Multiple sclerosis: advances in understanding, diagnosing, and treating the underlying disease

Glatiramer acetate as a clinically and cost-effective treatment of relapsing multiple sclerosis over 10 years of use within the National Health Service: Final results from the UK Risk Sharing Scheme

Background

The UK Risk Sharing Scheme (RSS) provided information on the effect of first-line multiple sclerosis (MS) disease-modifying treatments on long-term disability.

Objective

The aim is to provide results specific to glatiramer acetate (GA; Copaxone®) from the final 10-year analysis of the RSS.

Methods

A Markov model was used to assess clinical effectiveness measured as Expanded Disability Status Scale (EDSS) progression and utility loss. Untreated patients from the British Columbia MS cohort (1980-1995) were used as a 'virtual comparator' group. A separate Markov model assessed cost-effectiveness, based on a 50-year time horizon (with a 50% treatment waning effect imposed at 10 years) and using NHS list price (£513.95 per 28 days). Results were expressed in quality-adjusted life years (QALYs).

Results

In total, 755 patients with relapsing-remitting MS (RRMS) received GA, with a mean follow-up of 7.1 (standard deviation 1.3) years. EDSS progression was reduced by 23% (progression ratio 76.7, 95% confidence interval [CI] 69.0-84.3) and utility loss by 39% (progression ratio 61.0, 95% CI 52.7-69.3) compared with no treatment. There was no persistent waning in GA treatment effect over time (EDSS: p = 0.093; utilities: p = 0.119). The cost per QALY was £17,841.

Conclusion

GA had a beneficial effect on long-term disability and was a cost-effective treatment for RRMS.

Evidence of activation of the Nrf2 pathway in multiple sclerosis patients treated with delayed-release dimethyl fumarate in the Phase 3 DEFINE and CONFIRM studies

BACKGROUND

Delayed-release dimethyl fumarate (DMF) is an approved oral treatment for relapsing forms of multiple sclerosis (MS). Preclinical studies demonstrated that DMF activated the nuclear factor E2-related factor 2 (Nrf2) pathway. DMF and its primary metabolite monomethyl fumarate (MMF) were also shown to promote cytoprotection of cultured central nervous system (CNS) cells via the Nrf2 pathway.

OBJECTIVE

To investigate the activation of Nrf2 pathway following ex vivo stimulation of human peripheral blood mononuclear cells (PBMCs) with DMF or MMF, and in DMF-treated patients from two Phase 3 relapsing MS studies DEFINE and CONFIRM.

METHODS

Transcription of Nrf2 target genes NADPH:quinone oxidoreductase-1 (NQO1) and heme-oxygenase-1 (HO1) was measured using Taqman® assays. RNA samples were isolated from ex vivo-stimulated PBMCs and from whole blood samples of 200 patients each from placebo, twice daily (BID) and three times daily (TID) treatments.

RESULTS

DMF and MMF induced NQO1 and HO1 gene expression in ex vivo-stimulated PBMCs, DMF being the more potent inducer. Induction of NQO1 occurred at lower DMF concentrations compared to that of HO1. In DMF-treated patients, a statistically significant induction of NQO1 was observed relative to baseline and compared to placebo. No statistical significance was reached for HO1 induction.

CONCLUSION

These data provide the first evidence of Nrf2 pathway activation from two large pivotal Phase 3 studies of DMF-treated MS patients.

A consensus initiative for the assessment of patients newly diagnosed with multiple sclerosis in Spain: the eXamina Project

Aim: To create a national consensus checklist to assess newly diagnosed multiple sclerosis patients when considering treatment initiation in Spain. Materials & methods: The Delphi consensus method was used. A scientific committee drafted items/domains, 52 experts evaluated their inclusion in the project checklist and 47 experts assessed checklist use in clinical practice. Results: Forty-eight items from seven dimensions were selected: sociodemographics, n = 3; medical history, n = 10; multiple sclerosis clinical factors, n = 14; laboratory/MRI, n = 8; multiple sclerosis signs affecting treatment, n = 4; multiple sclerosis signs affecting management, n = 1; treatment-related features, n = 8. Understanding, acceptance, ease of use, effectiveness and suitability of checklist use were favorably rated by ≥75.5% of experts. Conclusion: This project provides a consensus checklist gathering necessary information when considering multiple sclerosis treatment in newly diagnosed patients.

