Clinical Presentations and Phenotypic Spectrum of Multiple Sclerosis at a University Hospital in Saudi Arabia

Unmet Needs and Treatment of Relapsing-Remitting Multiple Sclerosis in Saudi Arabia: Focus on the Role of Ofatumumab

Treatment-pattern data suggest that some patients with multiple sclerosis (MS) in the Kingdom of Saudi Arabia (KSA) may not be receiving optimal treatment. A virtual meeting of ten expert Saudi neurologists, held on October 23, 2020, discussed unmet needs in relapsing-remitting MS (RRMS), and the role of ofatumumab as a suitable treatment in the KSA. Multiple unmet needs were identified: poor quality of life, with high rates of depression and anxiety; a negative impact of MS on work ability; treatment choices that may compromise efficacy for safety or vice versa; inconvenient or complex dosage regimens; and limited access to patient education and support. Early use of highly effective disease-modifying treatments (DMTs) results in better patient outcomes than starting with less effective treatments and downstream escalation, but this strategy may be underutilized in the KSA. B cells are important in MS pathogenesis, and treatments targeting these may improve clinical outcomes. Ofatumumab differs from other B cell-depleting therapies, being a fully human monoclonal antibody that binds to CD20 at a completely separate site from the epitope bound by ocrelizumab, and being administered by subcutaneous injection. When compared with teriflunomide in two randomized, phase 3 clinical trials in patients with RRMS, ofatumumab was associated with significant reductions in annualized relapse rates, rates of confirmed disability worsening, and active lesions on magnetic resonance imaging. The incidence of adverse events, including serious infections, was similar with the two treatments. Ofatumumab is a valuable first- or second-line treatment option for RRMS in the KSA, particularly for patients who would benefit from highly effective DMTs early in the disease course, and for those who prefer the convenience of self-injection. Future research will clarify the position of ofatumumab in RRMS treatment, and comparative cost data may support the broad inclusion of ofatumumab in formularies across the KSA.

A Fuzzy Expert System for Early Diagnosis of Multiple Sclerosis

BACKGROUND

Artificial intelligence plays an important role in medicine. Specially, expert systems can be designed for diagnosis of disease.

OBJECTIVE

Artificial intelligence can be used for diagnosis of disease. This study proposes an expert system for diagnosis of Multiple Sclerosis based on clinical symptoms and demographic characteristics. Specially, it recommends patients to refer to a specialist for further investigation.

MATERIAL AND METHODS

In this empirical study, some symptoms of Multiple Sclerosis are mapped to fuzzy sets. Moreover, several rules are defined for prediction of Multiple Sclerosis. The fuzzy sets and rules form the knowledge base of the expert system. Patients enter their symptoms and demographic information via a user interface and Mamdani method is used in inference engine to produce the appropriate recommendation.

RESULTS

The precision, recall, and F-measure are used as criteria to analyze the efficiency of the expert system. The results show that the designed expert system can recommend patients for further investigation as effective as specialists. Specially, while the proposed expert system recommended referring to a doctor for some healthy users, most of the MS patients are diagnosed.

CONCLUSION

The proposed expert system in this study can analyze the symptoms of patients to predict the Multiple Sclerosis disease. Therefore, it can investigate initial status of patients in a rapid and cost-effective manner. Moreover, this system can be applied in situations and places, which human experts are unavailable.

A multicenter study to evaluate the disease burden and health economics of inpatients with multiple sclerosis in China

OBJECTIVE

To assess the disease burden and health economics of inpatients with multiple sclerosis (MS) in China by evaluating the direct, indirect, and intangible costs.

METHODS

A total of 863 patients were included for a cross-sectional retrospective study in 50 centers. The direct economic burden was measured by the cost of hospitalization and out-of-hospital application drugs, and the indirect economic burden was measured by the human capital method. The disability-adjusted life year (DALY) was used to express the intangible economic burden. Cost-utility analysis (CUA) using DALYs as indicators of health benefits was performed by calculating the incremental cost-utility ratio.

RESULTS

The mean direct economic burden/year, daily medication expenses/year, DALY, indirect economic burden, and indirect economic burden/year were 27,655.57 Yuan, 17,944.97 Yuan, 10.89 Yuan, 512,041.7 Yuan, and 11,299.85 Yuan, respectively. For the study period of two years, the direct economic burden, daily medication expense, and indirect economic burden were 48.6%, 31.5%, and 19.85% of the total economic burden, respectively. Disease burden and the number of episodes of remission were not statistically significant (p>0.001). The direct economic burden and total economic burden of the disease-modifying therapy (DMT) group were higher than those of the non-DMT group, but DALYs had no statistical significance (p>0.001). CUA showed that inpatients with MS in the DMT group received a DALY every time compared with the non-DMT group.

CONCLUSION

The DALY losses are concentrated in young and middle-aged Chinese people. In this two-year study, CUA prompted the application of DMT drugs to increase the economic burden and DALYs. However, follow-up time is still short, and further follow-up observation is required.

