High-dose, high-frequency recombinant interferon beta-1a in the treatment of multiple sclerosis

Drug Holiday of Interferon Beta 1b in Multiple Sclerosis: A Pilot, Randomized, Single Blind Study of Non-inferiority

Introduction: To compare a schedule with cyclic withdrawal (CW) of interferon beta (IFN-b) 1b, respect to the full regimen (FR), in relapsing-remitting MS (RR-MS).

Methods: Participants were randomly assigned to CW or FR schedule and monthly monitored with brain MRI scans for 12 months (three of run-in and 9 of treatment). CW schedule included drug withdrawal for 1 month after two of treatment for a total of three quarters over the 9-month treatment period. The assessing neurologist and the expert neuroradiologists were blind. After the blind phase of the study all participants took their indicated disease modifying therapies in a prospectively planned, open-label extension phase (up to 120 months).

Results: Of 60 randomized subjects 56 (29 in FR and 27 in CW group) completed the single-blind phase: the two groups were comparable, except for a non-significant difference in the number of contrast-enhanced lesions (CEL) at the end of run-in. The two-sided 90% CI for the ratio between median number of cumulative CEL was 0.29–1.07, allowing to significantly reject the null hypothesis of a ratio ≥1.2 and to meet the primary end-point of non-inferiority (the threshold and the ratio between median were chosen according to the non-normal distribution of the data). The differences (CW vs. FR) were also non-significant for secondary end points: mean cumulative number of T2-weighted new and enlarging lesions (3.48 ± 5.34 vs. 3.86 ± 6.76); mean number and volume (cm³) of black holes (1.24 ± 1.61 vs. 2.71 ± 4.56; 489.11 ± 1488.12 vs. 204.48 ± 396.98); number of patients with at least an active scan (21 vs. 22); mean relapse rate (0.52 ± 0.89 vs. 0.34 ± 0.66), relapse risk ratio adjusted for baseline variables (2.15 [0.64–7.18]), EDSS score (1.0 [1–1.56] vs. 1.5 [1–1.78]), proportion of patients with antibodies anti-IFN (5 [21%] vs. 8 [36%]). Fifty-four patients (27 for each study arm) completed the open-label phase. The annualized RR, EDSS, proportion of patients shifting to progressive disease and hazard ratio of shifting, adjusting for baseline covariates, were comparable between the two study groups.

Conclusions: A calendar with CW was non-inferior than FR at the beginning of IFN-b therapy, and may not affect the long-term outcome.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT00270816

Current perspectives on interferon Beta-1b for the treatment of multiple sclerosis

Interferon (IFN) beta-1b was the first disease-modifying therapy to be approved for the treatment of multiple sclerosis (MS), and over 21 years of follow-up data demonstrate its efficacy and long-term safety profile. Following recent regulatory approvals in the USA and European Union, IFN beta-1b is now one of the seven disease-modifying therapies [intramuscular IFN beta-1a; subcutaneous (SC) IFN beta-1a; IFN beta-1b SC; glatiramer acetate SC; oral dimethyl fumarate; oral teriflunomide; and intravenous alemtuzumab] indicated for first-line use in relapsing–remitting MS. Here we review the clinical trial and follow-up data for IFN beta-1b and discuss factors that clinicians may consider when selecting this treatment, both at first line in early MS, and later in the disease course.

Patient expectations and experiences of multiple sclerosis interferon β-1a treatment: a longitudinal, observational study in routine UK clinical practice

BACKGROUND

Premature discontinuation and poor treatment adherence are problems in chronic conditions, such as multiple sclerosis in which patients must take long-term treatment in order to receive maximum benefit from their medication. The Assessing needs In Multiple Sclerosis (AIMS) study explored factors related to premature treatment discontinuation and patients' experiences of subcutaneous (sc) interferon (IFN) β-1a treatment in the UK.

