ the risk of severe rebound phenomenon has to be considered. We aimed to investigate the use of NTZ in clinical routine and focused on identification of potential risk factors for disease reactivation after treatment discontinuation. At the Medical University of Innsbruck, Austria, we identified all MS patients who were treated with NTZ and performed a retrospective analysis on therapeutic decision making, disease course before, during and after treatment with NTZ and on risk factors for disease reactivation after NTZ discontinuation. 235 NTZ treated MS patients were included, of whom 105 had discontinued treatment. At NTZ start disease duration was 5.09 (IQR 2.09–10.57) years, average number of total relapses was 4 (IQR 3–6) and median EDSS 2.0 (range 0–6.5), whereby these values significantly decreased over time. Reduction of annualized relapse rate (ARR) on treatment was 93% and EDSS remained stable in 64%. In multivariate regression models only conversion to secondary progressive MS (SPMS) on treatment was significantly associated with lower risk of disease reactivation after NTZ, while ARR before treatment was associated with earlier disease reactivation. We could confirm the high therapeutic efficacy of NTZ which trends to be used earlier in the disease course nowadays. Discontinuation of NTZ seems safe only in patients who convert to SPMS during treatment, while higher ARR before NTZ increases the risk of disease reactivation after treatment discontinuation.
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Filippi M, Danesi R, Derfuss T, Duddy M, Gallo P, Gold R, Havrdová EK, Kornek B, Saccà F, Tintoré M, Weber J, Trojano M. Early and unrestricted access to high-efficacy disease-modifying therapies: a consensus to optimize benefits for people living with multiple sclerosis. J Neurol 2021; 269:1670-1677. [PMID: 34626224 PMCID: PMC8501364 DOI: 10.1007/s00415-021-10836-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 02/05/2023]
Abstract
Early intervention with high-efficacy disease-modifying therapy (HE DMT) may be the best strategy to delay irreversible neurological damage and progression of multiple sclerosis (MS). In European healthcare systems, however, patient access to HE DMTs in MS is often restricted to later stages of the disease due to restrictions in reimbursement despite broader regulatory labels. Although not every patient should be treated with HE DMTs at the initial stages of the disease, early and unrestricted access to HE DMTs with a positive benefit-risk profile and a reasonable value proposition will provide the freedom of choice for an appropriate treatment based on a shared decision between expert physicians and patients. This will further optimize outcomes and facilitate efficient resource allocation and sustainability in healthcare systems and society.
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Affiliation(s)
- Massimo Filippi
- Neurology Unit, Neurorehabilitation Unit, Neurophysiology Service, and Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | | | | | - Martin Duddy
- The Newcastle Upon Tyne Hospitals, Newcastle upon Tyne, UK
| | | | - Ralf Gold
- Ruhr-Universität Bochum, Bochum, Germany
| | - Eva Kubala Havrdová
- Department of Neurology, First Medical Faculty, Charles University, Prague, Czech Republic
| | | | - Francesco Saccà
- Università Degli Studi Di Napoli 'Federico II', Naples, Italy
| | - Mar Tintoré
- MS Centre of Catalonia at the Hospital Vall d'Hebron, Barcelona, Spain
| | - Jörg Weber
- Klinikum Klagenfurt,, Klagenfurt am Wörthersee, Austria
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Uher T, Havrdova EK, Benkert P, Bergsland N, Krasensky J, Srpova B, Dwyer M, Tyblova M, Meier S, Vaneckova M, Horakova D, Zivadinov R, Leppert D, Kalincik T, Kuhle J. Measurement of neurofilaments improves stratification of future disease activity in early multiple sclerosis. Mult Scler 2021; 27:2001-2013. [PMID: 34612753 DOI: 10.1177/13524585211047977] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The added value of neurofilament light chain levels in serum (sNfL) to the concept of no evidence of disease activity-3 (NEDA-3) has not yet been investigated in detail. OBJECTIVE To assess whether combination of sNfL with NEDA-3 status improves identification of patients at higher risk of disease activity during the following year. METHODS We analyzed 369 blood samples from 155 early relapsing-remitting MS patients on interferon beta-1a. We compared disease activity, including the rate of brain volume loss in subgroups defined by NEDA-3 status and high or low sNfL (> 90th or < 90th percentile). RESULTS In patients with disease activity (EDA-3), those with higher sNFL had higher odds of EDA-3 in the following year than those with low sNFL (86.5% vs 57.9%; OR = 4.25, 95% CI: [2.02, 8.95]; p = 0.0001) and greater whole brain volume loss during the following year (β = -0.36%; 95% CI = [-0.60, -0.13]; p = 0.002). Accordingly, NEDA-3 patients with high sNfL showed numerically higher disease activity (EDA-3) in the following year compared with those with low sNfL (57.1% vs 31.1%). CONCLUSION sNfL improves the ability to identify patients at higher risk of future disease activity, beyond their NEDA-3 status. Measurement of sNfL may assist clinicians in decision-making by providing more sensitive prognostic information.
