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Meißner J, Frahm N, Hecker M, Langhorst SE, Mashhadiakbar P, Streckenbach B, Burian K, Baldt J, Heidler F, Richter J, Zettl UK. Personality traits in patients with multiple sclerosis: their association with nicotine dependence and polypharmacy. Ther Adv Neurol Disord 2024; 17:17562864241279118. [PMID: 39411724 PMCID: PMC11475248 DOI: 10.1177/17562864241279118] [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: 05/30/2024] [Accepted: 07/29/2024] [Indexed: 10/19/2024] Open
Abstract
Background The modifiable risk factor exerting the most substantial influence on the development and disease course of multiple sclerosis (MS) is cigarette smoking. Furthermore, smoking is associated with a higher risk of suffering from one or more comorbidities and potentially contributes to polypharmacy. We aimed to use personality tests to explore health-promoting and harmful patient characteristics. Objective To investigate two important factors influencing the course of MS - the degree of smoking dependence and the status of polypharmacy - in association with personality traits. Design This is a bicentric, cross-sectional study. Methods We collected sociodemographic, clinical and medical data from patients with MS (n = 375) at two German neurological clinics. The participants were asked to complete the NEO Five-Factor Inventory (NEO-FFI) and the Temperament and Character Inventory-Revised (TCI-R). Relationships between variables were examined using correlation analyses, and differences between groups were examined using linear models. Current smokers with MS were also asked to complete the Fagerström questionnaire to categorize them into patients with mild, moderate and severe smoking dependence. Results In our sample, 67.5% were women, and the mean age was 48.1 years. The patients had a median Expanded Disability Status Scale of 3.0 at a median disease duration of 10 years. Patients with MS with severe smoking dependence had on average a significantly higher neuroticism score in the NEO-FFI compared to those with mild or moderate smoking dependence. Patients with MS and polypharmacy had significantly higher neuroticism scores than those without. In the extraversion scale of the NEO-FFI, patients with MS and polypharmacy had significantly lower scores on average. Significant differences were also found when analysing the TCI-R in patients with MS and heavy smoking dependence, with higher scores for harm avoidance (HA) and lower scores for reward dependence, self-directedness (S-D) and cooperativeness (CO) in various subscales. Polypharmacy in patients with MS was associated with higher scores for HA and self-transcendence. Furthermore, patients with polypharmacy showed lower values than patients without polypharmacy in individual subscales of the dimensions of persistence, S-D and CO. Conclusion Using the NEO-FFI, we were able to show that neuroticism is a detrimental trait and extraversion a protective trait in patients with MS in relation to nicotine dependence and polypharmacy. In addition, the evaluation of the TCI-R showed that high HA as well as low S-D and CO scores were more common in patients with MS and nicotine dependence or polypharmacy. With this knowledge, the risk of polypharmacy and smoking can be understood in the context of personality characteristics and targeted treatment and counselling can be provided.
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Affiliation(s)
- Janina Meißner
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Gehlsheimer Str. 20, Rostock 18147, Germany
- Ecumenic Hainich Hospital gGmbH, Pfafferode 102, Mühlhausen 99974, Germany
| | - Niklas Frahm
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Michael Hecker
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Silvan Elias Langhorst
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Pegah Mashhadiakbar
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Barbara Streckenbach
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
- Ecumenic Hainich Hospital gGmbH, Mühlhausen, Germany
| | - Katja Burian
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
- Ecumenic Hainich Hospital gGmbH, Mühlhausen, Germany
| | - Julia Baldt
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
- Ecumenic Hainich Hospital gGmbH, Mühlhausen, Germany
| | | | - Jörg Richter
- Ecumenic Hainich Hospital gGmbH, Mühlhausen, Germany
- Faculty of Health Sciences, University of Hull, Hull, UK
- The Palatine Centre, Durham Law School, Durham University, Durham, UK
| | - Uwe Klaus Zettl
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
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Zahoor I, Pan G, Cerghet M, Elbayoumi T, Mao-Draayer Y, Giri S, Palaniyandi SS. Current understanding of cardiovascular autonomic dysfunction in multiple sclerosis. Heliyon 2024; 10:e35753. [PMID: 39170118 PMCID: PMC11337049 DOI: 10.1016/j.heliyon.2024.e35753] [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: 05/30/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 08/23/2024] Open
Abstract
Autoimmune diseases, including multiple sclerosis (MS), are proven to increase the likelihood of developing cardiovascular disease (CVD) due to a robust systemic immune response and inflammation. MS can lead to cardiovascular abnormalities that are related to autonomic nervous system dysfunction by causing inflammatory lesions surrounding tracts of the autonomic nervous system in the brain and spinal cord. CVD in MS patients can affect an already damaged brain, thus worsening the disease course by causing brain atrophy and white matter disease. Currently, the true prevalence of cardiovascular dysfunction and associated death rates in patients with MS are mostly unknown and inconsistent. Treating vascular risk factors is recommended to improve the management of this disease. This review provides an updated summary of CVD prevalence in patients with MS, emphasizing the need for more preclinical studies using animal models to understand the pathogenesis of MS better. However, no distinct studies exist that explore the temporal effects and etiopathogenesis of immune/inflammatory cells on cardiac damage and dysfunction associated with MS, particularly in the cardiac myocardium. To this end, a thorough investigation into the clinical presentation and underlying mechanisms of CVD must be conducted in patients with MS and preclinical animal models. Additionally, clinicians should monitor for cardiovascular complications while prescribing medications to MS patients, as some MS drugs cause severe CVD.
