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Nasr Z, Casper TC, Waltz M, Virupakshaiah A, Lotze T, Shukla N, Chitnis T, Gorman M, Benson LA, Rodriguez M, Tillema JM, Krupp L, Schreiner T, Mar S, Rensel M, Rose J, Liu C, Guye S, Manlius C, Waubant E. Clinical and magnetic resonance imaging outcomes in pediatric-onset MS patients on fingolimod and ocrelizumab. Mult Scler Relat Disord 2024; 87:105647. [PMID: 38838422 DOI: 10.1016/j.msard.2024.105647] [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: 07/20/2023] [Revised: 03/25/2024] [Accepted: 04/25/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Observational studies looking at clinical a++nd MRI outcomes of treatments in pediatric MS, could assess current treatment algorithms, and provide insights for designing future clinical trials. OBJECTIVE To describe baseline characteristics and clinical and MRI outcomes in MS patients initiating ocrelizumab and fingolimod under 18 years of age. METHODS MS patients seen at 12 centers of US Network of Pediatric MS were included in this study if they had clinical and MRI follow-up and started treatment with either ocrelizumab or fingolimod prior to the age of 18. RESULTS Eighty-seven patients initiating fingolimod and 52 initiating ocrelizumab met the inclusion criteria. Before starting fingolimod, mean annualized relapse rate was 0.43 (95 % CI: 0.29 - 0.65) and 78 % developed new T2 lesions while during treatment it was 0.12 (95 % CI: 0.08 - 1.9) and 47 % developed new T2 lesions. In the ocrelizumab group, the mean annualized relapse rate prior to initiation of treatment was 0.64 (95 % CI: 0.38-1.09) and a total of 83 % of patients developed new T2 lesions while during treatment it was 0.09 (95 % CI: 0.04-0.21) and none developed new T2 lesions. CONCLUSION This study highlights the importance of evaluating current treatment methods and provides insights about the agents in the ongoing phase III trial comparing fingolimod and ocrelizumab.
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Affiliation(s)
- Zahra Nasr
- UCSF, Weill Institute for Neurosciences, San Francisco, United States.
| | - T Charles Casper
- University of Utah, Department of Pediatrics, Salt Lake City, United States
| | - Michael Waltz
- University of Utah, Department of Pediatrics, Salt Lake City, United States
| | | | - Tim Lotze
- Baylor College of Medicine/Texas Children's Hospital, Neurology and Developmental Neuroscience, Houston, United States
| | - Nikita Shukla
- Baylor College of Medicine/Texas Children's Hospital, Neurology and Developmental Neuroscience, Houston, United States
| | - Tanuja Chitnis
- Massachusetts General Hospital for Children, Mass General Brigham Pediatric MS Center, Boston, United States
| | - Mark Gorman
- Boston Children's Hospital, Pediatric Multiple Sclerosis and Related Disorders Program, Boston, United States
| | - Leslie A Benson
- Boston Children's Hospital, Pediatric Multiple Sclerosis and Related Disorders Program, Boston, United States
| | | | - Jan M Tillema
- Mayo Clinic, Pediatric MS Center, Rochester, United States
| | - Lauren Krupp
- New York University Langone Medical Center, Pediatric Multiple Sclerosis Center, New York, United States
| | - Teri Schreiner
- University of Colorado, Rocky Mountain MS Center, Aurora, United States
| | - Soe Mar
- Washington University, Pediatric MS and other Demyelinating Disease Center, St. Louis, United States
| | - Mary Rensel
- Cleveland Clinic, Mellen Center for Multiple Sclerosis, Cleveland, United States
| | - John Rose
- University of Utah, Department of Neurology, Salt Lake City, United States
| | - Chuang Liu
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
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Ghezzi A. Old and New Strategies in the Treatment of Pediatric Multiple Sclerosis: A Personal View for a New Treatment Approach. Neurol Ther 2024:10.1007/s40120-024-00633-6. [PMID: 38822947 DOI: 10.1007/s40120-024-00633-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/14/2024] [Indexed: 06/03/2024] Open
Abstract
Up to 10 years ago the most common approach to the treatment of pediatric MS (ped-MS) was to start with IFNB or GA (so-called first-line therapies or moderate-efficacy disease-modifying therapies [ME-DMTs]) and to switch to more aggressive treatments (or high-efficacy disease-modifying therapies [HE-DMTs]) in non-responder patients. The use of HE-DMTs as first choice was recommended in selected cases with an active, aggressive form of MS. Indications for the treatment of ped-MS were essentially derived from data of observational studies. Recently, results of three randomized clinical trials have been published as well as data from many observational studies evaluating the effect of new and more active DMTs, with clear evidence that HE-DMTs are more effective than ME-DMTs. Therefore, the paradigm of treatment for patients with MS onset before 18 years of age should be changed, offering treatment with HE-DMTs as first option, because of their superior effectiveness to prevent relapses and disease progression. HE-DMTs present an overall reassuring safety profile and obtain better adherence to treatment.
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Affiliation(s)
- Angelo Ghezzi
- Dipartimento di Scienze della Salute, Università Piemonte Orientale A. Avogadro, Via Solaroli 17, 28100, Novara, Italy.
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Spelman T, Simoneau G, Hyde R, Kuhelj R, Alroughani R, Ozakbas S, Karabudak R, Yamout BI, Khoury SJ, Terzi M, Boz C, Horakova D, Kubala Havrdova E, Weinstock-Guttman B, Patti F, Altintas A, Mrabet S, Gouider R, Inshasi J, Shaygannejad V, Eichau S, Ward WL, Butzkueven H. Comparative Effectiveness of Natalizumab, Fingolimod, and Injectable Therapies in Pediatric-Onset Multiple Sclerosis: A Registry-Based Study. Neurology 2024; 102:e208114. [PMID: 38447093 PMCID: PMC11033984 DOI: 10.1212/wnl.0000000000208114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/19/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with pediatric-onset multiple sclerosis (POMS) typically experience higher levels of inflammation with more frequent relapses, and though patients with POMS usually recover from relapses better than adults, patients with POMS reach irreversible disability at a younger age than adult-onset patients. There have been few randomized, placebo-controlled clinical trials of multiple sclerosis (MS) disease-modifying therapies (DMTs) in patients with POMS, and most available data are based on observational studies of off-label use of DMTs approved for adults. We assessed the effectiveness of natalizumab compared with fingolimod using injectable platform therapies as a reference in pediatric patients in the global MSBase registry. METHODS This retrospective study included patients with POMS who initiated treatment with an injectable DMT, natalizumab, or fingolimod between January 1, 2006, and May 3, 2021. Patients were matched using inverse probability treatment weighting. The primary outcome was time to first relapse from index therapy initiation. Secondary study outcomes included annualized relapse rate; proportions of relapse-free patients at 1, 2, and 5 years; time to treatment discontinuation; and times to 24-week confirmed disability worsening and confirmed disability improvement. RESULTS A total of 1,218 patients with POMS were included in this analysis. Patients treated with fingolimod had a significantly lower risk of relapse than patients treated with injectable DMTs (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.29-0.83; p = 0.008). After adjustment for prior DMT experience in the unmatched sample, patients treated with natalizumab had a significantly lower risk of relapse than patients treated either with injectable DMTs (HR, 0.15; 95% CI 0.07-0.31; p < 0.001) or fingolimod (HR, 0.37; 95% CI 0.14-1.00; p = 0.049). The adjusted secondary study outcomes were generally consistent with the primary outcome or with previous observations. The findings in the inverse probability treatment weighting-adjusted patient populations were confirmed in multiple sensitivity analyses. DISCUSSION Our analyses of relapse risk suggest that natalizumab is more effective than fingolimod in the control of relapses in this population with high rates of new inflammatory activity, consistent with previous studies of natalizumab and fingolimod in adult-onset patients and POMS. In addition, both fingolimod and natalizumab were more effective than first-line injectable therapies. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that patients with POMS treated with natalizumab had a lower risk of relapse than those with fingolimod.
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Affiliation(s)
- Tim Spelman
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Gabrielle Simoneau
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Robert Hyde
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Robert Kuhelj
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Raed Alroughani
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Serkan Ozakbas
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Rana Karabudak
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Bassem I Yamout
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Samia J Khoury
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Murat Terzi
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Cavit Boz
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Dana Horakova
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Eva Kubala Havrdova
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Bianca Weinstock-Guttman
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Francesco Patti
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Ayse Altintas
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Saloua Mrabet
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Riadh Gouider
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Jihad Inshasi
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Vahid Shaygannejad
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Sara Eichau
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - W Luke Ward
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Helmut Butzkueven
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
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4
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Venet M, Lepine A, Maarouf A, Biotti D, Boutiere C, Casez O, Cohen M, Durozard P, Demortière S, Giorgi L, Maillart E, Mathey G, Mazzola L, Rico A, Camdessanche JP, Deiva K, Pelletier J, Audoin B. Control of disease activity with large extended-interval dosing of rituximab/ocrelizumab in highly active pediatric multiple sclerosis. Mult Scler 2024; 30:261-265. [PMID: 38166437 DOI: 10.1177/13524585231223069] [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] [Indexed: 01/04/2024]
Abstract
Recent studies in adults suggested that extended-interval dosing of rituximab/ocrelizumab (RTX/OCR) larger than 12 months was safe and could improve safety. This was an observational cohort study of very active pediatric-onset multiple sclerosis (PoMS) (median (range) age, 16 (12-17) years) treated with RTX/OCR with 6 month standard-interval dosing (n = 9) or early extended-interval dosing (n = 12, median (range) interval 18 months (12-25)). Within a median (range) follow-up of 31 (12-63) months after RTX/OCR onset, one patient (standard-interval) experienced relapse and no patient showed disability worsening or new T2-weighted lesions. This study suggests that the effectiveness of RTX/OCR is maintained with a median extended-interval dosing of 18 months in patients with very active PoMS.
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Affiliation(s)
- Melany Venet
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
- Neurology Department, University Hospital, Saint-Etienne, France
| | - Anne Lepine
- Paediatric Neurology Department, Assistance Publique des Hôpitaux de Marseille, Hôpital Universitaire, Marseille, France
| | - Adil Maarouf
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | - Damien Biotti
- Centre Ressources et Compétences Sclérose en Plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France
- INSERM UMR1291-CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Clémence Boutiere
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | - Olivier Casez
- Neuro-inflammatory Disease Center, Centre Hospitalier Universitaire de Grenoble Alpes, Grenoble, France
| | - Mikael Cohen
- CRC-SEP CHU Nice, UR2CA-URRIS, Université Nice Cote d'Azur, Hôpital Pasteur 2, Nice, France
| | | | - Sarah Demortière
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | - Laetitia Giorgi
- Department of Paediatric Neurology, National Reference Center for Rare Inflammatory and auto-immune Brain and Spinal Diseases, Hopitaux Universitaires Paris-Saclay, Hôpital Bicêtre, Le Kremlin-Bicetre, France
- UMR 1184, Immunology of Viral Infections and Autoimmune Diseases, Universite Paris Saclay, Le Kremlin-Bicetre, France
| | - Elisabeth Maillart
- Department of Neurology, National Reference Center for Rare Inflammatory and auto-immune Brain and Spinal Diseases, Pitie Salpetriere Hospital, APHP, Paris, France
| | - Guillaume Mathey
- Neurology Unit, University Hospital of Nancy, Hôpital Central, Nancy Cedex, France
| | - Laure Mazzola
- Neurology Department, University Hospital, Saint-Etienne, France
| | - Audrey Rico
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | | | - Kumaran Deiva
- Department of Paediatric Neurology, National Reference Center for Rare Inflammatory and auto-immune Brain and Spinal Diseases, Hopitaux Universitaires Paris-Saclay, Hôpital Bicêtre, Le Kremlin-Bicetre, France
- UMR 1184, Immunology of Viral Infections and Autoimmune Diseases, Universite Paris Saclay, Le Kremlin-Bicetre, France
| | - Jean Pelletier
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
| | - Bertrand Audoin
- Department of Neurology, Aix Marseille Univ, APHM, Hôpital de la Timone, CNRS, CRMBM, Marseille, France
- Pôle de Neurosciences Cliniques, Service de Neurologie, Aix Marseille Univ, APHM, Hôpital de la Timone, Marseille, France
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5
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Jakimovski D, Bittner S, Zivadinov R, Morrow SA, Benedict RH, Zipp F, Weinstock-Guttman B. Multiple sclerosis. Lancet 2024; 403:183-202. [PMID: 37949093 DOI: 10.1016/s0140-6736(23)01473-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/08/2023] [Accepted: 07/12/2023] [Indexed: 11/12/2023]
Abstract
Multiple sclerosis remains one of the most common causes of neurological disability in the young adult population (aged 18-40 years). Novel pathophysiological findings underline the importance of the interaction between genetics and environment. Improvements in diagnostic criteria, harmonised guidelines for MRI, and globalised treatment recommendations have led to more accurate diagnosis and an earlier start of effective immunomodulatory treatment than previously. Understanding and capturing the long prodromal multiple sclerosis period would further improve diagnostic abilities and thus treatment initiation, eventually improving long-term disease outcomes. The large portfolio of currently available medications paved the way for personalised therapeutic strategies that will balance safety and effectiveness. Incorporation of cognitive interventions, lifestyle recommendations, and management of non-neurological comorbidities could further improve quality of life and outcomes. Future challenges include the development of medications that successfully target the neurodegenerative aspect of the disease and creation of sensitive imaging and fluid biomarkers that can effectively predict and monitor disease changes.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA; Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA; Center for Biomedical Imaging at the Clinical Translational Science Institute, State University of New York at Buffalo, Buffalo, NY, USA
| | - Sarah A Morrow
- Department of Clinical Neurological Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Ralph Hb Benedict
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
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Carvalho IV, dos Santos CS, Amaral J, Ribeiro JA, Pereira C, Pais RP, Palavra F. Multiple sclerosis under the age of ten: the challenge of a rare diagnosis in a special population - a case series. Front Neurosci 2023; 17:1297171. [PMID: 38174051 PMCID: PMC10761493 DOI: 10.3389/fnins.2023.1297171] [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: 09/19/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024] Open
Abstract
Introduction Multiple sclerosis (MS) is a chronic inflammatory demyelinating and degenerative disease of the central nervous system which, when it begins before the age of 18, is defined as paediatric MS. Most common clinical presentations include long tract involvement, brainstem/cerebellum syndromes, optic neuritis and acute disseminated encephalomyelitis. Paediatric-onset MS typically has a more inflammatory-active course and a higher lesion burden in imaging studies, but an extensive post-relapse recovery, with a slower long-term disability progression. The first demyelinating clinical attack occurs before 10 years old in less than 1% of patients, and, in this special population, the condition has particularities in clinical presentation, differential diagnosis, diagnostic assessment, current treatment options and outcome. Clinical cases We present the cases of four Caucasian children (2 girls) diagnosed with relapsing-remitting MS before the age of ten, with a mean age at the time of the first relapse of 7.4 ± 2.4 years. Clinical presentation included optic neuritis, myelitis, brainstem syndrome, and acute disseminated encephalomyelitis. Baseline MRI identified several lesions, frequently large and ill-defined. Two patients were included in clinical trials and two patients remain in clinical and imaging surveillance. Conclusion Diagnosis of MS before the age of 10 years is rare, but it has significant long-term physical and cognitive consequences, as well as a substantial impact on the current and future quality of life of the child and family. Early and correct diagnosis is essential. Prospective, randomized, large cohort studies are needed to assess the efficacy and safety of disease-modifying treatments in children under the age of ten.