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Affiliation(s)
- Tomas Uher
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Katerinska 30, 120 00 Prague, Czech Republic.,Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic/CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pascal Benkert
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA/IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Jan Krasensky
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Barbora Srpova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Michael Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Michaela Tyblova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Stephanie Meier
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Manuela Vaneckova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA/Center for Biomedical Imaging, Clinical and Translational Science Institute, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - David Leppert
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tomas Kalincik
- CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Melbourne MS Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, University of Basel, Basel, Switzerland
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Hartung HP, Meuth SG, Thompson AJ. Paradigm shifts: Early initiation of high-efficacy disease-modifying treatment in multiple sclerosis. Mult Scler 2021; 27:1473-1476. [PMID: 34472985 DOI: 10.1177/13524585211033190] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany/Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia; Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Alan J Thompson
- Queen Square MS Centre, UCL Institute of Neurology, London, UK
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Ziemssen T, Hoffmann F, Richter S, Engelmann U, White R. Alemtuzumab in a Large Real-Life Cohort: Interim Baseline Data of the TREAT-MS Study. Front Neurol 2021; 12:620758. [PMID: 34421780 PMCID: PMC8375470 DOI: 10.3389/fneur.2021.620758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
The non-interventional long-Term study foR obsErvAtion of Treatment with alemtuzumab in active relapsing-remitting MS (TREAT-MS) study collects the so far largest real-life cohort regarding utilization, long-term effectiveness, and safety of alemtuzumab, a humanized monoclonal antibody directed against the cell surface glycoprotein CD52, in adult patients with active relapsing-remitting multiple sclerosis (RRMS). An interim analysis of baseline parameters at inclusion of a non-interventional real-world study about alemtuzumab in Germany including previous multiple sclerosis (MS) medication utilization, MS activity, severity, and duration, as well as comorbidities was performed. Of the 883 patients, 71.6% were women. Mean age was 35.7 ± 9.2 years, time since first MS symptoms (=disease duration) is 8.0 ± 6.8 years, and Expanded Disability Status Scale (EDSS) is 2.7 ± 1.8 points (range, 0.0-7.5 points). The number of relapses in the 12 and 24 months prior to inclusion were 1.6 ± 1.2 and 2.2 ± 1.8, respectively. Of the patients, 14.4% were treatment naive, while for the majority, a wide spectrum of MS disease-modifying treatments (DMTs) and treatment sequences were documented. Overall, interferon beta (IFN-beta) was reported most frequently (52.4%), followed by fingolimod (35.2%), natalizumab (34.9%), and glatiramer acetate (28.9%). Patients with longer disease duration and higher EDSS had a higher number of previous DMTs. Compared to the pivotal phase 2/3 studies, RRMS patients starting alemtuzumab treatment had a longer disease duration in real-world conditions. There was variety of different treatment sequences before the final switch to alemtuzumab. In the future, linking these treatment sequences or other baseline characteristics with effectiveness and safety outcomes might be useful to support treatment decisions. Registered at Paul-Ehrlich-Institut under NIS 281.
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Affiliation(s)
- Tjalf Ziemssen
- Department of Neurology, Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Frank Hoffmann
- Klinik für Neurologie, Krankenhaus Martha-Maria Halle-Doelau, Halle (Saale), Germany
| | - Stephan Richter
- Zentrum für Neurologie und Psychiatrie, MIND, Stuttgart, Germany
| | - Ulrich Engelmann
- Medical Affairs, Sanofi-Aventis Deutschland GmbH, Neu-Isenburg, Germany
| | - Robin White
- Medical Affairs, Sanofi-Aventis Deutschland GmbH, Neu-Isenburg, Germany
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Abstract
Autoimmune neurogenic dysphagia refers to manifestation of dysphagia due to autoimmune diseases affecting muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. Dysphagia is either part of the evolving clinical symptomatology of an underlying neurological autoimmunity or occurs as a sole manifestation, acutely or insidiously. This opinion article reviews the autoimmune neurological causes of dysphagia, highlights clinical clues and laboratory testing that facilitate early diagnosis, especially when dysphagia is the presenting symptom, and outlines the most effective immunotherapeutic approaches. Dysphagia is common in inflammatory myopathies, most prominently in inclusion body myositis, and is frequent in myasthenia gravis, occurring early in bulbar-onset disease or during the course of progressive, generalized disease. Acute-onset dysphagia is often seen in Guillain–Barre syndrome variants and slowly progressive dysphagia in paraneoplastic neuropathies highlighted by the presence of specific autoantibodies. The most common causes of CNS autoimmune dysphagia are demyelinating and inflammatory lesions in the brainstem, occurring in patients with multiple sclerosis and neuromyelitis optica spectrum disorders. Less common, but often overlooked, is dysphagia in stiff-person syndrome especially in conjunction with cerebellar ataxia and high anti-GAD autoantibodies, and in gastrointestinal dysmotility syndromes associated with autoantibodies against the ganglionic acetyl-choline receptor. In the setting of many neurological autoimmunities, acute-onset or progressive dysphagia is a potentially treatable condition, requiring increased awareness for prompt diagnosis and early immunotherapy initiation.