METHODS

A questionnaire-based survey was integrated into the Bupa Home Healthcare patient-support program, which delivers sc IFN β-1a to patients in their home. Data were collected via patient questionnaires incorporated into routine clinical care and administered upon registration of a new patient by the coordinator, following initial delivery of treatment, prior to each delivery during therapy and at the end of treatment. Univariate and multivariate analyses were performed to identify factors associated with premature discontinuation.

RESULTS

Data were collected from 2,390 patients (1,267 new; 1,123 existing) from 59 UK prescribing centers (November 2006-April 2011). Following the first delivery of sc IFN β-1a, 94% (1,149/1,225) of patients had received training, and 73% (818/1,120) reported that they had no concerns. In total, 24% of new patients discontinued therapy by the end of the study. In the univariate model, none of the candidate variables tested were significant predictors of treatment discontinuation. The strongest predictors of discontinuation in multivariate analyses were lack of information prior to starting treatment and patients feeling unwell on treatment and geographic region (P<0.05 for each variable).

CONCLUSION

This study suggests that patients feeling well on treatment and provision of high-quality information are the main determinants of persistence with sc IFN β-1a therapy. A package of care that targets these issues should therefore be considered when initiating sc IFN β-1a therapy.

[Interferon-β1b in multiple sclerosis therapy: more than 20 years clinical experience]

The introduction of interferon-β1b in 1993 in the USA and 2 years later in Europe made it possible for the first time to alter the course of the disease in patients with relapsing-remitting multiple sclerosis (MS). Subsequently, interferon-β1b was approved for the treatment of patients with active secondary progressive MS (1999) and early relapsing-remitting MS following a first demyelinating event (clinically isolated syndrome, CIS) (2006). Here we provide an overview of the clinical experience gathered during more than 20 years of interferon-β use focusing on long-term efficacy and safety and the impact of early initiation of treatment. Furthermore, the following aspects will be discussed: putative mechanisms of action of interferon-β, indications for a disease-modifying therapy, clinical relevance of neutralizing antibodies, importance of adherence in MS therapy, high versus low frequency therapy, combination therapies with interferon-β and safety of interferon-β in children and adolescents with MS and during pregnancy.

Interferon-beta therapy in multiple sclerosis: the short-term and long-term effects on the patients' individual gene expression in peripheral blood

Therapy with interferon-beta (IFN-beta) is a mainstay in the management of relapsing-remitting multiple sclerosis (MS), with proven long-term effectiveness and safety. Much has been learned about the molecular mechanisms of action of IFN-beta in the past years. Previous studies described more than a hundred genes to be modulated in expression in blood cells in response to the therapy. However, for many of these genes, the precise temporal expression pattern and the therapeutic relevance are unclear. We used Affymetrix microarrays to investigate in more detail the gene expression changes in peripheral blood mononuclear cells from MS patients receiving subcutaneous IFN-beta-1a. The blood samples were obtained longitudinally at five different time points up to 2 years after the start of therapy, and the patients were clinically followed up for 5 years. We examined the functions of the genes that were upregulated or downregulated at the transcript level after short-term or long-term treatment. Moreover, we analyzed their mutual interactions and their regulation by transcription factors. Compared to pretreatment levels, 96 genes were identified as highly differentially expressed, many of them already after the first IFN-beta injection. The interactions between these genes form a large network with multiple feedback loops, indicating the complex crosstalk between innate and adaptive immune responses during therapy. We discuss the genes and biological processes that might be important to reduce disease activity by attenuating the proliferation of autoreactive immune cells and their migration into the central nervous system. In summary, we present novel insights that extend the current knowledge on the early and late pharmacodynamic effects of IFN-beta therapy and describe gene expression differences between the individual patients that reflect clinical heterogeneity.

Transfer of interferon β-1a into human breastmilk

AIM

This study determined the transfer of intramuscular interferon β-1a into human milk and provides an estimate of infant exposure to this antiviral in six women chronically receiving intramuscular interferon β-1a (Avonex(®), Biogen Idec, Research Triangle Park, NC).