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Affiliation(s)
- Inês V. Carvalho
- Center for Child Development – Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Constança Soares dos Santos
- Center for Child Development – Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Amaral
- Center for Child Development – Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Afonso Ribeiro
- Center for Child Development – Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Pereira
- Center for Child Development – Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Rui Pedro Pais
- Medical Image Department – Neuroradiology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Filipe Palavra
- Center for Child Development – Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Laboratory of Pharmacology and Experimental Therapeutics, Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra, Coimbra, Portugal
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7
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Geiger CK, Sheinson D, To TM, Jones D, Bonine NG. Treatment Patterns by Race and Ethnicity in Newly Diagnosed Persons with Multiple Sclerosis. Drugs Real World Outcomes 2023; 10:565-575. [PMID: 37733192 PMCID: PMC10730787 DOI: 10.1007/s40801-023-00387-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Non-Hispanic Black and Hispanic persons with MS (pwMS) are more likely to experience rapid disease progression and severe disability than non-Hispanic White pwMS; however, it is unknown how the initiation of high-efficacy disease-modifying therapies (DMTs) differs by race/ethnicity. This real-world study describes DMT treatment patterns in newly diagnosed pwMS in the United States (US) overall and by race/ethnicity. METHODS This retrospective analysis used the US Optum Market Clarity claims/electronic health records database (January 2015-September 2020). pwMS who were first diagnosed in 2016 or later and initiated any DMT in the two years following diagnosis were included. Continuous enrollment in the claims data for ≥ 12 months before and ≥ 24 months after diagnosis was required. Treatment patterns 2 years after diagnosis were analyzed descriptively overall and by race/ethnicity. RESULTS The sample included 682 newly diagnosed and treated pwMS (non-Hispanic Black, n = 99; non-Hispanic White, n = 479; Hispanic, n = 35; other/unknown race/ethnicity, n = 69). The mean time from diagnosis to DMT initiation was 4.9 months in all pwMS. Glatiramer acetate and dimethyl fumarate were the most common first-line DMTs in non-Hispanic Black (28% and 20% respectively) and Hispanic pwMS (31%, 29%); however, glatiramer acetate and ocrelizumab were the most common in non-Hispanic White pwMS (33%, 18%). Use of first-line high-efficacy DMTs was limited across all race/ethnicity subgroups (11-29%), but uptake increased in non-Hispanic Black and White pwMS over the study period. CONCLUSION Use of high-efficacy DMTs was low across all race/ethnicity subgroups of newly diagnosed pwMS in the US, including populations at a greater risk of experiencing rapid disease progression and severe disability.
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Affiliation(s)
| | - Daniel Sheinson
- Genentech, Inc., 350 DNA Way, South San Francisco, CA, 94080, USA
| | - Tu My To
- Genentech, Inc., 350 DNA Way, South San Francisco, CA, 94080, USA
| | - David Jones
- Genentech, Inc., 350 DNA Way, South San Francisco, CA, 94080, USA
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8
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Castillo Villagrán D, Yeh EA. Pediatric Multiple Sclerosis: Changing the Trajectory of Progression. Curr Neurol Neurosci Rep 2023; 23:657-669. [PMID: 37792206 DOI: 10.1007/s11910-023-01300-3] [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] [Accepted: 09/01/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE OF REVIEW Multiple sclerosis is a chronic inflammatory disease of the central nervous system. When seen in children and adolescents, crucial stages of brain development and maturation may be affected. Prompt recognition of multiple sclerosis in this population is essential, as early intervention with disease-modifying therapies may change developmental trajectories associated with the disease. In this paper, we will review diagnostic criteria for pediatric multiple sclerosis, outcomes, differential diagnosis, and current therapeutic approaches. RECENT FINDINGS Recent studies have demonstrated the utility of newer structural and functional metrics in facilitating early recognition and diagnosis of pediatric MS. Knowledge about disease-modifying therapies in pediatric multiple sclerosis has expanded in recent years: important developmental impacts of earlier therapeutic intervention and use of highly effective therapies have been demonstrated. Pediatric MS is characterized by highly active disease and high disease burden. Advances in knowledge have led to early identification, diagnosis, and treatment. Lifestyle-related interventions and higher efficacy therapies are currently undergoing investigation.
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Affiliation(s)
- Daniela Castillo Villagrán
- Department of Pediatrics (Neurology), SickKids Research Institute, Division of Neurosciences and Mental Health, Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G1X8, Canada
| | - E Ann Yeh
- Department of Pediatrics (Neurology), SickKids Research Institute, Division of Neurosciences and Mental Health, Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G1X8, Canada.
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9
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Sutter PA, Ménoret A, Jellison ER, Nicaise AM, Bradbury AM, Vella AT, Bongarzone ER, Crocker SJ. CD8+ T cell depletion prevents neuropathology in a mouse model of globoid cell leukodystrophy. J Exp Med 2023; 220:e20221862. [PMID: 37310382 PMCID: PMC10266545 DOI: 10.1084/jem.20221862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 04/10/2023] [Accepted: 05/26/2023] [Indexed: 06/14/2023] Open
Abstract
Globoid cell leukodystrophy (GLD) or Krabbe's disease is a fatal genetic demyelinating disease of the central nervous system caused by loss-of-function mutations in the galactosylceramidase (galc) gene. While the metabolic basis for disease is known, the understanding of how this results in neuropathology is not well understood. Herein, we report that the rapid and protracted elevation of CD8+ cytotoxic T lymphocytes occurs coincident with clinical disease in a mouse model of GLD. Administration of a function-blocking antibody against CD8α effectively prevented disease onset, reduced morbidity and mortality, and prevented CNS demyelination in mice. These data indicate that subsequent to the genetic cause of disease, neuropathology is driven by pathogenic CD8+ T cells, thus offering novel therapeutic potential for treatment of GLD.
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Affiliation(s)
- Pearl A. Sutter
- Department of Neuroscience, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Antoine Ménoret
- Department of Immunology, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Evan R. Jellison
- Department of Immunology, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Alexandra M. Nicaise
- Department of Neuroscience, University of Connecticut School of Medicine, Farmington, CT, USA
- Department of Clinical Neuroscience and National Institute for Health Research Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Allison M. Bradbury
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Anthony T. Vella
- Department of Immunology, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Ernesto R. Bongarzone
- Department of Anatomy and Cell Biology, University of Illinois at Chicago, Chicago, IL, USA
| | - Stephen J. Crocker
- Department of Neuroscience, University of Connecticut School of Medicine, Farmington, CT, USA
- Department of Immunology, University of Connecticut School of Medicine, Farmington, CT, USA
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10
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Gold R, Barnett M, Chan A, Feng H, Fujihara K, Giovannoni G, Montalbán X, Shi FD, Tintoré M, Xue Q, Yang C, Zhou H. Clinical use of dimethyl fumarate in multiple sclerosis treatment: an update to include China, using a modified Delphi method. Ther Adv Neurol Disord 2023; 16:17562864231180734. [PMID: 37465201 PMCID: PMC10350766 DOI: 10.1177/17562864231180734] [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: 12/20/2022] [Accepted: 05/20/2023] [Indexed: 07/20/2023] Open
Abstract
Dimethyl fumarate (DMF) is a widely used oral disease-modifying therapy for multiple sclerosis (MS). Its efficacy and safety profiles are supported by over a decade of experience. Differences exist between Asia and Europe/United States in the prevalence and characteristics of MS; most data for DMF are derived from populations outside Asia. DMF was recently (2021) approved for use in China. The objectives of this review were to evaluate the evidence for DMF's profile, to provide an update to healthcare providers on current knowledge surrounding its use and to assess the relevance of existing data to use in China. This study used a modified Delphi method based on the insights of a scientific Steering Committee (SC), with a structured literature review conducted to assess the data of DMF. The literature review covered all papers in English (from 01 January 2011 to 21 February 2022) that include 'dimethyl fumarate' and 'multiple sclerosis', and their MeSH terms, on PubMed, supplemented by EMBASE and Citeline searches. Papers were categorized by topic and assessed for relevance and quality, before being used to formulate statements summarizing the literature on each subject. SC members voted on/revised statements, requiring ⩾80% agreement and ⩽10% disagreement for inclusion. Statements not reaching this level were discussed further until agreement was reached or until there was agreement to remove the statement. A total of 1030 papers were retrieved and used to formulate the statements and evidence summaries considered by the SC members. A total of 45 statements were agreed by the SC members. The findings support the positive efficacy and safety profile of DMF in treating patients with MS. Limited Chinese patient data are an ongoing consideration; however, based on current evidence, the statements are considered applicable to both the global and Chinese populations. DMF is a valuable addition to address unmet MS treatment needs in China. Registration: Not applicable.
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Affiliation(s)
- Ralf Gold
- Department of Neurology, Ruhr University Bochum, Bochum 44791, Germany
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney and Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew Chan
- Department of Neurology, Inselspital (Bern University Hospital), University of Bern, Bern, Switzerland
| | - Huiyu Feng
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Gavin Giovannoni
- Department of Neurology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Xavier Montalbán
- Neurology Department, Multiple Sclerosis Center of Catalonia (Cemcat), Vall d’Hebron University Hospital, Barcelona, Spain
| | - Fu-Dong Shi
- Department of Neurology, Institute of Neuroimmunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Mar Tintoré
- Neurology Department, Multiple Sclerosis Center of Catalonia (Cemcat), Vall d’Hebron University Hospital, Barcelona, Spain
| | - Qun Xue
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chunsheng Yang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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11
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Zettl UK, Rommer PS, Aktas O, Wagner T, Richter J, Oschmann P, Cepek L, Elias-Hamp B, Gehring K, Chan A, Hecker M. Interferon beta-1a sc at 25 years: a mainstay in the treatment of multiple sclerosis over the period of one generation. Expert Rev Clin Immunol 2023; 19:1343-1359. [PMID: 37694381 DOI: 10.1080/1744666x.2023.2248391] [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: 06/07/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Interferon beta (IFN beta) preparations are an established group of drugs used for immunomodulation in patients with multiple sclerosis (MS). Subcutaneously (sc) applied interferon beta-1a (IFN beta-1a sc) has been in continuous clinical use for 25 years as a disease-modifying treatment. AREAS COVERED Based on data published since 2018, we discuss recent insights from analyses of the pivotal trial PRISMS and its long-term extension as well as from newer randomized studies with IFN beta-1a sc as the reference treatment, the use of IFN beta-1a sc across the patient life span and as a bridging therapy, recent data regarding the mechanisms of action, and potential benefits of IFN beta-1a sc regarding vaccine responses. EXPERT OPINION IFN beta-1a sc paved the way to effective immunomodulatory treatment of MS, enabled meaningful insights into the disease process, and remains a valid therapeutic option in selected vulnerable MS patient groups.