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29
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Frisch ES, Pretzsch R, Weber MS. A Milestone in Multiple Sclerosis Therapy: Monoclonal Antibodies Against CD20-Yet Progress Continues. Neurotherapeutics 2021; 18:1602-1622. [PMID: 33880738 PMCID: PMC8609066 DOI: 10.1007/s13311-021-01048-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 02/04/2023] Open
Abstract
Multiple sclerosis (MS), which is a chronic inflammatory disease of the central nervous system, still represents one of the most common causes of persisting disability with an early disease onset. Growing evidence suggests B cells to play a crucial role in its pathogenesis and progression. Over the last decades, monoclonal antibodies (mabs) against the surface protein CD20 have been intensively studied as a B cell targeting therapy in relapsing MS (RMS) as well as primary progressive MS (PPMS). Pivotal studies on anti-CD20 therapy in RMS showed remarkable clinical and radiological effects, especially on acute inflammation and relapse biology. These results paved the way for further research on the implication of B cells in the pathogenesis of MS. Besides controlling relapse development in RMS, ocrelizumab (OCR) also showed clinical benefits in patients with PPMS and became the first approved drug for this disease course. In this review, we provide an overview of the current anti-CD20 mabs used or tested for the treatment of MS-namely rituximab (RTX), OCR, ofatumumab (OFA), and ublituximab (UB). Besides their effectiveness, we also discuss possible limitations and safety concerns especially in regard to long-term treatment, both for this class of drugs overall as well as for each anti-CD20 mab individually. Additionally, we elucidate to what extent anti-CD20 therapy may alter the function of other immune cells, both directly or indirectly. Finally, we cover the current knowledge on repopulation of CD20+ cells after cessation of anti-CD20 treatment and discuss future aspirations towards alternative, further developed B cell silencing therapies.
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MESH Headings
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antigens, CD20/immunology
- B-Lymphocytes, Regulatory/drug effects
- B-Lymphocytes, Regulatory/immunology
- Clinical Trials as Topic/methods
- Humans
- Multiple Sclerosis/drug therapy
- Multiple Sclerosis/immunology
- Multiple Sclerosis, Chronic Progressive/drug therapy
- Multiple Sclerosis, Chronic Progressive/immunology
- Multiple Sclerosis, Relapsing-Remitting/drug therapy
- Multiple Sclerosis, Relapsing-Remitting/immunology
- Rituximab/pharmacology
- Rituximab/therapeutic use
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Affiliation(s)
- Esther S Frisch
- Institute of Neuropathology, University Medical Center, Georg August University, 37099, Göttingen, Germany
- Department of Neurology, University Medical Center, Georg August University, 37099, Göttingen, Germany
| | - Roxanne Pretzsch
- Institute of Neuropathology, University Medical Center, Georg August University, 37099, Göttingen, Germany
- Department of Neurology, University Medical Center, Georg August University, 37099, Göttingen, Germany
| | - Martin S Weber
- Institute of Neuropathology, University Medical Center, Georg August University, 37099, Göttingen, Germany.
- Department of Neurology, University Medical Center, Georg August University, 37099, Göttingen, Germany.
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30
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Hunter SF, Aburashed RA, Alroughani R, Chan A, Dive D, Eichau S, Kantor D, Kim HJ, Lycke J, Macdonell RAL, Pozzilli C, Scott T, Sharrack B, Wiendl H, Chung L, Daizadeh N, Baker DP, Vermersch P. Confirmed 6-Month Disability Improvement and Worsening Correlate with Long-term Disability Outcomes in Alemtuzumab-Treated Patients with Multiple Sclerosis: Post Hoc Analysis of the CARE-MS Studies. Neurol Ther 2021; 10:803-818. [PMID: 34165694 PMCID: PMC8571457 DOI: 10.1007/s40120-021-00262-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/03/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction In the 2-year CARE-MS trials (NCT00530348; NCT00548405) in patients with relapsing–remitting multiple sclerosis, alemtuzumab showed superior efficacy versus subcutaneous interferon beta-1a. Efficacy was maintained in two consecutive extensions (NCT00930553; NCT02255656). This post hoc analysis compared disability outcomes over 9 years among alemtuzumab-treated patients according to whether they experienced confirmed disability improvement (CDI) or worsening (CDW) or neither CDI nor CDW. Methods CARE-MS patients were randomized to receive two alemtuzumab courses (12 mg/day; 5 days at baseline; 3 days at 12 months), with additional as-needed 3-day courses in the extensions. CDI or CDW were defined as ≥ 1.0-point decrease or increase, respectively, in Expanded Disability Status Scale (EDSS) score from core study baseline confirmed over 6 months, assessed in patients with baseline EDSS score ≥ 2.0. Improved or stable EDSS scores were defined as ≥ 1-point decrease or ≤ 0.5-point change (either direction), respectively, from core study baseline. Functional systems (FS) scores were also assessed. Results Of 511 eligible patients, 43% experienced CDI and 34% experienced CDW at any time through year 9 (patients experiencing both CDI and CDW were counted in each individual group); 29% experienced neither CDI nor CDW. At year 9, patients with CDI had a −0.58-point mean EDSS score change from baseline; 88% had stable or improved EDSS scores. Improvements occurred across all FS, primarily in sensory, pyramidal, and cerebellar domains. Patients with CDW had a +1.71-point mean EDSS score change; 16% had stable or improved EDSS scores. Patients with neither CDI nor CDW had a −0.10-point mean EDSS score change; 98% had stable or improved EDSS scores. Conclusion CDI achievement at any point during the CARE-MS studies was associated with improved disability at year 9, highlighting the potential of alemtuzumab to change the multiple sclerosis course. Conversely, CDW at any point was associated with worsened disability at year 9. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-021-00262-3.
