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Chitnis T, Banwell B, Kappos L, Arnold DL, Gücüyener K, Deiva K, Saubadu S, Hu W, Benamor M, Le-Halpere A, Truffinet P, Tardieu M. Teriflunomide in pediatric patients with relapsing multiple sclerosis: Open-label extension of TERIKIDS. Mult Scler 2024:13524585241242050. [PMID: 38619037 DOI: 10.1177/13524585241242050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
BACKGROUND The double-blind TERIKIDS study demonstrated the efficacy and safety of teriflunomide. OBJECTIVE To evaluate the efficacy, safety, and tolerability of continuous teriflunomide treatment in the TERIKIDS open-label extension. METHODS In the double-blind period, children with relapsing MS were randomized to placebo or teriflunomide (14 mg adult-equivalent dose) for ⩽ 96 weeks. Participants received teriflunomide for ⩽ 192 weeks post-randomization in the open-label extension. RESULTS The mean age at screening was 14.6 years. For teriflunomide/teriflunomide versus placebo/teriflunomide, estimated clinical relapse risk was reduced by 38% (hazard ratio (HR) 0.62; 95% confidence interval (CI) 0.39-0.98; p = 0.11) and numbers of gadolinium-enhancing T1 and new/enlarging T2 lesions were reduced by 43% (relative risk (RR) 0.570; 95% CI 0.33-0.98; p = 0.043) and 49% (RR 0.511; 95% CI 0.34-0.76; p = 0.001), respectively, in the combined double-blind and open-label periods. There was a trend toward reduced risk of 24-week sustained disability progression for teriflunomide/teriflunomide versus placebo/teriflunomide (HR 0.47; 95% CI 0.23-0.96). During the open-label extension, incidences of safety-related discontinuations were 4.0% (teriflunomide/teriflunomide) and 13.5% (placebo/teriflunomide), including two children who developed pancreatitis in the teriflunomide/teriflunomide group. CONCLUSION Teriflunomide reduced the long-term risk of focal inflammatory activity, with generally manageable tolerability and no new safety signals. Further evidence would strengthen clinical efficacy findings.ClinicalTrials.gov: NCT02201108.
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Affiliation(s)
- Tanuja Chitnis
- Massachusetts General Hospital for Children, Boston, MA, USA
| | - Brenda Banwell
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University of Basel, Basel, Switzerland/MS Center and Neurologic Clinic and Policlinic, Departments of Biomedicine and Clinical Research, University Hospital of Basel, Basel, Switzerland
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada
- NeuroRx Research, Montréal, QC, Canada
| | - Kivilcim Gücüyener
- Gazi Universitesi Tip Fakultesi Pediatrik Nöroloji Bilim Dali, Ankara, Turkey
| | - Kumaran Deiva
- Department of Pediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Paris, France
| | | | | | | | | | | | - Marc Tardieu
- Department of Pediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Paris, France
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Montalban X, Piasecka-Stryczynska K, Kuhle J, Benkert P, Arnold DL, Weber MS, Seitzinger A, Guehring H, Shaw J, Tomic D, Hyvert Y, Harlow DE, Dyroff M, Wolinsky JS. Efficacy and safety results after >3.5 years of treatment with the Bruton's tyrosine kinase inhibitor evobrutinib in relapsing multiple sclerosis: Long-term follow-up of a Phase II randomised clinical trial with a cerebrospinal fluid sub-study. Mult Scler 2024; 30:558-570. [PMID: 38436271 PMCID: PMC11080380 DOI: 10.1177/13524585241234783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/19/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Evobrutinib - an oral, central nervous system (CNS)-penetrant, and highly selective Bruton's tyrosine kinase inhibitor - has shown efficacy in a 48-week, double-blind, Phase II trial in patients with relapsing MS. OBJECTIVE Report results of the Phase II open-label extension (OLE; up to week 192 from randomisation) and a cerebrospinal fluid (CSF) sub-study. METHODS In the 48-week double-blind period (DBP), patients received evobrutinib 25 mg once-daily, 75 mg once-daily, 75 mg twice-daily or placebo (switched to evobrutinib 25 mg once-daily after week 24). Patients could then enter the OLE, receiving evobrutinib 75 mg once-daily (mean (± standard deviation (SD)) duration = 50.6 weeks (±6.0)) before switching to 75 mg twice-daily. RESULTS Of 164 evobrutinib-treated patients who entered the OLE, 128 (78.0%) completed ⩾192 weeks of treatment. Patients receiving DBP evobrutinib 75 mg twice-daily: annualised relapse rate at week 48 (0.11 (95% confidence interval (CI) = 0.04-0.25)) was maintained with the OLE twice-daily dose up to week 192 (0.11 (0.05-0.22)); Expanded Disability Status Scale score remained stable; serum neurofilament light chain fell to levels like a non-MS population (Z-scores); T1 gadolinium-enhancing lesion numbers remained low. No new safety signals were identified. In the OLE, evobrutinib was detected in the CSF of all sub-study patients. CONCLUSION Long-term evobrutinib treatment was well tolerated and associated with a sustained low level of disease activity. Evobrutinib was present in CSF at concentrations similar to plasma.
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Affiliation(s)
- Xavier Montalban
- Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | | | - Jens Kuhle
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Pascal Benkert
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada; NeuroRx, Montreal, QC, Canada
| | - Martin S Weber
- Institute of Neuropathology, Department of Neurology, University Medical Center, University of Göttingen, Göttingen, Germany; Fraunhofer-Institute for Translational Medicine and Pharmacology ITMP, Göttingen, Germany
| | | | | | - Jamie Shaw
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | - Davorka Tomic
- Ares Trading SA, Eysins, Switzerland, an affiliate of Merck KGaA
| | | | - Danielle E Harlow
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | - Martin Dyroff
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | - Jerry S Wolinsky
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX, USA
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3
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Arnold DL, Elliott C, Martin EC, Hyvert Y, Tomic D, Montalban X. Effect of Evobrutinib on Slowly Expanding Lesion Volume in Relapsing Multiple Sclerosis: A Post Hoc Analysis of a Phase 2 Trial. Neurology 2024; 102:e208058. [PMID: 38335474 PMCID: PMC11067693 DOI: 10.1212/wnl.0000000000208058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 10/19/2023] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic active lesions (CALs) are demyelinated multiple sclerosis (MS) lesions with ongoing microglia/macrophage activity, resulting in irreversible neuronal damage and axonal loss. Evobrutinib is a highly selective, covalent, CNS-penetrant, Bruton tyrosine kinase inhibitor. This post hoc analysis evaluated the effect of evobrutinib on slowly expanding lesion (SEL) volume, an MRI marker of CALs, assessed baseline-week 48 in a phase 2, double-blind, randomized trial (NCT02975349) in relapsing MS (RMS). METHODS In the 48-week, double-blind trial, adult patients received evobrutinib (25 mg once daily [QD], 75 mg QD, or 75 mg twice daily [BID]), placebo (switched to evobrutinib 25 mg QD after week 24), or open-label dimethyl fumarate (DMF) 240 mg BID. SELs were defined as slowly and consistently radially expanding areas of preexisting T2 lesions of ≥10 contiguous voxels (∼30 mm3) over time. SELs were identified by MRI and assessed by the Jacobian determinant of the nonlinear deformation from baseline to week 48. SEL volume analysis, stratified by baseline T2 lesion volume tertiles, was based on week 48/end-of-treatment status (completers/non-completers). Treatment effect was analyzed using the stratified Hodges-Lehmann estimate of shift in distribution and stratified Wilcoxon rank-sum test. Comparisons of evobrutinib and DMF vs placebo/evobrutinib 25 mg QD were made. Subgroup analyses used pooled treatment groups (evobrutinib high dose [75 mg QD/BID] vs low dose [placebo/evobrutinib 25 mg QD]). RESULTS The SEL analysis set included 223 patients (mean [SD] age: 42.4 [10.7] years; 69.3% female; 87.4% relapsing/remitting MS). Mean (SD) SEL volume was 2,099 (2,981.0) mm3 with evobrutinib 75 mg BID vs 2,681 (3,624.2) mm3 with placebo/evobrutinib 25 mg QD. Median number of SELs/patient ranged from 7 to 11 across treatments. SEL volume decreased with increasing evobrutinib dose vs placebo/evobrutinib 25 mg QD, and no difference with DMF vs placebo/evobrutinib 25 mg QD was noted. SEL volume significantly decreased with evobrutinib 75 mg BID vs placebo/evobrutinib 25 mg QD (-474.5 mm3 [-1,098.0 to -3.0], p = 0.047) and vs DMF (-711.6 [-1,290.0 to -149.0], p = 0.011). SEL volume was significantly reduced for evobrutinib high vs low dose within baseline Expanded Disability Status Scale ≥3.5 and longer disease duration (≥8.5 years) subgroups. DISCUSSION Evobrutinib reduced SEL volume in a dose-dependent manner in RMS, with a significant reduction with evobrutinib 75 mg BID. This is evident that evobrutinib affects brain lesions associated with chronic inflammation and tissue loss. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov number: NCT02975349. Submitted to ClinicalTrials.gov on November 29, 2016. First patient enrolled: March 7, 2017. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that evobrutinib reduces the volume of SELs assessed on MRI comparing baseline with week 48, in patients with RMS.
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Affiliation(s)
- Douglas L Arnold
- From the Montreal Neurological Institute (D.L.A.), McGill University; NeuroRx Research (D.L.A., C.E.), Montreal, Quebec, Canada; EMD Serono (E.C.M.), Billerica, MA; The Healthcare Business of Merck KGaA (Y.H.); Ares Trading SA (D.T.), Eysins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany; and Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (X.M.), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Colm Elliott
- From the Montreal Neurological Institute (D.L.A.), McGill University; NeuroRx Research (D.L.A., C.E.), Montreal, Quebec, Canada; EMD Serono (E.C.M.), Billerica, MA; The Healthcare Business of Merck KGaA (Y.H.); Ares Trading SA (D.T.), Eysins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany; and Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (X.M.), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Emily C Martin
- From the Montreal Neurological Institute (D.L.A.), McGill University; NeuroRx Research (D.L.A., C.E.), Montreal, Quebec, Canada; EMD Serono (E.C.M.), Billerica, MA; The Healthcare Business of Merck KGaA (Y.H.); Ares Trading SA (D.T.), Eysins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany; and Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (X.M.), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Yann Hyvert
- From the Montreal Neurological Institute (D.L.A.), McGill University; NeuroRx Research (D.L.A., C.E.), Montreal, Quebec, Canada; EMD Serono (E.C.M.), Billerica, MA; The Healthcare Business of Merck KGaA (Y.H.); Ares Trading SA (D.T.), Eysins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany; and Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (X.M.), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Davorka Tomic
- From the Montreal Neurological Institute (D.L.A.), McGill University; NeuroRx Research (D.L.A., C.E.), Montreal, Quebec, Canada; EMD Serono (E.C.M.), Billerica, MA; The Healthcare Business of Merck KGaA (Y.H.); Ares Trading SA (D.T.), Eysins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany; and Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (X.M.), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Xavier Montalban
- From the Montreal Neurological Institute (D.L.A.), McGill University; NeuroRx Research (D.L.A., C.E.), Montreal, Quebec, Canada; EMD Serono (E.C.M.), Billerica, MA; The Healthcare Business of Merck KGaA (Y.H.); Ares Trading SA (D.T.), Eysins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany; and Centre d'Esclerosi Múltiple de Catalunya (Cemcat) (X.M.), Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Zhu F, Zhao Y, Arnold DL, Bar‐Or A, Bernstein CN, Bonner C, Graham M, Hart J, Knox N, Marrie RA, Mirza AI, O'Mahony J, Van Domselaar G, Yeh EA, Banwell B, Waubant E, Tremlett H. A cross-sectional study of MRI features and the gut microbiome in pediatric-onset multiple sclerosis. Ann Clin Transl Neurol 2024; 11:486-496. [PMID: 38130033 PMCID: PMC10863907 DOI: 10.1002/acn3.51970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/27/2023] [Accepted: 11/24/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE To identify gut microbiome features associated with MRI lesion burden in persons with pediatric-onset multiple sclerosis (symptom onset <18 years). METHODS A cross-sectional study involving the Canadian Paediatric Demyelinating Disease Network study participants. Gut microbiome features (alpha diversity, phylum- and genus-level taxa) were derived using 16S rRNA sequencing from stool samples. T1- and T2-weighted lesion volumes were measured on brain MRI obtained within 6 months of stool sample procurement. Associations between the gut microbiota and MRI metrics (cube-root-transformed) were assessed using standard and Lasso regression models. RESULTS Thirty-four participants were included; mean ages at symptom onset and MRI were 15.1 and 19.0 years, respectively, and 79% were female. The T1- and T2-weighted lesion volumes were not significantly associated with alpha diversity (age and sex-adjusted p > 0.08). At the phylum level, high Tenericutes (relative abundance) was associated with higher T1 and T2 volumes (β coefficient = 0.25, 0.37) and high Firmicutes, Patescibacteria or Actinobacteria with lower lesion volumes (β coefficient = -0.30 to -0.07). At the genus level, high Ruminiclostridium, whereas low Coprococcus 3 and low Erysipelatoclostridium were associated with higher lesion volumes. INTERPRETATION Our study characterized the gut microbiota features associated with MRI lesion burden in pediatric-onset MS, shedding light onto possible pathophysiological mechanisms.