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Affiliation(s)
- Uwe Klaus Zettl
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Paulus Stefan Rommer
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | | | | | | | | | | | - Andrew Chan
- Department of Neurology, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Michael Hecker
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
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12
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Costa GD, Comi G. Teriflunomide: an oral therapy for first-line treatment of children and adolescents living with relapsing-remitting multiple sclerosis. Expert Rev Neurother 2023; 23:681-687. [PMID: 37382446 DOI: 10.1080/14737175.2023.2229953] [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: 05/03/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Different disease-modifying therapies (DMTs) have been developed to slow down the progression of pediatric multiple sclerosis (MS). Teriflunomide is one such DMT that has recently been approved for use in pediatric MS in the European Union. AREAS COVERED The article provides an introduction to the mechanism of action of teriflunomide, reviews the clinical trials conducted on the safety and efficacy of the drug, and the optimal dosing and monitoring strategies. EXPERT OPINION Teriflunomide is an oral medication that has shown promise in improving outcomes for pediatric MS patients, including reduced relapse rates and improved quality of life. However, more research is needed to determine its long-term safety in pediatric patients. As MS often presents with an aggressive course in children, the choice of disease-modifying treatment should be carefully evaluated, with a preference for second-line therapy. Despite the potential benefits of teriflunomide, changes in clinical practice may be hindered by factors such as cost and physician familiarity with alternative treatments. Longer-term studies and biomarker identification are areas for improvement, but the future of research in this area holds promise for the continued development and refinement of disease-modifying therapies and more personalized, targeted treatments for pediatric MS patients.
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Affiliation(s)
| | - Giancarlo Comi
- Faculy of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Multiple Sclerosis center, Casa di Cura Igea, Milan, Italy
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13
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Saponaro AC, Tully T, Maillart E, Maurey H, Deiva K. Treatments of paediatric multiple sclerosis: Efficacy and tolerance in a longitudinal follow-up study. Eur J Paediatr Neurol 2023; 45:22-28. [PMID: 37245449 DOI: 10.1016/j.ejpn.2023.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/30/2023]
Abstract
AIM To compare the efficacy and safety of newer and/or second-line disease-modifying treatments (DMTs) with interferon beta-1a. METHOD This observational retrospective study included patients younger than 18 years old in the French KIDBIOSEP cohort who had a diagnosis of relapsing multiple sclerosis between 2008 and 2019 and received at least one DMT. Primary outcome was the annualized relapse rate (ARR). Secondary outcomes were the risk of new T2 or gadolinium-enhanced lesions on brain MRI. RESULTS Among 78 patients enrolled, 50 were exposed to interferon and 76 to newer DMTs. Mean ARR went from 1.65 during pre-treatment period to 0.45 with interferon (p < 0.001). Newer DMTs reduced ARR compared to interferon: fingolimod 0.27 (p = 0.013), teriflunomide 0.25 (p = 0.225), dimethyl-fumarate 0.14 (p = 0.045), natalizumab 0.03 (p = 0.007). Risk of new lesions on MRI was reduced with interferon compared to pre-treatment period; it decreased even more with newer DMTs for T2 lesions. Regarding risk of new gadolinium-enhanced lesions, the added value of new treatments compared to interferon was less obvious, except for natalizumab (p = 0.031). CONCLUSION In this real-world setting, newer DMTs showed better efficacy than interferon beta-1a on ARR and risk of new T2 lesions, with a good safety profile. Natalizumab tend to emerge as the most effective treatment.
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Affiliation(s)
- Anne-Charlotte Saponaro
- Paediatric Neurology Unit, Children's Medicine Department, Children's Hospital, University Hospital of Nancy, France.
| | - Thomas Tully
- Sorbonne Université, CNRS, IRD, INRA, Institute of Ecology and Environmental Sciences, iEES Paris, UMR7618, France.
| | - Elisabeth Maillart
- Department of Neurology, National Reference Center for Rare Inflammatory and auto-immune Brain and Spinal Diseases, Pitie Salpetriere Hospital, APHP, Paris, France
| | - Hélène Maurey
- Department of Pediatric Neurology, National Reference Center for Rare Inflammatory and auto-immune Brain and Spinal Diseases, Hopitaux Universitaires Paris-Saclay, Hôpital Bicêtre, Le Kremlin-Bicetre, 94276, France
| | - Kumaran Deiva
- Department of Pediatric Neurology, National Reference Center for Rare Inflammatory and auto-immune Brain and Spinal Diseases, Hopitaux Universitaires Paris-Saclay, Hôpital Bicêtre, Le Kremlin-Bicetre, 94276, France; UMR 1184, Immunology of Viral Infections and Autoimmune Diseases, Universite Paris Saclay, Le Kremlin-Bicetre, France.
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14
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Kornbluh AB, Kahn I. Pediatric Multiple Sclerosis. Semin Pediatr Neurol 2023; 46:101054. [PMID: 37451754 DOI: 10.1016/j.spen.2023.101054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/07/2023] [Accepted: 05/07/2023] [Indexed: 07/18/2023]
Abstract
The current diagnostic criteria for pediatric onset multiple sclerosis (POMS) are summarized, as well as the evidence for performance of the most recent iteration of McDonald criteria in the pediatric population. Next, the varied roles of MRI in POMS are reviewed, including diagnostic considerations and research-based utilization. The primary role of bloodwork and cerebrospinal fluid studies in the diagnosis of POMS is to rule out disease mimics. Prognostically, POMS portends a more inflammatory course with higher relapse rate and disability reached at younger ages compared with AOMS counterparts. As such, there is an emerging trend toward the earlier use of highly efficacious disease modifying therapies to target prompt immunomodulatory disease control. Current POMS disease modifying therapies (DMTs) and active clinical POMS trials are detailed.
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Affiliation(s)
- Alexandra B Kornbluh
- Children's National Hospital, Washington, DC; George Washington School of Medicine and Health Sciences, Washington, DC
| | - Ilana Kahn
- Children's National Hospital, Washington, DC; George Washington School of Medicine and Health Sciences, Washington, DC.
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15
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Malani Shukla N, Casper TC, Ness J, Wheeler Y, Chitnis T, Lotze T, Gorman M, Benson L, Weinstock-Guttmann B, Aaen G, Rodriguez M, Tillema JM, Krupp L, Schreiner T, Mar S, Goyal M, Rensel M, Abrams A, Rose J, Waltz M, Liu T, Manlius C, Waubant E. Demographic Features and Clinical Course of Patients With Pediatric-Onset Multiple Sclerosis on Newer Disease-Modifying Treatments. Pediatr Neurol 2023; 145:125-131. [PMID: 37348193 DOI: 10.1016/j.pediatrneurol.2023.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/09/2023] [Accepted: 04/24/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Treatment of pediatric-onset multiple sclerosis (POMS) is challenging given the lack of safety and efficacy data in the pediatric population for many of the disease-modifying treatments (DMTs) approved for use in adults with MS. Our objective was to describe the demographic features and clinical and radiologic course of patients with POMS treated with the commonly used newer DMTs within the US Network of Pediatric MS Centers (NPMSC). METHODS This is an analysis of prospectively collected data from patients who initiated treatment before age 18 with the DMTs listed below at the 12 regional pediatric MS referral centers participating in the NPMSC. RESULTS One hundred sixty-eight patients on dimethyl fumarate, 96 on fingolimod, 151 on natalizumab, 166 on rituximab, and 37 on ocrelizumab met criteria for analysis. Mean age at DMT initiation ranged from 15.2 to 16.5 years. Disease duration at the time of initiation of index DMT ranged from 1.1 to 1.6 years with treatment duration of 0.9-2.0 years. Mean annualized relapse rate (ARR) in the year prior to initiating index DMT ranged from 0.4 to 1.0. Mean ARR while on index DMT ranged from 0.05 to 0.20. New T2 and enhancing lesions occurred in 75%-88% and 55%-73% of the patients, respectively, during the year prior to initiating index DMT. After initiating index DMT, new T2 and enhancing lesions occurred in 0%-46% and 11%-34% patients, respectively. Rates of NEDA-2 (no evidence of disease activity) ranged from 76% to 91% at 6 months of treatment with index DMTs and 66% to 84% at 12 months of treatment with index DMTs. CONCLUSIONS Though limited by relatively short treatment duration with the index DMTs, our data suggest clinical and MRI benefit, as well as high rates of NEDA-2, in a large number of POMS patients, which can be used to guide future studies in this population.
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Affiliation(s)
- Nikita Malani Shukla
- Baylor College of Medicine/Texas Children's Hospital, Neurology and Developmental Neuroscience, Houston, Texas.
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jayne Ness
- Center for Pediatric-Onset Demyelinating Disease, Children's Hospital of Alabama, Birmingham, Alabama
| | - Yolanda Wheeler
- Center for Pediatric-Onset Demyelinating Disease, Children's Hospital of Alabama, Birmingham, Alabama
| | - Tanuja Chitnis
- Mass General Brigham Pediatric MS Center, Massachusetts General Hospital for Children, Yawkey Center for Outpatient Care, Boston, Massachusetts
| | - Timothy Lotze
- Baylor College of Medicine/Texas Children's Hospital, Neurology and Developmental Neuroscience, Houston, Texas
| | - Mark Gorman
- Pediatric Multiple Sclerosis and Related Disorders Program, Boston Children's Hospital, Department of Neurology, Boston, Massachusetts
| | - Leslie Benson
- Pediatric Multiple Sclerosis and Related Disorders Program, Boston Children's Hospital, Department of Neurology, Boston, Massachusetts
| | | | - Greg Aaen
- Pediatric Multiple Sclerosis Center at Loma Linda University Children's Hospital, San Bernardino, California
| | | | | | - Lauren Krupp
- New York University Langone Medical Center, Pediatric Multiple Sclerosis Center, New York, New York
| | - Teri Schreiner
- Rocky Mountain MS Center, University of Colorado, Aurora, Colorado
| | - Soe Mar
- Pediatric MS and other Demyelinating Disease Center, Washington University, St. Louis, Missouri
| | - Manu Goyal
- Pediatric MS and other Demyelinating Disease Center, Washington University, St. Louis, Missouri
| | - Mary Rensel
- Cleveland Clinic, Mellen Center for Multiple Sclerosis, Cleveland, Ohio
| | - Aaron Abrams
- Cleveland Clinic, Mellen Center for Multiple Sclerosis, Cleveland, Ohio
| | - John Rose
- Department of Neurology, University of Utah, Salt Lake City, Utah
| | - Michael Waltz
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Tony Liu
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
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16
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Vaheb S, Ghaffary EM, Shaygannejad V, Mirmosayyeb O. Fingolimod-induced bladder lymphoma in a patient with multiple sclerosis. Clin Case Rep 2023; 11:e7280. [PMID: 37113637 PMCID: PMC10126755 DOI: 10.1002/ccr3.7280] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Key Clinical Message Malignancies were reported in some studies following taking Fingolimod. We reported a case of bladder lymphoma after taking Fingolimod. Physicians should consider the carcinogenic effects of Fingolimod in long-term use and replace it with safer medicines. Abstract Fingolimod is a medication with a potential cure to control multiple sclerosis (MS) relapses. Here we describe a 32-year-old woman with relapsing-remitting multiple sclerosis who developed bladder lymphoma induced by long-term use of Fingolimod. Physicians should consider the carcinogenic effects of Fingolimod in long-term use and replace it with safer medicines.