Prevalence of Anxiety and Depression in Patients With Multiple Sclerosis in Saudi Arabia: A Cross-Sectional Study

Introduction

Multiple sclerosis (MS) is a chronic disease of progressive demyelination in the central nervous system and carries a significant risk for depression and other psychological difficulties associated with low quality of life. There is a paucity of data on the prevalence of anxiety and depression in Saudi Arabia among patients with MS. We conducted a cross-sectional study to determine the prevalence of anxiety and depression in Saudi Arabia among patients with MS by age, disease severity, compliance to medication, and social support.

Methods

This cross-sectional study measured the prevalence of anxiety and depression in 184 adult patients with MS. The patients were selected through a random sampling method from a pool of MS societies in Saudi Arabia. The participants completed self-administered questionnaires that included demographic variables. The participants also completed the Patient Health Questionnaire-9 (PHQ-9) and the General Anxiety Disorder-7 (GAD-7) questionnaire.

Results

Depression was detected among 139 (75.5%) patients with MS, with most participants having mild depression (31%). More women (83.1%) experienced depression than men (62.1%; p = 0.002). Anxiety disorder was present in 123 (66.8%) patients with MS, and most had mild anxiety (n = 56; 30.4%).

Conclusion

We found a very high rate of depression and anxiety among patients with MS in Saudi Arabia. Our results highlight the need for periodic screening and examination of patients with MS by psychiatrists to facilitate the early detection and treatment of these comorbidities, potentially improving patient quality of life and health outcomes.

The Spectrum of Clinical Presentation of Multiple Sclerosis and Neuromyelitis Optica Spectrum Disorder in Young Patients of Our Community

Background Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory, demyelinating syndrome of the central nervous system (CNS) which affects the spinal cord and optic nerves. The aim of our study was to evaluate the clinical appearance of multiple sclerosis and neuromyelitis optica spectrum disease in young children in our community Materials and methods This cross-sectional study was done in the neurology departments of the Combined Military Hospital & Pak Emirates Military Hospital Rawalpindi for six months from April 2020 to September 2020. Eighty people between the ages of 18 and 45 with Guillain-Barre syndrome (GBS), multiple sclerosis (MS), and neuromyelitis optica spectrum disorder participated in this prospective research. The patient's demographic profile includes information such as age, gender, length and kind of sickness, and symptoms. The relationship of socio-demographic factors was assessed with the involvement of more than one organ system at the time of presentation. Results The final study comprised of 80 patients of whom 31 (38.5 percent) were men and 49 (61.25%) were women. Fifty-four (67.5%) patients were diagnosed with multiple sclerosis while 26 (32.5%) had neuromyelitis optica spectrum disorders. Most of the patients presented with sensory symptoms followed by visual disturbances. Twenty-nine (37%) had involvement of more than one system while 51 (63%) had involvement of only one system at the time of presentation. Female gender and having a diagnosis of multiple sclerosis had a statistically significant relationship with involvement of one than one system. Conclusions In individuals with MS and NMO, motor, sensory, and visual symptoms were often observed at the time of presentation. Involvement of one than one system at the time of presentation was fairly common among these patients and females and patients having a diagnosis of multiple sclerosis were more at risk of involvement of more than one system.

Epidemiology of multiple sclerosis in Lebanon: A rising prevalence in the middle east

BACKGROUND

The epidemiology of multiple sclerosis (MS) has been studied in many countries of the Middle East but the prevalence and incidence of MS in Lebanon is still unknown.

OBJECTIVES

To determine the incidence and prevalence of MS in Lebanon.

METHODS

Lebanese patients diagnosed with MS between January 2018 and December 2018 were identified using the database of governmental third-party payers. The crude, age- and sex-specific 2018 prevalence and incidence among Lebanese patients were calculated.

RESULTS

2248 MS patients were identified of whom 67.1% were women (female: male ratio 2:1) with a mean age of 41.8 ± 12.96 years. The 2018 prevalence of MS was 62.91 cases per 100,000 persons (95% CI: 60.41 - 65.41). The overall incidence of MS in Lebanon was 8.36 cases per 100,000 (95% CI: 7.45 - 9.27) with a mean age at onset of 34.5 ± 12.5 years.

CONCLUSION

This is the first study to assess prevalence and incidence of MS in Lebanon, confirming that Lebanon is a moderate to high-risk area for MS. Those high rates are commensurate with recently published studies from the Middle East, pointing to a significant rise in incidence and prevalence of this disease in our region.

MS and Disability Progression in Latin America, Africa, Asia and the Middle East: A Systematic Review

BACKGROUND

There is evidence of an increased prevalence and disease burden of Multiple Sclerosis (MS) in parts of the world where the risk was once considered low, such as Latin America (LA), Sub-Saharan Africa, Asia and the Middle East-North Africa (MENA). Despite the growing number of clinical reports, the phenotype and course of MS in these regions remains understudied compared with Europe and North America. We aimed to investigate MS phenotypes and long-term clinical outcomes across these regions.