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Affiliation(s)
- Feng Zhu
- Department of Medicine (Neurology)The University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Yinshan Zhao
- Department of Medicine (Neurology)The University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Douglas L. Arnold
- Department of Neurology and NeurosurgeryMcGill University Faculty of MedicineMontrealQuebecCanada
| | - Amit Bar‐Or
- Department of Neurology, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- The Children's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Charles N. Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
- Inflammatory Bowel Disease Clinical and Research CentreUniversity of ManitobaWinnipegManitobaCanada
| | - Christine Bonner
- National Microbiology LaboratoryPublic Health Agency of CanadaWinnipegManitobaCanada
| | - Morag Graham
- National Microbiology LaboratoryPublic Health Agency of CanadaWinnipegManitobaCanada
- Department of Medical Microbiology and Infectious DiseasesUniversity of ManitobaWinnipegManitobaCanada
| | - Janace Hart
- Department of NeurologyUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Natalie Knox
- National Microbiology LaboratoryPublic Health Agency of CanadaWinnipegManitobaCanada
- Department of Medical Microbiology and Infectious DiseasesUniversity of ManitobaWinnipegManitobaCanada
| | - Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Ali I. Mirza
- Department of Medicine (Neurology)The University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Julia O'Mahony
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Gary Van Domselaar
- National Microbiology LaboratoryPublic Health Agency of CanadaWinnipegManitobaCanada
- Department of Medical Microbiology and Infectious DiseasesUniversity of ManitobaWinnipegManitobaCanada
| | - E. Ann Yeh
- Department of Neurology and NeurosurgeryMcGill University Faculty of MedicineMontrealQuebecCanada
| | - Brenda Banwell
- Department of Neurology, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- The Children's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Emmanuelle Waubant
- Department of NeurologyUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Helen Tremlett
- Department of Medicine (Neurology)The University of British ColumbiaVancouverBritish ColumbiaCanada
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Nakamura K, Elliott C, Lee H, Narayanan S, Arnold DL. Brain volume increase after discontinuing natalizumab therapy: Evidence for reversible pseudoatrophy. Mult Scler Relat Disord 2024; 81:105123. [PMID: 37976981 DOI: 10.1016/j.msard.2023.105123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 09/02/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND The phenomenon of pseudoatropy after initiation of anti-inflammatory therapy is believed to be reversible, but a rebound in brain volume following cessation of highly-effective therapy has not been reported. OBJECTIVES To evaluate brain volume change in a treatment interruption study (RESTORE) in which relapsing-remitting multiple sclerosis (RRMS) patients were randomized to switch from natalizumab to placebo, from natalizumab to once-monthly intravenous methylprednisolone (IVMP), or to remain on natalizumab. METHODS T2 lesion volume (T2LV), baseline normalized brain volumes, and follow-up percent brain volume changes (PBVC) were calculated. Approximate T2 relaxation-time (pT2) was calculated within the brain mask and the T2 lesions to estimate changes in water content. Linear mixed effects models were used to detect differences in T2LV, pT2 in whole brain, pT2 in T2-weighted lesions, and PBVC among the placebo, natalizumab, and IVMP groups. We also estimated contributions of T2LV and pT2 (in whole brain and T2 lesions) to PBVC. RESULTS T2LV increased in the placebo group (by 0.66 ml/year, p<0.0001) and IVMP (+1.98 ml/year, p = 0.05) groups relative to the natalizumab group. The rates of PBVC were significantly different: -0.239%/year with continued natalizumab and +0.126 %/year after switch to placebo (p = 0.03), while the IVMP group showed brain volume loss (-0.74 %/ year, p = 0.08). pT2 was not statistically different between the groups (p ≥ 0.29) and did not have significant effects on PBVC (p ≥ 0.25). CONCLUSION The increase in the brain volume in patients witching from natalizumab to placebo is consistent with reversal of so-called pseudoatrophy after starting natalizumab.
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Affiliation(s)
- Kunio Nakamura
- McConnell Brain Imaging Centre, Montreal Neurological Institute Hospital, and Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, QC H3A 2B4, Canada; Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, ND20, Cleveland, Ohio 44195, USA.
| | - Colm Elliott
- Centre for Intelligent Machines, McGill University, 3480 Rue University, Montréal, QC H3A 2A7, Canada. NeuroRx Research, 3575 Park Avenue, Suite #5322, Montreal, Quebec H2 × 4B3, Canada; NeuroRx Research, 3575 Park Avenue, Suite #5322, Montreal, Quebec H2 × 4B3, Canada
| | - Hyunwoo Lee
- McConnell Brain Imaging Centre, Montreal Neurological Institute Hospital, and Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, QC H3A 2B4, Canada; Division of Neurology, Department of Medicine, University of British Columbia S154-2211 Wesbrook Mall, Vancouver, BC V6T2B5, Canada
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute Hospital, and Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, QC H3A 2B4, Canada; NeuroRx Research, 3575 Park Avenue, Suite #5322, Montreal, Quebec H2 × 4B3, Canada
| | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute Hospital, and Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, QC H3A 2B4, Canada; NeuroRx Research, 3575 Park Avenue, Suite #5322, Montreal, Quebec H2 × 4B3, Canada
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Singer BA, Arnold DL, Drulovic J, Freedman MS, Gold R, Gudesblatt M, Jasinska E, LaGanke CC, Naismith RT, Negroski D, Oh J, Hernandez Perez MA, Selmaj K, Then Bergh F, Wundes A, Ziemssen T, Castro-Borrero W, Chen H, Levin S, Scaramozza M, Shankar SL, Wang T, Wray S. Diroximel fumarate in patients with relapsing-remitting multiple sclerosis: Final safety and efficacy results from the phase 3 EVOLVE-MS-1 study. Mult Scler 2023; 29:1795-1807. [PMID: 37905526 PMCID: PMC10687803 DOI: 10.1177/13524585231205708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Diroximel fumarate (DRF) is approved for adults with relapsing-remitting multiple sclerosis (RRMS) in Europe and for relapsing forms of MS in the United States. DRF and dimethyl fumarate (DMF) yield bioequivalent exposure of the active metabolite monomethyl fumarate. Prior studies indicated fewer gastrointestinal (GI)-related adverse events (AEs) with DRF compared with DMF. OBJECTIVE To report final outcomes from EVOLVE-MS-1. METHODS EVOLVE-MS-1 was an open-label, 96-week, phase 3 study assessing DRF safety, tolerability, and efficacy in patients with RRMS. The primary endpoint was safety and tolerability; efficacy endpoints were exploratory. RESULTS Overall, 75.7% (800/1057) of patients completed the study; median exposure was 1.8 (range: 0.0-2.0) years. AEs occurred in 938 (88.7%) patients, mostly of mild (28.9%) or moderate (50.3%) severity. DRF was discontinued due to AEs in 85 (8.0%) patients, with < 2% discontinuing due to GI or flushing/flushing-related AEs. At Week 96, mean number of gadolinium-enhancing lesions was significantly reduced from baseline (72.7%; p < 0.0001); adjusted annualized relapse rate was 0.13 (95% confidence interval: 0.11-0.15). CONCLUSION DRF was generally well tolerated over 2 years, with few discontinuations due to AEs; radiological measures indicated decreased disease activity from baseline. These outcomes support DRF as a treatment option in patients with RRMS.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
- NeuroRx Research Inc., Montreal, QC, Canada
| | - Jelena Drulovic
- Clinic of Neurology, University of Belgrade, Belgrade, Serbia
| | - Mark S Freedman
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ralf Gold
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - Mark Gudesblatt
- NYU Langone South Shore Neurologic Associates, Patchogue, NY, USA
| | - Elzbieta Jasinska
- Collegium Medicum UJK, and Clinical Center, RESMEDICA, Kielce, Poland
| | | | | | | | - Jiwon Oh
- Division of Neurology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Krzysztof Selmaj
- Center of Neurology, Lodz, Poland
- Department of Neurology, University of Warmia and Mazury, Olsztyn, Poland
| | | | - Annette Wundes
- Department of Neurology, University of Washington Medical Center, Seattle, WA, USA
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, Dresden, Germany
| | | | | | | | | | | | | | - Sibyl Wray
- Hope Neurology MS Center, Knoxville, TN, USA
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Colato E, Prados F, Stutters J, Bianchi A, Narayanan S, Arnold DL, Wheeler-Kingshott C, Barkhof F, Ciccarelli O, Chard DT, Eshaghi A. Networks of microstructural damage predict disability in multiple sclerosis. J Neurol Neurosurg Psychiatry 2023; 94:992-1003. [PMID: 37468305 DOI: 10.1136/jnnp-2022-330203] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 06/13/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Network-based measures are emerging MRI markers in multiple sclerosis (MS). We aimed to identify networks of white (WM) and grey matter (GM) damage that predict disability progression and cognitive worsening using data-driven methods. METHODS We analysed data from 1836 participants with different MS phenotypes (843 in a discovery cohort and 842 in a replication cohort). We calculated standardised T1-weighted/T2-weighted (sT1w/T2w) ratio maps in brain GM and WM, and applied spatial independent component analysis to identify networks of covarying microstructural damage. Clinical outcomes were Expanded Disability Status Scale worsening confirmed at 24 weeks (24-week confirmed disability progression (CDP)) and time to cognitive worsening assessed by the Symbol Digit Modalities Test (SDMT). We used Cox proportional hazard models to calculate predictive value of network measures. RESULTS We identified 8 WM and 7 GM sT1w/T2w networks (of regional covariation in sT1w/T2w measures) in both cohorts. Network loading represents the degree of covariation in regional T1/T2 ratio within a given network. The loading factor in the anterior corona radiata and temporo-parieto-frontal components were associated with higher risks of developing CDP both in the discovery (HR=0.85, p<0.05 and HR=0.83, p<0.05, respectively) and replication cohorts (HR=0.84, p<0.05 and HR=0.80, p<0.005, respectively). The decreasing or increasing loading factor in the arcuate fasciculus, corpus callosum, deep GM, cortico-cerebellar patterns and lesion load were associated with a higher risk of developing SDMT worsening both in the discovery (HR=0.82, p<0.01; HR=0.87, p<0.05; HR=0.75, p<0.001; HR=0.86, p<0.05 and HR=1.27, p<0.0001) and replication cohorts (HR=0.82, p<0.005; HR=0.73, p<0.0001; HR=0.80, p<0.005; HR=0.85, p<0.01 and HR=1.26, p<0.0001). CONCLUSIONS GM and WM networks of microstructural changes predict disability and cognitive worsening in MS. Our approach may be used to identify patients at greater risk of disability worsening and stratify cohorts in treatment trials.
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Affiliation(s)
- Elisa Colato
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Ferran Prados
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Centre for Medical Image Computing (CMIC), Department of Computer Science, University College London, London, UK
- Centre for Medical Image Computing (CMIC), Department of Medical Physics and Biomedical Engineering, University College London, London, UK
- e-Health Center, Universitat Oberta de Catalunya, Barcelona, Spain
| | - Jonathan Stutters
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Alessia Bianchi
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Québec, Canada
| | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Québec, Canada
| | - Claudia Wheeler-Kingshott
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Brain Connectivity Centre, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Frederik Barkhof
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Centre for Medical Image Computing (CMIC), Department of Medical Physics and Biomedical Engineering, University College London, London, UK
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location Vrije Universiteit, Amsterdam, Netherlands
- Institute for Health Research (NIHR), University College London Hospitals (UCLH) Biomedical Research Centre (BRC), London, UK
| | - Olga Ciccarelli
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Institute for Health Research (NIHR), University College London Hospitals (UCLH) Biomedical Research Centre (BRC), London, UK
| | - Declan T Chard
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Institute for Health Research (NIHR), University College London Hospitals (UCLH) Biomedical Research Centre (BRC), London, UK
| | - Arman Eshaghi
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Centre for Medical Image Computing (CMIC), Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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Jiang X, Shen C, Caba B, Arnold DL, Elliott C, Zhu B, Fisher E, Belachew S, Gafson AR. Assessing the utility of magnetic resonance imaging-based "SuStaIn" disease subtyping for precision medicine in relapsing-remitting and secondary progressive multiple sclerosis. Mult Scler Relat Disord 2023; 77:104869. [PMID: 37459715 DOI: 10.1016/j.msard.2023.104869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/16/2023] [Accepted: 07/01/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Patient stratification and individualized treatment decisions based on multiple sclerosis (MS) clinical phenotypes are arbitrary. Subtype and Staging Inference (SuStaIn), a published machine learning algorithm, was developed to identify data-driven disease subtypes with distinct temporal progression patterns using brain magnetic resonance imaging; its clinical utility has not been assessed. The objective of this study was to explore the prognostic capability of SuStaIn subtyping and whether it is a useful personalized predictor of treatment effects of natalizumab and dimethyl fumarate. METHODS Subtypes were available from the trained SuStaIn model for 3 phase 3 clinical trials in relapsing-remitting and secondary progressive MS. Regression models were used to determine whether baseline SuStaIn subtypes could predict on-study clinical and radiological disease activity and progression. Differences in treatment responses relative to placebo between subtypes were determined using interaction terms between treatment and subtype. RESULTS Natalizumab and dimethyl fumarate reduced inflammatory disease activity in all SuStaIn subtypes (all p < 0.001). SuStaIn MS subtyping alone did not discriminate responder heterogeneity based on new lesion formation and disease progression (p > 0.05 across subtypes). CONCLUSION SuStaIn subtypes correlated with disease severity and functional impairment at baseline but were not predictive of disability progression and could not discriminate treatment response heterogeneity.
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Affiliation(s)
| | - Changyu Shen
- Biogen, 225 Binney Street, Cambridge, MA 02142, USA
| | - Bastien Caba
- Biogen, 225 Binney Street, Cambridge, MA 02142, USA
| | - Douglas L Arnold
- NeuroRx Research, Montreal, Quebec, Canada; McGill University, Montreal, Quebec, Canada
| | | | - Bing Zhu
- Biogen, 225 Binney Street, Cambridge, MA 02142, USA
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9
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Fadda G, Cardenas de la Parra A, O'Mahony J, Waters P, Yeh EA, Bar-Or A, Marrie RA, Narayanan S, Arnold DL, Collins DL, Banwell B. Deviation From Normative Whole Brain and Deep Gray Matter Growth in Children With MOGAD, MS, and Monophasic Seronegative Demyelination. Neurology 2023; 101:e425-e437. [PMID: 37258297 PMCID: PMC10435061 DOI: 10.1212/wnl.0000000000207429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 04/04/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric-acquired demyelination of the CNS associated with antibodies directed against myelin oligodendrocyte glycoprotein (MOG; MOG antibody-associated disease [MOGAD]) occurs as a monophasic or relapsing disease and with variable but often extensive T2 lesions in the brain. The impact of MOGAD on brain growth during maturation is unknown. We quantified the effect of pediatric MOGAD on brain growth trajectories and compared this with the growth trajectories of age-matched and sex-matched healthy children and children with multiple sclerosis (MS, a chronic relapsing disease known to lead to failure of normal brain growth and to loss of brain volume) and monophasic seronegative demyelination. METHODS We included children enrolled at incident attack in the prospective longitudinal Canadian Pediatric Demyelinating Disease Study who were recruited at the 3 largest enrollment sites, underwent research brain MRI scans, and were tested for serum MOG-IgG. Children seropositive for MOG-IgG were diagnosed with MOGAD. MS was diagnosed per the 2017 McDonald criteria. Monophasic seronegative demyelination was confirmed in children with no clinical or MRI evidence of recurrent demyelination and negative results for MOG-IgG and aquaporin-4-IgG. Whole and regional brain volumes were computed through symmetric nonlinear registration to templates. We computed age-normalized and sex-normalized z scores for brain volume using a normative dataset of 813 brain MRI scans obtained from typically developing children and used mixed-effect models to assess potential deviation from brain growth trajectories. RESULTS We assessed brain volumes of 46 children with MOGAD, 26 with MS, and 51 with monophasic seronegative demyelinating syndrome. Children with MOGAD exhibited delayed (p < 0.001) age-expected and sex-expected growth of thalamus, caudate, and globus pallidus, normalized for the whole brain volume. Divergence from expected growth was particularly pronounced in the first year postonset and was detected even in children with monophasic MOGAD. Thalamic volume abnormalities were less pronounced in children with MOGAD compared with those in children with MS. DISCUSSION The onset of MOGAD during childhood adversely affects the expected trajectory of growth of deep gray matter structures, with accelerated changes in the months after an acute attack. Further studies are required to better determine the relative impact of monophasic vs relapsing MOGAD and whether relapsing MOGAD with attacks isolated to the optic nerves or spinal cord affects brain volume over time.