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Affiliation(s)
- Samuel F Hunter
- Advanced Neurosciences Institute, 101 Forrest Crossing Blvd., Franklin, TN, 37064, USA.
| | - Rany A Aburashed
- Institute for Neurosciences and Multiple Sclerosis, Owosso, MI, USA
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Andrew Chan
- Department of Neurology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Seville, Spain
| | - Daniel Kantor
- Florida Atlantic University, Boca Raton, FL, USA.,Nova Southeastern University, Fort Lauderdale, FL, USA.,Penn Center for Global Health, Philadelphia, PA, USA
| | - Ho Jin Kim
- Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Richard A L Macdonell
- Austin Health and Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Carlo Pozzilli
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Thomas Scott
- Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, PA, USA
| | - Basil Sharrack
- Sheffield NIHR Neuroscience BRC and Sheffield Teaching Hospitals, Sheffield, UK
| | | | | | | | | | - Patrick Vermersch
- Univ. Lille, INSERM U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
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Natural history of relapsing remitting multiple sclerosis in a long-lasting cohort from a tertiary MS centre in Portugal. Mult Scler Relat Disord 2021; 54:103091. [PMID: 34246020 DOI: 10.1016/j.msard.2021.103091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 05/27/2021] [Accepted: 06/13/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Several disease-modifying therapies (DMTs) have emerged in the last two decades for the treatment of multiple sclerosis (MS). The increasing use of these therapies has enhanced the need to study its impact on long-term disease progression and on the natural history of MS. This study aimed to characterize a Portuguese MS patient cohort in what concerns the natural history of disease by exploring differences throughout 3 decades. METHODS Longitudinal, retrospective, non-interventional study. Patients aged ≥ 18 years old, with confirmed diagnosis of relapsing-remitting MS (RRMS), were included. Biodemographic and clinical characteristics (MS diagnosis, patient follow-up, relapses, treatment, and exams) were assessed and compared according to the first appointment date throughout 10-year spans (1987-1996; 1997-2006; 2007-2016). RESULTS 548 patients were included in this analysis. Significant differences were observed between decades for evoked potential (EP) and cerebrospinal fluid (CSF) exams conducted at diagnosis, the first with less expression on the last decade; the median number of relapses per year (higher in the subgroup 07-16); EDSS at baseline and at last appointment (both higher in the subgroup 87-96); and the percentage of patients achieving EDSS 3.0 and EDSS 6.0 (increased in the subgroup 87-96). Additionally, time from diagnosis to first treatment was significantly lower in patients from the most recent decade, and a greater percentage of such patients, compared to the other two subgroups, was, at last appointment, under a second line DMT. CONCLUSION In general, our study reflects findings from longitudinal studies on MS progression already published in the literature. In recent years, the growing number of more effective DMTs, along with earlier disease detection, and improvements in access to healthcare appear to have had a positive impact on patients' access to treatment and, consequently, disease progression. Additional studies, with increased follow up time, are needed to further investigate the effect of treatment improvement in the natural history of MS.
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Simonsen CS, Flemmen HØ, Broch L, Brunborg C, Berg-Hansen P, Moen SM, Celius EG. Early High Efficacy Treatment in Multiple Sclerosis Is the Best Predictor of Future Disease Activity Over 1 and 2 Years in a Norwegian Population-Based Registry. Front Neurol 2021; 12:693017. [PMID: 34220694 PMCID: PMC8248666 DOI: 10.3389/fneur.2021.693017] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/25/2021] [Indexed: 11/14/2022] Open
Abstract
Background: Moderate and high efficacy disease modifying therapies (DMTs) have a profound effect on disease activity. The current treatment guidelines only recommend high efficacy DMTs for patients with highly active MS. The objective was to examine the impact of initial treatment choice in achieving no evidence of disease activity (NEDA) at year 1 and 2. Methods: Using a real-world population-based registry with limited selection bias from the southeast of Norway, we determined how many patients achieved NEDA on moderate and high efficacy DMTs. Results: 68.0% of patients who started a high efficacy DMT as the first drug achieved NEDA at year 1 and 52.4% at year 2 as compared to 36.0 and 19.4% of patients who started a moderate efficacy DMT as a first drug. The odds ratio (OR) of achieving NEDA on high efficacy drugs compared to moderate efficacy drugs as a first drug at year 1 was 3.9 (95% CI 2.4–6.1, p < 0.001). The OR for high efficacy DMT as the second drug was 2.5 (95% CI 1.7–3.9, p < 0.001), and was not significant for the third drug. Patients with a medium or high risk of disease activity were significantly more likely to achieve NEDA on a high efficacy therapy as a first drug compared to moderate efficacy therapy as a first drug. Conclusions: Achieving NEDA at year 1 and 2 is significantly more likely in patients on high-efficacy disease modifying therapies than on moderate efficacy therapies, and the first choice of treatment is the most important. The immunomodulatory treatment guidelines should be updated to ensure early, high efficacy therapy for the majority of patients diagnosed with MS.
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Affiliation(s)
- Cecilia Smith Simonsen
- Department of Neurology, Vestre Viken Hospital Trust, Drammen, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Heidi Øyen Flemmen
- Department of Neurology, Telemark Hospital Trust, Skien, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Line Broch
- Department of Neurology, Vestre Viken Hospital Trust, Drammen, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Cathrine Brunborg
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Pål Berg-Hansen
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Elisabeth Gulowsen Celius
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Abstract
PURPOSE OF REVIEW To assess the reasons for considering discontinuation of disease-modifying therapies (DMTs)in patients with multiple sclerosis (MS). Relevant aspects of the natural history, pathology, and immunology are analyzed. RECENT FINDINGS A number of retrospective observational studies in aggregate indicate that stopping DMTs may be attempted in older individuals with stable disease. Prognostic factors have been identified informing about the risk of recurrence of disease activity after DMT discontinuation. SUMMARY Several clinical scenarios provide a rationale to stop DMTs in people with MS. Cumulative evidence has been gathered recently allowing us to more precisely weigh the risks against the benefits. This information aids in the decision process.