METHOD

A Boolean search of the medical literature was conducted between January 1980 and April 30, 2020. PubMed, SCOPUS, Global Health, and the Cochrane databases, were used to identify all relevant citations. Articles were collated and managed on Covidence® software. We independently appraised the articles for meeting study criteria and for quality using the Critical Appraisal Skills Program (CASP) and the Specialist Unit for Review Evidence (SURE) system.

RESULTS

A total of 1,639 studies were imported for screening. After removing 545 duplicates, two authors assessed 1,094 abstracts and selected 515 for full-text screening. 72 articles met study criteria, including 19 studies from LA, 4 from sub-Saharan Africa, 24 from Asia and 25 from MENA. The overall sex ratio was 2.5:1 (female: male). Disability was assessed using the Expanded Disability Status Scale (EDSS). Longitudinal disability progression and time to standard endpoints was compared by region and with relevant Western reports. Patients with MS living in the MENA region appear to reach disability milestones faster than those in the Western world, although this finding is not uniform. South Asia shows distinct disability features compared with East Asia, more closely resembling those of the West. Disease morbidity in East Asia appears more benign than in the West after careful exclusion of neuromyelitis optica spectrum disorder cases. Populations in LA tend to have similar MS features to the Western world, but some exceptions exist, including African descendants that reach disability milestones earlier. Using all studies with appropriate survival analysis, the mean time to EDSS 6.0 was 16.97 years with a heterogeneity index of 24.59.

CONCLUSION

The clinical phenotypes and disability progression of MS in LA, Africa, Asia and the MENA region have similarities to Western MS. In some regions and subpopulations there is evidence of a more aggressive course, possibly due to a combination of genetic and environmental factors. More population-based longitudinal data are needed, particularly in Sub-Saharan Africa.

No evidence of disease activity-3 (NEDA-3) status in patients with relapsing remitting multiple sclerosis: Evidence from Saudi cohort receiving mainly Interferon

BACKGROUND

No evidence of disease activity (NEDA) is a composite surrogate assessing the responsiveness to various disease-modifying treatments (DMTs) in patients with relapsing and remitting multiple sclerosis (RRMS), addressing clinical as well as radiological disease activity. Despite the rising prevalence of multiple sclerosis in Saudi Arabia (SA), there is a lack of evidence focusing on this important aspect in the management of RRMS. This study aimed to identify the prevalence of NEDA-3 status achievement in patients with RRMS on DMTs (mainly the interferon) and to describe the factors affecting its attainment.

METHOD

This was a retrospective, cross-sectional study carried out at King Fahd University Hospital after obtaining institutional ethical approval. The electronic records of 119 patients diagnosed with RRMS were reviewed. Clinical manifestations at initial presentation, relapse after starting treatment, disability progression, and development of new lesions on follow-up magnetic resonance imaging were all documented to assess NEDA-3 status. Data were analyzed using Statistical Package for Social Sciences, version 22.

RESULTS

NEDA-3 status was achieved in 41 (33.6%) patients. The female-to-male ratio for all patients was 1.5:1. Interferon (IFN) was the most commonly prescribed DMT. NEDA-3 status was achieved in 30.9% of patients receiving IFN. Mean baseline Expanded Disability Status Scale in patients who did not achieve NEDA-3 was 2.8±1.8. Patients with ataxia (P = <0.001), sphincter disturbances (P=0.002) and infra-tentorial brain lesions (P=0.03) were less likely to achieve NEDA-3 status. Involvement of pyramidal, cerebellar and more than one system at initial presentation was more frequent in patients who could not achieve NEDA-3 status (P=0.002) CONCLUSION: Less than one third of total patients on IFN as DMT could achieve NEDA-3 status in our cohort of patients which is in agreement with the literature published in the West. We could not properly asses NEDA-3 status for other DMTs in our center due to the very small sample size of patients on these DMTs, and recommend future studies including larger number of patients on DMTs other than IFN. Significant differences were identified between the two groups of patients with respect to attainment of NEDA-3 status, which requires further verification by multicenter prospective studies.

Is non-traditional therapy for multiple sclerosis overwhelming in Saudi Arabia

Objectives:

To describe the prevalence, knowledge and attitudes about complementary and alternative medicine (CAM) use and the proportion that seek advice from their physician about CAM use.

Methods:

This cross-sectional observational study was performed in multiple sclerosis (MS) clinic of King Fahd Hospital of Universityin Alkhobar, Kingdom of Saudi Arabia from January-June 2017. A total of 133 patients have completed the survey.

Results:

The mean age of patients was 32.3±7.6 years and 84 (63.2 %) were female. Approximately 83.5% of the patients reported the use of CAM. Among all the reported forms of CAM, vitamins were the most prevalent form, followed by cupping, special prayers and meditation. The majority of patients (62%) obtained knowledge of CAM through social media. A significant number of patients (75.6%) did not disclose the use of CAM to their physician. There was a trend for using CAM more in highly educated, older age, and female patients. The most commonly reported rationale to use CAM was overall improvement in health status.

Conclusion:

The use of CAM among Saudi patients with MS is highly prevalent, without disclosure of its use to physicians. These factors should be taken into account in the doctor-patient consultation to avoid adverse events.