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Affiliation(s)
- Giulia Fadda
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Alonso Cardenas de la Parra
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Julia O'Mahony
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Patrick Waters
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - E Ann Yeh
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Amit Bar-Or
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Ruth Ann Marrie
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Sridar Narayanan
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Douglas L Arnold
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - D Louis Collins
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Brenda Banwell
- From the Department of Medicine (G.F), University of Ottawa, Ottawa Hospital Research Institute; Montreal Neurological Institute (A.C.P., S.N., D.L.A., D.L.C.), McGill University, Quebec; Department of Community Health Sciences (J.O.M., R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Nuffield Department of Clinical Neurosciences (P.W.), John Radcliffe Hospital, University of Oxford, United Kingdom; Department of Pediatrics (E.A.Y.), University of Toronto, Ontario, Canada; Center for Neuroinflammation and Neurotherapeutics (A.B.-O.), and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Internal Medicine (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; and Division of Child Neurology (B.B.), Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania.
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Kolind S, Gaetano L, Assemlal HE, Bernasconi C, Bonati U, Elliott C, Hagenbuch N, Magon S, Arnold DL, Traboulsee A. Ocrelizumab-treated patients with relapsing multiple sclerosis show volume loss rates similar to healthy aging. Mult Scler 2023; 29:741-747. [PMID: 37148240 PMCID: PMC10176619 DOI: 10.1177/13524585231162586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system characterized by two major and interconnected hallmarks: inflammation and progressive neurodegeneration. OBJECTIVE The aim of this work was to compare neurodegenerative processes, in the form of global and regional brain volume loss rates, in healthy controls (HCs) and in patients with relapsing MS (RMS) treated with ocrelizumab, which suppresses acute inflammation. METHODS Whole brain, white matter, cortical gray matter, thalamic, and cerebellar volume loss rates were assessed in 44 HCs that were part of a substudy in the OPERA II randomized controlled trial (NCT01412333) and 59 patients with RMS enrolled in the same substudy as well as age- and sex-matched patients in OPERA I (NCT01247324) and II. Volume loss rates were computed using random coefficients models over a period of 2 years. RESULTS Ocrelizumab-treated patients showed global and regional brain volume loss rates that were approaching that of HCs. CONCLUSION These findings are consistent with an important role of inflammation on overall tissue loss and the role of ocrelizumab in reducing this phenomenon.
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Affiliation(s)
- Shannon Kolind
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | | | | | | | - Douglas L Arnold
- NeuroRx Research, Montreal, QC, Canada/Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Anthony Traboulsee
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Elliott C, Rudko DA, Arnold DL, Fetco D, Elkady AM, Araujo D, Zhu B, Gafson A, Tian Z, Belachew S, Bradley DP, Fisher E. Lesion-level correspondence and longitudinal properties of paramagnetic rim and slowly expanding lesions in multiple sclerosis. Mult Scler 2023; 29:680-690. [PMID: 37036134 PMCID: PMC10176750 DOI: 10.1177/13524585231162262] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
BACKGROUND Paramagnetic rim lesions (PRLs) and slowly expanding lesions (SELs) have been posited as markers of chronic active lesions (CALs). OBJECTIVE To assess the lesion-level concordance of PRLs and SELs in MS and to characterize changes in brain tissue integrity in CALs over time. METHODS MRIs were analyzed from a substudy of AFFINITY [NCT03222973], a phase 2 trial of opicinumab in relapsing MS. Assessments included (1) identification of SELs based on longitudinal MRIs over 72 weeks, and identification of PRLs on susceptibility-weighted imaging (SWI) filtered phase images at week 72; (2) evaluation of subject-level correlation of SEL and PRL counts, volumes, and degree of lesion-level overlap between SELs and PRLs; and (3) characterization of tissue integrity over time in overlapping and non-overlapping SELs and PRLs. RESULTS In 41 subjects, 119 chronic PRLs and 267 SELs were detected. Of 119 (39.5%) chronic PRLs, 47 co-localized with a SEL; 46/267 (17.2%) SELs co-localized with a PRL. PRLs co-localized with SELs showed expansion and worsening microstructural damage over time. SELs with and without co-localization with PRLs showed ongoing tissue damage. CONCLUSIONS Chronic MS lesions identified as both PRL and SEL were associated with the most severe accumulation of tissue damage. TRIAL REGISTRATION AFFINITY [NCT03222973].
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Affiliation(s)
| | - David A Rudko
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada/McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, Montreal, QC, Canada/Department of Biomedical Engineering, McGill University, Montreal, QC, Canada
| | - Douglas L Arnold
- NeuroRx Research, Montreal, QC, Canada/Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Dumitru Fetco
- NeuroRx Research, Montreal, QC, Canada/Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Ahmed M Elkady
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada/McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, Montreal, QC, Canada/Department of Biomedical Engineering, McGill University, Montreal, QC, Canada
| | - David Araujo
- NeuroRx Research, Montreal, QC, Canada/Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
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12
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Kuhle J, Chitnis T, Banwell B, Tardieu M, Arnold DL, Rawlings AM, Geertsen SS, Lublin AL, Saubadu S, Truffinet P, Kappos L. Plasma neurofilament light chain in children with relapsing MS receiving teriflunomide or placebo: A post hoc analysis of the randomized TERIKIDS trial. Mult Scler 2023; 29:385-394. [PMID: 36632983 PMCID: PMC9972233 DOI: 10.1177/13524585221144742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The phase 3 TERIKIDS study demonstrated efficacy and manageable safety for teriflunomide versus placebo in children with relapsing multiple sclerosis (RMS). OBJECTIVE Evaluate plasma neurofilament light chain (pNfL) concentrations in TERIKIDS. METHODS Patients received placebo or teriflunomide (14 mg adult equivalent) for up to 96 weeks in the double-blind (DB) period. In the open-label extension (OLE), all patients received teriflunomide until up to 192 weeks after randomization. pNfL was measured using single-molecule array assay (Simoa® NF-light™). RESULTS Baseline mean age was 14.5 years; 69.4% were female. Baseline geometric least square mean pNfL levels were similar for teriflunomide (n = 78) and placebo (n = 33) patients (19.83 vs 18.30 pg/mL). Over the combined DB and OLE periods, pNfL values were lower for teriflunomide versus placebo (analysis of variance p < 0.01; Week 192: 10.61 vs 17.32 pg/mL). Observed between-group pNfL differences were attenuated upon adjustment for gadolinium (Gd)-enhancing or new/enlarged T2 lesion counts at DB Week 24. Higher baseline pNfL levels were associated with shorter time since first MS symptom onset, higher baseline Gd-enhancing lesion counts and T2 lesion volume, and increased hazard of high magnetic resonance imaging activity or clinical relapse during the DB period. CONCLUSION Teriflunomide treatment was associated with significantly reduced pNfL levels in children with RMS. CLINICALTRIALS.GOV IDENTIFIER NCT02201108.
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Affiliation(s)
- Jens Kuhle
- J Kuhle MS Center, Neurology and Research
Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments
of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University
Hospital Basel and University Basel, Petersgraben 4, 4031 Basel, Switzerland.
| | - Tanuja Chitnis
- Massachusetts General Hospital for Children,
Boston, MA, USA
| | - Brenda Banwell
- Children’s Hospital of Philadelphia, University
of Pennsylvania, Philadelphia, PA, USA
| | - Marc Tardieu
- Hôpitaux Universitaires Paris-Sud, Paris,
France
| | - Douglas L Arnold
- McGill University, Montréal, QC, Canada NeuroRx
Research, Montréal, QC, Canada
| | | | | | | | | | | | - Ludwig Kappos
- MS Center, Neurology and Research Center for
Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of
Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University
Hospital Basel and University Basel, Basel, Switzerland
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Vermersch P, Arnold DL, Wolinsky J, Havrdova EK, Kinkolykh A, Hyvert Y, Tomic D, Montalban X. MRI and Clinical Outcomes of Evobrutinib, a Bruton's Tyrosine Kinase Inhibitor, in Relapsing Multiple Sclerosis Over 2.5 Years of the Open-Label Extension to a Phase 2 Trial. Mult Scler Relat Disord 2023. [DOI: 10.1016/j.msard.2022.104360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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14
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Ryerson LZ, Foley JF, Defer G, Cohen JA, Arnold DL, Butzkueven H, Cutter G, Giovannoni G, Killestein J, Wiendl H, Sinks S, Kuhelj R, Bodhinathan K, Lasky T. Exploratory clinical efficacy and patient-reported outcomes from NOVA: A randomized controlled study of intravenous natalizumab 6-week dosing versus continued 4-week dosing for relapsing-remitting multiple sclerosis. Mult Scler Relat Disord 2023; 72:104561. [PMID: 36931078 DOI: 10.1016/j.msard.2023.104561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/09/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Natalizumab (TYSABRI®) 300 mg administered intravenously every-4-weeks (Q4W) is approved for treatment of relapsing-remitting multiple sclerosis but is associated with increased risk of progressive multifocal leukoencephalopathy (PML). Extended natalizumab dosing intervals of approximately every-6-weeks (Q6W) are associated with a lower risk of PML. Primary and secondary clinical outcomes from the NOVA randomized clinical trial (NCT03689972) suggest that effective disease control is maintained in patients who were stable during treatment with natalizumab Q4W for ≥12 months and who then switched to Q6W dosing. We compared additional exploratory clinical and patient-reported outcomes (PROs) from NOVA to assess the efficacy of Q6W dosing. METHODS Prespecified exploratory clinical efficacy endpoints in NOVA included change from baseline in Expanded Disability Status Scale (EDSS) score, Timed 25-Foot Walk (T25FW), dominant- and nondominant-hand 9-Hole Peg Test (9HPT), and Symbol Digit Modalities Test (SDMT). Exploratory patient-reported outcome (PRO) efficacy endpoints included change from baseline in the Treatment Satisfaction Questionnaire for Medication (TSQM), Neuro-QoL fatigue questionnaire, Multiple Sclerosis Impact Scale (MSIS-29), EuroQol 5 Dimensions (EQ-5D-5 L) index score, Clinical Global Impression (CGI)-Improvement (patient- and clinician-assessed) and CGI-Severity (clinician-assessed) rating scales. Estimated proportions of patients with confirmed EDSS improvement were based on Kaplan-Meier methods. Estimates of mean treatment differences for Q6W versus Q4W in other outcomes were assessed by least squares mean (LSM) and analyzed using a linear mixed model of repeated measures or ordinal logistic regression (CGI-scale). RESULTS Exploratory clinical and patient-reported outcomes were assessed in patients who received ≥1 dose of randomly assigned study treatment and had ≥1 postbaseline efficacy assessment (Q6W group, n = 247, and Q4W group, n = 242). Estimated proportions of patients with EDSS improvement at week 72 were similar for Q6W and Q4W groups (11.7% [19/163] vs 10.8% [17/158]; HR 1.02 [95% confidence interval [CI], 0.53-1.98]; P = 0.9501). At week 72, there were no significant differences between Q6W and Q4W groups in LSM change from baseline for T25FW (0.00, P = 0.975), 9HPT (dominant [0.22, P = 0.533] or nondominant [0.09, P = 0.862] hand), or SDMT (-1.03, P = 0.194). Similarly, there were no significant differences between Q6W and Q4W groups in LSM change from baseline for any PRO (TSQM, -1.00, P = 0.410; Neuro-QoL fatigue, 0.52, P = 0.292; MSIS-29 Psychological, 0.67, P = 0.572; MSIS-29 Physical, 0.74, P = 0.429; EQ-5D-5 L, 0.00, P = 0.978). For the EQ-5D-5 L, a higher proportion of Q6W patients than Q4W patients demonstrated worsening (≥0.5 standard deviation increase in the EQ-5D-5 L index score; P = 0.0475). From baseline to week 72 for Q6W versus Q4W, odds ratio (ORs) of LSM change in CGI scores did not show meaningful differences between groups (CGI-Improvement [patient]: OR [95% CI] 1.2 [0.80-1.73]; CGI-Improvement [physician]: 0.8 [0.47-1.36]; CGI-Severity [physician]: 1.0 [0.71-1.54]). CONCLUSIONS No significant differences were observed in change from baseline to week 72 between natalizumab Q6W and Q4W groups for all exploratory clinical or PRO-related endpoints assessed. For the EQ-5D-5 L, a higher proportion of Q6W than Q4W patients demonstrated worsening.
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Affiliation(s)
- Lana Zhovtis Ryerson
- Hackensack Meridian Medical Group - Neurology, Jersey Shore University Medical Center, Neptune City, NJ, United States of America.
| | - John F Foley
- Rocky Mountain MS Clinic, Salt Lake City, UT, United States of America
| | - Gilles Defer
- Department of Neurology, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Jeffrey A Cohen
- Mellen MS Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Douglas L Arnold
- Montréal Neurological Institute, McGill University, Montréal, QC, Canada; NeuroRx Research, Montréal, QC, Canada
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Gary Cutter
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL, United States of America
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK; Queen Mary University of London, London, UK
| | - Joep Killestein
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Susie Sinks
- Biogen, Cambridge, MA, United States of America
| | | | | | - Tyler Lasky
- Biogen, Cambridge, MA, United States of America
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15
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Longoni G, Martinez Chavez E, Young K, Brown RA, Bells S, Fetco D, Kim L, Grover SA, Costello F, Reginald A, Bar-Or A, Marrie RA, Arnold DL, Narayanan S, Branson HM, Banwell BL, Sled JG, Mabbott DJ, Yeh EA. Magnetization transfer saturation reveals subclinical optic nerve injury in pediatric-onset multiple sclerosis. Mult Scler 2023; 29:212-220. [PMID: 36545918 PMCID: PMC9925884 DOI: 10.1177/13524585221137500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The presence of subclinical optic nerve (ON) injury in youth living with pediatric-onset MS has not been fully elucidated. Magnetization transfer saturation (MTsat) is an advanced magnetic resonance imaging (MRI) parameter sensitive to myelin density and microstructural integrity, which can be applied to the study of the ON. OBJECTIVE The objective of this study was to investigate the presence of subclinical ON abnormalities in pediatric-onset MS by means of magnetization transfer saturation and evaluate their association with other structural and functional parameters of visual pathway integrity. METHODS Eleven youth living with pediatric-onset MS (ylPOMS) and no previous history of optic neuritis and 18 controls underwent standardized brain MRI, optical coherence tomography (OCT), Magnetoencephalography (MEG)-Visual Evoked Potentials (VEPs), and visual battery. Data were analyzed with mixed effect models. RESULTS While ON volume, OCT parameters, occipital MEG-VEPs outcomes, and visual function did not differ significantly between ylPOMS and controls, ylPOMS had lower MTsat in the supratentorial normal appearing white matter (-0.26 nU, p = 0.0023), and in both in the ON (-0.62 nU, p < 0.001) and in the normal appearing white matter of the optic radiation (-0.56 nU, p = 0.00071), with these being positively correlated (+0.57 nU, p = 0.00037). CONCLUSIONS Subclinical microstructural injury affects the ON of ylPOMS. This may appear as MTsat changes before being detectable by other currently available testing.