Core muscle characteristics during walking of patients with multiple sclerosis

The purpose of this study was to investigate core muscle characteristics during walking in patients with multiple sclerosis (MS). Eight patients (4 men) with relapsing-remitting MS (aged 44.9 +/- 8.6 yr) and sex-matched controls (37.9 +/- 8.4 yr) walked on a treadmill for 15 min at a self-selected speed. Positron emission tomography/computed tomography imaging was used to measure core muscle activity immediately after walking based on glucose uptake. Activity was not different between the MS and control group for any of the identified muscles (p > 0.28). Within the MS group, side differences in activity were identified in the lateral flexor group, the external and internal obliques, and the rectus abdominis (p < 0.05), with the less-affected side being activated more. Furthermore, greater muscle volume was found on the more-affected side of the transversus abdominis, quadratus lumborum, and the low-back extensor group (p < 0.03). These muscle characteristics suggest patients with MS utilize compensatory mechanisms during walking to maintain balance and posture. These strategies likely result in increased muscle energy cost and early fatigability.

Increasing Physical Activity and Participation in People With Multiple Sclerosis: A Review

Multiple sclerosis (MS) is a chronic progressive disease of the central nervous system (CNS) affecting >2.5 million people worldwide. Damage to neurons in the CNS causes various sensorimotor and cognitive symptoms, such as fatigue, pain, spasticity, memory deficits, and impairment of mobility. Until the late 1990s, it was believed that symptoms of MS would be worsened with physical exertion and people with MS were encouraged to limit physical activity and exertion. Not only has emerging evidence suggested that physical activity, including exercise, is safe for people with MS, there is also evidence that at least some of the disability that occurs after MS is due to secondary deconditioning from the sedentary lifestyle adopted because of the symptoms of MS, not just CNS damage alone. Therefore, not only is physical activity safe, it is also required for maintaining function and health in people with MS. The purpose of this article is to review the unique physical and social barriers to physical activity in people with MS, including those with moderate to severe disability who use a wheelchair or scooter for mobility. We will discuss how existing guidelines for physical activity may not meet the needs of people with MS and present evidence-based considerations for promoting physical activity in people with MS. Ultimately, the goal is to overcome the barriers to physical activity and improve health, participation, and quality of life in people with MS.

Soft Null Hypotheses: A Case Study of Image Enhancement Detection in Brain Lesions

This work is motivated by a study of a population of multiple sclerosis (MS) patients using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to identify active brain lesions. At each visit, a contrast agent is administered intravenously to a subject and a series of images are acquired to reveal the location and activity of MS lesions within the brain. Our goal is to identify the enhancing lesion locations at the subject level and lesion enhancement patterns at the population level. We analyze a total of 20 subjects scanned at 63 visits (∼30Gb), the largest population of such clinical brain images. After addressing the computational challenges, we propose possible solutions to the difficult problem of transforming a qualitative scientific null hypothesis, such as "this voxel does not enhance," to a well-defined and numerically testable null hypothesis based on the existing data. We call such procedure "soft null" hypothesis testing as opposed to the standard "hard null" hypothesis testing. This problem is fundamentally different from: (1) finding testing statistics when a quantitative null hypothesis is given; (2) clustering using a mixture distribution; or (3) setting a reasonable threshold with a parametric null assumption. Supplementary materials are available online.

Relationship between symptom change, relapse activity and disability progression in multiple sclerosis

BACKGROUND

Symptom changes may serve as a risk factor for relapse activity (RA) and disability progression (DP), which could facilitate multiple sclerosis (MS) treatment decisions.

OBJECTIVE

To assess the relationship of symptom change with RA and DP.

METHODS

We evaluated the relationship of symptom change with subsequent RA and DP using NARCOMS registry data reported over a five-year period. Symptom change was evaluated using both symptom worsening (SW) and average of Performance Scales (APS) scores. Disability progression was defined as a one-point or more increase in Patient-Determined Disease Steps (PDDS) score between two consecutive updates. Repeated measures logistic regression was used to investigate the relationship between symptom change and RA and DP.

RESULTS

SW and APS were both significant predictors of subsequent RA and DP. Both SW and APS have a significant interaction with levels of disability (Mildly Impaired versus Highly Impaired) for the prediction of the subsequent RA or DP. For Mildly Impaired MS subjects, both SW and APS were significant predictors of both RA and DP. However, for Highly Impaired MS subjects, SW did not significantly predict future RA and neither SW nor APS predicted disability progression.

CONCLUSION

Changes in self-reported overall symptomatology may precede and predict clinical relapse and future disability progression. The predictive power of symptom changes may only be present at lower levels of disability.

Relapses Requiring Intravenous Steroid Use and Multiple-Sclerosis-related Hospitalizations: Integrated Analysis of the Delayed-release Dimethyl Fumarate Phase III Studies

PURPOSE

The purpose was to report the effects of delayed-release dimethyl fumarate (DMF; also known as gastro-resistant DMF) on the number of relapses requiring intravenous (IV) steroids and multiple sclerosis (MS)-related hospitalizations using integrated data from the Phase III DEFINE and CONFIRM studies.