METHODS

Interferon β-1a was measured at various times at steady state in milk samples collected from women receiving interferon β-1a at 30 μg/week.

RESULTS

Average milk concentrations were 46.7, 97.4, 66.4, 77.5, 103.1, 108.3, 124, and 87.9 pg/mL at 0, 1, 4, 8, 12, 24, 48, and 72 hours, respectively, after dosing. Using the highest value measured (179 pg/mL), the estimated relative infant dose would be 0.006% of the maternal dose.

CONCLUSIONS

These data clearly suggest that interferon β-1a does not penetrate the milk compartment significantly and that levels in milk are far subclinical. No side effects were noted in any of the breastfed infants.

Statins for multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an inflammatory demyelinating disease of the human central nervous system. Statins, prescribed as cholesterol lowering agents, have shown possible effects for treating MS in experimental and preliminary clinical studies.

OBJECTIVES

To evaluate the efficacy and safety of statins administered alone or as add-on to approved treatments for MS.

SEARCH METHODS

The Trials Search Coordinator searched the Cochrane MS Group Trials Register (1 August 2011). We searched the Chinese National Knowledge Infrastructure (CNKI) (1979 to 1 August 2011), trials registers and conference proceedings. Pharmaceutical companies and authors of included studies were contacted for additional information.There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials comparing statins with placebo, or comparing statins in combination with approved treatments alone for patients with MS.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Four trials involving 458 participants were included. All trials compared statins (two evaluating atorvastatin and two simvastatin) plus interferon beta-1a with interferon beta-1a alone for treating MS. The methodological quality was good for three studies and poor for remaining one. None of them showed statistically significant difference between both treatment groups in reducing relapses, preventing disease progression or developing new T2 or gadolinium-enhanced lesions on MRI after 9, 12, 24 months follow up period. Statins resulted to be safe and well tolerated, no serious adverse effects were reported. Changes on quality of life after receiving statins were not reported in the trials.

AUTHORS' CONCLUSIONS

There is no convincing evidence to support the use of either atorvastatin or simvastatin as an adjunctive therapy in MS.

Impact of exposure to interferon beta-1a on outcomes in patients with relapsing-remitting multiple sclerosis: exploratory analyses from the PRISMS long-term follow-up study

OBJECTIVE

To explore the effects of exposure to subcutaneous (sc) interferon (IFN) beta-1a on efficacy in patients with relapsing-remitting multiple sclerosis (RRMS) enrolled in the PRISMS (Prevention of Relapses and disability by Interferon beta-1a Subcutaneously in Multiple Sclerosis) study.

METHODS

Patients with RRMS received IFN beta-1a, 44 or 22 µg sc three times weekly (tiw), or placebo, for 2 years, at which point placebo recipients were re-randomized to IFN beta-1a, 44 or 22 µg sc tiw, for a further 2-4 years. Long-term follow-up visits occurred 7-8 years after enrolment and allowed participation of patients who had previously discontinued treatment. Post hoc descriptive analyses were conducted within the lower (MIN) and upper (MAX) quartiles of patients divided according to cumulative dose of IFN beta-1a and cumulative time on treatment. Outcomes were explored in patients initially randomized to IFN beta-1a, 44 µg sc tiw, who had received continuous or noncontinuous therapy during the study.

RESULTS

For both cumulative dose and time analyses, the MIN and MAX groups comprised 96 and 95 patients, respectively. The continuous and noncontinuous groups included 45 and 91 patients, respectively. The MAX DOSE and MAX TIME groups had lower annualized relapse rates, lower rates of conversion to secondary progressive MS, lower percentages of patients with Expanded Disability Status Scale progression, higher percentages of relapse-free patients, and less T2 burden of disease than the MIN groups. The continuous therapy group had a lower annualized relapse rate and lower percentages of patients with Expanded Disability Status Scale progression or conversion to secondary progressive MS than the noncontinuous therapy group.