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Affiliation(s)
- Giulia Longoni
- Division of Neurology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada/Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Edgar Martinez Chavez
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kimberly Young
- Division of Neurology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Sonya Bells
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Dumitru Fetco
- McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Laura Kim
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie A Grover
- Division of Neurology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Fiona Costello
- Departments of Clinical Neurosciences and Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Arun Reginald
- Department of Ophthalmology and Visual Sciences, The University of Toronto, Toronto, ON, Canada
| | - Amit Bar-Or
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada/Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Helen M Branson
- Department of Diagnostic Imaging, University of Toronto, Toronto, ON, Canada
| | - Brenda L Banwell
- Division of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John G Sled
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Donald J Mabbott
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada/Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
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16
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Caba B, Cafaro A, Lombard A, Arnold DL, Elliott C, Liu D, Jiang X, Gafson A, Fisher E, Belachew SM, Paragios N. Single-timepoint low-dimensional characterization and classification of acute versus chronic multiple sclerosis lesions using machine learning. Neuroimage 2023; 265:119787. [PMID: 36473647 DOI: 10.1016/j.neuroimage.2022.119787] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/16/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease characterized by the appearance of focal lesions across the central nervous system. The discrimination of acute from chronic MS lesions may yield novel biomarkers of inflammatory disease activity which may support patient management in the clinical setting and provide endpoints in clinical trials. On a single timepoint and in the absence of a prior reference scan, existing methods for acute lesion detection rely on the segmentation of hyperintense foci on post-gadolinium T1-weighted magnetic resonance imaging (MRI), which may underestimate recent acute lesion activity. In this paper, we aim to improve the sensitivity of acute MS lesion detection in the single-timepoint setting, by developing a novel machine learning approach for the automatic detection of acute MS lesions, using single-timepoint conventional non-contrast T1- and T2-weighted brain MRI. The MRI input data are supplemented via the use of a convolutional neural network generating "lesion-free" reconstructions from original "lesion-present" scans using image inpainting. A multi-objective statistical ranking module evaluates the relevance of textural radiomic features from the core and periphery of lesion sites, compared within "lesion-free" versus "lesion-present" image pairs. Then, an ensemble classifier is optimized through a recursive loop seeking consensus both in the feature space (via a greedy feature-pruning approach) and in the classifier space (via model selection repeated after each pruning operation). This leads to the identification of a compact textural signature characterizing lesion phenotype. On the patch-level task of acute versus chronic MS lesion classification, our method achieves a balanced accuracy in the range of 74.3-74.6% on fully external validation cohorts.
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Affiliation(s)
- Bastien Caba
- Biogen Digital Health, Biogen, Cambridge, MA, USA.
| | | | | | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada; NeuroRx Research, Montreal, QC, Canada
| | | | - Dawei Liu
- Biogen Digital Health, Biogen, Cambridge, MA, USA
| | | | - Arie Gafson
- Biogen Digital Health, Biogen, Cambridge, MA, USA
| | | | | | - Nikos Paragios
- CentraleSupélec, University of Paris-Saclay, Gif-sur-Yvette, France; TheraPanacea, Paris, France
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17
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Gold R, Piani-Meier D, Kappos L, Bar-Or A, Vermersch P, Giovannoni G, Fox RJ, Arnold DL, Benedict RHB, Penner IK, Rouyrre N, Kilaru A, Karlsson G, Ritter S, Dahlke F, Hach T, Cree BAC. Siponimod vs placebo in active secondary progressive multiple sclerosis: a post hoc analysis from the phase 3 EXPAND study. J Neurol 2022; 269:5093-5104. [PMID: 35639197 PMCID: PMC9363350 DOI: 10.1007/s00415-022-11166-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 04/29/2022] [Accepted: 05/01/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Siponimod is a sphingosine 1-phosphate receptor modulator approved for active secondary progressive multiple sclerosis (aSPMS) in most countries; however, phase 3 EXPAND study data are from an SPMS population with/without disease activity. A need exists to characterize efficacy/safety of siponimod in aSPMS. METHODS Post hoc analysis of participants with aSPMS (≥ 1 relapse in 2 years before study and/or ≥ 1 T1 gadolinium-enhancing [Gd +] magnetic resonance imaging [MRI] lesions at baseline) receiving oral siponimod (2 mg/day) or placebo for up to 3 years in EXPAND. ENDPOINTS 3-month/6-month confirmed disability progression (3mCDP/6mCDP); 3-month confirmed ≥ 20% worsening in Timed 25-Foot Walk (T25FW); 6-month confirmed improvement/worsening in Symbol Digit Modalities Test (SDMT) scores (≥ 4-point change); T2 lesion volume (T2LV) change from baseline; number of T1 Gd + lesions baseline-month 24; number of new/enlarging (N/E) T2 lesions over all visits. RESULTS Data from 779 participants with aSPMS were analysed. Siponimod reduced risk of 3mCDP/6mCDP vs placebo (by 31%/37%, respectively; p < 0.01); there was no significant effect on T25FW. Siponimod increased likelihood of 6-month confirmed SDMT improvement vs placebo (by 62%; p = 0.007) and reduced risk of 6-month confirmed SDMT worsening (by 27%; p = 0.060). Siponimod was associated with less increase in T2LV (1316.3 vs 13.3 mm3; p < 0.0001), and fewer T1 Gd + and N/E T2 lesions than placebo (85% and 80% reductions, respectively; p < 0.0001). CONCLUSIONS In aSPMS, siponimod reduced risk of disability progression and was associated with benefits on cognition and MRI outcomes vs placebo. TRIAL REGISTRATION ClinicalTrials.gov number: NCT01665144.
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Affiliation(s)
- Ralf Gold
- Department of Neurology, St. Josef Hospital and Ruhr University of Bochum, Bochum, Germany.
| | | | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB) and Multiple Sclerosis Center, Departments of Head, Spine and Neuromedicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick Vermersch
- University of Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas L Arnold
- NeuroRx Research, Montreal, QC, Canada and Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | | | - Iris-Katharina Penner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | | | | | | | | | - Bruce A C Cree
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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18
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Cree BAC, Arnold DL, Fox RJ, Gold R, Vermersch P, Benedict RHB, Bar-Or A, Piani-Meier D, Rouyrre N, Ritter S, Kilaru A, Karlsson G, Giovannoni G, Kappos L. Long-term efficacy and safety of siponimod in patients with secondary progressive multiple sclerosis: Analysis of EXPAND core and extension data up to >5 years. Mult Scler 2022; 28:1591-1605. [PMID: 35380078 PMCID: PMC9315196 DOI: 10.1177/13524585221083194] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Siponimod significantly reduced the risk of confirmed disability progression (CDP), worsening in cognitive processing speed (CPS), relapses, and magnetic resonance imaging (MRI) measures of brain atrophy and inflammation versus placebo in secondary progressive multiple sclerosis (SPMS) patients in the Phase 3 EXPAND study. OBJECTIVE The aim of this study was to assess long-term efficacy and safety of siponimod 2 mg/day from the EXPAND study including the extension part, up to > 5 years. METHODS In the open-label extension part, participants receiving placebo during the core part were switched to siponimod (placebo-siponimod group) and those on siponimod continued the same treatment (continuous siponimod group). RESULTS Continuous siponimod reduced the risk of 6-month CDP by 22% (hazard ratio (HR) (95% confidence interval (CI)): 0.78 (0.66-0.92) p = 0.0026) and 6-month confirmed worsening in CPS by 23% (HR (95% CI): 0.77 (0.65-0.92) p = 0.0047) versus the placebo-siponimod group. Sustained efficacy on annualized relapse rate, total and regional brain atrophy, and inflammatory disease activity was also observed. No new, unexpected safety signals for siponimod were identified over the long term. CONCLUSION The sustained efficacy and consistent long-term safety profile of siponimod up to > 5 years support its clinical utility for long-term treatment of SPMS. Benefits in the continuous siponimod versus placebo-siponimod group highlight the significance of earlier treatment initiation. TRIAL REGISTRATION NUMBER NCT01665144.
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Affiliation(s)
- Bruce AC Cree
- BAC Cree Department of Neurology, UCSF
Weill Institute for Neurosciences, University of California San Francisco, 675
Nelson Rising Lane, Box 3206, San Francisco, CA 94158, USA.
| | - Douglas L Arnold
- NeuroRx Research, and Montreal Neurological
Institute and Hospital, Department of Neurology and Neurosurgery, McGill
University, Montreal, QC, Canada
| | - Robert J Fox
- Mellen Center for Treatment and Research in
Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH,
USA
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital and
Ruhr-University Bochum, Bochum, Germany
| | - Patrick Vermersch
- Univ. Lille, INSERM U1172 LilNCog, CHU Lille,
FHU Precise, Lille, France
| | | | - Amit Bar-Or
- Center for Neuroinflammation and Experimental
Therapeutics and Department of Neurology, Perelman School of Medicine,
University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | - Gavin Giovannoni
- Blizard Institute, Barts and The London School
of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic, Departments
of Medicine, Clinical Research, Biomedicine and Biomedical Engineering,
University Hospital, University of Basel, Basel, Switzerland
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19
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Tagge IJ, Leppert IR, Fetco D, Campbell JS, Rudko DA, Brown RA, Stikov N, Pike GB, Giacomini PS, Arnold DL, Narayanan S. Permanent tissue damage in multiple sclerosis lesions is associated with reduced pre-lesion myelin and axon volume fractions. Mult Scler 2022; 28:2027-2037. [PMID: 35903888 PMCID: PMC9574230 DOI: 10.1177/13524585221110585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The use of advanced magnetic resonance imaging (MRI) techniques in MS research has led to new insights in lesion evolution and disease outcomes. It has not yet been determined if, or how, pre-lesional abnormalities in normal-appearing white matter (NAWM) relate to the long-term evolution of new lesions. OBJECTIVE To investigate the relationship between abnormalities in MRI measures of axonal and myelin volume fractions (AVF and MVF) in NAWM preceding development of black-hole (BH) and non-BH lesions in people with MS. METHODS We obtained magnetization transfer and diffusion MRI at 6-month intervals in patients with MS to estimate MVF and AVF during lesion evolution. Lesions were classified as either BH or non-BH on the final imaging visit using T1 maps. RESULTS Longitudinal data from 97 new T2 lesions from 9 participants were analyzed; 25 lesions in 8 participants were classified as BH 6-12 months after initial appearance. Pre-lesion MVF, AVF, and MVF/AVF were significantly lower, and T1 was significantly higher, in the lesions that later became BHs (p < 0.001) compared to those that did not. No significant pre-lesion abnormalities were found in non-BH lesions (p > 0.05). CONCLUSION The present work demonstrated that pre-lesion abnormalities are associated with worse long-term lesion-level outcome.
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Affiliation(s)
- Ian J Tagge
- McConnell Brain Imaging Center, Montreal Neurological Institute & Hospital, Montreal, QC, Canada
| | - Ilana R Leppert
- McConnell Brain Imaging Center, Montreal Neurological Institute & Hospital, Montreal, QC, Canada
| | - Dumitru Fetco
- McConnell Brain Imaging Center, Montreal Neurological Institute & Hospital, Montreal, QC, Canada
| | - Jennifer Sw Campbell
- McConnell Brain Imaging Center, Montreal Neurological Institute & Hospital, Montreal, QC, Canada
| | - David A Rudko
- McConnell Brain Imaging Center, Montreal Neurological Institute & Hospital, Montreal, QC, Canada
| | - Robert A Brown
- McConnell Brain Imaging Center, Montreal Neurological Institute & Hospital, Montreal, QC, Canada
| | - Nikola Stikov
- Electrical Engineering, Polytechnique Montreal, Montreal, QC, Canada
| | - G Bruce Pike
- Departments of Radiology and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Paul S Giacomini
- Neurology and Neurosurgery, Montreal Neurological Institute & Hospital, Montreal, QC, Canada
| | - Douglas L Arnold
- McConnell Brain Imaging Center, Montreal Neurological Institute & Hospital, Montreal, QC, Canada
| | - Sridar Narayanan
- McConnell Brain Imaging Center, Montreal Neurological Institute & Hospital, Montreal, QC, Canada
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20
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Mirza AI, Zhu F, Knox N, Forbes JD, Bonner C, Van Domselaar G, Bernstein CN, Graham M, Marrie RA, Hart J, Yeh EA, Arnold DL, Bar-Or A, O'Mahony J, Zhao Y, Hsiao W, Banwell B, Waubant E, Tremlett H. The metabolic potential of the paediatric-onset multiple sclerosis gut microbiome. Mult Scler Relat Disord 2022; 63:103829. [DOI: 10.1016/j.msard.2022.103829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/23/2022] [Accepted: 04/21/2022] [Indexed: 11/16/2022]
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21
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Foley JF, Defer G, Ryerson LZ, Cohen JA, Arnold DL, Butzkueven H, Cutter G, Giovannoni G, Killestein J, Wiendl H, Smirnakis K, Xiao S, Kong G, Kuhelj R, Campbell N, Dwyer C, Buzzard K, Spies J, Parratt J, van Pesch V, Willekens B, Perrotta G, Bartholomé E, Grand'Maison F, Jacques F, Giacomini P, Vosoughi R, Girard JM, de Seze J, Lebrun Frenay C, Ruet A, Laplaud DA, Reifschneider G, Wagner B, Rauer S, Pul R, Seipelt M, Berthele A, Klotz L, Kallmann BA, Paul F, Achiron A, Lus G, Centonze D, Patti F, Grimaldi L, Hupperts R, Frequin S, Fermont J, Madueno SE, Alonso Torres AM, Costa-Frossard França L, Meca-Lallana JE, Ruiz LB, Pearson O, Rog D, Evangelou N, Ismail A, Lathi E, Fox E, Leist T, Sloane J, Wu G, Khatri B, Steingo B, Thrower B, Gudesblatt M, Calkwood J, Bandari D, Scagnelli J, Laganke C, Robertson D, Kipp L, Belkin M, Cohan S, Goldstick L, Courtney A, Vargas W, Sylvester A, Srinivasan J, Kannan M, Picone M, English J, Napoli S, Balabanov R, Zaydan I, Nicholas J, Kaplan J, Lublin F, Riser E, Miller T, Alvarez E, Wray S, Gross J, Pawate S, Hersh C, McCarthy L, Crayton H, Graves J. Comparison of switching to 6-week dosing of natalizumab versus continuing with 4-week dosing in patients with relapsing-remitting multiple sclerosis (NOVA): a randomised, controlled, open-label, phase 3b trial. Lancet Neurol 2022; 21:608-619. [PMID: 35483387 DOI: 10.1016/s1474-4422(22)00143-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/28/2022] [Accepted: 03/31/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Treatment with natalizumab once every 4 weeks is approved for patients with relapsing-remitting multiple sclerosis, but is associated with a risk of progressive multifocal leukoencephalopathy. Switching to extended-interval dosing is associated with lower progressive multifocal leukoencephalopathy risk, but the efficacy of this approach is unclear. We aimed to assess the safety and efficacy of natalizumab once every 6 weeks compared with once every 4 weeks in patients with relapsing-remitting multiple sclerosis. METHODS We did a randomised, controlled, open-label, phase 3b trial (NOVA) at 89 multiple sclerosis centres across 11 countries in the Americas, Europe, and Western Pacific. Included participants were aged 18-60 years with relapsing-remitting multiple sclerosis and had been treated with intravenous natalizumab 300 mg once every 4 weeks with no relapses for at least 12 months before randomisation, with no missed doses in the previous 3 months. Participants were randomly assigned (1:1), using a randomisation sequence generated by the study funder and contract personnel with interactive response technology, to switch to natalizumab once every 6 weeks or continue with once every 4 weeks. The centralised MRI reader, independent neurology evaluation committee, site examining neurologists, site backup examining neurologists, and site examining technicians were masked to study group assignments. The primary endpoint was the number of new or newly enlarging T2 hyperintense lesions at week 72, assessed in all participants who received at least one dose of assigned treatment and had at least one postbaseline MRI, relapse, or neurological examination or efficacy assessment. Missing primary endpoint data were handled under prespecified primary and secondary estimands: the primary estimand included all data, regardless of whether participants remained on the assigned treatment; the secondary estimand classed all data obtained after treatment discontinuation or study withdrawal as missing. Safety was assessed in all participants who received at least one dose of study treatment. Study enrolment is closed and an open-label extension study is ongoing. This study is registered with EudraCT, 2018-002145-11, and ClinicalTrials.gov, NCT03689972. FINDINGS Between Dec 26, 2018, and Aug 30, 2019, 605 patients were assessed for eligibility and 499 were enrolled and assigned to receive natalizumab once every 6 weeks (n=251) or once every 4 weeks (n=248). After prespecified adjustments for missing data, mean numbers of new or newly enlarging T2 hyperintense lesions at week 72 were 0·20 (95% CI 0·07-0·63) in the once every 6 weeks group and 0·05 (0·01-0·22) in the once every 4 weeks group (mean lesion ratio 4·24 [95% CI 0·86-20·85]; p=0·076) under the primary estimand, and 0·31 (95% CI 0·12-0·82) and 0·06 (0·01-0·31; mean lesion ratio 4·93 [95% CI 1·05-23·20]; p=0·044) under the secondary estimand. Two participants in the once every 6 weeks group with extreme new or newly enlarging T2 hyperintense lesion numbers (≥25) contributed most of the excess lesions. Adverse events occurred in 194 (78%) of 250 participants in the once every 6 weeks group and 190 (77%) of 247 in the once every 4 weeks group, and serious adverse events occurred in 17 (7%) and 17 (7%), respectively. No deaths were reported. There was one case of asymptomatic progressive multifocal leukoencephalopathy (without clinical signs) in the once every 6 weeks group, and no cases in the once every 4 weeks group; 6 months after diagnosis, the participant was without increased disability and remained classified as asymptomatic. INTERPRETATION We found a numerical difference in the mean number of new or newly enlarging T2 hyperintense lesions at week 72 between the once every 6 weeks and once every 4 weeks groups, which reached significance under the secondary estimand, but interpretation of statistical differences (or absence thereof) is limited because disease activity in the once every 4 weeks group was lower than expected. The safety profiles of natalizumab once every 6 weeks and once every 4 weeks were similar. Although this trial was not powered to assess differences in risk of progressive multifocal leukoencephalopathy, the occurrence of the (asymptomatic) case underscores the importance of monitoring and risk factor consideration in all patients receiving natalizumab. FUNDING Biogen.