METHODS

DEFINE and CONFIRM were randomized, double-blind, placebo-controlled, multicenter studies that evaluated the efficacy and safety of DMF over a 2-year period in patients with relapsing-remitting MS (RRMS). Patients were randomized (1:1:1) to receive oral DMF 240 mg BID or TID, placebo, or glatiramer acetate (CONFIRM only). Eligible subjects (aged 18-55 years) had an EDSS score of 0-5.0 and experienced either ≥1 relapse in the 12 months or had ≥1 gadolinium-enhanced lesion on brain MRI in the 6 weeks, before randomization. Data DEFINE and CONFIRM were pooled and analyzed using a negative binomial regression model (adjusted for study and region). Data obtained after subjects switched to an alternative MS therapy were not included in the analysis. Only relapses confirmed by the Independent Neurology Evaluation Committee were included in the analysis of relapses requiring IV steroids.

FINDINGS

The study population (intention-to-treat) comprised 2301 patients who received either placebo (n = 771), DMF BID (n = 769), or DMF TID (n = 761). Baseline demographic and disease characteristics were generally well balanced among treatment groups. Throughout the 2-year studies, the total number of relapses treated with methylprednisolone was 402, 221, and 209 in the placebo, DMF BID, and DMF TID groups, respectively. A smaller proportion of patients in the DMF BID (168 of 769 [21.8%]) and DMF TID (151 of 761 [19.8%]) groups experienced ≥1 relapse requiring IV steroids compared with the placebo group (284 of 771 [36.8%]). The total number of MS-related hospitalizations over 2 years was 136, 94, and 74 in the placebo, DMF BID, and DMF TID groups. A smaller proportion of patients in the DMF BID (73 of 769 [9.5%]) and DMF TID (57 of 761 [7.5%]) groups had ≥1 MS-related hospitalization compared with the placebo group (104 of 771 [13.5%]).

IMPLICATIONS

DMF is an effective and well tolerated therapy for RRMS. In addition to clinical benefits, the use of DMF may be associated with reduced patient burden and health economic savings, resulting from a decrease in resource utilization associated with relapses. ClinicalTrials.gov identifiers: NCT00420212 and NCT00451451.

Spasticity in multiple sclerosis and role of glatiramer acetate treatment

INTRODUCTION

Spasticity is one of the most disabling and difficult-to-treat symptoms shown by patients with multiple sclerosis, who often show a suboptimal and unsatisfactory response to classic treatment and new available nonpharmacological alternatives. Due to the progressive nature of this condition, the early management should be essential to improve long-term outcomes.

METHODS

We performed a narrative literature review of the contribution of spasticity to the burden of multiple sclerosis and the potential role of classic disease-modifying drugs.

RESULTS

Added to the underlying pathophysiology of spasticity, certain external factors and drugs such as interferon may exacerbate the existing condition, hence their awareness is crucial as part of an effective management of spasticity. Furthermore, the evidence for the effectiveness of glatiramer acetate in preventing spasticity in naïve patients and in those switching from interferon should not be ignored.

CONCLUSIONS

This literature review proposes the examination of spasticity and the influence of classic disease-modifying agents on the level of existing condition among the variables to be considered when deciding on therapy for multiple sclerosis in clinical practice.

Postmarketing Safety Profile of Subcutaneous Interferon Beta-1a Given 3 Times Weekly: A Retrospective Administrative Claims Analysis

BACKGROUND

Health insurance administrative claims databases represent a valuable source of information regarding the safety profile of marketed products as used in actual clinical practice in a broader range of patients than that assessed in clinical trials. Interferon beta-1a administered subcutaneously 3 times weekly (IFN β-1a SC tiw), which was approved in 2002 by the FDA for the treatment of relapsing-remitting multiple sclerosis (MS), has over a decade of postmarketing experience. To date, however, its postmarketing safety profile has not been described using a real-world evidence source such as administrative claims data.

OBJECTIVE

To describe the safety profile of IFN β-1a SC tiw as presented in its U.S. prescribing information (PI) for patients with MS initiating IFN β-1a SC tiw therapy using data from U.S. health care administrative claims databases.

METHODS

This study featured an observational and retrospective "new start" cohort design using data from the Truven MarketScan Commercial and Medicare Supplemental health care administrative claims databases. Patients were eligible for inclusion if they were aged ≥ 18 years; had ≥ 1 diagnosis for MS recorded between January 1, 2006, and December 31, 2012; had ≥ 2 prescriptions for IFN β-1a SC tiw; and had ≥ 90 days of continuous eligibility pre-index date and ≥ 180 days of continuous eligibility post-index date. Patients with a prescription for IFN β-1a SC tiw without a MS diagnosis were excluded. Patients were followed from first prescription for IFN β-1a SC tiw (index date) until date of therapy switch or discontinuation, end of insurance eligibility, or end of observation period. Adverse events (AEs) examined were those listed in the Warnings and Precautions, Adverse Reactions, and Postmarketing Experience sections of the 2014 U.S. PI. Outcomes of interest were identified at the Medical Dictionary for Regulatory Activities (version 17.1) Preferred Term level and then coded to the corresponding ICD-9-CM criteria. Descriptive analyses of patient demographic, health status, health care utilization, and adherence status were performed, and incidence rates (IRs) per 100 person-years of labeled AEs with corresponding 95% CIs were calculated. The IR calculation was based on events that presented after therapy initiation and that were not present in the 90-day pre-index period.