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Affiliation(s)
- Saeed Vaheb
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Elham Moases Ghaffary
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Vahid Shaygannejad
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
- Department of Neurology, School of MedicineIsfahan University of Medical SciencesIsfahanIran
| | - Omid Mirmosayyeb
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
- Department of Neurology, School of MedicineIsfahan University of Medical SciencesIsfahanIran
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17
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Martins C, Samões R, Silva AM, Santos E, Figueiroa S. Pediatric Multiple Sclerosis-Experience of a Tertiary Care Center. Neuropediatrics 2023; 54:58-63. [PMID: 36646103 DOI: 10.1055/s-0042-1759843] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Pediatric-onset multiple sclerosis (POMS) accounts for 3 to 10% of all MS diagnoses. POMS is usually characterized by prominent disease activity, and patients are at higher risk of developing physical disability and cognitive impairment. OBJECTIVE This article characterizes a cohort of POMS patients followed at the pediatric neurology unit of a Portuguese tertiary hospital. METHODS Retrospective observational study. Clinical records of all patients with POMS between 2011 and 2020 were revised. RESULTS A total of 21 patients, with a female:male ratio of 11:10 and a mean age of onset of 14.8 years were included. Clinical manifestations at presentation included myelitis in eight patients (two with associated brainstem syndrome), optic neuritis in six (one with associated cerebellar syndrome), supratentorial symptoms in four, and isolated brainstem syndrome in two. Twenty patients had oligoclonal immunoglobulin G bands in cerebrospinal fluid. Supra- and infratentorial involvement was identified in the first brain magnetic resonance imaging of nine patients. Initial relapses were treated with intravenous steroids in 19 patients. The mean time for diagnosis was 2.8 months. Eleven patients were on first-line treatment (nine on β-interferon, two on teriflunomide) and 10 on second-line treatment (six on natalizumab, three on fingolimod, one on ocrelizumab). The mean annual relapse rate was 0.29 (range, 0.01-3), and the median Expanded Disability Status Scale was 1. Four patients reported learning disabilities and/or cognitive deficits. CONCLUSION About half of patients in this cohort were on second-line disease-modifying treatment, with 19% showing cognitive impairment. Efforts to establish an early diagnosis are crucial to improving these patients' outcomes.
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Affiliation(s)
- Cecília Martins
- Department of Pediatrics, Centro Hospitalar do Médio Ave, V. N. Famalicão, Portugal.,Department of Pediatric Neurology, Centro Materno Infantil do Norte/Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Raquel Samões
- Department of Neurology, Hospital Santo António/Centro Hospitalar Universitário do Porto, Porto, Portugal.,Multidisciplinary Unit for Biomedical Research, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - Ana Martins Silva
- Department of Neurology, Hospital Santo António/Centro Hospitalar Universitário do Porto, Porto, Portugal.,Multidisciplinary Unit for Biomedical Research, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - Ernestina Santos
- Department of Neurology, Hospital Santo António/Centro Hospitalar Universitário do Porto, Porto, Portugal.,Multidisciplinary Unit for Biomedical Research, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - Sónia Figueiroa
- Department of Pediatric Neurology, Centro Materno Infantil do Norte/Centro Hospitalar Universitário do Porto, Porto, Portugal
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18
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Piri Cinar B, Konuskan B, Anlar B, Ozakbas S. Narrative review based on fingolimod therapy in pediatric MS. SAGE Open Med 2023; 11:20503121231171996. [PMID: 37181277 PMCID: PMC10170592 DOI: 10.1177/20503121231171996] [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: 06/16/2022] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
The course of pediatric-onset multiple sclerosis and adult multiple sclerosis shows some clinical differences. The rate of having a second attack after the first clinical event is 80% in children and around 45% in adults but the time to the second event is similar in all age groups. The pediatric group usually has a more aggressive onset than adults. On the other hand, a higher rate of complete recovery is observed in pediatric-onset multiple sclerosis after the first clinical event compared to the adult group. Despite a highly active initial disease course, pediatric-onset multiple sclerosis patients show a slower increase in disability than patients with adult-onset disease. This is thought to be due to greater remyelination capacity and plasticity of the developing brain. The management of pediatric-onset multiple sclerosis includes safety issues as well as effective disease control. In the pediatric-onset multiple sclerosis group, similar to adult multiple sclerosis, injectable treatments have been used for many years with reasonable efficacy and safety. Since 2011, oral treatments and then infusion treatments have been approved and used effectively in adult multiple sclerosis and have gradually entered clinical use in the pediatric-onset multiple sclerosis group. However, clinical trials are fewer, smaller, and include shorter follow-up due to the much lower prevalence of pediatric-onset multiple sclerosis than adult multiple sclerosis. This is particularly important in the era of recent disease-modifying treatments. This review of the literature presents existing data on the safety and efficacy of fingolimod, pointing to a relatively favorable profile.
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Affiliation(s)
- Bilge Piri Cinar
- Samsun University, Samsun, Turkey
- Bilge Piri Cinar, Neurology Department, School of Medicine, Samsun University, Samsun, Turkey.
| | - Bahadır Konuskan
- University of Health Sciences Turkey, Etlik City Hospital, Ankara, Turkey
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19
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Re-examining the characteristics of pediatric multiple sclerosis in the era of antibody-associated demyelinating syndromes. Eur J Paediatr Neurol 2022; 41:8-18. [PMID: 36137476 DOI: 10.1016/j.ejpn.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/13/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The discovery of anti-myelin oligodendrocyte glycoprotein (MOG)-IgG and anti-aquaporin 4 (AQP4)-IgG and the observation on certain patients previously diagnosed with multiple sclerosis (MS) actually have an antibody-mediated disease mandated re-evaluation of pediatric MS series. AIM To describe the characteristics of recent pediatric MS cases by age groups and compare with the cohort established before 2015. METHOD Data of pediatric MS patients diagnosed between 2015 and 2021 were collected from 44 pediatric neurology centers across Türkiye. Clinical and paraclinical features were compared between patients with disease onset before 12 years (earlier onset) and ≥12 years (later onset) as well as between our current (2015-2021) and previous (<2015) cohorts. RESULTS A total of 634 children (456 girls) were enrolled, 89 (14%) were of earlier onset. The earlier-onset group had lower female/male ratio, more frequent initial diagnosis of acute disseminated encephalomyelitis (ADEM), more frequent brainstem symptoms, longer interval between the first two attacks, less frequent spinal cord involvement on magnetic resonance imaging (MRI), and lower prevalence of cerebrospinal fluid (CSF)-restricted oligoclonal bands (OCBs). The earlier-onset group was less likely to respond to initial disease-modifying treatments. Compared to our previous cohort, the current series had fewer patients with onset <12 years, initial presentation with ADEM-like features, brainstem or cerebellar symptoms, seizures, and spinal lesions on MRI. The female/male ratio, the frequency of sensorial symptoms, and CSF-restricted OCBs were higher than reported in our previous cohort. CONCLUSION Pediatric MS starting before 12 years was less common than reported previously, likely due to exclusion of patients with antibody-mediated diseases. The results underline the importance of antibody testing and indicate pediatric MS may be a more homogeneous disorder and more similar to adult-onset MS than previously thought.
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20
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Constantinescu V, Akgün K, Ziemssen T. Current status and new developments in sphingosine-1-phosphate receptor antagonism: fingolimod and more. Expert Opin Drug Metab Toxicol 2022; 18:675-693. [PMID: 36260948 DOI: 10.1080/17425255.2022.2138330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Fingolimod was the first oral disease-modifying treatment approved for relapsing-remitting multiple sclerosis (MS) that serves as a sphingosine-1-phosphate receptor (S1PR) agonist. The efficacy is primarily mediated by S1PR subtype 1 activation, leading to agonist-induced down-modulation of receptor expression and further functional antagonism, blocking the egression of auto-aggressive lymphocytes from the lymph nodes in the peripheral compartment. The role of S1P signaling in the regulation of other pathways in human organisms through different S1PR subtypes has received much attention due to its immune-modulatory function and its significance for the regeneration of the central nervous system (CNS). The more selective second-generation S1PR modulators have improved safety and tolerability profiles. AREAS COVERED This review has been carried out based on current data on S1PR modulators, emphasizing the benefits of recent advances in this emergent class of immunomodulatory treatment for MS. EXPERT OPINION Ongoing clinical research suggests that S1PR modulators represent an alternative to first-line therapies in selected cases of MS. A better understanding of the relevance of selective S1PR pathways and the ambition to optimize selective modulation has improved the safety and tolerability of S1PR modulators in MS therapy and opened new perspectives for the treatment of other diseases.
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Affiliation(s)
- Victor Constantinescu
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Katja Akgün
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
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21
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Abstract
PURPOSE OF REVIEW This article reviews the clinical presentation, diagnostic evaluation, treatment, and prognosis of the most common monophasic and relapsing acquired demyelinating disorders presenting in childhood. RECENT FINDINGS Our understanding of neuroimmune disorders of the central nervous system is rapidly expanding. Several clinical and paraclinical factors help to inform the diagnosis and ultimately the suspicion for a monophasic versus relapsing course, including the age of the patient (prepubertal versus postpubertal), presence or absence of clinical encephalopathy, identification of serum autoantibodies (eg, myelin oligodendrocyte glycoprotein [MOG] and aquaporin-4), presence of intrathecally unique oligoclonal bands, and location/extent of radiologic abnormalities. Collaborative international research efforts have facilitated understanding of the safety and efficacy of currently available immunotherapies in children with acquired demyelinating disorders, particularly multiple sclerosis. SUMMARY Although many of the demyelinating disorders presented in this article can affect children and adults across the age spectrum, the clinical and radiologic phenotypes, treatment considerations, and long-term prognoses are often distinct in children.
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22
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Interrogating large multiple sclerosis registries and databases: what information can be gained? Curr Opin Neurol 2022; 35:271-277. [PMID: 35674068 DOI: 10.1097/wco.0000000000001057] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Although substantial progress has been made in understanding the natural history of multiple sclerosis (MS) and the development of new therapies, many questions concerning disease behavior and therapeutics remain to be answered. Data generated from real-world observational studies, based on large MS registries and databases and analyzed with advanced statistical methods, are offering the scientific community answers to some of these questions that are otherwise difficult or impossible to address. This review focuses on observational studies published in the last 2 years designed to compare the effectiveness of escalation vs. induction treatment strategies, to assess the effectiveness of treatment in pediatric-onset and late-onset MS, and to identify the clinical phenotype of secondary progressive (SP)MS. RECENT FINDINGS The main findings originating from real-world studies suggest that MS patients who will qualify for high-efficacy disease-modifying therapies (DMTs) should be offered these as early as possible to prevent irreversible accumulation of neurological disability. Especially pediatric patients derive substantial benefits from early treatment. In patients with late-onset MS, sustained exposure to DMTs may result in more favorable outcomes. Data-driven definitions are more accurate in defining transition to SPMS than diagnosis based solely on neurologists' judgment. SUMMARY Patients, physicians, industry, and policy-makers have all benefited from real-world evidence based on registry data, in answering questions of diagnostics, choice of treatment, and timing of treatment decisions.
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23
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Ghadiri F, Sahraian MA, Baghbanian SM, Ashtari F, Razazian N, Majdinasab N, Poursadeghfard M, Hatamian H, Harirchian MH, Beladimoghadam N, Azimi A, Sharifipour E, Hosseini S, Bayat A, Kamali H, Hosseni Nejad Mir N, Faraji F, Mozhdehipanah H, Modara F, Navardi S, Heidari H, Ayoubi S, Naser Moghadasi A, Eskandarieh S. Prescription trends of disease-modifying treatments for multiple sclerosis in Iran over the past 30 years. Mult Scler Relat Disord 2022; 61:103777. [PMID: 35390594 DOI: 10.1016/j.msard.2022.103777] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/02/2022] [Accepted: 03/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Iran, as a middle income country, is one of the places with high and rising prevalence of multiple sclerosis (MS). Regarding the substantial economic burden, reviewing the trend in prescribed disease modifying treatments (DMTs) could be of help. Here we studied the DMT information of nearly 14000 MS cases and its trends change for 30 years to improve health services to patients. METHODS The population base of this descriptive-analytical (cross-sectional) study consisted of all MS patients in the nationwide MS registry of Iran (NMSRI), up to August 1, 2021. Registrars from 15 provinces, 24 cities, 13 hospitals,8 MS associations, 16 private offices, and 7 clinics had entered the data. RESULTS Overall, 14316 cases were enrolled. The majority (76.1%) were female. The youngest and eldest patients were 5 and 78 years old, respectively. Diagnosis delay was under one year in most cases (median: 0, IQR: 0 - 1). Most (61.4%) had RRMS. Generally, platform injectables (IFN beta, glatiramer acetate) were the most used DMTs until 2010. It seems that introduction of newer agents (antiCD20s and oral DMTs) resulted in a decrease in the use of former drugs since around 2015. Some unusual practices are prominent such as using not approved DMTs for PPMS over the years, or administering high efficacy drugs like natalizumab for CIS. The results indicate the remaining popularity of first line injectable DMTs in female and pediatric patients. DISCUSSION Mean age (SD) at onset in our study (29 ± 8.8) is near the statistics in Asia and Oceania (28 ± 0.7). Concerns about COVID-19 had a noticeable impact on administering high efficacy drugs like rituximab and fingolimod. However, in male patients this approach has not been the case. It may be related to more aggressive disease course in this group. The other possible explanation could be planning for pregnancy in female cases. The popularity of platform injectable drugs in pediatric MS may be related to its favorable safety profile over the years. Another point in this group, is the superiority of rituximab over other highly efficient medications.