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Affiliation(s)
- Insha Zahoor
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Guodong Pan
- Division of Hypertension and Vascular Research, Department of Internal Medicine, Henry Ford Health, Detroit, MI, USA
| | - Mirela Cerghet
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Tamer Elbayoumi
- Department of Pharmaceutical Sciences, College of Pharmacy, Midwestern University, Glendale, AZ, USA
| | - Yang Mao-Draayer
- Multiple Sclerosis Center of Excellence, Autoimmunity Center of Excellence, Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Shailendra Giri
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Suresh Selvaraj Palaniyandi
- Division of Hypertension and Vascular Research, Department of Internal Medicine, Henry Ford Health, Detroit, MI, USA
- Department of Physiology, Wayne State University, Detroit, MI, USA
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de Seze J, Dive D, Ayrignac X, Castelnovo G, Payet M, Rayah A, Gobbi C, Vermersch P, Zecca C. Narrative Review on the Use of Cladribine Tablets as Exit Therapy for Stable Elderly Patients with Multiple Sclerosis. Neurol Ther 2024; 13:519-533. [PMID: 38587749 PMCID: PMC11136913 DOI: 10.1007/s40120-024-00603-y] [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: 02/13/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
The number of ageing people with relapsing multiple sclerosis (RMS) is increasing. The efficacy of disease-modifying therapies (DMTs) for RMS declines with age. Also, older persons with MS may be more susceptible to infections, hospitalisations and malignancy. Aging people with MS have higher rates of comorbidities versus aged-matched controls, increasing the individual risk of disability. We review the therapeutic properties of cladribine tablets (CladT) in ageing people with RMS, with regard to their utility for allowing these individuals to cease continuous administration of a DMT (i.e. to act as an "exit therapy"). CladT is thought to be an immune reconstitution therapy, in that two short courses of oral treatment 1 year apart provide suppression of MS disease activity in responders that far outlasts the duration of treatment and post-treatment reductions in lymphocyte counts. Post hoc analyses, long-term follow-up of populations with RMS in randomised trials, and real-world evidence suggest that the efficacy of CladT is probably independent of age, although more data in the elderly are still needed. No clear adverse signals for lymphopenia or other adverse safety signals have emerged with increasing age, although immunosenescence in the setting of age-related "inflammaging" may predispose elderly patients to a higher risk of infections. Updating vaccination status is recommended, especially against pneumococci and herpes zoster for older patients, to minimise the risk of these infections. CladT may be a useful alternative treatment for ageing people with MS who often bear a burden of multiple comorbidities and polypharmacy and who are more exposed to the adverse effects of continuous immunosuppressive therapy.
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Affiliation(s)
- Jerome de Seze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France.