RESULTS

The top 6 AEs included influenza-like symptoms (IR = 15.65, 95% CI = 14.96-16.36); malaise (IR = 15.33, 95% CI = 14.65-16.04; fatigue (IR = 15.02, 95% CI = 14.35-15.72); abdominal pain (IR = 10.18, 95% CI = 9.67-10.70); chest pain (IR = 8.48, 95% CI = 8.03-8.95); and depression (IR = 7.75, 95% CI = 7.32-8.20). In contrast, the 6 lowest IRs were for maculo-papular rash (IR = 0.01, 95% CI = 0.00-0.04; injection-site necrosis (IR = 0.01, 95% CI = 0.00-0.03); erythema multiforme (IR = 0.01, 95% CI = 0.00-0.04); hypoesthesia (IR = 0.00, 95% CI = 0.00-0.02); Stevens-Johnson Syndrome (IR = 0.00, 95% CI = 0.00-0.02); and xerophthalmia (IR = 0.00, 95% CI = 0.00-0.02).

CONCLUSIONS

Study results show strong convergence between the real-world safety profile of IFN β-1a SC tiw and its U.S. label. Our findings demonstrate the value of using real-world evidence obtained from administrative claims to complement clinical trial and postmarketing surveillance data in order to characterize the safety profile of established products, such as IFN β-1a SC tiw, in the postmarketing context.

Peripheral blood biomarkers in multiple sclerosis

Multiple sclerosis is the most common autoimmune disorder affecting the central nervous system. The heterogeneity of pathophysiological processes in MS contributes to the highly variable course of the disease and unpredictable response to therapies. The major focus of the research on MS is the identification of biomarkers in biological fluids, such as cerebrospinal fluid or blood, to guide patient management reliably. Because of the difficulties in obtaining spinal fluid samples and the necessity for lumbar puncture to make a diagnosis has reduced, the research of blood-based biomarkers may provide increasingly important tools for clinical practice. However, currently there are no clearly established MS blood-based biomarkers. The availability of reliable biomarkers could radically alter the management of MS at critical phases of the disease spectrum, allowing for intervention strategies that may prevent evolution to long-term neurological disability. This article provides an overview of this research field and focuses on recent advances in blood-based biomarker research.

Dimethyl fumarate and monoethyl fumarate exhibit differential effects on KEAP1, NRF2 activation, and glutathione depletion in vitro

Delayed-release dimethyl fumarate (also known as gastro-resistant dimethyl fumarate), an oral therapeutic containing dimethyl fumarate (DMF) as the active ingredient, is currently approved for the treatment of relapsing multiple sclerosis. DMF is also a component in a distinct mixture product with 3 different salts of monoethyl fumarate (MEF), which is marketed for the treatment of psoriasis. Previous studies have provided insight into the pharmacologic properties of DMF, including modulation of kelch-like ECH-associated protein 1 (KEAP1), activation of the nuclear factor (erythroid-derived 2)-like 2 (NRF2) pathway, and glutathione (GSH) modulation; however, those of MEF remain largely unexplored. Therefore, the aim of this study was to evaluate the in vitro effects of DMF and MEF on KEAP1 modification, activation of the NRF2 pathway, and GSH conjugation. Using mass spectrometry, DMF treatment resulted in a robust modification of specific cysteine residues on KEAP1. In comparison, the overall degree of KEAP1 modification following MEF treatment was significantly less or undetectable. Consistent with KEAP1 cysteine modification, DMF treatment resulted in nuclear translocation of NRF2 and a robust transcriptional response in treated cells, as did MEF; however, the responses to MEF were of a lower magnitude or distinct compared to DMF. DMF was also shown to produce an acute concentration-dependent depletion of GSH; however, GSH levels eventually recovered and rose above baseline by 24 hours. In contrast, MEF did not cause acute reductions in GSH, but did produce an increase by 24 hours. Overall, these studies demonstrate that DMF and MEF are both pharmacologically active, but have differing degrees of activity as well as unique actions. These differences would be expected to result in divergent effects on downstream biology.