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Affiliation(s)
- Fereshteh Ghadiri
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Fereshteh Ashtari
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nazanin Razazian
- Department of Neurology, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nastaran Majdinasab
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Poursadeghfard
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamidreza Hatamian
- Department of Neurology, School of Medicine, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohammad Hossein Harirchian
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nahid Beladimoghadam
- Department of Neurology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amirreza Azimi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Sharifipour
- Department of Neurology, School of Medicine, Neuroscience Research Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
| | - Samaneh Hosseini
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Asghar Bayat
- Department of Neurology, Shahrekord University of Medical Sciences and Health Services, Shahrekord, Iran
| | - Hoda Kamali
- Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Nahid Hosseni Nejad Mir
- Department of Internal Medicine, School of Medicine, Shohadaye Ashayer Hospital, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fardin Faraji
- Department of Neurology, School of Medicine, Arak University of Medical Sciences, Arak, Iran
| | | | - Farhad Modara
- School of Medicine, Shahid Mostafa Khomeini Hospital, Ilam University of Medical Sciences, Ilam, Iran
| | - Samira Navardi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hora Heidari
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeideh Ayoubi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abdorreza Naser Moghadasi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Sharareh Eskandarieh
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
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24
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Treatment of multiple sclerosis in children: A brief overview. Clin Immunol 2022; 237:108947. [PMID: 35123059 DOI: 10.1016/j.clim.2022.108947] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/29/2021] [Accepted: 01/31/2022] [Indexed: 11/20/2022]
Abstract
Multiple sclerosis (MS) is the most common autoimmune, chronic inflammatory demyelinating disorder of the central nervous system. Pediatric-onset MS (POMS), as opposed to adult-onset MS (AOMS), is a rare condition, presenting similar clinical features to AOMS, but a more active course of the disease, with higher relapse rates and greater white and grey matter damage. To date, the therapeutic approaches to treat POMS have been extrapolated from observational studies and data from trials conducted on adults, raising concerns about their efficacy and safety in the pediatric population. Herein, we discuss the most common therapeutic strategies used in POMS management, basing on the individual clinical practice and experience.
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25
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Menascu S, Fattal-Valevski A, Vaknin-Dembinsky A, Milo R, Geva K, Magalashvili D, Dolev M, Flecther S, Kalron A, Miron S, Hoffmann C, Aloni R, Gurevich M, Achiron A. Effect of natalizumab treatment on the rate of No Evidence of Disease Activity in young adults with multiple sclerosis in relation to pubertal stage. J Neurol Sci 2022; 432:120074. [PMID: 34875473 DOI: 10.1016/j.jns.2021.120074] [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: 06/01/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
Approximately 40% of young-onset multiple sclerosis (MS) patients experience breakthrough disease, which carries a high risk for long-term disability, and requires using therapies beyond traditional first-line agents. Despite the increasing use of newer disease-modifying treatments (DMTs) in this population, data are not available to guide the need for escalating DMTs and there is a scarcity of data on the effects of natalizumab in children and young adults with active disease. We performed a retrospective analysis of the rate of No Evidence of Disease Activity (NEDA), tolerability, and safety of natalizumab in a multi-center cohort of 36 children and young adults with highly active MS. All patients had active disease and initiated treatment with natalizumab. The primary endpoint was the rate of achieving NEDA-3 status, within two years of natalizumab treatment. To examine a possible effect of age on the outcome of treatment, outcomes were also analyzed by pre-pubertal (n = 13 children aged 9-13 years) and pubertal subgroups (n = 23 young adolescents aged 14-20 years). The NEDA-3 status of the pre-pubertal group was 92% in the first and second year and in the pubertal group - 96% in the first year and 92% in the second year. Natalizumab reduced the number and volume of brain lesions in both pre-pubertal and pubertal groups. Treatment was well-tolerated, only 8 patients (22.2%) had adverse events during the 2-year study period. Our analysis shows that natalizumab is effective and well-tolerated in pre-pubertal and pubertal MS patients.
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Affiliation(s)
- Shay Menascu
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Aviva Fattal-Valevski
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; Pediatric Neurology Unit, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Ron Milo
- Department of Neurology, Barzilai Medical Center, Ashkelon, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Keren Geva
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; Pediatric Neurology Unit, Meir Medical Center, Kfar-Saba, Israel
| | - David Magalashvili
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Mark Dolev
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shlomo Flecther
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology, Shamir Medical Center (Assaf Harofeh), Be'er Ya'akov, Israel
| | - Alon Kalron
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shmulik Miron
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Chen Hoffmann
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; Department of Radiology, Sheba Medical Center, Ramat Gan, Israel
| | - Roy Aloni
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Michael Gurevich
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Anat Achiron
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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26
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Jakimovski D, Awan S, Eckert SP, Farooq O, Weinstock-Guttman B. Multiple Sclerosis in Children: Differential Diagnosis, Prognosis, and Disease-Modifying Treatment. CNS Drugs 2022; 36:45-59. [PMID: 34940954 PMCID: PMC8697541 DOI: 10.1007/s40263-021-00887-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 12/19/2022]
Abstract
Pediatric-onset multiple sclerosis (POMS) is a rare neuroinflammatory and neurodegenerative disease that has a significant impact on long-term physical and cognitive patient outcomes. A small percentage of multiple sclerosis (MS) diagnoses occur before the age of 18 years. Before treatment initiation, a careful differential diagnosis and exclusion of other similar acquired demyelinating syndromes such as anti-aquaporin-4-associated neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody spectrum disorder (MOGSD) is warranted. The recent 2017 changes to the McDonald criteria can successfully predict up to 71% of MS diagnoses and have good specificity of 95% and sensitivity of 71%. Additional measures such as the presence of T1-weighted hypointense lesions and/or contrast-enhancing lesions significantly increase the accuracy of diagnosis. In adults, early use of disease-modifying therapies (DMTs) is instrumental to a better long-term prognosis, including lower rates of relapse and disability worsening, and numerous FDA-approved therapies for adult-onset MS are available. However, unlike their adult counterparts, the development, testing, and regulatory approval of POMS treatments have been significantly slower and hindered by logistic and/or ethical considerations. Currently, only two MS DMTs (fingolimod and teriflunomide) have been tested in large phase III trials and approved by regulatory agencies for use in POMS. First-line therapies not approved by the FDA for use in children (interferon-β and glatiramer acetate) are also commonly used and result in a significant reduction in inflammatory activity when compared with non-treated POMS patients. An increasing number of POMS patients are now treated with moderate efficacy therapies such as dimethyl fumarate and high-efficacy therapies such as natalizumab, anti-CD20 monoclonal antibodies, anti-CD52 monoclonal antibodies, and/or autologous hematopoietic stem cell transplantation. These high-efficacy DMTs generally provide additional reduction in inflammatory activity when compared with the first-line medications (up to 62% of relapse-rate reduction). Therefore, a number of phase II and III trials are currently investigating their efficacy and safety in POMS patients. In this review, we discuss potential changes in the regulatory approval process for POMS patients that are recommended for DMTs already approved for the adult MS population, including smaller sample size for pharmacokinetic/pharmacodynamic studies, MRI-centered primary outcomes, and/or inclusion of teenagers in the adult trials.
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Affiliation(s)
- Dejan Jakimovski
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA ,Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY USA
| | - Samreen Awan
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA
| | - Svetlana P. Eckert
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA
| | - Osman Farooq
- Division of Pediatric Neurology, Oishei Children’s Hospital of Buffalo, Buffalo, NY USA ,Department of Neurology, Jacobs School of Medicine, State University of New York at Buffalo, Buffalo, NY USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY, 14202, USA.
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27
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Abrams AW, March A, Porat D, Bhayana K, Rensel M. Treatment Updates in Paediatric-onset Multiple Sclerosis. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A number of new disease-modifying therapies have recently been developed and approved for use in adult-onset multiple sclerosis. However, few treatment options are approved for patients with paediatric-onset multiple sclerosis. There are an increasing number of clinical trials evaluating the efficacy and safety of disease-modifying therapies in children and teens living with multiple sclerosis. Clinical trials are difficult to complete in rare diseases like paediatric-onset multiple sclerosis; however, it is critical to assess safety and monitoring in this vulnerable population by applying robust research methodology to randomized controlled clinical trials. Longer-term extension analyses are also needed to better evaluate the efficacy, dosing and long-term safety of adult disease-modifying therapy for use in paediatric-onset multiple sclerosis. Future research should focus on defining optimal first-line disease-modifying therapy in paediatric-onset multiple sclerosis as related to both efficacy and safety, improving recruitment and completion rates of clinical trials, identifying relevant biomarkers of disease activity, analysing outcome measures related to treatment response and assessing long-term safety for this unique population living with a chronic disease.
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28
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Sandesjö F, Wassmer E, Deiva K, Amato MP, Chitnis T, Hemingway C, Krupp L, Pohl D, Rostasy K, Waubant E, Banwell B, Wickström R. Current international trends in the treatment of multiple sclerosis in children-Impact of the COVID-19 pandemic. Mult Scler Relat Disord 2021; 56:103277. [PMID: 34624643 PMCID: PMC8474759 DOI: 10.1016/j.msard.2021.103277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Only recently has the first disease-modifying therapy been approved for children with multiple sclerosis (MS) and practice patterns including substantial off-label use have evolved. Understanding attitudes towards treatment of paediatric MS and whether this has changed due to the ongoing COVID-19 pandemic is vital to guide future therapeutic trials and for developing guidelines that reflect practice. METHODS We performed an online survey within the International Paediatric Multiple Sclerosis Study Group between July and September 2020. The survey was sent to 130 members from 25 countries and consisted of five sections: demographic data, treatment, disease modifying therapies and COVID-19, outcome and three patient cases. RESULTS The survey was completed by 66 members (51%), both paediatric neurologists and adult neurologists. Fingolimod and β-interferons were the most frequently used disease-modifying therapies, especially among paediatric neurologists. Almost a third (31%) of respondents had altered their prescribing practice due to COVID-19, in particular at the beginning of the pandemic. CONCLUSIONS The survey results indicate a tendency of moving from the traditional escalation therapy starting with injectables towards an early start with newer, highly effective disease modifying therapies. The COVID-19 pandemic only slightly affected prescribing patterns and treatment choices in paediatric MS.
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Affiliation(s)
- Fredrik Sandesjö
- Neuropediatric Unit, Department of Women´s and Children´s Health, Karolinska Institutet, Sweden
| | - Evangeline Wassmer
- Birmingham Women and Children's Hospital, School of Life and Health Sciences, Aston University, Birmingham, United Kingdom
| | - Kumaran Deiva
- Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Bicêtre Hospital, Pediatric Neurology Departement, and National Referral Center for rare inflammatory brain and spinal diseases, Le Kremlin-Bicêtre, France
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Italy, IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Tanuja Chitnis
- Department of Neurology, Division of Child Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Lauren Krupp
- NYU MS Comprehensive Care Center, Grossman School of Medicine, New York University, New York City, NY, USA
| | - Daniela Pohl
- Division of Neurology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Kevin Rostasy
- Department of Pediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Germany
| | - Emanuelle Waubant
- UCSF Regional Pediatric MS clinic, Department of Neurology, San Francisco, CA 94158, USA
| | - Brenda Banwell
- The Children's Hospital of Philadelphia, Division of Neurology, Philadelphia, PA, USA; University of Pennsylvania, Departments of Neurology and Pediatrics, Perelman School of Medicine, Philadelphia, PA, USA
| | - Ronny Wickström
- Neuropediatric Unit, Department of Women´s and Children´s Health, Karolinska Institutet, Sweden.
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Abstract
Pediatric neuroinflammatory conditions are a complex group of disorders with a wide range of clinical presentations. Patients can present with a combination of focal neurologic deficits, encephalopathy, seizures, movement disorders, or psychiatric manifestations. There are several ways that pediatric neuroinflammatory conditions can be classified, including clinical presentation, pathophysiologic mechanism, and imaging and laboratory findings. In this article, we group these conditions into acquired demyelinating diseases, immune-mediated epilepsies/encephalopathies, primary rheumatologic conditions with central nervous system (CNS) manifestations, CNS vasculitis, and neurodegenerative/genetic conditions with immune-mediated pathophysiology and discuss epidemiology, pathophysiology, clinical presentation, treatment, and prognosis of each disorder.