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Skeen MB, Pani L. Biomarkers and Surrogate End points in Multiple Sclerosis Trials: Regulatory Issues. J Clin Neurophysiol 2021; 38:181-185. [PMID: 33958568 DOI: 10.1097/wnp.0000000000000732] [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: 11/26/2022] Open
Abstract
SUMMARY Evoked potentials have assisted in the diagnosis of multiple sclerosis for years, but the potential to demonstrate pathophysiologic change has prompted a reconsideration of their potential role as outcome measures in clinical trials of multiple sclerosis. The use of any surrogate end point or biomarker in clinical trials requires a thorough understanding of that end point's performance characteristics and utility in a particular setting. This article explores regulatory issues regarding the use of biomarkers and surrogate end points in clinical trials of multiple sclerosis with particular emphasis on challenges faced by evoked potential studies.
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Affiliation(s)
- Mark B Skeen
- Department of Neurology, Division of Multiple Sclerosis and Neuroimmunology, Duke University Medical Center, Durham, North Carolina, U.S.A.; and
| | - Luca Pani
- Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, Florida, U.S.A
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Autologous hematopoietic stem cell transplantation in multiple sclerosis: a global approval and availability review. Bone Marrow Transplant 2021; 56:1754-1756. [PMID: 33824434 DOI: 10.1038/s41409-021-01276-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/21/2021] [Accepted: 03/18/2021] [Indexed: 11/09/2022]
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Green AJ. MRI findings in blinded trials should be available to treating physicians - Commentary. Mult Scler 2021; 27:816-817. [PMID: 33779363 DOI: 10.1177/13524585211003506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- A J Green
- Division of Neuroimmunology and Glial Biology, Department of Neurology, Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, CA, USA/Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA/School of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Boyko A, Therapontos C, Horakova D, Szilasiová J, Kalniņa J, Kolontareva J, Gross-Paju K, Selmaj K, Sereike I, Milo R, Gabelić T, Rot U. Approaches and challenges in the diagnosis and management of secondary progressive multiple sclerosis: A Central Eastern European perspective from healthcare professionals. Mult Scler Relat Disord 2021; 50:102778. [PMID: 33592384 DOI: 10.1016/j.msard.2021.102778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 10/22/2022]
Abstract
Secondary progressive multiple sclerosis (SPMS) is a debilitating condition characterized by gradual worsening after an initial relapsing disease course. Despite the recent advances in our understanding of the disease, the diagnosis and treatment of SPMS continue to be challenging in routine clinical practice. The aim of this review article is to present the views of leading MS experts on the challenges in the diagnosis and management of SPMS and clinicians' perspectives in Central and Eastern Europe. This article also provides recommendations of MS experts to improve the situation with diagnosis and management of SPMS. Many countries within Central and Eastern Europe have high prevalence of MS (>100 per 100,000 population). Consistent with the global trend, in the absence of reliable tests or biomarkers, SPMS at early stage remains undiagnosed. Due to diagnostic uncertainty and lack of a universally accepted disease definition, clinicians rely more on retrospective analysis of the clinical symptoms to confirm the diagnosis. With the lack of awareness and poor understanding of the timing of the onset of SPMS, clinicians may tend to direct attention to relapses than the symptoms of progression, which leads to underestimation of SPMS. Although several predictors of progression to SPMS have been identified, their predictive value is highly variable. Therefore, defining the transitioning period as a separate stage of MS is essential. According to experts' opinion, frequent follow-up of patients and periodic assessment of progression are recommended for the timely identification of patients transitioning from RRMS to SPMS. MSProDiscuss Tool is an example of a quick assessment tool for identifying patients progressing from RRMS to SPMS. MS progression is usually assessed by changes in Expanded Disability Status Scale (EDSS) scores. As EDSS scores tend to fluctuate when measured in the short term (3-6 months), a longer period (≥12 months) may be needed to confirm the progression. Assessment of cognitive function is also important for evaluating secondary progression. Compartmentalization of inflammation within the central nervous system is an important reason behind the limited success of disease-modifying therapies (DMTs) for treating SPMS. Most of the DMTs fail to cross the blood-brain barrier; only 38% of the tested DMTs achieved their primary endpoint in SPMS. In Europe, siponimod is the first oral treatment for adults with active SPMS. Particularly, in Central and Eastern Europe, patients with SPMS are still being prescribed less efficacious DMTs and interferons. The absence of alternative treatments in SPMS supports the use of new products (siponimod and others); however the decision to initiate siponimod therapy in more severe patients (EDSS score of 7 or higher) should be individualized in consultation with the payers. The focus should be on early treatment initiation to delay disease progression.