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Affiliation(s)
- John F Foley
- Rocky Mountain MS Clinic, Salt Lake City, UT, USA.
| | - Gilles Defer
- Department of Neurology, Centre Hospitalier Universitaire de Caen, Caen, France
| | | | - Jeffrey A Cohen
- Mellen MS Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada; NeuroRx Research, Montréal, QC, Canada
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Gary Cutter
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL, USA
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK; Queen Mary University of London, London, UK
| | - Joep Killestein
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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Cree BA, Selmaj KW, Steinman L, Comi G, Bar-Or A, Arnold DL, Hartung HP, Montalbán X, Havrdová EK, Sheffield JK, Minton N, Cheng CY, Silva D, Kappos L, Cohen JA. Long-term safety and efficacy of ozanimod in relapsing multiple sclerosis: Up to 5 years of follow-up in the DAYBREAK open-label extension trial. Mult Scler 2022; 28:1944-1962. [PMID: 35765217 PMCID: PMC9493410 DOI: 10.1177/13524585221102584] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Ozanimod, an oral sphingosine 1-phosphate receptor 1 and 5 modulator, is
approved in multiple countries for treatment of relapsing forms of MS. Objective: To characterize long-term safety and efficacy of ozanimod. Methods: Patients with relapsing MS who completed a phase 1‒3 ozanimod trial were
eligible for an open-label extension study (DAYBREAK) of ozanimod 0.92 mg/d.
DAYBREAK began 16 October 2015; cutoff for this interim analysis was 2
February 2021. Results: This analysis included 2494 participants with mean 46.8 (SD 11.9; range
0.033‒62.7) months of ozanimod exposure in DAYBREAK. During DAYBREAK, 2143
patients (85.9%) had treatment-emergent adverse events (TEAEs; similar in
nature to those in the parent trials), 298 (11.9%) had a serious TEAE, and
75 (3.0%) discontinued treatment due to TEAEs. Serious infections (2.8%),
herpes zoster infections (1.7%), confirmed macular edema cases (0.2%), and
cardiac TEAEs (2.8%) were infrequent. Adjusted annualized relapse rate was
0.103 (95% confidence interval, 0.086‒0.123). Over 48 months, 71% of
patients remained relapse free. Adjusted mean numbers of new/enlarging T2
lesions/scan and gadolinium-enhancing lesions were low and similar across
parent trial treatment subgroups. Conclusions: This long-term extension of ozanimod trials confirmed a favorable
safety/tolerability profile and sustained benefit on clinical and magnetic
resonance imaging measures of disease activity.
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Affiliation(s)
- Bruce Ac Cree
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Krzysztof W Selmaj
- Center for Neurology, Łódź, Poland and Collegium Medicum, Department of Neurology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Lawrence Steinman
- Department of Neurology and Neurological Sciences, Beckman Center for Molecular Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Giancarlo Comi
- Vita-Salute San Raffaele University and Casa di Cura del Policlinico, Milan, Italy
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Arnold
- NeuroRx Research and Montréal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany/Brain and Mind Centre, The University of Sydney, Sydney, Australia/Department of Neurology, Medical University of Vienna, Vienna, Austria/Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Xavier Montalbán
- Department of Neurology-Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Eva K Havrdová
- Department of Neurology and Center for Clinical Neuroscience, First Medical Faculty, Charles University, Prague, Czech Republic
| | | | | | | | | | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Head, Spine and Neuromedicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
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Beynon V, George IC, Elliott C, Arnold DL, Ke J, Chen H, Zhu L, Ke C, Giovannoni G, Scaramozza M, Campbell N, Bradley DP, Franchimont N, Gafson A, Belachew S. Chronic lesion activity and disability progression in secondary progressive multiple sclerosis. BMJ Neurol Open 2022; 4:e000240. [PMID: 35720980 PMCID: PMC9185385 DOI: 10.1136/bmjno-2021-000240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/15/2022] [Indexed: 11/04/2022] Open
Abstract
Objective Slowly expanding lesions (SELs), a subgroup of chronic white matter lesions that gradually expand over time, have been shown to predict disability accumulation in primary progressive multiple sclerosis (MS) disease. However, the relationships between SELs, acute lesion activity (ALA), overall chronic lesion activity (CLA) and disability progression are not well understood. In this study, we examined the ASCEND phase III clinical trial, which compared natalizumab with placebo in secondary progressive MS (SPMS). Methods Patients with complete imaging datasets between baseline and week 108 (N=600) were analysed for SEL prevalence (the number and volume of SELs), disability progression, ALA (assessed by gadolinium-enhancing lesions and new T2-hyperintense lesions) and CLA (assessed by T1-hypointense lesion volume increase within baseline T2-non-enhancing lesions identified as SELs and non-SELs). Results CLA in both SELs and non-SELs was greater in patients with SPMS with confirmed disability progression than in those with no progression. In the complete absence of ALA at baseline and on study, SEL prevalence was significantly lower, while CLA within non-SELs remained associated with disability progression. Natalizumab decreased SEL prevalence and CLA in SELs and non-SELs compared with placebo. Conclusions This study shows that CLA in patients with SPMS is decreased but persists in the absence of ALA and is associated with disability progression, highlighting the need for therapeutics targeting all mechanisms of CLA, including smouldering inflammation and neurodegeneration. Trial registration number NCT01416181.
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Affiliation(s)
- Vanessa Beynon
- Global Research & Development, Biogen, Cambridge, Massachusetts, USA
| | - Ilena C George
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Douglas L Arnold
- NeuroRx Research, Montreal, Quebec, Canada.,McConnell Brain Imaging Centre, McGill University, Montreal, Quebec, Canada
| | - Jun Ke
- Biostatistics, Biogen Inc, Cambridge, Massachusetts, USA
| | - Huaihou Chen
- Biostatistics, Biogen Inc, Cambridge, Massachusetts, USA
| | - Li Zhu
- Biostatistics, Biogen Inc, Cambridge, Massachusetts, USA
| | - Chunlei Ke
- Biostatistics, Biogen Inc, Cambridge, Massachusetts, USA
| | - Gavin Giovannoni
- Neuroscience and Trauma, Barts and The London School of Medicine and Dentistry Blizard Institute, London, UK
| | | | - Nolan Campbell
- Global Medical, Biogen Inc, Cambridge, Massachusetts, USA
| | | | | | - Arie Gafson
- Digital Health, Biogen Inc, Cambridge, Massachusetts, USA
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Arnold DL, Sprenger T, Bar-Or A, Wolinsky JS, Kappos L, Kolind S, Bonati U, Magon S, van Beek J, Koendgen H, Bortolami O, Bernasconi C, Gaetano L, Traboulsee A. Ocrelizumab reduces thalamic volume loss in patients with RMS and PPMS. Mult Scler 2022; 28:1927-1936. [PMID: 35672926 PMCID: PMC9493406 DOI: 10.1177/13524585221097561] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In multiple sclerosis (MS), thalamic integrity is affected directly by demyelination and neuronal loss, and indirectly by gray/white matter lesions outside the thalamus, altering thalamic neuronal projections. Objective: To assess the efficacy of ocrelizumab compared with interferon beta-1a (IFNβ1a)/placebo on thalamic volume loss and the effect of switching to ocrelizumab on volume change in the Phase III trials in relapsing MS (RMS, OPERA I/II; NCT01247324/NCT01412333) and in primary progressive MS (PPMS, ORATORIO; NCT01194570). Methods: Thalamic volume change was computed using paired Jacobian integration and analyzed using an adjusted mixed-effects repeated measurement model. Results: Over the double-blind period, ocrelizumab treatment significantly reduced thalamic volume loss with the largest effect size (Cohen’s d: RMS: 0.561 at week 96; PPMS: 0.427 at week 120) compared with whole brain, cortical gray matter, and white matter volume loss. At the end of up to 7 years of follow-up, patients initially randomized to ocrelizumab still showed less thalamic volume loss than those switching from IFNβ1a ( p < 0.001) or placebo ( p < 0.001). Conclusion: Ocrelizumab effectively reduced thalamic volume loss compared with IFNβ1a/placebo. Early treatment effects on thalamic tissue preservation persisted over time. Thalamic volume loss could be a potential sensitive marker of persisting tissue damage.
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Affiliation(s)
- Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada/NeuroRx Research, Montreal, QC, Canada
| | - Till Sprenger
- Department of Neurology, DKD Helios Klinik Wiesbaden, Wiesbaden, Germany/Research Center for Clinical Neuroimmunology and Neuroscience and MS Center, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Amit Bar-Or
- Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jerry S Wolinsky
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience and MS Center, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | | | | | - Johan van Beek
- F. Hoffmann-La Roche Ltd, Basel, Switzerland/Biogen, Baar, Switzerland
| | - Harold Koendgen
- F. Hoffmann-La Roche Ltd, Basel, Switzerland/UCB Farchim SA, Bulle, Switzerland
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Arnold DL, Bar-Or A, Cree BAC, Giovannoni G, Gold R, Vermersch P, Piani-Meier D, Arnould S, Kappos L. 115 Impact of siponimod on myelination across SPMS subgroups: post-hoc analysis from EXPAND MRI substudy. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundChanges in magnetization transfer ratio (MTR) are a marker of changes in myelin density and brain tissue integrity. Siponimod improved lesional MTR recovery in the overall EXPAND secondary progressive multiple sclerosis (SPMS) population.ObjectivesInvestigate the effect of siponimod on MTR changes in SPMS subgroups.MethodsThis prospective sub-study assessed the effect of siponimod versus placebo on median nor- malized MTR (nMTR) in normal appearing brain tissue (NABT), cortical Grey Matter (cGM) and normal appearing white matter (NAWM). Subgroups were defined by: disease history, severity and duration, EDSS score, Symbol Digit Modalities Test score, and inflammatory disease activity.ResultsThere was an attenuation in median nMTR decrease versus placebo across all subgroups (all p<0.05 except EDSS≥6 subgroup, p=0.064). In the active SPMS subgroup, siponimod attenuated median nMTR decrease across NABT, cGM and NAWM by 91–109% (p<0.01 all); and in the non-active SPMS subgroup by 170– 198% (p=0.0151 for NAWM, p>0.05 for NABT, cGM).ConclusionsOver 24 months, siponimod attenuated the decrease in median nMTR in brain tissues across patient subgroups characterized by disease activity and severity, with most pronounced effects in NAWM. This supports preclinical studies, showing beneficial CNS effects on myelination.teresa.sawtell@novartis.com
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26
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Arnold DL, Fox RJ, Bar-Or A, Cree BAC, Giovannoni G, Gold R, Vermersch PR, Meier DP, Arnould S, Kappos L. 045 Effect of siponimod on cortical grey matter and thalamic volume in secondary progressive multiple sclerosis. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundGrey matter (GM) loss is associated with cognitive decline and physical disability in multiple sclerosis (MS). In Phase 3 EXPAND study, siponimod significantly reduced disability progression, cognitive decline and whole brain volume loss in patients with secondary progressive MS (SPMS).MethodsMagnetic resonance imaging (MRI) from EXPAND were pooled and analysed using high reso- lution T1 and conventional MRI. Analysis included intent-to-treat population (full analysis set, FAS) and per protocol set (PPS). Change from baseline in cortical grey matter (cGM) and thalamic volumes were assessed.ResultsIn the FAS, adjusted mean percent change in volume from baseline at M12 and M24, respectively, was −0.07 versus −0.59 (88% reduction vs placebo, p<0.0001) and −0.51 versus −0.90 (43% reduction; p<0.0001) for cGM; −0.54 versus −1.01 (47% reduction; p< 0.0001) and −1.20 versus −1.74 (31% reduction; p=0.0001) for the thalamus. PPS values were 0.01 versus −0.60 (100% reduction; p< 0.0001) and −0.39 versus−1.04 (63% reduction; p< 0.0001) for cGM; −0.47 vs −0.94 (50% reduction; p< 0.0001) and −1.02 versus −1.77 (42% reduction; p< 0.0001) for the thalamus.ConclusionsSiponimod significantly reduced cGM and thalamic volume loss compared with placebo in patients with SPMS.g.giovannoni@qmul.ac.uk
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Bells S, Longoni G, Berenbaum T, de Medeiros CB, Narayanan S, Banwell BL, Arnold DL, Mabbott DJ, Ann Yeh E. Patterns of white and gray structural abnormality associated with paediatric demyelinating disorders. Neuroimage Clin 2022; 34:103001. [PMID: 35381508 PMCID: PMC8980471 DOI: 10.1016/j.nicl.2022.103001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/21/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022]
Abstract
A multi-modal approach was used to evaluate the visual pathway from anterior (retina) to posterior (visual cortex) in both paediatric MOGAD and MS patients. MS patients exhibited more widespread white matter abnormalities; MOGAD patients exhibited white matter changes primarily within the optic radiation. The pattern of cortical thinning differed in MS and MOGAD patients. Reduced RNFLT was associated with lower axonal density in MOGAD and tortuosity in MS.