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Affiliation(s)
- Nikita Malani Shukla
- Department of Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA.
| | - Timothy E Lotze
- Department of Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA
| | - Eyal Muscal
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Co-appointment in Department of Neurology and Developmental Neuroscience, 6701 Fannin Street, 11th Floor, Houston, TX 77030, USA
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30
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Baroncini D, Simone M, Iaffaldano P, Brescia Morra V, Lanzillo R, Filippi M, Romeo M, Patti F, Chisari CG, Cocco E, Fenu G, Salemi G, Ragonese P, Inglese M, Cellerino M, Margari L, Comi G, Zaffaroni M, Ghezzi A. Risk of Persistent Disability in Patients With Pediatric-Onset Multiple Sclerosis. JAMA Neurol 2021; 78:726-735. [PMID: 33938921 DOI: 10.1001/jamaneurol.2021.1008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Availability of new disease-modifying therapies (DMTs) and changes of therapeutic paradigms have led to a general improvement of multiple sclerosis (MS) prognosis in adults. It is still unclear whether this improvement also involves patients with pediatric-onset MS (POMS), whose early management is more challenging. Objective To evaluate changes in the prognosis of POMS over time in association with changes in therapeutic and managing standards. Design, Setting, and Participants Retrospective, multicenter, observational study. Data were extracted and collected in May 2019 from the Italian MS Registry, a digital database including more than 59 000 patients. Inclusion criteria were MS onset before age 18 years, diagnosis before January 2014, and disease duration of at least 3 years. Exclusion criteria were primary progressive MS, Expanded Disability Status Scale (EDSS) score of at least 8 one year after onset, unavailability of diagnosis date, and less than 2 EDSS score evaluations. Eligible patients were 4704 patients with POMS. According to these criteria, we enrolled 3198 patients, excluding 1506. Exposures We compared time to reach disability milestones by epoch of MS diagnosis (<1993, 1993-1999, 2000-2006, and 2007-2013), adjusting for possible confounders linked to EDSS evaluations and clinical disease activity. We then analyzed the difference among the 4 diagnosis epochs regarding demographic characteristics, clinical disease activity at onset, and DMTs management. Main Outcomes and Measures Disability milestones were EDSS score 4.0 and 6.0, confirmed in the following clinical evaluation and in the last available visit. Results We enrolled 3198 patients with POMS (mean age at onset, 15.2 years; 69% female; median time to diagnosis, 3.2 years; annualized relapse rate in first 1 and 3 years, 1.3 and 0.6, respectively), with a mean (SD) follow-up of 21.8 (11.7) years. Median survival times to reach EDSS score of 4.0 and 6.0 were 31.7 and 40.5 years. The cumulative risk of reaching disability milestones gradually decreased over time, both for EDSS score of 4.0 (hazard ratio [HR], 0.70; 95% CI, 0.58-0.83 in 1993-1999; HR, 0.48; 95% CI, 0.38-0.60 in 2000-2006; and HR, 0.44; 95% CI, 0.32-0.59 in 2007-2013) and 6.0 (HR, 0.72; 95% CI, 0.57-0.90; HR, 0.44; 95% CI, 0.33-0.60; and HR, 0.30; 0.20-0.46). In later diagnosis epochs, a greater number of patients with POMS were treated with DMTs, especially high-potency drugs, that were given earlier and for a longer period. Demographic characteristics and clinical disease activity at onset did not change significantly over time. Conclusions and Relevance In POMS, the risk of persistent disability has been reduced by 50% to 70% in recent diagnosis epochs, probably owing to improvement in therapeutic and managing standards.
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Affiliation(s)
- Damiano Baroncini
- Multiple Sclerosis Center, Gallarate Hospital, ASST Valle Olona, Gallarate (VA), Italy
| | - Marta Simone
- Child Neuropsychiatry Unit, Department of Biomedical Sciences and Oncology, University of Bari "Aldo Moro," Bari, Italy
| | - Pietro Iaffaldano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Care and Research Center, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
| | - Roberta Lanzillo
- Multiple Sclerosis Clinical Care and Research Center, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
| | - Massimo Filippi
- Department of Neurology and Neurophysiology, MS Center, and Neuroimaging Research Unit, Vita-Salute San Raffaele University and San Raffaele Scientific Institute, Milan, Italy
| | - Marzia Romeo
- Department of Neurology and Neurorehabilitation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Patti
- Policlinico Catania, Department of Medical, Surgery Science and Advanced Technology "GF Ingrassia," Section of Neurosciences, MS Center, University of Catania, Catania, Italy
| | - Clara Grazia Chisari
- Policlinico Catania, Department of Medical, Surgery Science and Advanced Technology "GF Ingrassia," Section of Neurosciences, MS Center, University of Catania, Catania, Italy
| | - Eleonora Cocco
- Department of Medical Science and Public Health, University of Cagliari and Multiple Sclerosis Center, Cagliari, Italy
| | - Giuseppe Fenu
- Department of Medical Science and Public Health, University of Cagliari and Multiple Sclerosis Center, Cagliari, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neurosciences, and advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Paolo Ragonese
- Department of Biomedicine, Neurosciences, and advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Maria Cellerino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Lucia Margari
- Child Neuropsychiatry Unit, Department of Biomedical Sciences and Oncology, University of Bari "Aldo Moro," Bari, Italy
| | - Giancarlo Comi
- Multiple Sclerosis Center, Gallarate Hospital, ASST Valle Olona, Gallarate (VA), Italy.,Institute of Experimental Neurology and Multiple Sclerosis Center IRCCS, San Raffaele Hospital, Milan, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, Gallarate Hospital, ASST Valle Olona, Gallarate (VA), Italy
| | - Angelo Ghezzi
- Multiple Sclerosis Center, Gallarate Hospital, ASST Valle Olona, Gallarate (VA), Italy
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Margoni M, Rinaldi F, Perini P, Gallo P. Therapy of Pediatric-Onset Multiple Sclerosis: State of the Art, Challenges, and Opportunities. Front Neurol 2021; 12:676095. [PMID: 34079516 PMCID: PMC8165183 DOI: 10.3389/fneur.2021.676095] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/08/2021] [Indexed: 11/13/2022] Open
Abstract
Treatment of pediatric-onset multiple sclerosis (POMS) has been tailored after observational studies and data obtained from clinical trials in adult-onset multiple sclerosis (AOMS) patients. There are an increasing number of new therapeutic agents for AOMS, and many will be formally studied for use also in POMS. However, there are important efficacy and safety concerns regarding the use of these therapies in children and young adults. This review will discuss the current state of the art of POMS therapy and will focus on the newer therapies (oral and infusion disease-modifying drugs) and on those still currently under investigation.
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Affiliation(s)
- Monica Margoni
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy.,Padova Neuroscience Centre, University of Padua, Padua, Italy
| | - Francesca Rinaldi
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy
| | - Paola Perini
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy
| | - Paolo Gallo
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy.,Department of Neurosciences, Medical School, University of Padua, Padua, Italy
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32
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Simpson A, Mowry EM, Newsome SD. Early Aggressive Treatment Approaches for Multiple Sclerosis. Curr Treat Options Neurol 2021; 23:19. [PMID: 34025110 PMCID: PMC8121641 DOI: 10.1007/s11940-021-00677-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 12/19/2022]
Abstract
Purpose of review This review presents a comprehensive analysis of the current high-efficacy disease-modifying therapies (DMTs) available for treatment of multiple sclerosis (MS). We discuss the existing approved and emerging therapeutics in patients with relapsing and progressive forms of MS using data from clinical trials and observational studies. Treatment considerations in pediatric and pregnant populations are also reviewed. Finally, we discuss the treatment paradigms of the escalation and early aggressive approaches to treatment of MS, with review of ongoing clinical trials to compare these approaches. Recent findings Natalizumab has shown promising data on efficacy in not only randomized trials but also observational studies when compared with placebo, the injectable DMTs, and fingolimod. The anti-CD20 B cell depleting therapies (rituximab, ocrelizumab, and ofatumumab) have also demonstrated superiority in randomized clinical trials compared to their comparator group (placebo, interferon, and teriflunomide, respectively) and rituximab has shown in observational studies to be more effective than older injectable therapies and some of the oral therapies. Alemtuzumab has shown good efficacy in randomized controlled trials and observational studies yet has several potentially severe side effects limiting its use. Mitoxantrone has similarly demonstrated significant reduction in new disease activity compared to placebo but is rarely used due to its severe side effects. Cladribine is an oral DMT often grouped in discussion with other higher efficacy DMTs but may be slightly less effective than the other therapies described in this review. Many emerging targets for therapeutic intervention are currently under investigation that may prove to be beneficial in early aggressive MS, including autologous hematopoietic stem cell transplantation. Summary Traditionally, MS has been treated with an escalation approach, starting patients on a modestly effective DMT and subsequently escalating to a higher efficacy DMT when there is evidence of clinical and/or radiologic breakthrough activity. With the development of higher efficacy therapies and emerging data showing the potential positive long-term impact of these therapies when started earlier in the disease course, many clinicians have shifted to an early aggressive treatment approach in which patients are initially started on a higher efficacy DMT. Two clinical trials, the TRaditional versus Early Aggressive Therapy for MS (TREAT-MS) trial and the Determining the Effectiveness of earLy Intensive Versus Escalation approaches for the treatment of Relapsing-remitting MS (DELIVER-MS) trial, aim to directly compare these treatment strategies and their impact on clinical and radiologic outcomes.
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Affiliation(s)
- Alexandra Simpson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA.,Division of Neuroimmunology and Neurological Infections, Johns Hopkins Hospital, 600 North Wolfe St., Pathology 627, Baltimore, MD 21287 USA
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33
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Fingolimod as first-line treatment in pediatric-onset multiple sclerosis: a case report. Neurol Sci 2021; 42:25-28. [PMID: 33712907 DOI: 10.1007/s10072-020-05027-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/23/2020] [Indexed: 11/27/2022]
Abstract
Pediatric-onset multiple sclerosis (MS) has a highly active and aggressive course, which can have a devastating effect on the physical and cognitive functioning of a child if not treated appropriately with effective disease-modifying drugs. The optimal treatment strategy of pediatric MS is currently unknown and debate continues as to whether treatment escalation or initiation of a highly active therapy provides a better outcome. Here, we present the case of a 16-year-old female diagnosed with highly active relapsing-remitting MS (age at onset: 14 years) who received first-line treatment with fingolimod within 1 year of the first recorded symptom. Since starting fingolimod, the course of the disease has essentially been stable. No new or active lesions were observed in magnetic resonance imaging scans performed at 3 and 12 months after starting fingolimod, and treatment was well tolerated. These data suggest that, in this case, early treatment with first-line fingolimod was able to slow disease progression.
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34
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Luchesa Smith A, Benetou C, Bullock H, Kuczynski A, Rudebeck S, Hanson K, Crichton S, Mankad K, Siddiqui A, Byrne S, Lim M, Hemingway C. Progress in the Management of Paediatric-Onset Multiple Sclerosis. CHILDREN (BASEL, SWITZERLAND) 2020; 7:E222. [PMID: 33182341 PMCID: PMC7695340 DOI: 10.3390/children7110222] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/01/2020] [Accepted: 11/06/2020] [Indexed: 11/16/2022]
Abstract
Considerable progress has been made in the understanding and treatment of paediatric-onset multiple sclerosis (POMS); how this has translated into more effective care is less well understood. Here, we evaluate how recent advances have affected patient management and outcomes with a retrospective review of POMS patients managed at two paediatric neuroimmunology centres. Two cohorts, seen within a decade, were compared to investigate associations between management approaches and outcomes. Demographic, clinical and neurocognitive data were extracted from case notes and analysed. Of 51 patients, 24 were seen during the period 2007-2010 and 27 during the period 2015-2016. Median age at onset was 13.7 years; time from symptom onset to diagnosis was 9 months. Disease-modifying therapies were commenced in 19 earlier-cohort and 24 later-cohort patients. Median time from diagnosis to treatment was 9 months for earlier vs. 3.5 months in later patients (p = 0.013). A wider variety of treatments were used in the later cohort (four medications earlier vs. seven in the later and two clinical trials), with increased quality of life and neurocognitive monitoring (8% vs. 48% completed PedsQL quality of life inventory; 58% vs. 89% completed neurocognitive assessment). In both cohorts, patients were responsive to disease-modifying therapy (mean annualised relapse rate pre-treatment 2.7 vs. 1.7, mean post-treatment 0.74 vs. 0.37 in earlier vs. later cohorts). In conclusion, over the years, POMS patients were treated sooner with a wider variety of medications and monitored more comprehensively. However, this hugely uncontrolled cohort did not allow us to identify key determinants for the improvements observed.
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Affiliation(s)
| | - Christina Benetou
- Children’s Neurosciences, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (C.B.); (S.R.); (S.C.); (A.S.); (S.B.)
| | - Hayley Bullock
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK; (H.B.); (K.H.)
| | - Adam Kuczynski
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK;
| | - Sarah Rudebeck
- Children’s Neurosciences, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (C.B.); (S.R.); (S.C.); (A.S.); (S.B.)
| | - Katie Hanson
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK; (H.B.); (K.H.)
| | - Sarah Crichton
- Children’s Neurosciences, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (C.B.); (S.R.); (S.C.); (A.S.); (S.B.)
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK;
| | - Ata Siddiqui
- Children’s Neurosciences, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (C.B.); (S.R.); (S.C.); (A.S.); (S.B.)
- Department of Neuroradiology, King’s College Hospital, London SE5 9RS, UK
| | - Susan Byrne
- Children’s Neurosciences, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (C.B.); (S.R.); (S.C.); (A.S.); (S.B.)
| | - Ming Lim
- Children’s Neurosciences, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; (C.B.); (S.R.); (S.C.); (A.S.); (S.B.)
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London SE5 9NU, UK
| | - Cheryl Hemingway
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK; (H.B.); (K.H.)