| | - Dominique Dive
- Department of Neurology, Liège University Hospital, Liège, Belgium
| | - Xavier Ayrignac
- Department of Neurology, University of Montpellier, INM, INSERM, Montpellier University Hospital, Montpellier, France
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Marianne Payet
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Amel Rayah
- Merck Santé S.A.S., an Affiliate of Merck KGaA, Lyon, France
| | - Claudio Gobbi
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Patrick Vermersch
- University of Lille, INSERM U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Chiara Zecca
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
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Brüggemann F, Gross S, Süße M, Hok P, Strauss S, Ziemssen T, Frahm N, Zettl UK, Grothe M. Polypharmacy in patients with multiple sclerosis and the impact on levels of care and therapy units. Front Neurol 2023; 14:1330066. [PMID: 38187151 PMCID: PMC10768059 DOI: 10.3389/fneur.2023.1330066] [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: 10/30/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Abstract
Background The aim of this study was to examine the societal costs of polypharmacy in patients with multiple sclerosis (MS). We therefore focused on the association between the number of medications on the level of care (LOC), the German classification of the need for care, and the number of therapy sessions (TTU). Methods In addition to demographic information and medication, 101 MS patients performed the Multiple Sclerosis Health Resource Utilization Survey (MS-HRS). Medications were subdivided into a total number of medications (TD), MS-related medication [MSD, i.e., disease-modifying drugs (DMDs) and symptomatic treatment (SD)], and medication for comorbidities (CDs). Multivariate linear regression models were performed to estimate if the amount of each medication type affects LOC or TTU. Results Polypharmacy appeared in 54 patients at the time of the survey. The relative risk (RR) of LOC 1 increased significantly by 2.46 (p = 0.001) per TD and by 2.55 (p = 0.004) per MSD, but not per CD (RR 1.44; p = 0.092). The effect of RR on MSD was driven by SD (RR 2.2; p = 0.013) but not DMD (RR 2.6; p = 0.4). RR of MSD remained significant for LOC 2 (1.77; p = 0.009) and LOC 3/4 (1.91; p = 0.015), with a strong trend in RR of SD, but not DMD. TTU increased significantly per MSD (p = 0.012), but not per TD (p = 0.081) and CD (p = 0.724). Conclusion The number of MSDs is related to the likelihood of a higher level of care and the number of therapy sessions and is therefore a good indication of the extent of the societal costs.
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Affiliation(s)
- Finn Brüggemann
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Stefan Gross
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Marie Süße
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Pavel Hok
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Sebastian Strauss
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Tjalf Ziemssen
- MS Center, Center of Clinical Neuroscience, University Clinic Carl-Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Niklas Frahm
- Department of Neurology, University Medicine Rostock, Rostock, Germany
| | - Uwe K. Zettl
- Department of Neurology, University Medicine Rostock, Rostock, Germany
| | - Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
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Pérez AS, Casado SE, Payero MÁ, Pueyo ÁE, Bernabé ÁGA, Zamora NP, Ruiz PD, González AML. [Translated Article] Disease-modifying treatments for patients with multiple sclerosis in Spain. FARMACIA HOSPITALARIA 2023; 47:T155-T160. [PMID: 37394376 DOI: 10.1016/j.farma.2023.05.005] [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: 12/24/2022] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 07/04/2023] Open
Abstract
Multiple sclerosis is a chronic demyelinating disease of the central nervous system and long-term disabling. Different disease-modifying treatments are available. These patients, despite being generally young, have high comorbidity and risk of polymedication due to their complex symptomatology and disability. OBJECTIVE PRIMARY To determine the type of disease-modifying treatment in patients seen in Spanish hospital pharmacy departments. SECONDARY OBJECTIVES to determine concomitant treatments, determine the prevalence of polypharmacy, identify the prevalence of interactions and analyze pharmacotherapeutic complexity. METHOD Observational, cross-sectional, multicentre study. All patients with a diagnosis of multiple sclerosis and active disease-modifying treatment who were seen in outpatient clinics or day hospitals during the second week of February 2021 were included. Modifying treatment, comorbidities and concomitant treatments were collected to determine multimorbidity pattern, polypharmacy, pharmacotherapeutic complexity (Medication Regimen Complexity Index) and drug-drug interactions. RESULTS 1407 patients from 57 centres in 15 autonomous communities were included. The most frequent form of disease presentation was the relapsing remitting form (89.3%). The most prescribed disease-modifying treatment was dimethyl fumarate (19.1%), followed by teriflunomide (14.0%). Of the parenteral disease-modifying treatments, the two most prescribed were glatiramer acetate and natalizumab with 11.1% and 10.8%. 24.7% of the patients had 1 comorbidity and 39.8% had at least 2 comorbidities. 13.3% belonged to at least one of the defined patterns of multimorbidity and 16.5% belonged to 2 or more patterns. The concomitant treatments prescribed were psychotropic drugs (35.5%); antiepileptic drugs (13.9%) and antihypertensive drugs and drugs for cardiovascular pathologies (12.4%). The presence of polypharmacy was 32.7% and extreme polypharmacy 8.1%. The prevalence of interactions was 14.8%. Median pharmacotherapeutic complexity was 8.0 (IQR: 3.3-15.0). CONCLUSIONS We have described the disease-modifying treatment of patients with multiple sclerosis seen in Spanish pharmacy services and characterized concomitant treatments, the prevalence of polypharmacy, interactions, and their complexity.