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Affiliation(s)
- Alexey Boyko
- Department of Neurology, Neurosurgery and Medical Genetics, Pirogov's Russian National Research Medical University, Moscow, Russian Federation; Department of Neuropharmacology, Federal Center of Brain and Neurotechnology, Moscow, Russian Federation.
| | | | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine Charles University and General University Hospital in Prague, Czech Republic
| | - Jarmila Szilasiová
- Department of Neurology, Faculty of Medicine, P. J. Safarik University, Kosice, Slovakia
| | - Jolanta Kalniņa
- Centre of Multiple Sclerosis, Latvian Maritime Medicine Centre, Rīga, Latvija
| | | | - Katrin Gross-Paju
- West-Tallinn Central Hospital Centre for Neurological Diseases, Tallinn, Estonia; TalTech, Tallinn, Estonia
| | - Krzysztof Selmaj
- Center for Neurology, Lodz, Poland; Collegium Medicum, Department of Neurology, University of Warmia and Mazury, Olsztyn, Poland
| | - Ieva Sereike
- Centre of Neurology, Vilnius University, Vilnius, Lithuania
| | - Ron Milo
- Department of Neurology, Barzilai Medical Center, Ashkelon, Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
| | - Tereza Gabelić
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Uroš Rot
- Department of Neurology University Medical Center Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Celius EG, Thompson H, Pontaga M, Langdon D, Laroni A, Potra S, Bharadia T, Yeandle D, Shanahan J, van Galen P, Alexandri N, Kesselring J. Disease Progression in Multiple Sclerosis: A Literature Review Exploring Patient Perspectives. Patient Prefer Adherence 2021; 15:15-27. [PMID: 33447018 PMCID: PMC7802794 DOI: 10.2147/ppa.s268829] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/20/2020] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Multiple sclerosis (MS) prognosis is often uncertain. This literature review considers patients' understanding of, and perspectives on, MS progression to better comprehend the unmet needs of people with MS (PwMS), in order to improve treatment adherence and quality of life (QoL). METHODS Literature searches for peer-reviewed papers concerning patient perspectives on the progression of MS and comparable conditions, published between January 2000 and January 2020, were conducted. RESULTS Little qualitative evidence exists that examines PwMS' perspectives on MS progression. The understanding and meaning ascribed to terms such as "disease progression" vary. Some PwMS find disease labels stigmatizing, confusing, and disconnected from reality. The lack of a clear definition of progression and discrepancies between PwMS and healthcare professional (HCP) perspectives may contribute to misunderstanding and poor communication. Patient descriptions of progression and relapses include symptoms in addition to those evaluated by standard severity and disability measures. Compared with HCPs, PwMS are still focused on relapse prevention but place higher priority on QoL and ascribe different relative importance to the causes of poor adherence to treatment plans. PwMS want to discuss progression and likely prognosis. Such communication needs to be personalized and delivered with sensitivity, at an appropriate time. Poor treatment adherence may arise from a lack of understanding and poor communication, particularly around treatment goals. The few studies that directly considered patient perspectives on the progression of comparable conditions supported and extended the perspectives of PwMS. Lack of adequate communication by HCPs was the most common theme. CONCLUSION Patient perspectives on disease progression in MS and other chronic progressive conditions are under-investigated and under-reported. The limited evidence available highlights the importance of providing adequate information and effective HCP communication. While further studies are needed, the current evidence base offers information and insights that may help HCPs to enhance patient care, well-being, and treatment adherence.
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Affiliation(s)
- Elisabeth G Celius
- Deparment of Neurology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Correspondence: Elisabeth G Celius Department of Neurology, Oslo University Hospital, Rikshospitalet, Postboks 4950 Nydalen, Oslo0424, NorwayTel +47 91 50 27 70 Email
| | - Heidi Thompson
- The Neurology Centre, Craigavon Area Hospital, Portadown, UK
| | | | - Dawn Langdon
- Department of Psychology, Royal Holloway, University of London, London, UK
| | - Alice Laroni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Italy and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Stanca Potra
- Patient Member of the MS in the 21st Century Steering Group, Bucharest, Romania
| | - Trishna Bharadia
- Patient Member of the MS in the 21st Century Steering Group, Buckinghamshire, UK
| | - David Yeandle
- Patient Member of the MS in the 21st Century Steering Group, Southampton, UK
| | - Jane Shanahan
- Patient Member of the MS in the 21st Century Steering Group, Ascot, UK
| | - Pieter van Galen
- Patient Member of the MS in the 21st Century Steering Group, Overijse, Belgium
| | - Nektaria Alexandri
- Global Medical Affairs, Neurology and Immunology, Merck KGaA, Darmstadt, Germany
| | - Jürg Kesselring
- Department of Neurology & Neurorehabilitation, Kliniken Valens, Valens, Switzerland
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Clinical Perspectives on the Molecular and Pharmacological Attributes of Anti-CD20 Therapies for Multiple Sclerosis. CNS Drugs 2021; 35:985-997. [PMID: 34370283 PMCID: PMC8351586 DOI: 10.1007/s40263-021-00843-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 11/26/2022]
Abstract
Anti-CD20 therapies have demonstrated considerable efficacy in the treatment of relapsing multiple sclerosis, constituting a high-efficacy treatment approach for reducing relapse risk and mitigating disability progression. These therapies have been shown to strongly deplete circulating B cells and small subsets of CD3+ CD4 and CD8 T cells that express low levels of CD20. While the clinical profiles of the various anti-CD20 monoclonal antibodies used in treating multiple sclerosis are well-described in the literature, greater understanding of the implications of their distinct molecular and pharmacological attributes is needed. In this review, we focus on four anti-CD20 monoclonal antibodies-rituximab, ocrelizumab, ofatumumab, and ublituximab-that are currently used, approved, or in late-stage clinical development for the treatment of multiple sclerosis. We provide clinical perspectives on the potential implications of differences in molecular structures, target epitopes, dosing regimens, mechanisms and impact on B-cell depletion and reconstitution, immunogenicity, administration-related reactions, and infection risks.