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Santoro JD, Waltz M, Aaen G, Belman A, Benson L, Gorman M, Goyal MS, Graves JS, Harris Y, Krupp L, Lotze T, Mar S, Moodley M, Ness J, Rensel M, Rodriguez M, Schreiner T, Tillema JM, Waubant E, Weinstock-Guttman B, Hurtubise BF, Roalstad S, Rose J, Casper TC, Chitnis T. Pediatric Multiple Sclerosis Severity Score in a large US cohort. Neurology 2020; 95:e1844-e1853. [PMID: 32690790 DOI: 10.1212/wnl.0000000000010414] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/10/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To characterize disease severity and distribution of disability in pediatric-onset multiple sclerosis (POMS) and to develop an optimized modeling scale for measuring disability, we performed a multicenter retrospective analysis of disability scores in 873 persons with POMS over time and compared this to previously published data in adults with multiple sclerosis (MS). METHODS This was a retrospective analysis of prospectively collected data collected from 12 centers of the US Network of Pediatric MS Centers. Patients were stratified by the number of years from first symptoms of MS to Expanded Disability Status Scale (EDSS) assessment and an MS severity score (Pediatric Multiple Sclerosis Severity Score [Ped-MSSS]) was calculated per criteria developed by Roxburgh et al. in 2005. RESULTS In total, 873 patients were evaluated. In our cohort, 52%, 19.4%, and 1.5% of all patients at any time point reached an EDSS of 2.0, 3.0, and 6.0. Comparison of our Ped-MSSS scores and previously published adult Multiple Sclerosis Severity Scores (MSSS) showed slower progression of Ped-MSSS with increasing gaps between higher EDSS score and years after diagnosis. Decile scores in our POMS cohort for EDSS of 2.0, 3.0, and 6.0 were 8.00/9.46/9.94, 7.86/9.39/9.91, and 7.32/9.01/9.86 at 2, 5, and 10 years, respectively. Notable predictors of disease progression in both EDSS and Ped-MSSS models were ever having a motor relapse and EDSS at year 1. Symbol Digit Modalities Test (SDMT) scores were inversely correlated with duration of disease activity and cerebral functional score. CONCLUSIONS Persons with POMS exhibit lower EDSS scores compared to persons with adult-onset MS. Use of a Ped-MSSS model may provide an alternative to EDSS scoring in clinical assessment of disease severity and disability accrual.
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Affiliation(s)
- Jonathan D Santoro
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA.
| | - Michael Waltz
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Greg Aaen
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Anita Belman
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Leslie Benson
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Mark Gorman
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Manu S Goyal
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Jennifer S Graves
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Yolanda Harris
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Lauren Krupp
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Timothy Lotze
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Soe Mar
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Manikum Moodley
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Jayne Ness
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Mary Rensel
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Moses Rodriguez
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Teri Schreiner
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Jan-Mendelt Tillema
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Emmanuelle Waubant
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Bianca Weinstock-Guttman
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Brigitte F Hurtubise
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Shelly Roalstad
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - John Rose
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - T Charles Casper
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Tanuja Chitnis
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA.
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36
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Hacohen Y, Banwell B, Ciccarelli O. What does first-line therapy mean for paediatric multiple sclerosis in the current era? Mult Scler 2020; 27:1970-1976. [PMID: 32633605 DOI: 10.1177/1352458520937644] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Paediatric multiple sclerosis (MS) is associated with higher relapse rate, rapid magnetic resonance imaging lesion accrual early in the disease course and worse cognitive outcome and physical disability in the long term compared to adult-onset disease. Current treatment strategies are largely centre-specific and reliant on adult protocols. The aim of this review is to examine which treatment options should be considered first line for paediatric MS and we attempt to answer the question if injectable first-line disease-modifying therapies (DMTs) are still an optimal option. To answer this question, we review the effects of early onset disease on clinical course and outcomes, with specific considerations on risks and benefits of treatments for paediatric MS. Considering the impact of disease activity on brain atrophy, cognitive impairment and development of secondary progressive MS at a younger age, we would recommend treating paediatric MS as a highly active disease, favouring the early use of highly effective DMTs rather than injectable DMTs.
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Affiliation(s)
- Yael Hacohen
- Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, University College London, London, UK/Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Brenda Banwell
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA/Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Olga Ciccarelli
- Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, University College London, London, UK/NIHR UCLH Biomedical Research Centre, London, UK
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Jure Hunt D, Traboulsee A. Short-term outcomes of pediatric multiple sclerosis patients treated with alemtuzumab at a Canadian University multiple sclerosis clinic. Mult Scler J Exp Transl Clin 2020; 6:2055217320926613. [PMID: 32655877 PMCID: PMC7333501 DOI: 10.1177/2055217320926613] [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: 10/29/2019] [Accepted: 04/04/2020] [Indexed: 11/15/2022] Open
Abstract
There is a lack of literature documenting the use of alemtuzumab in pediatric multiple sclerosis (MS) patients. Here we describe a 16-year-old and a 17-year-old patient receiving alemtuzumab and being followed for 37 months and 20 months, respectively. Both patients experienced a 1.0 decrease in Expanded Disability Status Scale since initial alemtuzumab infusion and had stable disease. No serious infusion reactions, infections, or definite relapses were recorded on follow-up. Alemtuzumab has been relatively well-tolerated and effective; however, larger, longer-term studies are necessary to understand the specific risks and benefits of alemtuzumab in pediatric MS.
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Affiliation(s)
| | - Anthony Traboulsee
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada
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Ghezzi A, Banwell B, Bar-Or A, Chitnis T, Dale RC, Gorman M, Kornek B, Krupp L, Krysko KM, Nosadini M, Rostasy K, Salzer J, Schreiner T, Tenembaum S, Waubant E. Rituximab in patients with pediatric multiple sclerosis and other demyelinating disorders of the CNS: Practical considerations. Mult Scler 2020; 27:1814-1822. [PMID: 32552353 DOI: 10.1177/1352458520932798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Anti-CD20 therapies have established efficacy in the treatment of immune-mediated neurological and non-neurological diseases. Rituximab, one of the first B-cell-directed therapies, is relatively inexpensive compared to newer anti-CD20 molecules, is available in many countries, and has been used off-label in pediatric patients with neuroimmune conditions. The objective of this paper is to describe the experience with rituximab in pediatric multiple sclerosis and other inflammatory immune-mediated disorders of the central nervous system (CNS), and to define a protocol for its use in clinical practice, in particular addressing doses, interval of administration, duration of treatment, and tests to perform at baseline and during follow-up.
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Affiliation(s)
- Angelo Ghezzi
- Centro Studi Sclerosi Multipla, Ospedale di Gallarate, ASST Valleolona, Gallarate, Italy
| | - Brenda Banwell
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Bar-Or
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA/Center for Neuroinflammation and Experimental Therapeutics and the Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tanuja Chitnis
- Partners Pediatric MS Center, Massachusetts General Hospital, Boston, MA, USA
| | - Russell C Dale
- Kids Neuroscience Centre and Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Mark Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Lauren Krupp
- Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Margherita Nosadini
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Kevin Rostasy
- Department of Pediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Witten, Germany
| | - Jonatan Salzer
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Teri Schreiner
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Silvia Tenembaum
- Pediatric Neuroimmunology Program, Department of Neurology, National Pediatric Hospital Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Emmanuelle Waubant
- UCSF Pediatric MS Clinic and UCSF Adult MS Clinic, Department of Neurology, University of California at San Francisco, San Francisco CA, USA
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Ghezzi A, Amato MP, Edan G, Hartung HP, Havrdová EK, Kappos L, Montalban X, Pozzilli C, Sorensen PS, Trojano M, Vermersch P, Comi G. The introduction of new medications in pediatric multiple sclerosis: Open issues and challenges. Mult Scler 2020; 27:479-482. [PMID: 32539596 DOI: 10.1177/1352458520930620] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Disease-modifying drugs (DMDs) for multiple sclerosis (MS) have been evaluated in pediatric patients in observational studies demonstrating a similar, even better clinical effect compared to adults, with a similar safety. Only fingolimod has been tested in a randomized controlled trial (RCT) and is approved for pediatric multiple sclerosis (ped-MS). Numerous methodological, practical, and ethical issues underline that RCTs are difficult to conduct in ped-MS. This also creates a lack of safety information. To facilitate the availability of new agents in ped-MS, we encourage to develop a different approach based on pharmacokinetic/pharmacodynamic studies to yield information on optimal doses and implementation of obligatory registries to obtain information on safety as primary endpoint.
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Affiliation(s)
- Angelo Ghezzi
- Centro Studi Sclerosi Multipla, Ospedale di Gallarate, Gallarate, Italy
| | - Maria Pia Amato
- Department of NEUROFARBA, University of Florence, Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Gilles Edan
- CIC 1414 INSERM, Department of Neurology, CHU Rennes, Rennes, France
| | - Hans-Peter Hartung
- Department of Neurology, UKD and Center of Neurology and Neuropsychiatry, Heinrich-Heine-University, Düsseldorf, Germany
| | - Eva Kubala Havrdová
- Department of Neurology and Center for Clinical Neuroscience, First Medical Faculty, Charles University, Prague, Czech Republic
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | - Xavier Montalban
- St Michael's Hospital, University of Toronto, Toronto, ON, Canada; Department of Neurology, Cemcat, Hospital Vall d'Hebron, Barcelona, Spain
| | - Carlo Pozzilli
- Multiple Sclerosis Center, Sant' Andrea Hospital, Rome, Italy
| | - Per Soelber Sorensen
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University and Rigshospitalet, Copenhagen, Denmark
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Patrich Vermersch
- University of Lille, INSERM UMR-S1172, CHU Lille, FHU Imminent, Lille, France
| | - Giancarlo Comi
- Istituto di Neurologia Sperimentale (INSPE), IRCCS Ospedale San Raffaele, Milan, Italy
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Greenberg B, Kolodny S, Wang M, Deshpande C. Utilization and Treatment Patterns of Disease-Modifying Therapy in Pediatric Patients with Multiple Sclerosis in the United States. Int J MS Care 2020; 23:101-105. [PMID: 34177381 DOI: 10.7224/1537-2073.2019-095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background The current landscape and treatment patterns of disease-modifying therapy (DMT) use in pediatric patients with multiple sclerosis (MS) are not yet well understood. This study examined DMT utilization and treatment patterns in pediatric patients newly diagnosed as having MS. Methods Pediatric patients (<18 years old) with two MS diagnosis claims from January 1, 2010, to December 31, 2016, were identified from the MarketScan Commercial Database. The index date was defined as the date of first MS diagnosis, and patients were followed up for 1 year post-index date. Outcomes evaluated included percentage of patients who initiated treatment after MS diagnosis, different DMTs initiated, treatment discontinuation, and switching treatment during follow-up. Results Of 182,057 patients newly diagnosed as having MS, 288 pediatric patients (mean age, 14 years; 61% female) were identified. Within the first year of diagnosis, 188 patients (65.3%) did not receive any DMT. The most common first-initiated treatments were interferons and glatiramer acetate (83%), but 28% of patients switched or discontinued from first-initiated treatment within 6 months of treatment initiation. Conclusions This study suggests that a considerable proportion of pediatric patients with MS remain untreated within 1 year of diagnosis. Patients most commonly initiated injectables as their first DMT. Overall, therapy failed early in approximately one in three patients. Thus, the study warrants urgency in treating these patients with currently approved treatment options.
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Krysko KM, Graves JS, Rensel M, Weinstock-Guttman B, Rutatangwa A, Aaen G, Belman A, Benson L, Chitnis T, Gorman M, Goyal MS, Harris Y, Krupp L, Lotze T, Mar S, Moodley M, Ness J, Rodriguez M, Rose J, Schreiner T, Tillema JM, Waltz M, Casper TC, Waubant E. Real-World Effectiveness of Initial Disease-Modifying Therapies in Pediatric Multiple Sclerosis. Ann Neurol 2020; 88:42-55. [PMID: 32267005 DOI: 10.1002/ana.25737] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To assess real-world effectiveness of initial treatment with newer compared to injectable disease-modifying therapies (DMTs) on disease activity in pediatric multiple sclerosis (MS) and clinically isolated syndrome (CIS). METHODS This is a cohort study of children with MS/CIS followed at 12 clinics in the US Network of Pediatric MS Centers, who received initial therapy with newer (fingolimod, dimethyl fumarate, teriflunomide, natalizumab, rituximab, ocrelizumab) or injectable (interferon-β, glatiramer acetate) DMTs. Propensity scores (PSs) were computed, including preidentified confounders. Relapse rate while on initial DMT was modeled with negative binomial regression, adjusted for PS-quintile. Time to new/enlarging T2-hyperintense and gadolinium-enhancing lesions on brain magnetic resonance imaging were modeled with midpoint survival analyses, adjusted for PS-quintile. RESULTS A total of 741 children began therapy before 18 years, 197 with newer and 544 with injectable DMTs. Those started on newer DMTs were older (15.2 vs injectable 14.4 years, p = 0.001) and less likely to have a monofocal presentation. In PS-quintile-adjusted analysis, those on newer DMTs had a lower relapse rate than those on injectables (rate ratio = 0.45, 95% confidence interval (CI) = 0.29-0.70, p < 0.001; rate difference = 0.27, 95% CI = 0.14-0.40, p = 0.004). One would need to treat with newer rather than injectable DMTs for 3.7 person-years to prevent 1 relapse. Those started on newer DMTs had a lower rate of new/enlarging T2 (hazard ratio [HR] = 0.51, 95% CI = 0.36-0.72, p < 0.001) and gadolinium-enhancing lesions (HR = 0.38, 95% CI = 0.23-0.63, p < 0.001) than those on injectables. INTERPRETATION Initial treatment of pediatric MS/CIS with newer DMTs led to better disease activity control compared to injectables, supporting greater effectiveness of newer therapies. Long-term safety data for newer DMTs are required. ANN NEUROL 2020 ANN NEUROL 2020;88:42-55.