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Affiliation(s)
| | | | | | | | | | | | - Pilar Diaz Ruiz
- Servicio de Farmacia, Hospital Universitario Ntra, Sra. de Candelaria, Santa Cruz de Tenerife, Spain
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Pérez AS, Casado SE, Álvarez Payero M, Escolano Pueyo ÁE, Arévalo Bernabé ÁG, Padullés Zamora N, Diaz Ruiz P, López González AM. Disease-modifying treatments for patients with multiple sclerosis in Spain. FARMACIA HOSPITALARIA 2023; 47:155-160. [PMID: 37142541 DOI: 10.1016/j.farma.2023.03.009] [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: 12/24/2022] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 05/06/2023] Open
Abstract
Multiple sclerosis is a chronic demyelinating disease of the central nervous system and long-term disabling. Different disease-modifying treatments are available. These patients, despite being generally young, have high comorbidity and risk of polymedication due to their complex symptomatology and disability. OBJECTIVE PRIMARY To determine the type of disease-modifying treatment in patients seen in Spanish hospital pharmacy departments. SECONDARY OBJECTIVES To determine concomitant treatments, determine the prevalence of polypharmacy, identify the prevalence of interactions and analyse pharmacotherapeutic complexity. METHOD Observational, cross-sectional, multicentre study. All patients with a diagnosis of multiple sclerosis and active disease-modifying treatment who were seen in outpatient clinics or day hospitals during the second week of February 2021 were included. Modifying treatment, comorbidities and concomitant treatments were collected to determine multimorbidity pattern, polypharmacy, pharmacotherapeutic complexity (Medication Regimen Complexity Index) and drug-drug interactions. RESULTS 1,407 patients from 57 centres in 15 autonomous communities were included. The most frequent form of disease presentation was the relapsing remitting form (89.3%). The most prescribed disease-modifying treatment was dimethyl fumarate (19.1%), followed by teriflunomide (14.0%). Of the parenteral disease-modifying treatments, the two most prescribed were glatiramer acetate and natalizumab with 11.1% and 10.8%. 24.7% of the patients had one comorbidity and 39.8% had at least 2 comorbidities. 13.3% belonged to at least one of the defined patterns of multimorbidity and 16.5% belonged to 2 or more patterns. The concomitant treatments prescribed were psychotropic drugs (35.5%); antiepileptic drugs (13.9%) and antihypertensive drugs and drugs for cardiovascular pathologies (12.4%). The presence of polypharmacy was 32.7% and extreme polypharmacy 8.1%. The prevalence of interactions was 14.8%. Median pharmacotherapeutic complexity was 8.0 (IQR: 3.3 -- 15.0). CONCLUSIONS We have described the disease-modifying treatment of patients with multiple sclerosis seen in Spanish pharmacy services and characterised concomitant treatments, the prevalence of polypharmacy, interactions, and their complexity.
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Affiliation(s)
| | | | | | | | | | | | - Pilar Diaz Ruiz
- Servicio de Farmacia, Hospital Universitario Nuestra Sra. de Candelaria, Santa Cruz de Tenerife, España
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Chertcoff A, Ng HS, Zhu F, Zhao Y, Tremlett H. Polypharmacy and multiple sclerosis: A population-based study. Mult Scler 2023; 29:107-118. [PMID: 36301629 PMCID: PMC9896267 DOI: 10.1177/13524585221122207] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND Little is known about polypharmacy and multiple sclerosis (MS). OBJECTIVES To estimate polypharmacy prevalence in a population-based MS cohort and compare persons with/without polypharmacy. METHODS Using administrative and pharmacy data from Canada, we estimated polypharmacy prevalence (⩾5 concurrent medications for >30 consecutive days) in MS individuals in 2017. We compared the characteristics of persons with/without polypharmacy and described the number of polypharmacy days, the most common medication classes contributing to polypharmacy and hyper-polypharmacy prevalence (⩾10 medications). RESULTS Of 14,227 included individuals (75% women), mean age = 55.4 (standard deviation (SD): 13.2) years; 28% (n = 3995) met criteria for polypharmacy (median polypharmacy days = 273 (interquartile range (IQR): 120-345)). Odds of polypharmacy were higher for women (adjusted odds ratio (aOR) = 1.14; 95% confidence intervals (CI):1.04-1.25), older individuals (aORs 50-64 years = 2.04; 95% CI:1.84-2.26; ⩾65 years = 3.26; 95% CI: 2.92-3.63 vs. <50 years), those with more comorbidities (e.g. ⩾3 vs. none, aOR = 6.03; 95% CI: 5.05-7.22) and lower socioeconomic status (SES) (e.g. most (SES-Q1) vs. least deprived (SES-Q5) aOR = 1.64; 95% CI: 1.44-1.86). Medication classes most commonly contributing to polypharmacy were as follows: antidepressants (66% of polypharmacy days), antiepileptics (47%), and peptic ulcer drugs (41%). Antidepressants were most frequently co-prescribed with antiepileptics (34% of polypharmacy days) and peptic ulcer drugs (27%). Five percent of persons (716/14,227) experienced hyper-polypharmacy. CONCLUSION More than one in four MS persons met criteria for polypharmacy. The odds of polypharmacy were higher for women, older persons, and those with more comorbidities, but lower SES.