The impact of multiple sclerosis (MS) and myelin oligodendrocyte glycoprotein (MOG) - associated disorders (MOGAD) on brain structure in youth remains poorly understood. Reductions in cortical mantle thickness on structural MRI and abnormal diffusion-based white matter metrics (e.g., diffusion tensor parameters) have been well documented in MS but not in MOGAD. Characterizing structural abnormalities found in children with these disorders can help clarify the differences and similarities in their impact on neuroanatomy. Importantly, while MS and MOGAD affect the entire CNS, the visual pathway is of particular interest in both groups, as most patients have evidence for clinical or subclinical involvement of the anterior visual pathway. Thus, the visual pathway is of key interest in analyses of structural abnormalities in these disorders and may distinguish MOGAD from MS patients. In this study we collected MRI data on 18 MS patients, 14 MOGAD patients and 26 age- and sex-matched typically developing children (TDC). Full-brain group differences in fixel diffusion measures (fibre-bundle populations) and cortical thickness measures were tested using age and sex as covariates. Visual pathway analysis was performed by extracting mean diffusion measures within lesion free optic radiations, cortical thickness within the visual cortex, and retinal nerve fibre layer (RNFL) and ganglion cell layer thickness measures from optical coherence tomography (OCT). Fixel based analysis (FBA) revealed MS patients have widespread abnormal white matter within the corticospinal tract, inferior longitudinal fasciculus, and optic radiations, while within MOGAD patients, non-lesional impact on white matter was found primarily in the right optic radiation. Cortical thickness measures were reduced predominately in the temporal and parietal lobes in MS patients and in frontal, cingulate and visual cortices in MOGAD patients. Additionally, our findings of associations between reduced RNFLT and axonal density in MOGAD and TORT in MS patients in the optic radiations imply widespread axonal and myelin damage in the visual pathway, respectively. Overall, our approach of combining FBA, cortical thickness and OCT measures has helped evaluate similarities and differences in brain structure in MS and MOGAD patients in comparison to TDC.
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Affiliation(s)
- Sonya Bells
- Neurosciences and Mental Health Program, Research Institute, Hospital for Sick Children, Toronto, Canada; Pediatric Neurology, Spectrum Health Helen Devos Children's Hospital, Grand Rapids, USA; Department of Pediatrics and Human Development, Michigan State University, East Lansing, USA
| | - Giulia Longoni
- Neurosciences and Mental Health Program, Research Institute, Hospital for Sick Children, Toronto, Canada; Department of Neurology, Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Tara Berenbaum
- Neurosciences and Mental Health Program, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Cynthia B de Medeiros
- Neurosciences and Mental Health Program, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Sridar Narayanan
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Brenda L Banwell
- Division of Child Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, USA
| | - Douglas L Arnold
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Donald J Mabbott
- Neurosciences and Mental Health Program, Research Institute, Hospital for Sick Children, Toronto, Canada; Department of Psychology, University of Toronto, Toronto, Canada
| | - E Ann Yeh
- Neurosciences and Mental Health Program, Research Institute, Hospital for Sick Children, Toronto, Canada; Department of Neurology, Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Toronto, Canada.
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Fadda G, Waters P, Woodhall M, Brown RA, O'Mahony J, Castro DA, Longoni G, Yeh EA, Marrie RA, Arnold DL, Banwell B, Bar-Or A. Serum MOG-IgG in children meeting multiple sclerosis diagnostic criteria. Mult Scler 2022; 28:1697-1709. [PMID: 35581944 PMCID: PMC9442635 DOI: 10.1177/13524585221093789] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is now recognized as distinct from multiple sclerosis (MS). Objective: To evaluate the importance of considering myelin oligodendrocyte glycoprotein (MOG)-immunoglobulin-G (IgG) serology when applying MS diagnostic criteria in children. Methods: Within a prospective cohort of children meeting MS criteria (median follow-up = 6 years, interquartile range (IQR) = 4–9), we measured MOG-IgG in serial archived serum obtained from presentation, and compared imaging and clinical features between seropositive and seronegative participants. Results: Of 65 children meeting MS criteria (median age = 14.0 years, IQR = 10.9–15.1), 12 (18%) had MOG-IgG at disease onset. Seropositive participants were younger, had brain magnetic resonance imaging (MRI) features atypical for MS, rarely had cerebrospinal fluid (CSF) oligoclonal bands (2/8, 25%), and accumulated fewer T2 lesions over time. On serial samples, 5/12 (42%) were persistently seropositive, 5/12 (42%) became seronegative, and 2/12 (17%) had fluctuating results. All 12 children experienced a disease course different from typical MS. Conclusion: While children with MOG-IgG can have clinical, CSF, and MRI features conforming to MS criteria, the presence of MOG-IgG is associated with atypical features and predicts a non-MS disease course. Given MOG-IgG seropositivity can wane over time, testing at first attack is of considerable importance for the diagnosis of MOGAD.
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Affiliation(s)
- Giulia Fadda
- Center for Neuroinflammation and Neurotherapeutics, and Multiple Sclerosis Division, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA/Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Patrick Waters
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Mark Woodhall
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Julia O'Mahony
- Institute of Health Policy, Management and Evaluation, University of Toronto and The Hospital for Sick Children, Toronto, ON, Canada
| | - Denise A Castro
- Department of Diagnostic Imaging, Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada/Department of Diagnostic Radiology, Queen's University, Kingston, ON, Canada
| | - Giulia Longoni
- Department of Pediatrics (Neurology), The Hospital for Sick Children, Division of Neuroscience and Mental Health, SickKids Research Institute, University of Toronto, Toronto, ON, Canada
| | - E Ann Yeh
- Department of Pediatrics (Neurology), The Hospital for Sick Children, Division of Neuroscience and Mental Health, SickKids Research Institute, University of Toronto, Toronto, ON, Canada
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Brenda Banwell
- Division of Child Neurology, Department of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Bar-Or
- Center for Neuroinflammation and Neurotherapeutics, and Multiple Sclerosis Division, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Espinoza DA, Mexhitaj I, Smiler J, Mafra F, Da Silva RP, Fadda G, Yeh EA, Marrie RA, Arnold DL, Li R, Banwell B, Bar-Or A. Proteogenomic immune signatures delineate the landscape of pediatric acquired demyelinating syndromes. The Journal of Immunology 2022. [DOI: 10.4049/jimmunol.208.supp.108.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Abstract
Approximately 20–30% of children presenting with acquired inflammatory demyelinating syndromes (ADS) have multiple sclerosis (MS). Another 30% harbor serum antibodies against myelin oligodendrocyte glycoprotein and are referred to as having MOG-associated disease (MOGAD). While MS and MOGAD can have similar features, differences in response to immune therapies point to distinct underlying immune mechanisms.
To assess potentially distinct immune mechanisms underlying MS and MOGAD, we applied proteogenomics to high quality cryopreserved peripheral blood mononuclear cells collected from patients with ADS prior to institution of immune therapy, as well as from healthy controls. CITE-Seq profiling was applied to a total of 92,716 single cells with equal contribution from 24 children (6 healthy donors; 6 with ADS but neither MS or MOGAD; 6 with MOGAD; and 6 with MS, ascertained with long-term follow-up).
Analysis revealed a pan-ADS enrichment of atypical (CD11c+) B cells compared to healthy controls. Children with MS were distinguished from children with MOGAD by MS-specific enrichments of checkpoint-molecule (TIGIT and CD137)-expressing CD8 memory T cells, STAT4+ Th1 CD4 memory T cells and CD56dim/CD16+ NK cells.
Overall, our study identifies distinct features of circulating cellular immune profiles that may serve to distinguish children with MS and MOGAD, and provides novel insights into early immune mechanisms that may be involved in each of these conditions.
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Affiliation(s)
- Diego A Espinoza
- 1Immunology Graduate Group, Perelman School of Medicine, University of Pennsylvania
| | - Ina Mexhitaj
- 2Perelman School of Medicine, University of Pennsylvania
| | | | - Fernanda Mafra
- 3Center for Applied Genomics, Children's Hospital of Philadelphia
| | | | - Giulia Fadda
- 2Perelman School of Medicine, University of Pennsylvania
| | - E Ann Yeh
- 5Hospital for Sick Children, University of Toronto, Canada
| | - Ruth Ann Marrie
- 6Max Rady College of Medicine, University of Manitoba, Canada
| | | | - Rui Li
- 2Perelman School of Medicine, University of Pennsylvania
| | | | - Amit Bar-Or
- 2Perelman School of Medicine, University of Pennsylvania
- 4Children's Hospital of Philadelphia
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30
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Ziemssen T, Arnold DL, Alvarez E, Cross AH, Willi R, Li B, Kukkaro P, Kropshofer H, Ramanathan K, Merschhemke M, Kieseier B, Su W, Häring DA, Hauser SL, Kappos L, Kuhle J. Prognostic Value of Serum Neurofilament Light Chain for Disease Activity and Worsening in Patients With Relapsing Multiple Sclerosis: Results From the Phase 3 ASCLEPIOS I and II Trials. Front Immunol 2022; 13:852563. [PMID: 35432382 PMCID: PMC9009385 DOI: 10.3389/fimmu.2022.852563] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/07/2022] [Indexed: 11/27/2022] Open
Abstract
Objective This study aims to confirm the prognostic value of baseline serum neurofilament light chain (sNfL) for on-study disease activity and worsening in patients with relapsing MS (RMS). Background Previous post-hoc studies suggested that sNfL could be a prognostic biomarker in RMS. In the phase 3 ASCLEPIOS I/II trials in which ofatumumab demonstrated better efficacy outcomes than teriflunomide, treatment with ofatumumab also led to significantly reduced sNfL levels compared to teriflunomide treatment. Design/Methods In this study, we report protocol-planned analyses from the pooled ASCLEPIOS I/II trials (N=1882). Per protocol, patients were stratified by median baseline sNfL levels (9.3 pg/ml) into high (>median) and low (≤median) categories to prognosticate: annualized rate of new/enlarging T2 (neT2) lesions in year 1 and 2, annualized relapse rate, annual percentage change in whole brain (WB) and regional brain volume [thalamus, white matter (WM), cortical gray matter (cGM)], and disability outcomes. Similar analyses were performed for the recently diagnosed (within 3 years), treatment-naive patients (no prior disease-modifying therapy) subgroup. Results High versus low sNfL at baseline was prognostic of increased on-study T2 lesion formation at year 1 (relative increase: ofatumumab +158%; teriflunomide +69%, both p<0.001), which persisted in year 2 (+65%, p=0.124; +46%, p=0.003); of higher annual percentage change of WB volume (ofatumumab, −0.32% vs. −0.24%, p=0.044, and teriflunomide, −0.43% vs. −0.29%, p=0.002), thalamic volume (−0.56% vs. −0.31%, p=0.047 and −0.94% vs. −0.49%, p<0.001), and WM volume (−0.30% vs. −0.19%, p=0.083 and −0.38% vs. −0.18%, p=0.003) but not of cGM volume (−0.39% vs. −0.32%, p=0.337 and −0.49% vs. −0.46%, p=0.563). A single sNfL assessment at baseline was not prognostic for on-study relapses or disability worsening. Results were similar in the subgroup of recently diagnosed, treatment-naive patients. Conclusion This study confirms that baseline sNfL levels are prognostic of future on-study lesion formation and whole brain and regional atrophy in all RMS patients, including recently diagnosed, treatment-naive patients.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Clinic Carl-Gustav Carus, Dresden, Germany
- *Correspondence: Tjalf Ziemssen,
| | - Douglas L. Arnold
- Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
- NeuroRx Research, Montreal, QC, Canada
| | - Enrique Alvarez
- Department of Neurology, Rocky Mountain MS Center at the University of Colorado, Aurora, CO, United States
| | - Anne H. Cross
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, United States
| | | | - Bingbing Li
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | | | | | | | | | | | - Wendy Su
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | | | - Stephen L. Hauser
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic and MS Center, Department of Head, Spine and Neuromedicine, University Hospital Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Jens Kuhle
- Neurologic Clinic and Policlinic and MS Center, Department of Head, Spine and Neuromedicine, University Hospital Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
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31
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Longoni G, Brown RA, Oyefiade A, Iruthayanathan R, Wilbur C, Shams S, Noguera A, Grover SA, O'Mahony J, Chung L, Wan MJ, Mah JK, Costello F, Arnold DL, Marrie RA, Bar-Or A, Banwell B, Mabbott D, Reginald AY, Yeh EA. Progressive retinal changes in pediatric multiple sclerosis. Mult Scler Relat Disord 2022; 61:103761. [PMID: 35349885 DOI: 10.1016/j.msard.2022.103761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 11/19/2022]
Abstract
Objectives To determine to what extent acute demyelinating episodes versus chronic degenerative phenomena drive retinal neuroaxonal damage in pediatric acquired demyelinating syndromes (ADS). Methods We acquired optical coherence tomography (OCT) data (follow-up range: 2 weeks - 5 years, at variable intervals from presentation) in pediatric participants who had multiple sclerosis (MS), monophasic ADS, or were healthy. Multivariable mixed effects models were used to assess the association of the number of demyelinating episodes (either optic neuritis [ON], or non-ON relapses) with changes in retinal nerve fiber layer (RNFL) or ganglion cell layer-inner plexiform layer (GCIPL) thickness. Results 64 OCT sans from 23 MS, and 33 scans from 12 monophasic ADS participants were compared with 68 scans from 62 healthy participants. The first ON episode had the biggest impact on RNFL or GCIPL thickness in monophasic ADS (RNFL: -7.9 µm, CI=5.5, p = 0.0056; GCIPL: -8.4 µm, CI=4.4, p = 0.0002) and MS (RNFL: -16 µm, CI = 3.7, p < 10-6; GCIPL: -15 µm, CI = 2.6, p < 10-6). Non-ON relapses were also associated with small but significant retinal thickness reductions in MS (RNFL: -2.6 µm/relapse, CI = 1.4, p = 0.0003; GCIPL: -2.8 µm/relapse, CI = 0.89, p < 10-6). MS participants showed progressive GCIPL thinning independent of acute demyelinating episodes (-2.7 µm/year, CI = 1.9, p = 0.0058). Conclusions We showed a prominent impact of early ON episodes on OCT measures of neuroaxonal structure in patients with ADS. We also demonstrated negative effects of non-ON relapses, and the presence of chronic retinal neurodegenerative changes, in youth with MS.
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Affiliation(s)
- Giulia Longoni
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert A Brown
- McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Ade Oyefiade
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Renisha Iruthayanathan
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Colin Wilbur
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Shahriar Shams
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Austin Noguera
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie A Grover
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Julia O'Mahony
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Luke Chung
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael J Wan
- Department of Ophthalmology and Visual Sciences, The University of Toronto, Toronto, ON, Canada
| | - Jean K Mah
- Departments of Clinical Neurosciences and Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Fiona Costello
- Departments of Clinical Neurosciences and Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada; Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada
| | - Amit Bar-Or
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brenda Banwell
- Division of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Donald Mabbott
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Arun Y Reginald
- Department of Ophthalmology and Visual Sciences, The University of Toronto, Toronto, ON, Canada
| | - E Ann Yeh
- Department of Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, Division of Neurology, University of Toronto, Toronto, ON, Canada.