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Affiliation(s)
- Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Jennifer S Graves
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA.,Department of Neurology, University of California, San Diego, La Jolla, CA
| | - Mary Rensel
- Department of Neurology, Cleveland Clinic, Cleveland, OH
| | | | - Alice Rutatangwa
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Gregory Aaen
- Department of Pediatrics, Loma Linda University, San Bernardino, CA
| | - Anita Belman
- Department of Neurology, New York University Langone Medical Center, New York, NY
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Tanuja Chitnis
- Department of Pediatric Neurology, Massachusetts General Hospital, Boston, MA
| | - Mark Gorman
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Manu S Goyal
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, St Louis, MO
| | - Yolanda Harris
- Department of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Lauren Krupp
- Department of Neurology, New York University Langone Medical Center, New York, NY
| | - Timothy Lotze
- Department of Neurology, Texas Children's Hospital, Houston, TX
| | - Soe Mar
- Department of Neurology, Washington University in Saint Louis, St Louis, MO
| | - Manikum Moodley
- Department of Pediatrics and Neurology, Dell Children's Hospital, University of Texas, Austin, TX
| | - Jayne Ness
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | | | - John Rose
- Department of Neurology, University of Utah, Salt Lake City, UT
| | - Teri Schreiner
- Departments of Neurology and Pediatrics, University of Colorado, Aurora, CO
| | | | - Michael Waltz
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Emmanuelle Waubant
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
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Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations. Can J Neurol Sci 2020; 47:437-455. [DOI: 10.1017/cjn.2020.66] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract:The Canadian Multiple Sclerosis Working Group has updated its treatment optimization recommendations (TORs) on the optimal use of disease-modifying therapies for patients with all forms of multiple sclerosis (MS). Recommendations provide guidance on initiating effective treatment early in the course of disease, monitoring response to therapy, and modifying or switching therapies to optimize disease control. The current TORs also address the treatment of pediatric MS, progressive MS and the identification and treatment of aggressive forms of the disease. Newer therapies offer improved efficacy, but also have potential safety concerns that must be adequately balanced, notably when treatment sequencing is considered. There are added discussions regarding the management of pregnancy, the future potential of biomarkers and consideration as to when it may be prudent to stop therapy. These TORs are meant to be used and interpreted by all neurologists with a special interest in the management of MS.
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Current Advances in Pediatric Onset Multiple Sclerosis. Biomedicines 2020; 8:biomedicines8040071. [PMID: 32231060 PMCID: PMC7235875 DOI: 10.3390/biomedicines8040071] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 01/01/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune inflammatory disease affecting the central nervous system leading to demyelination. MS in the pediatric population is rare, but has been shown to lead to significant disability over the duration of the disease. As we have learned more about pediatric MS, there has been a development of improved diagnostic criteria leading to earlier diagnosis, earlier initiation of disease-modifying therapies (DMT), and an increasing number of DMT used in the treatment of pediatric MS. Over time, treatment with DMT has trended towards the initiation of higher efficacy treatment at time of diagnosis to help prevent further disease progression and accrual of disability over time, and there is evidence in current literature that supports this change in treatment patterns. In this review, we discuss the current knowledge in diagnosis, treatment, and clinical outcomes in pediatric MS.
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Abstract
PURPOSE OF REVIEW To summarize recent developments in the classification, investigation and management of pediatric optic neuritis (PON). RECENT FINDINGS A recent surge in interest surrounding antibodies to myelin oligodendrocyte glycoprotein antibody (MOG-Ab) has instigated a paradigm shift in our assessment of children with PON. This serological marker is associated with a broad spectrum of demyelinating syndromes that are clinically and radiologically distinct from multiple sclerosis (MS) and aquaporin-4 antibody positive neuromyelitis optica spectrum disorder (AQP4+NMOSD). Optic neuritis is the most common presenting phenotype of MOG-Ab positive-associated disease (MOG+AD). MOG-Ab seropositivity is much more common in the pediatric population and it predicts a better prognosis than MS or AQP4+NMOSD, except in the subset that exhibit a recurrent phenotype. SUMMARY A better grasp of MOG+AD features and its natural history has facilitated more accurate risk stratification of children after a presenting episode of PON. Consequently, the initial investigation of PON has broadened to include serology, along with neuroimaging and cerebrospinal fluid analysis. Acute treatment of PON and chronic immunotherapy is also becoming better tailored to the suspected or confirmed diagnoses of MS, AQP4+NMOSD and MOG+AD.
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Affiliation(s)
- Jane H. Lock
- Departments of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Nancy J. Newman
- Departments of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, United States
- Departments of Ophthalmology, Neurology, Emory University School of Medicine, Atlanta, Georgia, United States
- Departments of Ophthalmology, Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Valérie Biousse
- Departments of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, United States
- Departments of Ophthalmology, Neurology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Jason H. Peragallo
- Departments of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, United States
- Departments of Ophthalmology, Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
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Abstract
PURPOSE OF REVIEW With the recognition that pediatric-onset multiple sclerosis (POMS) is characterized by more prominent disease activity, earlier age at onset of disability milestones, and more prominent cognitive impairment compared with physical disability earlier in the disease course compared with adult-onset multiple sclerosis (AOMS), there has been increasing interest in identifying optimal and safe treatment approaches to achieve better disease control in this group. Injectable therapies have been traditionally used as first line in this population, although not formally approved. This review focuses on current treatment and monitoring approaches in POMS. RECENT FINDINGS In the past few years, and despite the paucity of FDA-approved medications for use in POMS, an increasing trend toward using newer disease-modifying therapies (DMTs) in this group is observed. However, escalation (as opposed to induction) remains the most frequent approach, and many children continue to be untreated before age 18, particularly before age 12. The only FDA- and EMA-approved disease-modifying therapy in POMS is fingolimod; however, dimethyl fumarate, teriflunomide, natalizumab, ocrelizumab, and alemtuzumab either have been evaluated in observational studies or are being currently investigated in formal randomized controlled trials for use in POMS and appear to be safe in this group. Autologous hematopoietic stem cell transplantation has also been evaluated in a small series. Clinical outcome measures and MS biomarkers have been poorly studied in POMS; however, the use of composite functional scores, neurofilament light chain, optical coherence tomography, and imaging findings is being increasingly investigated to improve early diagnosis and efficient monitoring of POMS. Off-label use of newer DMTs in POMS is increasing, and based on retrospective data, and phase 2 trials, this approach appears to be safe in children. Results from ongoing trials will help clarify the safety and efficacy of these therapies in the future. Fingolimod is the only FDA-approved medication for use in POMS. Outcome measures and biomarkers used in AOMS are being studied in POMS and are greatly needed to quantify treatment response in this group.
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Abstract
Pediatric-onset multiple sclerosis (MS) comprises 2-5% of MS cases, and is known to be associated with high disease activity and the accumulation of disability at an earlier age than their adult-onset counterparts. Appropriate therapy leading to disease control has the potential to alter the known trajectory of adverse long-term physical, cognitive, and psychosocial outcomes in this population. Thus, optimizing treatment for children and adolescents with MS is of paramount importance. The last decade has seen a growing number of disease-modifying therapies approved for relapsing MS in adults, and available agents now include oral, injectable, and infusion therapies. Recently, the development of randomized controlled MS trials in youth has led to the first agent approved by the US FDA for the treatment of pediatric MS-fingolimod. With this, we have entered a new era of knowledge and treatment in this population and ongoing pediatric trials are expected to further inform clinical management. With the emergence of highly effective therapies targeting the inflammatory component of the disease, there has been increased interest in identifying treatment strategies that instead target mechanisms such as remyelination/repair, neuroprotection, or rehabilitation. The potential role for such emerging therapies in the treatment of pediatric MS remains an important area of study. In this review, we discuss current evidence for MS therapies in children including the treatment of acute relapses, disease-modifying therapies, and symptomatic management. We will also discuss evidence for emerging therapies, including remyelinating and neuroprotective agents.
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Affiliation(s)
- Colin Wilbur
- Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Division of Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Rensel M. Long-Term Treatment Strategies of Pediatric Multiple Sclerosis, Including the use of Disease Modifying Therapies. CHILDREN-BASEL 2019; 6:children6060073. [PMID: 31159312 PMCID: PMC6617229 DOI: 10.3390/children6060073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/02/2019] [Accepted: 05/14/2019] [Indexed: 01/20/2023]
Abstract
Multiple sclerosis (MS) presenting in the pediatric years can lead to landmark disability levels younger in life than adult onset MS and so therefore early and effective treatment remains paramount for long-term outcomes. The goals of MS therapeutics in adults have widened to address multiple mechanisms: anti-inflammatory, neuroprotective, and myelin repair, yet the optimal paradigm for MS therapies in the pediatric population is not known. Pediatric onset MS add complexities due to the ongoing development of the central nervous system and the immune system. Clinical trials have led to an increasing number of pharmaceutical therapies for adult onset MS (AOMS), one POMS randomized controlled trial is completed and other trials are ongoing, yet due to the low prevalence of POMS, the dynamic landscape and risk management of the MS disease modifying therapies (DMT) it remains more difficult to complete trials in POMS. There is consensus that controlled clinical trials leading to appropriate and safe therapies for POMS are important for a multitude of reasons that include unique pediatric pharmacokinetics, short and long-term safety, developmental issues, clinical benefits, and regulatory approval. This review will focus on new treatment goals, paradigm, strategies, monitoring, compliance, and products in the long-term treatment of POMS. The discussion will focus on these new concepts and the published data related to DMT use in POMS. This review provides significant insight into new concepts of treatment goals and current approaches to enhance the lives of the POMS patients now and in the future.
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Affiliation(s)
- Mary Rensel
- The Mellen Center, Department of Neurology, Cleveland Clinic, Cleveland, OH 44195, USA.
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Waubant E, Banwell B, Wassmer E, Sormani MP, Amato MP, Hintzen R, Krupp L, Rostásy K, Tenembaum S, Chitnis T. Clinical trials of disease-modifying agents in pediatric MS: Opportunities, challenges, and recommendations from the IPMSSG. Neurology 2019; 92:e2538-e2549. [PMID: 31043474 PMCID: PMC6556085 DOI: 10.1212/wnl.0000000000007572] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/31/2019] [Indexed: 11/17/2022] Open
Abstract
Objective The impetus for this consensus discussion was to recommend clinical trial designs that can deliver high-quality data for effective therapies for pediatric patients, in a reasonable timeframe, with a key focus on short- and long-term safety. Methods The International Pediatric Multiple Sclerosis Study Group convened a meeting of experts to review the advances in the understanding of pediatric-onset multiple sclerosis (MS) and the advent of clinical trials for this population. Results In the last few years, convincing evidence has emerged that the biological processes involved in MS are largely shared across the age span. As such, treatments proven efficacious for the care of adults with MS have a biological rationale for use in pediatric MS given the relapsing-remitting course at onset and high relapse frequency. There are also ethical considerations on conducting clinical trials in this age group including the use of placebo owing to highly active disease. It is imperative to reconsider study design and implementation based on what information is needed. Are studies needed for efficacy or should safety be the primary goal? Further, there have been major recruitment challenges in recently completed and ongoing pediatric MS trials. Phase 3 trials for every newly approved therapy for adult MS in the pediatric MS population are simply not feasible. Conclusions A primary goal is to ensure high-quality evidence-based treatment for children and adolescents with MS, which will improve our understanding of the safety of these agents and remove regulatory or insurance-based limitations in access to treatment.
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Affiliation(s)
- Emmanuelle Waubant
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston.
| | - Brenda Banwell
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Evangeline Wassmer
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Maria-Pia Sormani
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Maria-Pia Amato
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Rogier Hintzen
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Lauren Krupp
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Kevin Rostásy
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Silvia Tenembaum
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Tanuja Chitnis
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
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Aktuelle Therapieempfehlungen bei multipler Sklerose im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0655-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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