CONCLUSIONS

The findings of these post hoc analyses suggest that high exposure to sc IFN beta-1a may be associated with better clinical outcomes than low exposure, and also highlight the importance of maximizing adherence. Additional prospective investigation is warranted to evaluate further the effects of treatment exposure on outcomes and to determine the benefits of interventions to improve adherence.

Severe depression, suicide attempts, and ideation during the use of interferon beta by patients with multiple sclerosis

BACKGROUND

Interferon (IFN) beta is a safe and efficient drug for treating multiple sclerosis (MS). It is widely accepted that previously depressed patients may get worse when using IFN-beta. There are few reports on the association of IFN-beta and severe depression among patients without previous psychiatric history.

METHODS

Discussion of a case of a patient with MS who developed severe depression and attempted suicide while using IFN-beta encouraged us to review the subject. A group of neurologists in Brazil retrospectively gathered together their similar cases for the present paper.

RESULTS

The present paper reports on 11 cases of severe depression with suicide attempts or ideation among patients with MS who were using IFN-beta. These patients had no previous history of any psychiatric disease. Nine patients developed the symptoms over a relatively short period (4 months, on average). Two patients developed severe depression after more than 1 year of treatment with IFN-beta. Phobic, aggressive, behavioral, psychotic, and manic symptoms also were observed in these patients, thus suggesting the existence of a complex mood-behavior disorder associated with this drug. Interferon beta withdrawal led to complete remission of symptoms. The Naranjo algorithm established a highly probable association between IFN-beta and this adverse reaction in these patients.

CONCLUSIONS

Although uncommon, severe depression with suicide ideation or attempts may be observed during treatment of MS with IFN-beta. This association should not discourage the use of this drug, but physicians need to be aware of this possible adverse event from IFN-beta.

Statins for multiple sclerosis

BACKGROUND

Multiple sclerosis is an inflammatory demyelinating disease of the human central nervous system. Statins, prescribed as cholesterol lowering agents, have shown beneficial effects for treating MS in experimental and preliminary clinical studies.

OBJECTIVES

To evaluate the efficacy and safety of statins administered alone or as add-on to approved treatments for MS.

SEARCH STRATEGY

We searched the Cochrane MS Group Trials Register (April 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2010), MEDLINE (PubMed) (January 1966 to April 2010), EMBASE (January 1974 to April 2010), the Chinese Biomedical Database (CBM) (1979 to April 2010) and the Chinese National Knowledge Infrastructure (CNKI) (1979 to April 2010). We searched trials registers and conference proceedings and contacted pharmaceutical companies and authors of included studies included for additional information.There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials comparing statins with placebo, or comparing statins in combination with approved treatments alone in for patients with MS.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Two trials involving 71 participants were included. Both trials compared atorvastatin plus beta interferon with beta interferon alone for treating MS. Only one was assessed of good methodological quality while the other one of poor methodological quality. Neither of them showed statistically significant difference between both treatment groups in reducing relapses, preventing disease progression or developing new T2 or gadolinium-enhanced lesions on MRI after 9 or 24 months follow up period. When combined with beta interferon, atorvastatin resulted to be safe and well tolerated, no serious adverse effects were reported. Changes on quality of life after receiving statins were not reported in the trials. Six trials which assess simvastatin or atorvastatin monotherapy or added to beta interferon for MS are still ongoing or awaiting publication.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support statins as an effective treatment for patients with MS. Future high quality randomised controlled trials are needed.Improvements in methodology in trials which are ongoing or awaiting publication, are required for meaningful synthesis of data.

[Interferon β for multiple sclerosis. How much is good enough?]