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Affiliation(s)
- Anibal Chertcoff
- Faculty of Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, UBC Hospital, Vancouver, BC, Canada
| | - Huah Shin Ng
- Faculty of Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, UBC Hospital, Vancouver, BC, Canada/College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Feng Zhu
- Faculty of Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, UBC Hospital, Vancouver, BC, Canada
| | - Yinshan Zhao
- Faculty of Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, UBC Hospital, Vancouver, BC, Canada
| | - Helen Tremlett
- H Tremlett Faculty of Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, UBC Hospital, Room S126, 2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada.
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Gebhardt M, Kropp P, Hoffmann F, Zettl UK. Headache in multiple sclerosis - pharmacological aspects. Curr Pharm Des 2021; 28:445-453. [PMID: 34551691 DOI: 10.2174/1381612827666210922114100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/19/2021] [Indexed: 12/11/2022]
Abstract
For decades, headache was not considered a typical symptom of multiple sclerosis (MS) and was construed as a "red flag" for important differential diagnoses such as cerebral vasculitis. Meanwhile, several studies have demonstrated an increased prevalence of headache in MS compared to the general population. This is due to the heterogeneity of headache genesis with frequent occurrence of both primary and secondary headaches in MS. On the one hand, MS and migraine are often comorbid. On the other hand, secondary headaches occur frequently, especially in the course of MS relapses. These are often migraine-like headaches caused by inflammation, which can improve as a result of MS-specific therapy. Headaches are particularly common in the early stages of chronic inflammatory CNS disease, where inflammatory activity is greatest. In addition, headache can also occur as a side effect of disease-modifying drugs (DMDs). Headache can occur with most DMDs and is most frequently described with interferon-beta therapy. The aim of this work is to present the prevalence of headache and describe the heterogeneity of possible causes of headache in MS. In addition, important therapeutic aspects in the treatment of MS patients in general will be presented as well as different approaches to the treatment of headache in MS depending on the etiological classification.
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Affiliation(s)
- Marcel Gebhardt
- Krankenhaus Martha-Maria Halle-Dölau, Klinik für Neurologie, Röntgenstraße 1, 06120 Halle. Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, Medical Faculty, University of Rostock, Gehlsheimer Straße 20, 18147, Rostock. Germany
| | | | - Uwe K Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock. Germany
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Patti F, Penaherrera JN, Zieger L, Wicklein EM. Clinical characteristics of middle-aged and older patients with MS treated with interferon beta-1b: post-hoc analysis of a 2-year, prospective, international, observational study. BMC Neurol 2021; 21:324. [PMID: 34425763 PMCID: PMC8381478 DOI: 10.1186/s12883-021-02347-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/28/2021] [Indexed: 12/18/2022] Open
Abstract
Background Despite trends towards the increased age of patients living with multiple sclerosis (MS), little is known about the response of older adults with MS to disease-modifying therapies (DMTs). Thus, a post-hoc analysis was undertaken using data from a 2-year, international, non-interventional, prospective cohort study (NCT00787657; BEACON: BEtaferon prospective study on Adherence, COping and Nurse support) of patients above the age of 40 years with MS and starting interferon beta-1b (IFNB-1b) treatment within 6 months before study entry. Methods Middle-aged and older patients with MS were divided into two sub-groups: 41–50 years and > 50 years. Treatment with IFNB-1b started within 6 months before study entry. Patients were followed-up for a 2-year observation period. Assessments included disease history and course, annualised relapse rate (ARR), Expanded Disability Scale Score (EDSS), treatment adherence, Hospital Anxiety and Depression Scale (HADS), and adverse events (AE). Results At baseline, the intention-to-treat (ITT) population (n = 481) aged 41–50 years (n = 327) and > 50 years (n = 154), had mean (standard deviation [SD]) ages of 45.1 (2.8) and 56.2 (4.2) years, maximum age of 72 years, and duration of MS since onset of symptoms of 3.9 (5.2) and 5.9 (7.1) years, respectively. At baseline, the proportion of patients with relapsing–remitting MS (RRMS) was 96.3 and 94.9 %, and secondary progressive MS (SPMS) was 3.7 and 5.1 %, in the 41–50 and > 50 years sub-groups, respectively. The ARR in the 2 years before study start was 0.93 (0.48) and 0.86 (0.54) for the 41–50 and > 50 years groups, respectively, and decreased since study start to 0.20 (1.09) and 0.07 (0.37), respectively. The percentage of patients with anxiety and depression, as measured by HADS, were stable over the study period. Polypharmacy (five or more medications) was seen in 32.3 and 41.2 % of patients aged 41–50 and > 50 years. No unexpected AEs were reported. Conclusions This study provides observational data on patients between 40 and 72 years of age, suggesting that IFNB-1b can be an effective and well-tolerated treatment option in MS patients of advanced age. Trial registration ClinicalTrials.gov, NCT00787657.