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Bomprezzi R, Chen AP, Hemond CC. Cervical spondylosis is a risk factor for localized spinal cord lesions in multiple sclerosis. Clin Neurol Neurosurg 2020; 199:106311. [DOI: 10.1016/j.clineuro.2020.106311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 11/28/2022]
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Sant'Anna MB, Giardini AC, Ribeiro MAC, Lopes FSR, Teixeira NB, Kimura LF, Bufalo MC, Ribeiro OG, Borrego A, Cabrera WHK, Ferreira JCB, Zambelli VO, Sant'Anna OA, Picolo G. The Crotoxin:SBA-15 Complex Down-Regulates the Incidence and Intensity of Experimental Autoimmune Encephalomyelitis Through Peripheral and Central Actions. Front Immunol 2020; 11:591563. [PMID: 33193433 PMCID: PMC7655790 DOI: 10.3389/fimmu.2020.591563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/05/2020] [Indexed: 01/18/2023] Open
Abstract
Crotoxin (CTX), the main neurotoxin from Crotalus durissus terrificus snake venom, has anti-inflammatory, immunomodulatory and antinociceptive activities. However, the CTX-induced toxicity may compromise its use. Under this scenario, the use of nanoparticle such as nanostructured mesoporous silica (SBA-15) as a carrier might become a feasible approach to improve CTX safety. Here, we determined the benefits of SBA-15 on CTX-related neuroinflammatory and immunomodulatory properties during experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis that replicates several histopathological and immunological features observed in humans. We showed that a single administration of CTX:SBA-15 (54 μg/kg) was more effective in reducing pain and ameliorated the clinical score (motor impairment) in EAE animals compared to the CTX-treated EAE group; therefore, improving the disease outcome. Of interest, CTX:SBA-15, but not unconjugated CTX, prevented EAE-induced atrophy and loss of muscle function. Further supporting an immune mechanism, CTX:SBA-15 treatment reduced both recruitment and proliferation of peripheral Th17 cells as well as diminished IL-17 expression and glial cells activation in the spinal cord in EAE animals when compared with CTX-treated EAE group. Finally, CTX:SBA-15, but not unconjugated CTX, prevented the EAE-induced cell infiltration in the CNS. These results provide evidence that SBA-15 maximizes the immunomodulatory and anti-inflammatory effects of CTX in an EAE model; therefore, suggesting that SBA-15 has the potential to improve CTX effectiveness in the treatment of MS.
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Affiliation(s)
| | - Aline C Giardini
- Laboratory of Pain and Signaling, Butantan Institute, Sao Paulo, Brazil
| | - Marcio A C Ribeiro
- Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Flavia S R Lopes
- Laboratory of Pain and Signaling, Butantan Institute, Sao Paulo, Brazil
| | | | - Louise F Kimura
- Laboratory of Pain and Signaling, Butantan Institute, Sao Paulo, Brazil
| | - Michelle C Bufalo
- Laboratory of Pain and Signaling, Butantan Institute, Sao Paulo, Brazil
| | | | - Andrea Borrego
- Laboratory of Immunogenetics, Butantan Institute, Sao Paulo, Brazil
| | - Wafa H K Cabrera
- Laboratory of Immunogenetics, Butantan Institute, Sao Paulo, Brazil
| | - Julio C B Ferreira
- Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil.,Department of Chemical and Systems Biology, School of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Vanessa O Zambelli
- Laboratory of Pain and Signaling, Butantan Institute, Sao Paulo, Brazil.,Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | | | - Gisele Picolo
- Laboratory of Pain and Signaling, Butantan Institute, Sao Paulo, Brazil
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High-Efficacy Disease-Modifying Therapies in People with Relapsing-Remitting Multiple Sclerosis: The Role of Risk Attitude in Treatment Decisions. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 14:241-248. [PMID: 32975737 DOI: 10.1007/s40271-020-00454-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Risk attitude is defined as the willingness to tolerate risk to achieve a greater expected return. Limited information is available on how relapsing-remitting multiple sclerosis people's perceptions about disease trajectory and risk attitude may influence treatment choices. METHODS A non-interventional study applying principles of behavioral economics was conducted to assess willingness to receive unwarranted high-efficacy disease-modifying therapy (DMT) according to best-practice guidelines. People with relapsing-remitting multiple sclerosis (PwRRMS) according to 2010 McDonald criteria completed a survey on symptom severity, risk preferences, and management of simulated case scenarios mimicking the current treatment landscape. PwRRMS's choice for high-efficacy agents was established as the participant's selection of monoclonal antibodies for case scenarios with at least 2 years of clinical and radiological stability. RESULTS A total of 211 PwRRMS were studied (mean age 39.1 ± 9.5 years, 70.1% female, mean Expanded Disability Status Scale score 1.8 ± 1.1). Almost 50% (n = 96) opted for a high-efficacy DMT despite the lack of evidence of disease activity. Younger age and risk-seeking behavior were associated with an increased likelihood of selecting unwarranted high-efficacy DMT [odds ratio (OR) 2.00, 95% confidence interval (CI) 1.02-3.93, p = 0.043, and OR 2.17, 95% CI 1.09-4.30, p = 0.027, respectively]. Clinical characteristics or subjective perception of symptom severity had no influence on participants' treatment choices. CONCLUSION Identifying PwRRMS with risk-seeking behavior would be crucial to implementing specific educational strategies to manage information on disease prognosis, treatment expectations, and safety risk knowledge.