Walking Speed and Brain Glucose Uptake are Uncoupled in Patients with Multiple Sclerosis

Motor impairments of the upper and lower extremities are common symptoms of multiple sclerosis (MS). While some peripheral effects like muscle weakness and loss of balance have been shown to influence these symptoms, central nervous system activity has not been fully elucidated. The purpose of this study was to determine if alterations in glucose uptake were associated with motor impairments in patients with multiple sclerosis. Eight patients with multiple sclerosis (four men) and eight sex matched healthy controls performed 15 min of treadmill walking at a self-selected pace, during which ≈322 MBq of the positron emission tomography (PET) glucose analog [¹⁸F]-fluorodeoxyglucose (FDG) was injected. Immediately after the cessation of walking, participants underwent PET imaging. Patients with MS had lower FDG uptake in ≈40% of the brain compared to the healthy controls (p_FWE-corr < 0.001, q_FDR-corr < 0.001, k_e = 93851) and walked at a slower speed [MS, 1.1 (0.2), controls 1.4 (0.1), m/s, P = 0.014]. Within the area of lower FDG uptake 15 regions were identified. Of these 15 regions, 13 were found to have strong to moderate correlations to walking speed within the healthy controls (r > −0.75, P < 0.032). Within patients with MS only 3 of the 15 regions showed significant correlations: insula (r = −0.74, P = 0.036), hippocampus (r = −0.72, P = 0.045), and calcarine sulcus (r = −0.77, P = 0.026). This data suggest that walking impairments in patients with MS may be due to network wide alterations in glucose metabolism. Understanding how brain activity and metabolism are altered in patients with MS may allow for better measures of disability and disease status within this clinical population.

Glucose uptake heterogeneity of the leg muscles is similar between patients with multiple sclerosis and healthy controls during walking

BACKGROUND

Difficulties in ambulation are one of the main problems reported by patients with multiple sclerosis. A previous study by our research group showed increased recruitment of muscle groups during walking, but the influence of skeletal muscle properties, such as muscle fiber activity, has not been fully elucidated. The purpose of this investigation was to use the novel method of calculating glucose uptake heterogeneity in the leg muscles of patients with multiple sclerosis and compare these results to healthy controls.

METHODS

Eight patients with multiple sclerosis (4 men) and 8 healthy controls (4 men) performed 15 min of treadmill walking at a comfortable self-selected speed following muscle strength tests. Participants were injected with ≈ 8 mCi of [(18)F]-fluorodeoxyglucose during walking after which positron emission tomography/computed tomography imaging was performed.

FINDINGS

No differences in muscle strength were detected between multiple sclerosis and control groups (P>0.27). Within the multiple sclerosis, group differences in muscle volume existed between the stronger and weaker legs in the vastus lateralis, semitendinosus, and semimembranosus (P<0.03). Glucose uptake heterogeneity between the groups was not different for any muscle group or individual muscle of the legs (P>0.16, P≥0.05).

INTERPRETATIONS

Patients with multiple sclerosis and healthy controls showed similar muscle fiber activity during walking. Interpretations of these results, with respect to our previous study, suggest that walking difficulties in patients with multiple sclerosis may be more associated with altered central nervous system motor patterns rather than alterations in skeletal muscle properties.

Care ethics for guiding the process of multiple sclerosis diagnosis

Multiple sclerosis (MS) is a chronic neurological disorder for which there is no definitive diagnostic test. Uncertainty characterises most of its features with diagnosis reached through a process of elimination. Coping with uncertainty has been recognised as a significant problem for MS patients. Discussions in the literature concerning the ethics of MS diagnosis have focused on an ethics of duty emphasising the rules for disclosure and healthcare professionals' obligations to provide information to patients. This narrow construal of the ethics at stake with MS diagnosis may be driven by a common misperception that diagnosis is an event, or series of events, rather than a process. Scant attention has been given to the dynamic, situated relational space between patient and physician as they journey potentially together (or apart) through the process of diagnosis. The healthcare provider cannot properly judge 'the how, what and when' of MS disclosure merely by applying rules pertaining to general professional duties to tell the truth and patients' rights to know their medical status. Proper disclosure and effective communication require the practice of flexible, caring responsibility and sustained, ongoing attention to the particular relational needs of 'this' patient in her own situational context. Accordingly, this article argues that care ethics is especially useful (but not without certain limitations) for attending to a broader swath of responsibilities (different from minimal duties) and affective components implicated in meeting patients' overall needs for care as the patient and physician cope with uncertainty through the process of establishing an MS diagnosis.