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Affiliation(s)
- Francesco Patti
- Department of Medical and Surgical and Advanced Technologies, GF Ingrassia, Neuroscience Section, University of Catania, Catania, Italy.
| | | | - Lorissa Zieger
- Parexel Inc (at the time of this analysis), Berlin, Germany.,Current address: Freelance Biostatistician, Berlin, Germany
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Frahm N, Hecker M, Zettl U. Polypharmacy in chronic neurological diseases: Multiple sclerosis, dementia and Parkinson's disease. Curr Pharm Des 2021; 27:4008-4016. [PMID: 34323180 DOI: 10.2174/1381612827666210728102832] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/02/2021] [Indexed: 11/22/2022]
Abstract
Polypharmacy is an important aspect of medication management and particularly affects elderly and chronically ill people. Patients with dementia, Parkinson's disease (PD) or multiple sclerosis (MS) are at high risk for multimedication due to their complex symptomatology. Our aim was to provide an overview of different definitions of polypharmacy and to present the current state of research on polypharmacy in patients with dementia, PD or MS. The most common definition of polypharmacy in the literature is the concomitant use of ≥5 medications (quantitative definition approach). Polypharmacy rates of up to >50% have been reported for patients with dementia, PD or MS, although MS patients are on average significantly younger than those with dementia or PD. The main predictor of polypharmacy is the complex symptom profile of these neurological disorders. Potentially inappropriate medication (PIM), drug-drug interactions, poor treatment adherence, severe disease course, cognitive impairment, hospitalisation, poor quality of life, frailty and mortality have been associated with polypharmacy in patients with dementia, PD or MS. For patients with polypharmacy, either the avoidance of PIM (selective deprescribing) or the substitution of PIM with more suitable drugs (appropriate polypharmacy) is recommended to achieve a more effective therapeutic management.
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Affiliation(s)
- Niklas Frahm
- Department of Neurology, Neuroimmunology Section, Rostock University Medical Center, Rostock, Germany
| | - Michael Hecker
- Department of Neurology, Neuroimmunology Section, Rostock University Medical Center, Rostock, Germany
| | - Uwe Zettl
- Department of Neurology, Neuroimmunology Section, Rostock University Medical Center, Rostock, Germany
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Oliveira VMD, Rios CC, Gubert VT, Ferreira CM, Vasconcelos-Pereira EFD, Toffoli-Kadri MC, Monreal MTFD. Association of clinical epidemiological factors to polypharmacy among patients with multiple sclerosis: real-life data. ABCS HEALTH SCIENCES 2021. [DOI: 10.7322/abcshs.2020137.1899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Introduction: Treatment for multiple sclerosis should focus on relapse prevention and treatment, as well as symptom and disease progression control, which require the use of multiple medications. Objective: To evaluate the association of polypharmacy and related clinical, epidemiological factors in multiple sclerosis patient cohorts. Methods: It was conducted a prospective study of multiple sclerosis patients that held a prescription of disease-modifying drugs between January and December 2017. The medications were analyzed and classified as either long-term or as-needed medications for therapeutic objective and prescription status purposes. Results: During 2017, 124 patients were attended, 106 were eligible for the study, and 81 agreed to participate. The average age was 40.95±11.69 years. The disease duration varied between 6 months and 30 years, with a median of 7 years. More than half of the multiple sclerosis patients suffered from comorbidities (54.32%), and 76.54% were categorized as polypharmacy. The comparison of polypharmacy between the groups yielded significant differences for comorbidities and employment status and regarding age between patients with polypharmacy and patients without polypharmacy of long-term medications. Conclusion: The age of the patient and the presence of comorbidities are important factors related to polypharmacy.