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Switching to fingolimod in PREFERMS: Effect of treatment history and naïvety on clinical, MRI and treatment satisfaction outcomes ✰. Mult Scler Relat Disord 2020; 45:102346. [PMID: 32717684 DOI: 10.1016/j.msard.2020.102346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/22/2020] [Accepted: 06/29/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Injectable disease-modifying therapies (iDMTs) are often used as first-line treatments for relapsing multiple sclerosis. Fingolimod is frequently used following treatment with iDMTs. Whether prior iDMT treatment impacts the effectiveness of subsequent fingolimod therapy is unclear. Here, we assessed switching from iDMTs to fingolimod, and the impact of treatment history on fingolimod escalation using data from the 12-month 'Prospective, Randomized, active-controlled, open-label study to Evaluate patient retention on Fingolimod versus approved first-line disease-modifying thErapies in adults with Relapsing-remitting Multiple Sclerosis' (PREFERMS). The study design and results at the end of randomized treatment (EoRT) in PREFERMS have been published. METHODS Both treatment-naïve patients and those who had previously received an iDMT were eligible for enrolment in PREFERMS, and one treatment switch was permitted on study. Pre-specified exploratory analyses compared outcomes in those randomized to fingolimod or to an iDMT at end of study (EoS), which included time spent on randomized and on switch treatment. Post hoc exploratory analyses (unadjusted for multiplicity owing to the large number of comparisons) among patients randomized to an iDMT who switched to fingolimod, compared outcomes longitudinally before (EoRT) and after (EoS) switching, and compared outcomes at EoRT and EoS among subgroups stratified by iDMT-treatment history. Outcomes included brain volume, various measures of gadolinium-enhancing [Gd+] lesion counts, annualized relapse rate (ARR), Symbol Digit Modalities Test (SDMT) score, patient-reported treatment satisfaction using the Medication Satisfaction Questionnaire (MSQ) and adverse event (AE) rates. RESULTS At EoS, 255 of 439 patients randomized to an iDMT had switched to fingolimod and 27 of 436 patients randomized to fingolimod had switched to an iDMT. By EoS, 44.2% of total treatment exposure in the iDMT group was to fingolimod and the mean time spent on fingolimod in this group was 220 days (approximately 7 months). Outcomes in the fingolimod group at EoS (brain volume, changes in Gd+ lesion counts, ARR, oral SDMT score and MSQ score) were similar to those seen at EoRT, but in the iDMT group these outcomes were more favorable at EoS than at EoRT and were similar to rates seen in the fingolimod group. Among patients who switched from iDMT to fingolimod, there were longitudinal improvements in ARR (EoRT, 0.3 [95% confidence interval (CI), 0.2-0.4]; EoS, 0.2 [0.1-0.3]; odds ratio, 0.5 [0.3-0.9]) and in treatment satisfaction (proportion of patients with MSQ > 5; EoRT, 67.4%; EoS, 90.4%; odds ratio, 5.7 [95% CI, 3.4-9.4]) after fingolimod treatment, and changes in brain volume, Gd+ lesion count, and AEs or AEs causing discontinuation were also more favorable at EoS than at EoRT. In all patient groups stratified by iDMT-treatment history, differences in outcomes narrowed or disappeared after fingolimod treatment. CONCLUSION These analyses indicate that patients in PREFERMS had improved outcomes within months of switching to fingolimod from an iDMT and that improvements occurred irrespective of the number of iDMTs previously administered. These data provide a unique opportunity to explore clinical, radiological and safety outcomes associated with a range of clinically relevant treatment pathways.
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Coyle PK. Commentary: The Multiple Sclerosis Controversy: Is It Escalation or Induction High Efficacy? Neurotherapeutics 2020; 17:971-972. [PMID: 32488481 PMCID: PMC7609745 DOI: 10.1007/s13311-020-00869-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, 11794, USA.
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Assessing Pharmacists' Preferences towards Efficacy Attributes of Disease-Modifying Therapies in Relapsing-Remitting Multiple Sclerosis. PHARMACY 2020; 8:pharmacy8020061. [PMID: 32272683 PMCID: PMC7356901 DOI: 10.3390/pharmacy8020061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/30/2020] [Accepted: 04/05/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction: Hospital pharmacists are increasingly playing a critical role in the care of patients with multiple sclerosis (MS). However, little is known about their preferences and perspectives towards different attributes of disease-modifying therapies (DMTs). The objective of this research was to assess pharmacists´ preferences for DMT efficacy attributes. Methods: A multicenter, non-interventional, cross-sectional, web-based study was conducted. Preventing relapses, delaying disease progression, controlling radiological activity, and preserving health-related quality of life (HRQoL) and cognition were the attributes selected based on a literature review and a focus group with six hospital pharmacists. Conjoint analysis was used to determine preferences in eight hypothetical treatment scenarios, combining different levels of each attribute and ranking them from most to least preferred. Results: Sixty-five hospital pharmacists completed the study (mean age: 43.5 ± 7.8 years, 63.1% female, mean years of professional experience: 16.1 ± 7.4 years). Participants placed the greatest preference on delaying disease progression (35.7%) and preserving HRQoL (21.6%) and cognition (21.6%). Importance was consistent in all groups of pharmacists stratified according to demographic characteristics, experience, research background, and volume of patients seen per year. Conclusions: Understanding which treatment characteristics are meaningful to hospital pharmacists may help to enhance their synergistic role in the multidisciplinary management of patients with MS.
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