Updates on clinically isolated syndrome and diagnostic criteria for multiple sclerosis

Clinically isolated syndrome (CIS) is a central nervous system demyelinating event isolated in time that is compatible with the possible future development of multiple sclerosis (MS). Early risk stratification for conversion to MS helps with treatment decisions. Magnetic resonance imaging (MRI) is currently the most useful tool to evaluate risk. Cerebrospinal fluid studies and evoked potentials may also be used to assess the likelihood of MS. Four clinical trials evaluating the benefits of either interferon β (IFN-β) or glatiramer acetate (GA) within the first 3 months after a high-risk CIS demonstrate decreased rates of conversion to clinically definite MS (CDMS) and a lesser degree of MRI progression with early treatment. In the 3-, 5-, and 10-year extension studies of 2 formulations of IFN-β, the decreased conversion rate to CDMS remained meaningful when comparing early treatment of CIS to treatment delayed by a median of 2 to 3 years. Diagnostic criteria have been developed based on the clinical and MRI follow-up of large cohorts with CIS and provide guidance on how to utilize clinical activity in combination with radiographic information to diagnose MS. The most recent 2010 McDonald criteria simplify requirements for dissemination in time and space and allow for diagnosis of MS from a baseline brain MRI if there are both silent gadolinium-enhancing lesions and nonenhancing lesions on the same imaging study. The diagnostic criteria for MS require special consideration in children at risk for acute disseminated encephalomyelitis (ADEM), in older adults who may have small vessel ischemic disease, and in ethnic groups that more commonly develop neuromyelitis optica (NMO).

The role of chromogranin B in an animal model of multiple sclerosis

Chromogranin B (CGB) is a high capacity, low affinity calcium binding protein in the endoplasmic reticulum (ER) that binds to the inositol 1,4,5 trisphosphate receptor (InsP3R) and amplifies calcium release from ER stores. Recently, it was discovered that levels of CGB-derived peptides are decreased in the cerebrospinal fluid of multiple sclerosis (MS) patients. One of the mechanisms by which neurodegeneration in MS is thought to occur is through increased levels of intra-axonal calcium. The combination of excess intracellular calcium and dysregulated levels of CGB in MS led us to hypothesize that CGB may be involved in MS pathophysiology. Here, we show in a mouse model of MS that CGB levels are elevated in neurons prior to onset of symptoms. Once symptoms develop, CGB protein levels increase with disease severity. Additionally, we show that elevated levels of CGB may have a role in the pathophysiology of MS and suggest that the initial elevation of CGB, prior to symptom onset, is due to inflammatory processes. Upon development of symptoms, CGB accumulation in neurons results from decreased ubiquitination and decreased secretion. Furthermore, we show that calpain activity is increased and levels of InsP3R are decreased. From these results, we suggest that the elevated levels of CGB and altered InsP3R levels may contribute to the axonal/neuronal damage and dysregulated calcium homeostasis observed in MS. Additionally, we propose that CGB can be a biomarker that predicts the onset and severity of disease in patients with MS.

Multiple sclerosis: managing patients in primary care

In this era of the Patient Centered Medical Home model of care, chronic diseases such as multiple sclerosis (MS) are managed in partnership with specialty care practices. For the patient and family living with MS, assuring that patients get proper care when and where they need it requires that nurse practitioners understand their role in assessing and managing complex chronic diseases.

Pharmacotherapeuetic Options for the Treatment of Multiple Sclerosis

Multiple sclerosis is the most common progressive and disabling neurological condition in young adults. Neuro-inflammation is an early and persistent change and forms the basis of most pharmacotherapy for this disease. Immunomodulatory drugs are mainly biologies (β-interferons, a four amino acid peptide, and a monoclonal antibody to a cell adhesion molecule on the blood-CNS barrier) that either attenuate the inflammatory response or block the movement of immune cells into the CNS. They reduce the rate of relapse, but have little or no effect on the progression of disability. The market landscape for MS drugs is in the midst of major change because the patent life of many of these medicines will soon expire, which will lead to the emergence of biosimilars. In addition, new small molecule immunomodulatory and palliative drugs have entered the market, with more in the pipeline; a number of monoclonal antibodies and other immunomodulatory drugs are also in clinical development.

Use of an online community to develop patient-reported outcome instruments: the Multiple Sclerosis Treatment Adherence Questionnaire (MS-TAQ)

Background

Patients with multiple sclerosis (MS) may face barriers, such as treatment fatigue, memory problems, or side effects, that may influence their adherence to medication.

Objective

The objective of our study was to use an online community to develop a self-report questionnaire to quantify adherence and barriers to achieving adherence, that is specific to MS disease-modifying treatments (DMTs) and predictive of missed doses.

Methods

A review of the scientific literature and analysis of discussions between MS patients on PatientsLikeMe.com were used to generate survey items salient to patients. Cognitive debriefing was used to refine the items. The Multiple Sclerosis Treatment Adherence Questionnaire (MS-TAQ) contains 30 questions in three subscales: Barriers, Side Effects, and Coping Strategies.