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Thelen J, Zvonarev V, Lam S, Burkhardt C, Lynch S, Bruce J. Polypharmacy in Multiple Sclerosis: Current Knowledge and Future Directions. MISSOURI MEDICINE 2021; 118:239-245. [PMID: 34149084 PMCID: PMC8210980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Polypharmacy, or the daily use of five or more medications, is well documented in older adults and linked to negative outcomes such as medication errors, adverse drug reactions, and increased healthcare utilization. Like older adults, people with multiple sclerosis (PwMS) are susceptible to polypharmacy, owing to the variety of treatments used to address individual multiple sclerosis (MS) symptoms and other comorbidities. Between 15-65% of PwMS meet criteria for polypharmacy; in this population, polypharmacy is associated with increased reports of fatigue, subjective cognitive impairment, and reduced quality of life. Despite evidence of adverse outcomes, polypharmacy among PwMS remains a neglected area of research. This article examines the current literature regarding polypharmacy in MS, as well as implications for clinical practice and directions for future research.
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Affiliation(s)
- Joanie Thelen
- Department of Psychology, University of Missouri - Kansas City, Kansas City, Missouri (UMKC KCMO)
| | - Valeriy Zvonarev
- Department of Psychiatry, University of Missouri - Kansas City, Kansas City, Missouri (UMKC KCMO)
| | - Sarah Lam
- Medical Student, School of Medicine (SOM), University of Missouri - Kansas City, Kansas City, Missouri (UMKC KCMO)
| | - Crystal Burkhardt
- Department of Pharmacy Practice, School of Pharmacy, University of Kansas, Lawrence, Kansas
| | - Sharon Lynch
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
| | - Jared Bruce
- Department of Biomedical and Health Informatics, the UMKC-KCMO
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Kister I, Bacon T, Cutter GR. A longitudinal study of symptom botheration in Multiple Sclerosis. Mult Scler Relat Disord 2020; 46:102585. [PMID: 33296981 DOI: 10.1016/j.msard.2020.102585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND It is well documented that ambulatory disability in MS worsens over time, but there is a dearth of information on symptom evolution in other domains commonly affected by MS. METHODS SymptoMScreen (SyMS) is a validated tool for assessing symptom severity in 12 domains commonly affected by MS. Patients who attended two specialized MS centers filled out SyMS at each visit. We included in the study patients with neurologist-diagnosed MS who completed two SyMS questionnaires separated at least 12 months. We used the first and final assessment and adjusted for time on study, baseline SyMS score, age, sex, race, MS type, disability strata, and site. Changes over time were also examined using Markov chain estimates of moving from one level of botheration to another for each domain over 1-year periods. RESULTS A total of 1,014 MS patients met the inclusion criteria. Mean composite SyMS score was 1.4 (±1.16) at baseline and increased by 0.084 (±0.73) points during 21.0 (±5.5) months of followup (p<0.0001). The initial mean composite SyMS score correlated strongly with the final mean composite SyMS score (r=0.81). Individual domain SyMS scores at baseline were highest for fatigue: 2.2 (±1.7), and lowest for vision: 1.1 (±1.3) and dexterity: 1.1 (±1.4). Small but significant increases during followup were seen in dexterity, bladder, vision, and pain domains, while significant decreases were seen in anxiety and sensory domains. We observed a high degree of inter-individual variability in symptom severity with the more extreme scores tending to resolve over time. CONCLUSIONS Symptom botheration increases modestly year-to-year, as would be expected in a slowly progressive disease that evolves over decades. Initial symptom burden strongly correlated with final symptom burden, but there was a high degree of individual variability in symptom severity.
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Affiliation(s)
- Ilya Kister
- NYU Multiple Sclerosis Comprehensive Care Center, NYU Langone Medical Center, New York, NY; NJ, USA.
| | - Tamar Bacon
- NYU Multiple Sclerosis Comprehensive Care Center, NYU Langone Medical Center, New York, NY; NJ, USA
| | - Gary R Cutter
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL
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Abstract
The relationship between headache and multiple sclerosis (MS) has been a matter of controversy for over 60 years. Headaches are still rated as a "red flag", indicating alternative diagnoses to MS, although in the last few years numerous studies have shown a frequent association between headache and MS. In recent studies on MS patients, a link was found between lower age/shorter disease duration of MS and frequent headaches. A study of 50 patients manifesting MS for the first time showed the highest headache prevalence in MS of 78% reported so far.Headaches can also be a possible side effect of most disease-modifying MS drugs. In many cases, however, the headache appears to be a symptom of MS in terms of secondary headache. This is also supported by pathophysiological implications, for example, by detecting B cell follicles in the meninges of MS patients.Migraine is the most common type of headache in MS. In some cases, this is a comorbidity of two diseases with many similarities, but headaches caused by inflammatory MS lesions also appear to be phenomenologically very similar to classic migraines; thus, distinguishing between them is often only successful with the help of thorough differential diagnostics (cerebrospinal fluid, MRI etc.).The task of future studies must be to specify the phenomenology of headache in MS even more precisely, in order to, to gain knowledge in, among others, patients with radiologically isolated syndrome, who often suffer from headache, because in these patients a considerable differential diagnostic and therapeutic uncertainty exists.