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Nakamura K, Mokliatchouk O, Arnold DL, Yousry TA, Kappos L, Richert N, Ayling-Rouse K, Miller C, Fisher E. Effects of Dimethyl Fumarate on Brain Atrophy in Relapsing-Remitting Multiple Sclerosis: Pooled Analysis Phase 3 DEFINE and CONFIRM Studies. Front Neurol 2022; 13:809273. [PMID: 35370887 PMCID: PMC8973916 DOI: 10.3389/fneur.2022.809273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Objective In the pivotal DEFINE and CONFIRM trials for dimethyl fumarate (DMF), patterns of brain volume changes were different, potentially due to low sample sizes and because MRIs were analyzed at two different reading centers. We evaluated effects of DMF on brain volume change in patients with multiple sclerosis (MS) through reanalysis of pooled images from DEFINE/CONFIRM trials in one reading center. Methods MRIs from DEFINE/CONFIRM at weeks 0, 24, 48, and 96 from patients randomized to twice-daily DMF or placebo (PBO) were reanalyzed at the Cleveland Clinic to measure brain parenchymal fraction (BPF). To account for pseudoatrophy, brain volume estimates were re-baselined to calculate changes for weeks 48–96. Results Across studies, 301 and 314 patients receiving DMF and PBO, respectively, had analyzable MRIs. In weeks 0–48, mean ± SE percentage change in BPF was −0.44 ± 0.04 vs. −0.34 ± 0.04% in DMF vs. PBO, respectively, whereas in weeks 48–96, mean ± SE percentage change in BPF was −0.27 ± 0.03 vs. −0.41 ± 0.04% in DMF vs. PBO, respectively. The mixed-effect model for repeated measures showed similar results: in weeks 48–96, estimated change (95% confidence interval) in BPF was −0.0021 (−0.0027, −0.0016) for DMF vs. −0.0033 (−0.0039, −0.0028) for PBO (35.9% reduction; p = 0.0025). Conclusions The lower rate of whole brain volume loss with DMF in this pooled BPF analysis in the second year vs. PBO is consistent with its effects on relapses, disability, and MRI lesions. Brain volume changes in the first year may be explained by pseudoatrophy effects also described in other MS clinical trials.
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Affiliation(s)
- Kunio Nakamura
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | - Douglas L. Arnold
- McConnell Brain Imaging Center, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Tarek A. Yousry
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Institute of Neurology, London, United Kingdom
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | | | | | | | - Elizabeth Fisher
- Biogen, Cambridge, MA, United States
- *Correspondence: Elizabeth Fisher
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Arnold DL, Piani-Meier D, Bar-Or A, Benedict RH, Cree BA, Giovannoni G, Gold R, Vermersch P, Arnould S, Dahlke F, Hach T, Ritter S, Karlsson G, Kappos L, Fox RJ. Effect of siponimod on magnetic resonance imaging measures of neurodegeneration and myelination in secondary progressive multiple sclerosis: Gray matter atrophy and magnetization transfer ratio analyses from the EXPAND phase 3 trial. Mult Scler 2022; 28:1526-1540. [PMID: 35261318 PMCID: PMC9315182 DOI: 10.1177/13524585221076717] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) measurements of gray matter (GM) atrophy and magnetization transfer ratio (MTR; correlate of myelination) may provide better insights than conventional MRI regarding brain tissue integrity/myelination in multiple sclerosis (MS). OBJECTIVE To examine the effect of siponimod in the EXPAND trial on whole-brain and GM atrophy, newly formed normalized magnetization transfer ratio (nMTR) lesions, and nMTR-assessed integrity of normal-appearing brain tissue (NABT), cortical GM (cGM), and normal-appearing white matter (NAWM). METHODS Patients with secondary progressive multiple sclerosis (SPMS) received siponimod (2 mg/day; n =1037) or placebo (n = 523). Endpoints included percentage change from baseline to months 12/24 in whole-brain, cGM, and thalamic volumes; change in nMTR from baseline to months 12/24 in NABT, cGM, and NAWM; MTR recovery in newly formed lesions. RESULTS Compared with placebo, siponimod significantly reduced progression of whole-brain and GM atrophy over 12/24 months, and was associated with improvements in brain tissue integrity/myelination within newly formed nMTR lesions and across NABT, cGM, and NAWM over 24 months. Effects were consistent across age, disease duration, inflammatory activity subgroups, and disease severity. CONCLUSION Siponimod reduced brain tissue damage in patients with SPMS as evidenced by objective measures of brain tissue integrity/myelination. This is consistent with central nervous system (CNS) effects observed in preclinical models. ClinicalTrials.gov number: NCT01665144.
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Affiliation(s)
- Douglas L Arnold
- NeuroRx, Montreal, QC, Canada/Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | | | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Bruce Ac Cree
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ralf Gold
- Department of Neurology, St Josef-Hospital/Ruhr-University Bochum, Bochum, Germany
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Sophie Arnould
- Novartis Pharma AG, Basel, Switzerland; *at the time of writing
| | - Frank Dahlke
- Novartis Pharma AG, Basel, Switzerland; *at the time of writing
| | - Thomas Hach
- Novartis Pharma AG, Basel, Switzerland; *at the time of writing
| | - Shannon Ritter
- Novartis Pharma AG, Basel, Switzerland; *at the time of writing
| | - Göril Karlsson
- Novartis Pharma AG, Basel, Switzerland; *at the time of writing
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB) and MS Center, Departments of Head, Spine and Neuromedicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Mirza AI, Zhu F, Knox N, Forbes JD, Van Domselaar G, Bernstein CN, Graham M, Marrie RA, Hart J, Yeh EA, Arnold DL, Bar-Or A, O'Mahony J, Zhao Y, Hsiao W, Banwell B, Waubant E, Tremlett H. Metagenomic Analysis of the Pediatric-Onset Multiple Sclerosis Gut Microbiome. Neurology 2022; 98:e1050-e1063. [PMID: 34937787 PMCID: PMC8967388 DOI: 10.1212/wnl.0000000000013245] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 12/13/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little is known of the functional potential of the gut microbiome in pediatric-onset multiple sclerosis (MS). We performed metagenomic analyses using stool samples from individuals with pediatric-onset MS and unaffected controls. METHODS Persons ≤21 years old enrolled in the Canadian Pediatric Demyelinating Disease Network providing a stool sample were eligible. Twenty patients with MS (McDonald criteria) with symptom onset <18 years were matched to 20 controls by sex, age (±3 years), stool consistency, and race. Microbial taxonomy and functional potentials were estimated from stool sample-derived metagenomic reads and compared by disease status (MS vs controls) and disease-modifying drug (DMD) exposure using alpha diversity, relative abundance, and prevalence using Wilcoxon rank sum, ALDEx2, and Fisher exact tests, respectively. RESULTS Individuals with MS were aged 13.6 years (mean) at symptom onset and 8 were DMD-naive. Mean ages at stool sample were 16.1 and 15.4 years for MS and control participants, respectively; 80% were girls. Alpha diversity of enzymes and proteins did not differ by disease or DMD status (p > 0.20), but metabolic pathways, gene annotations, and microbial taxonomy did. Individuals with MS (vs controls) exhibited higher methanogenesis prevalence (odds ratio 10, p = 0.044) and Methanobrevibacter abundance (log2 fold change [LFC] 1.7, p = 0.0014), but lower homolactic fermentation abundance (LFC -0.48, p = 0.039). Differences by DMD status included lower phosphate butyryl transferase for DMD-naive vs exposed patients with MS (LFC -1.0, p = 0.033). DISCUSSION The gut microbiome's functional potential and taxonomy differed between individuals with pediatric-onset MS vs controls, including higher prevalence of a methane-producing pathway from Archaea and depletion of the lactate fermentation pathway. DMD exposure was associated with butyrate-producing enzyme enrichment. Together these findings indicate that the gut microbiome of individuals with MS may have a disturbed functional potential.
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Affiliation(s)
- Ali I Mirza
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Feng Zhu
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Natalie Knox
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Jessica D Forbes
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Gary Van Domselaar
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Charles N Bernstein
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Morag Graham
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Ruth Ann Marrie
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Janace Hart
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - E Ann Yeh
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Douglas L Arnold
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Amit Bar-Or
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Julia O'Mahony
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Yinshan Zhao
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - William Hsiao
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Brenda Banwell
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Emmanuelle Waubant
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA
| | - Helen Tremlett
- From the Department of Medicine (Neurology) (A.I.M., F.Z., Y.Z., H.T.), The University of British Columbia, Vancouver; National Microbiology Laboratory (N.K., G.V.D., M.G.), Public Health Agency of Canada; Department of Medical Microbiology and Infectious Diseases (N.K., G.V.D., M.G.), Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences (C.N.B., R.A.M.), and Inflammatory Bowel Disease Clinical and Research Centre (C.N.B.), University of Manitoba, Winnipeg; Roy Romanow Provincial Laboratory (J.D.F.), Regina; Department of Pathology and Laboratory Medicine (J.D.F.), College of Medicine, University of Saskatchewan, Saskatoon, Canada; Department of Neurology (J.H., E.W.), University of California San Francisco; Department of Pediatrics (Neurology) (E.A.Y., J.O.), The Hospital for Sick Children, Toronto; Department of Neurology and Neurosurgery (D.L.A.), Montreal Neurological Institute, McGill University, Montreal, Canada; Centre for Neuroinflammation and Experimental Therapeutics and Department of Neurology (A.B.-O.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Faculty of Health Sciences (W.H.), Simon Fraser University, Burnaby, Canada; and The Children's Hospital of Philadelphia (B.B.), PA.
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Foley J, Defer G, Ryerson LZ, Cohen JA, Arnold DL, Butzkueven H, Cutter G, Giovannoni G, Killestein J, Wiendl H, Smirnakis K, Xiao S, Kong G, Kuhelj R, Campbell N. Primary Results of NOVA: A Randomized Controlled Study of the Efficacy of 6 Week Dosing of Natalizumab Versus Continued 4-Week Treatment for Multiple Sclerosis. Mult Scler Relat Disord 2022. [DOI: 10.1016/j.msard.2022.103626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Newsome SD, Scott TF, Arnold DL, Altincatal A, Naylor ML. Early treatment responses to peginterferon beta-1a are associated with longer-term clinical outcomes in patients with relapsing-remitting multiple sclerosis: Subgroup analyses of ADVANCE and ATTAIN. Mult Scler Relat Disord 2022; 57:103367. [PMID: 35158473 DOI: 10.1016/j.msard.2021.103367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/28/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early intervention with well-tolerated disease-modifying therapies (DMTs) for relapsing-remitting multiple sclerosis (RRMS) is recommended in order to delay disease progression, reduce neurologic damage, preserve brain volume, and optimize long-term patient outcomes. Lack of conversion of new/newly enlarging T2 (NET2) or gadolinium-enhancing (Gd+) lesions to chronic hypointensities (black hole conversion) and achievement of no evidence of disease activity (NEDA) early in the course of treatment are considered potential indicators of treatment effect and predictors of longer-term clinical outcomes. METHODS Patients with RRMS who were treated with peginterferon beta-1a in the 2-year ADVANCE phase 3 clinical trial (NCT0090639) and its 2-year open-label extension study, ATTAIN (NCT01332019), were grouped as newly diagnosed (diagnosed ≤1 year prior to enrollment and DMT naive) or non-newly diagnosed. For analyses of the impact of early treatment and disease activity control, the newly diagnosed and non-newly diagnosed subgroups were further divided based on whether they initiated peginterferon beta-1a every 2 weeks (Q2W) starting in study year 1 (continuously treated) or peginterferon beta-1a Q2W or every 4 weeks in study year 2 (delayed treatment). Patient subgroups were evaluated for conversion of NET2 or Gd+ lesions to persistent black holes (PBHs), brain atrophy (percentage change in whole brain volume [WBV]), achievement of NEDA composite outcomes, and the association of these disease activity measures with longer-term clinical outcomes (annualized relapse rate [ARR] and confirmed disability worsening [CDW]). RESULTS At 2 years, significantly fewer PBHs developed from NET2 lesions or Gd+ lesions in newly diagnosed and non-newly diagnosed patients continuously treated with peginterferon beta-1a than in the corresponding delayed-treatment groups (all p<0.0001). Percentage decrease in WBV from 6 months (rebaselined) to 2 years was significantly lower for newly diagnosed and non-newly diagnosed patients who received continuous peginterferon beta-1a treatment than for patients who received delayed treatment (both p ≤ 0.0442). In study year 1, a higher proportion of newly diagnosed and non-newly diagnosed patients treated with peginterferon beta-1a than those treated with placebo achieved NEDA (newly diagnosed: 28.3% vs 13.5% [p = 0.0010]; non-newly diagnosed: 40.8% vs 15.8% [p<0.0001]). NEDA rates remained stable over study years 2-4 for the newly diagnosed (range: 50.0%-53.9%) and non-newly diagnosed (range: 54.4%-57.0%) subgroups. Patients without PBH conversion had significantly lower ARR at 2 years (newly diagnosed: p = 0.0109; non-newly diagnosed: p = 0.0044) and a lower proportion of patients with 12-week CDW at 2 years (newly diagnosed: p = 0.2787; non-newly diagnosed: p = 0.0045) than the corresponding patient subgroups with PBH conversion. Patients who achieved NEDA in ADVANCE (study years 1-2) had a significantly lower ARR in ATTAIN (study years 3-4) than patients who did not achieve NEDA (newly diagnosed, p = 0.0003; non-newly diagnosed, p = 0.0001). Over 4 years, safety outcomes did not differ for the newly diagnosed and non-newly diagnosed patient subgroups. CONCLUSIONS These results indicate that newly diagnosed and non-newly diagnosed patients treated continuously with peginterferon beta-1a Q2W experienced better disease control over time than those who received delayed treatment. Patients with NEDA or evidence of less radiological disease activity in the first 2 years of treatment had better longer-term clinical outcomes than those with evidence of greater disease activity.
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Affiliation(s)
- Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Thomas F Scott
- Department of Neurology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, and NeuroRx Research, Montreal, QC, Canada
| | | | - Maria L Naylor
- Biogen, Cambridge, MA, USA, at the time of these analyses
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Mehta R, Christinck T, Nair T, Bussy A, Premasiri S, Costantino M, Chakravarthy MM, Arnold DL, Gal Y, Arbel T. Propagating Uncertainty Across Cascaded Medical Imaging Tasks for Improved Deep Learning Inference. IEEE Trans Med Imaging 2022; 41:360-373. [PMID: 34543193 DOI: 10.1109/tmi.2021.3114097] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Although deep networks have been shown to perform very well on a variety of medical imaging tasks, inference in the presence of pathology presents several challenges to common models. These challenges impede the integration of deep learning models into real clinical workflows, where the customary process of cascading deterministic outputs from a sequence of image-based inference steps (e.g. registration, segmentation) generally leads to an accumulation of errors that impacts the accuracy of downstream inference tasks. In this paper, we propose that by embedding uncertainty estimates across cascaded inference tasks, performance on the downstream inference tasks should be improved. We demonstrate the effectiveness of the proposed approach in three different clinical contexts: (i) We demonstrate that by propagating T2 weighted lesion segmentation results and their associated uncertainties, subsequent T2 lesion detection performance is improved when evaluated on a proprietary large-scale, multi-site, clinical trial dataset acquired from patients with Multiple Sclerosis. (ii) We show an improvement in brain tumour segmentation performance when the uncertainty map associated with a synthesised missing MR volume is provided as an additional input to a follow-up brain tumour segmentation network, when evaluated on the publicly available BraTS-2018 dataset. (iii) We show that by propagating uncertainties from a voxel-level hippocampus segmentation task, the subsequent regression of the Alzheimer's disease clinical score is improved.