Interferon β-1b (IFNB-1b, Betaferon®) was the first therapy for multiple sclerosis (MS) showing efficacy in a randomized controlled clinical trial. Early studies suggested a dose-dependency of the clinical efficacy of IFNB-1b. However, until recently no reliable clinical data were available to assess the potential of higher dosing to increase therapeutic efficacy. In addition, no clinical trials have been conducted to directly compare the efficacy of IFNB-1b with that of glatiramer acetate, an alternative first line treatment option for relapsing-remitting MS. Just recently, the prospective, randomized, multicenter study BEYOND was published which addressed both issues. In this review the BEYOND trial is reviewed and placed in the context of advantages and disadvantages of currently available first line therapies for MS.

Oral fingolimod for relapsing-remitting multiple sclerosis Evaluation of: Kappos L, Radue E-M, O'Connor P, et al. A placebo-controlled trial of oral fingolimod in relapsing multiple sclerosis. N Engl J Med 2010;362:387-401; and Cohen JA, Barkhof F, Comi G, et al. Oral fingolimod or intramuscular interferon for relapsing multiple sclerosis. N Engl J Med 2010;362:402-15

Most people with multiple sclerosis (MS) have the relapsing-remitting type. The objective was to evaluate two clinical trials of fingolimod in relapsing MS. FREEDOMS (FTY720 Research Evaluation Effects of Daily Oral therapy in Multiple Sclerosis), a Phase III placebo-controlled trial, showed that fingolimod (0.5 or 1.25 mg) reduced the relapse rate and disability in MS, compared with placebo. Fingolimod (0.5 or 1.25 mg) has been compared to interferon-beta-1a in a Phase III clinical trial (TRANSFORMS; Trial Assessing Injectable Interferon versus FTY720 Oral in Relapsing-Remitting Multiple Sclerosis) and shown to be more efficacious than interferon-beta-1a in reducing relapse rates. However, fingolimod did increase the risk of infections and skin cancers. Only the lower dose of fingolimod (0.5 mg), which possibly has less toxicity, should be considered for prevention of relapses in relapsing-remitting MS.

Clinical effects and tolerability of high-dose, high-frequency recombinant interferon beta-1a in patients with multiple sclerosis: maximizing therapy through long-term adherence

IMPORTANCE OF THE FIELD

High-dose, high-frequency IFN beta-1a in multiple sclerosis (MS) can prevent lesion formation, decrease the frequency/severity of relapses and delay progression of disability, with a proven safety profile. Rates of non-adherence are high. There are drugs under investigation that may have greater efficacy and different safety profiles from existing therapies.

AREAS COVERED IN THIS REVIEW

Evidence supporting the efficacy of IFN beta-1a, factors contributing to non-adherence, and strategies to combat non-adherence. It is hoped that these strategies, coupled with future advances in pharmacogenetics, might lead to better outcomes. The PubMed database was searched using the terms "multiple sclerosis" and "interferon beta-1a", for papers published between 1998 and 2010. Relevant manuscripts and pivotal papers from clinical trials were cited. Searches of abstracts from congresses were also performed to obtain recent findings.

WHAT THE READER WILL GAIN

An overview of early pivotal trials, comparative studies with other treatments, and recent studies assessing the development of this therapy.

TAKE HOME MESSAGE

Long-term treatment with IFN beta-1a has benefits in MS and a good safety profile. Although adherence outside of clinical trials can be poor, injection devices, better tolerated drug formulations and education regarding treatment expectations are some of the strategies employed to help patients to adhere to treatment in the hope of improving outcomes.

Identification of targets and new developments in the treatment of multiple sclerosis--focus on cladribine

Orally available disease-modifying drugs for relapsing-remitting multiple sclerosis (MS) represent an unmet need for this chronic and debilitating disease. Among 5 currently investigated drugs at phase 3 clinical stage, promising efficacy data for fingolimod and oral cladribine have recently been published. However, benefits need to be weighed against the risks to define the role of these compounds within current treatment regimens. In this review, data on the efficacy of a promising compound, oral cladribine, are discussed and balanced with known and anticipated risks in a postmarketing era, and finally gives an outlook on the potential place of this drug in treatment algorithms for MS in the future.