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Cross-sectional survey of complementary and alternative medicine used in Oregon and Southwest Washington to treat multiple sclerosis: A 17-Year update. Mult Scler Relat Disord 2020; 41:102041. [DOI: 10.1016/j.msard.2020.102041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/12/2020] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
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Alemtuzumab and prescription medication use in the MS population. Mult Scler Relat Disord 2020; 42:102086. [PMID: 32403069 DOI: 10.1016/j.msard.2020.102086] [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: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 11/23/2022]
Abstract
Medications are indicated to minimize adverse reactions with alemtuzumab treatment for multiple sclerosis, but polypharmacy can be problematic. We characterized prescriptions filled by 160 individuals before, during and after first infusion of alemtuzumab (Dec/2013-Jun/2017). Ninety-five percent of individuals filled ≥1 prescription(s) before alemtuzumab across 87 unique drug classes, averaging 5.3 prescriptions/person over 47 weeks. During the infusion period, 90% filled ≥1 prescription(s) for 40 new drug classes, averaging 2.2 prescriptions/person over 5 weeks. Twenty-four percent refilled ≥1 of these prescription(s) after alemtuzumab across 17 drug classes, averaging 0.3 refills/person over 24 weeks. There was substantial medication burden throughout the study.
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Frahm N, Hecker M, Zettl UK. Polypharmacy among patients with multiple sclerosis: a qualitative systematic review. Expert Opin Drug Saf 2020; 19:139-145. [DOI: 10.1080/14740338.2020.1720646] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Niklas Frahm
- Neuroimmunology Section, Department of Neurology, University Medicine Rostock, Rostock, Germany
| | - Michael Hecker
- Neuroimmunology Section, Department of Neurology, University Medicine Rostock, Rostock, Germany
| | - Uwe Klaus Zettl
- Neuroimmunology Section, Department of Neurology, University Medicine Rostock, Rostock, Germany
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Findling O, Hauer L, Pezawas T, Rommer PS, Struhal W, Sellner J. Cardiac Autonomic Dysfunction in Multiple Sclerosis: A Systematic Review of Current Knowledge and Impact of Immunotherapies. J Clin Med 2020; 9:E335. [PMID: 31991711 PMCID: PMC7073977 DOI: 10.3390/jcm9020335] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 12/14/2022] Open
Abstract
Cardiac autonomic dysfunction (CAD) has been reported in patients with multiple sclerosis (MS). This systematic review summarizes the evidence for the types and prevalence of CAD in MS patients, as well as its association with MS type, disease characteristics, fatigue and immunotherapies used to treat MS. The analysis revealed that CAD is correlated with pathophysiological processes of MS, can trigger serious cardiovascular complications that may reduce life expectancy, and may have implications for treatment with immunotherapies, especially fingolimod. Numerous mainly small case-control or cohort studies have reported various measures of CAD (particularly heart rate variation) in MS patients, showing higher rates of abnormality versus controls. A smaller number of studies have reported on cardiac autonomic symptoms in MS, including orthostatic intolerance/dizziness in around 50% of patients. CAD also appears to be associated with disease duration and to be more common in progressive than relapsing-remitting MS. However, although a substantial evidence base suggests that assessing CAD in people with MS may be important, standardised methods to evaluate CAD in these patients have not yet been established. In addition, no studies have yet looked at whether treating CAD can reduce the burden of MS symptoms, disease activity or the rate of progression.
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Affiliation(s)
- Oliver Findling
- Department of Neurology, Kantonsspital Aarau, 5001 Aarau, Switzerland;
- Department of Neurology, University Hospital Tulln, Karl-Landsteiner-University, 3420 Tulln, Austria;
| | - Larissa Hauer
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria;
| | - Thomas Pezawas
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria;
| | - Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Walter Struhal
- Department of Neurology, University Hospital Tulln, Karl-Landsteiner-University, 3420 Tulln, Austria;
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, 2130 Mistelbach, Austria
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, 81675 München, Germany
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria
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