Results

MS patients completed an online survey (response rate: 431 of 1209 invited, 35.7%). Between 16% (14/86) and 51% (51/100) of MS patients missed at least 1 dose of their DMT in the previous 28 days, with significant between-treatment differences. The MS-TAQ Barriers scale was positively correlated with the proportion of doses missed (r = .5), demonstrating a stronger relationship between adherence and perceived barriers than was found with clinical or demographic variables (r ≈ .3). The Coping Strategies subscale was negatively correlated with missed doses (r = -.3), suggesting that use of more coping strategies is associated with higher adherence.

Conclusions

Online communities can provide domains of interest and psychometric data to more rapidly develop and prototype patient-reported outcome instruments. The MS-TAQ offers patients and clinicians a simple method for identifying barriers to adherence, which may then be targeted through interventions.

Characterization of brain lesions in a mouse model of progressive multiple sclerosis

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system characterized by damage to the neuronal myelin sheath, which results in different levels of muscle paralysis that can lead to neuronal death. In most MS mouse models, the neurologic damage mostly affects the spinal cord with limited damage to the brain, which cannot be monitored by magnetic resonance imaging (MRI) as used for humans. We show that immunization of non-obese diabetic (NOD) mice with myelin oligodendrocyte glycoprotein peptide 35-55 leads to the development of relapsing-remitting stages, evident from days 20 to 70, which then develops into a chronic progressive stage. This cycle is similar to MS stages found in humans. Brain MRI gadolinium-enhanced T1-weighted image analysis showed an increased blood-brain barrier permeability in brain gray and white matter specific to the corpus callosum, fimbria, and internal capsule as found in humans. MRI fractional anisotropy analysis showed demyelination and axonal damage in identical regions. Immunohistologic analysis supported the MRI data. No evidence of brain lesions was found in a common model of MS using C57BL/6 mice. We suggest that an increase in astrocyte toxicity in experimental autoimmune encephalomyelitis-induced NOD mice may be linked to brain lesion development. We suggest using NOD mice as a suitable model for studying MS using MRI methods toward future diagnostic and drug development.

Dizzy and confused: a step-by-step evaluation of the clinician's favorite chief complaint

This article covers the general approach to patients who present to the emergency department with a complaint of dizziness or vertigo, and altered mentation. Patients' histories and physical examination findings are discussed first, then a pertinent differential diagnosis, ranging from neurological causes and poor perfusion states to toxicologic causes, is described along with the distinguishing features and potential diagnostic pitfalls of each problem. Case scenarios are presented and the treatment and disposition of patients from the emergency department are discussed.

Glatiramer acetate: successful desensitization for treatment of multiple sclerosis

BACKGROUND

Glatiramer acetate is an immunomodulatory drug that is widely prescribed for the treatment of multiple sclerosis. It is frequently associated with local injection site reactions and generalized urticaria. It is also associated with immediate postinjection systemic reactions in approximately 10% of patients. To our knowledge, no desensitization protocols for glatiramer acetate have been published to date.

OBJECTIVES

To evaluate the safety and efficacy of glatiramer acetate desensitization in a series of patients with multiple sclerosis.

METHODS

Six patients with multiple sclerosis and glatiramer acetate-associated local or systemic reactions underwent a 4-hour outpatient desensitization procedure at Cleveland Clinic between 2003 and 2008. Beginning with 20 ng, we administered subcutaneous glatiramer acetate suspension in increasing dosages every 15 minutes. Patient outcomes were monitored by return clinic visit and telephone follow-up.

RESULTS

No episodes of anaphylaxis or serious adverse reactions occurred during or immediately after desensitization. One patient suspended therapy after 14 months due to persistent local injection site reactions. All other patients successfully continued glatiramer acetate therapy.

CONCLUSION

Glatiramer acetate offers significant benefit to patients with multiple sclerosis. Our experience suggests that patients who suspend its use owing to local or systemic reactions can be successfully and safely desensitized and can resume medication use. To our knowledge, this is the first report of successful desensitization to glatiramer acetate in patients with multiple sclerosis.

Disease biomarkers in multiple sclerosis: potential for use in therapeutic decision making

Multiple sclerosis (MS) is an autoimmune disorder of the brain and spinal cord that predominantly affects white matter. MS has a variable clinical presentation and has no 'diagnostic' laboratory test; this often results in delays to definite diagnosis. In confronting the disease, early diagnosis and appropriate, timely therapeutic intervention are critical factors in ensuring favorable long-term outcomes. The availability of reliable biomarkers could radically alter our management of MS at critical phases of the disease spectrum. Identification of markers that could predict the development of MS in high-risk populations would allow for intervention strategies that may prevent evolution to definite disease. Work with anti-myelin antibodies and the ongoing analysis of microarray gene expression have thus far not yielded biomarkers that predict future disease development. Similarly, extensive studies with serum and cerebrospinal fluid (CSF) have not yielded a disease-specific and sensitive diagnostic biomarker for MS. Establishment of disease diagnosis always leads to questions about long-term prognosis because in an individual patient the natural history of the disease is clinically unpredictable. Biomarkers that correlate with myelin loss, spinal cord disease, grey matter and subcortical demyelination need to be developed in order to accurately predict the disease course. The bulk of effort in biomarker development in MS has been concentrated in the area of monitoring disease activity. At present, a disease 'activation' panel of CSF biomarkers would include the following: interleukin-6 or its soluble receptor, nitric oxide and nitric oxide synthase, osteopontin, and fetuin-A. Although disease activity in MS is predominantly inflammatory, disease progression is likely to be the result of neurodegeneration. Therefore, the roles of proteins indicative of neuronal, axonal, and glial loss such as neurofilaments, tau, 14-3-3 proteins, and N-acetylaspartate are all under investigation, as are proteins affecting remyelination and regeneration, such as Nogo-A. With the increasing awareness of cognition dysfunction in MS, molecules such as apolipoprotein and proteins in the amyloid precursor protein pathway implicated in dementia are also being examined. Serum biomarkers that help monitor therapeutic efficacy such as the titer of antibody to beta-interferon, a first-line medication in MS, are established in clinical practice. Ongoing work with biomarkers that reflect drug bioavailability and factors that distinguish between medication responders and nonresponders are also under investigation. The discovery of new biomarkers relies on applying advances in proteomics along with microarray gene and antigen analysis and will hopefully result in the establishment of specific biomarkers for MS.

Activities of the enzymes that hydrolyze adenine nucleotides in platelets from multiple sclerosis patients

Multiple sclerosis (MS) is the most common chronic disabling neurological disease in young adults. Alterations in platelet function have been observed in MS; however, the mechanism and the relevance of this blood cell disorder with regard to MS pathogenesis are not yet understood. The aim of this study was to evaluate activities of ectonucleoside thiphosphate diphosphohydrolase (NTPDase, CD39), ectonucleotide pyrophosphatase/phosphodiesterase (E-NPP), 5'-nucleotidase and adenosine deaminase (ADA) in platelets from patients with the relapsing-remitting form of MS (RRMS), as well as to analyze platelet aggregation and expression of NTPDase. The results obtained show that NTPDase, 5'-nucleotidase, E-NPP and ADA activities were decreased in platelets of RRMS patients when compared with the control group (p < 0.05). In addition, NTPDase expression in platelets was also decreased in these patients (p < 0.05); however, no differences were observed in platelet aggregation between RRMS patients and the control group. Our results suggest that the alterations in NTPDase, E-NPP, 5'-nucleotidase and ADA may have contributed to the alterations in platelet function in MS by altering the levels of nucleotides and nucleosides in the circulation.

Use of cognitive aids and other assistive technology by individuals with multiple sclerosis

PURPOSE

To investigate the use of assistive technology (AT), unmet needs for AT, and examine correlates of use of memory aids and cognitive strategies among individuals with multiple sclerosis (MS).

METHOD

A cross-sectional study of 1,063 community dwelling adults with MS in Washington State. A self-report survey assessed use of AT as well as depression, fatigue, mobility, and other demographic and disease related variables.

RESULTS

Some 70% of respondents reported using memory strategies and 50.7% reported using electronic memory aids. The strongest correlate of use of electronic memory aids was endorsement of difficulties thinking (OR: 2.09, p < 0.001) though younger age, higher education, and report of higher fatigue were also significant. Fatigue (OR: 1.27, p < 0.001) and depression (OR: 0.89, p < 0.001) were highly associated with use of memory strategies. Subjects who were older, unemployed, more depressed, and have more mobility disability were less likely to use memory strategies.

CONCLUSIONS

Use of AT for memory is widespread and further research should be conducted on efficacy of AT. Many individuals who might be presumed to need AT for memory most (older, less educated, more disability) are least likely to report use. Healthcare providers are urged to ask about memory AT and make appropriate referrals.

Diabetes insípido em paciente com esclerose múltipla

A esclerose múltipla (EM) é uma doença crônica e progressiva que se caracteriza por surtos de desmielinização que podem atingir qualquer topografia do cérebro, medula espinhal e nervo óptico. Sendo o diabetes insípido (DI) central causado, principalmente, em virtude de danos do sistema nervoso central (tais como trauma, cirurgia, tumor, infecção, sarcoidose), a EM está inclusa entre suas possíveis etiologias. Entretanto, a ocorrência dessa associação não é comumente descrita. A suspeita clínica deve ser feita na presença de poliúria e polidipsia ou hipernatremia refratária (em pacientes privados do acesso à água) durante a evolução da EM. Descreveremos um caso em que essa associação ocorreu e, após o início da terapêutica com desmopressina, a paciente reverteu o quadro clínico.