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Lublin FD, Häring DA, Ganjgahi H, Ocampo A, Hatami F, Čuklina J, Aarden P, Dahlke F, Arnold DL, Wiendl H, Chitnis T, Nichols TE, Kieseier BC, Bermel RA. OUP accepted manuscript. Brain 2022; 145:3147-3161. [PMID: 35104840 PMCID: PMC9536294 DOI: 10.1093/brain/awac016] [Citation(s) in RCA: 103] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/01/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with multiple sclerosis acquire disability either through relapse-associated worsening (RAW) or progression independent of relapse activity (PIRA). This study addresses the relative contribution of relapses to disability worsening over the course of the disease, how early progression begins and the extent to which multiple sclerosis therapies delay disability accumulation. Using the Novartis-Oxford multiple sclerosis (NO.MS) data pool spanning all multiple sclerosis phenotypes and paediatric multiple sclerosis, we evaluated ∼200 000 Expanded Disability Status Scale (EDSS) transitions from >27 000 patients with ≤15 years follow-up. We analysed three datasets: (i) A full analysis dataset containing all observational and randomized controlled clinical trials in which disability and relapses were assessed (n = 27 328); (ii) all phase 3 clinical trials (n = 8346); and (iii) all placebo-controlled phase 3 clinical trials (n = 4970). We determined the relative importance of RAW and PIRA, investigated the role of relapses on all-cause disability worsening using Andersen-Gill models and observed the impact of the mechanism of worsening and disease-modifying therapies on the time to reach milestone disability levels using time continuous Markov models. PIRA started early in the disease process, occurred in all phenotypes and became the principal driver of disability accumulation in the progressive phase of the disease. Relapses significantly increased the hazard of all-cause disability worsening events; following a year in which relapses occurred (versus a year without relapses), the hazard increased by 31–48% (all P < 0.001). Pre-existing disability and older age were the principal risk factors for incomplete relapse recovery. For placebo-treated patients with minimal disability (EDSS 1), it took 8.95 years until increased limitation in walking ability (EDSS 4) and 18.48 years to require walking assistance (EDSS 6). Treating patients with disease-modifying therapies delayed these times significantly by 3.51 years (95% confidence limit: 3.19, 3.96) and 3.09 years (2.60, 3.72), respectively. In patients with relapsing-remitting multiple sclerosis, those who worsened exclusively due to RAW events took a similar length of time to reach milestone EDSS values compared with those with PIRA events; the fastest transitions were observed in patients with PIRA and superimposed relapses. Our data confirm that relapses contribute to the accumulation of disability, primarily early in multiple sclerosis. PIRA begins in relapsing-remitting multiple sclerosis and becomes the dominant driver of disability accumulation as the disease evolves. Pre-existing disability and older age are the principal risk factors for further disability accumulation. The use of disease-modifying therapies delays disability accrual by years, with the potential to gain time being highest in the earliest stages of multiple sclerosis.
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Affiliation(s)
- Fred D Lublin
- Correspondence to: Professor Fred D. Lublin The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Icahn School of Medicine at Mount Sinai 5 East 98th Street, Box 1138 New York, NY 10029-6574, USA E-mail:
| | | | - Habib Ganjgahi
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Farhad Hatami
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | | | | | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Thomas E Nichols
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Robert A Bermel
- Department of Neurology, Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
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Dadar M, Mahmoud S, Narayanan S, Collins LD, Arnold DL, Maranzano J. Diffusely abnormal white matter converts to T2 lesion volume in the absence of MRI-detectable acute inflammation. Brain 2021; 145:2008-2017. [DOI: 10.1093/brain/awab448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/28/2021] [Accepted: 11/12/2021] [Indexed: 01/18/2023] Open
Abstract
Abstract
Diffusely abnormal white matter (DAWM), characterised by biochemical changes of myelin in the absence of frank demyelination, has been associated with clinical progression in secondary progressive MS (SPMS). However, little is known about changes of DAWM over time and their relation to focal white matter lesions (FWML).
The objectives of this work were: 1) To characterize the longitudinal evolution of FWML, DAWM, and DAWM that transforms into FWML, and 2) To determine whether gadolinium enhancement, known to be associated with the development of new FWML, is also related to DAWM voxels that transform into FWML.
Our data included 4220 MRI scans of 689 SPMS participants, followed for 156 weeks and 2677 scans of 686 RRMS participants, followed for 96 weeks. FWML and DAWM were segmented using a previously validated, automatic thresholding technique based on normalized T2 intensity values. Using longitudinally registered images, DAWM voxels at each visit that transformed into FWML on the last MRI scan as well as their overlap with gadolinium enhancing lesion masks were identified.
Our results showed that the average yearly rate of conversion of DAWM-to-FWML was 1.27 cc for SPMS and 0.80 cc for RRMS. FWML in SPMS participants significantly increased (t = 3.9; p = 0.0001) while DAWM significantly decreased (t = −4.3 p < 0.0001) and the ratio FWML:DAWM increased (t = 12.7; p < 0.00001). RRMS participants also showed an increase in the FWML:DAWM Ratio (t = 6.9; p < 0.00001) but without a significant change of the individual volumes. Gadolinium enhancement was associated with 7.3% and 18.7% of focal New T2 lesion formation in the infrequent scans of the RRMS and SPMS cohorts, respectively. In comparison, only 0.1% and 0.0% of DAWM-to-FWML voxels overlapped with gadolinium enhancement.
We conclude that DAWM transforms into FWML over time, in both RRMS and SPMS. DAWM appears to represent a form of pre-lesional pathology that contributes to T2 lesion volume increase over time, independent of new focal inflammation and gadolinium enhancement.
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Affiliation(s)
- Mahsa Dadar
- Radiology Department, Faculty of Medicine, Laval University, Quebec, Canada
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Sawsan Mahmoud
- Department of Anatomy, University of Quebec in Trois-Rivieres, Trois-Rivieres, Quebec, Canada
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Louis D. Collins
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Douglas L. Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Josefina Maranzano
- Department of Anatomy, University of Quebec in Trois-Rivieres, Trois-Rivieres, Quebec, Canada
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
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Chitnis T, Banwell B, Kappos L, Arnold DL, Gücüyener K, Deiva K, Skripchenko N, Cui LY, Saubadu S, Hu W, Benamor M, Le-Halpere A, Truffinet P, Tardieu M. Safety and efficacy of teriflunomide in paediatric multiple sclerosis (TERIKIDS): a multicentre, double-blind, phase 3, randomised, placebo-controlled trial. Lancet Neurol 2021; 20:1001-1011. [PMID: 34800398 DOI: 10.1016/s1474-4422(21)00364-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 09/17/2021] [Accepted: 10/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Therapeutic options for children with multiple sclerosis are scarce. Teriflunomide is approved in more than 80 countries for the treatment of adults with relapsing multiple sclerosis. The TERIKIDS study examined the safety and efficacy of teriflunomide in children with relapsing multiple sclerosis. METHODS The TERIKIDS trial was a multicentre, phase 3, double-blind, parallel-group, randomised, placebo-controlled study conducted at 57 clinical centres in 22 countries in Asia, Europe, the Middle East, North Africa, and North America. The trial enrolled patients aged 10-17 years, diagnosed with relapsing multiple sclerosis and with at least one relapse in the year preceding screening or at least two relapses in the 2 years preceding screening. Patients were randomly assigned (2:1) to oral teriflunomide (dosage equivalent to 14 mg in adults) or matching placebo, using an interactive web and voice response system, for up to 96 weeks. Personnel in all sites and all patients were masked to study treatment in the double-blind period. Early entry into a subsequent 96-week open-label extension phase was possible before the end of the double-blind period for patients with confirmed clinical relapse or high MRI activity (at least five new or enlarged T2 lesions at week 24, followed by at least nine new or enlarged T2 lesions at week 36, or at least five new or enlarged T2 lesions at weeks 36 and 48, or at weeks 48 and 72). The primary endpoint was time to first confirmed clinical relapse by the end of the double-blind period. Key secondary imaging endpoints were number of new or enlarged T2 lesions and number of gadolinium-enhancing lesions per MRI scan. Efficacy endpoints were analysed in the intention-to-treat population, and safety was assessed in all patients randomly assigned to treatment and exposed to the double-blind study medication. This study is registered with ClinicalTrials.gov (trial number NCT02201108) and is closed to recruitment, but an additional optional open-label extension is ongoing. FINDINGS Between July 24, 2014, and the date of last patient visit on Oct 25, 2019, 185 patients were screened for eligibility, 166 (90%) were enrolled, and 109 were randomly assigned teriflunomide and 57 were randomly assigned placebo. 102 (94%) of 109 and 53 (93%) of 57 completed the double-blind period. Switch to the ongoing open-label extension because of high MRI activity was more frequent than anticipated in the placebo group (14 [13%] of 109 patients in the teriflunomide group vs 15 [26%] of 57 in the placebo group), decreasing the power of the study. After 96 weeks, there was no difference in time to first confirmed clinical relapse with teriflunomide compared with placebo (hazard ratio 0·66, 95% CI 0·39-1·11; p=0·29). Teriflunomide reduced the number of new or enlarged T2 lesions versus placebo by 55% (relative risk 0·45, 95% CI 0·29-0·71; p=0·00061), and the number of gadolinium-enhancing lesions by 75% (relative risk 0·25, 0·13-0·51; p<0·0001). Adverse events occurred in 96 (88%) patients in the teriflunomide group and 47 (82%) patients in the placebo group; serious adverse events occurred in 12 (11%) patients in the teriflunomide group and 6 (11%) patients in the placebo group. Nasopharyngitis, upper-respiratory-tract infection, alopecia, paraesthesia, abdominal pain, and increased blood creatine phosphokinase were more frequent with teriflunomide than with placebo. During the double-blind phase, four patients in the teriflunomide group had pancreatic adverse events (two with acute pancreatitis and two with pancreatic enzyme elevation), of which three events led to treatment discontinuation. INTERPRETATION No significant difference in time to first confirmed clinical relapse was found, possibly because more patients than expected switched from the double-blind to the open-label treatment period because of high MRI activity. Key secondary imaging analyses and a prespecified sensitivity analysis of probability of relapse or high MRI activity suggest that teriflunomide might have beneficial effects in children with relapsing multiple sclerosis by reducing the risk of focal inflammatory activity. FUNDING Sanofi.
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Affiliation(s)
- Tanuja Chitnis
- Massachusetts General Hospital for Children, Boston, MA, USA.
| | - Brenda Banwell
- Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ludwig Kappos
- Research Centre for Clinical Neuroimmunology and Neuroscience Basel, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | - Douglas L Arnold
- NeuroRx Research, Montréal, QC, Canada; Montréal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Kivilcim Gücüyener
- Gazi Universitesi Tip Fakültesi Pediatrik Nöroloji Bilim Dali, Ankara, Turkey
| | | | - Natalia Skripchenko
- FSBI Research Institute for Paediatric Infectious Diseases FMBA Russia, St Petersburg, Russia
| | - Li-Ying Cui
- Peking Union Medical College Hospital, Beijing, China
| | | | | | | | | | | | - Marc Tardieu
- Hôpitaux Universitaires Paris-Sud, Paris, France
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Dahlke F, Arnold DL, Aarden P, Ganjgahi H, Häring DA, Čuklina J, Nichols TE, Gardiner S, Bermel R, Wiendl H. Characterisation of MS phenotypes across the age span using a novel data set integrating 34 clinical trials (NO.MS cohort): Age is a key contributor to presentation. Mult Scler 2021; 27:2062-2076. [PMID: 33507835 PMCID: PMC8564259 DOI: 10.1177/1352458520988637] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Oxford Big Data Institute, multiple sclerosis (MS) physicians and Novartis aim to address unresolved questions in MS with a novel comprehensive clinical trial data set. OBJECTIVE The objective of this study is to describe the Novartis-Oxford MS (NO.MS) data set and to explore the relationships between age, disease activity and disease worsening across MS phenotypes. METHODS We report key characteristics of NO.MS. We modelled MS lesion formation, relapse frequency, brain volume change and disability worsening cross-sectionally, as a function of patients' baseline age, using phase III study data (≈8000 patients). RESULTS NO.MS contains data of ≈35,000 patients (>200,000 brain images from ≈10,000 patients), with >10 years follow-up. (1) Focal disease activity is highest in paediatric patients and decreases with age, (2) brain volume loss is similar across age and phenotypes and (3) the youngest patients have the lowest likelihood (<25%) of disability worsening over 2 years while risk is higher (25%-75%) in older, disabled or progressive MS patients. Young patients benefit most from treatment. CONCLUSION NO.MS will illuminate questions related to MS characterisation, progression and prognosis. Age modulates relapse frequency and, thus, the phenotypic presentation of MS. Disease worsening across all phenotypes is mediated by age and appears to some extent be independent from new focal inflammatory activity.
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Affiliation(s)
| | - Douglas L Arnold
- Brain Imaging Centre, Montreal Neurological
Institute and Hospital, McGill University, Montréal, QC, Canada
| | | | - Habib Ganjgahi
- Oxford Big Data Institute, Li Ka Shing Centre
for Health Information and Discovery, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
| | | | | | - Thomas E Nichols
- Oxford Big Data Institute, Li Ka Shing Centre
for Health Information and Discovery, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
| | | | - Robert Bermel
- Department of Neurology, Mellen MS Center,
Cleveland Clinic, Cleveland, OH, USA
| | - Heinz Wiendl
- Department of Neurology, University Hospital
Münster, Münster, Germany
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Fadda G, Alves CA, O’Mahony J, Castro DA, Yeh EA, Marrie RA, Arnold DL, Waters P, Bar-Or A, Vossough A, Banwell B. Comparison of Spinal Cord Magnetic Resonance Imaging Features Among Children With Acquired Demyelinating Syndromes. JAMA Netw Open 2021; 4:e2128871. [PMID: 34643718 PMCID: PMC8515204 DOI: 10.1001/jamanetworkopen.2021.28871] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE The recognition of magnetic resonance imaging (MRI) features associated with distinct causes of myelitis in children is essential to guide investigations and support diagnostic categorization. OBJECTIVE To determine the clinical and MRI features and outcomes associated with spinal cord involvement in pediatric myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), multiple sclerosis (MS), and seronegative monophasic myelitis. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, participants were recruited between 2004 and 2017 through the multicenter Canadian Pediatric Demyelinating Disease Study, which enrolled youth younger than 18 years presenting within 90 days of an acquired demyelinating syndrome. Of the 430 participants recruited, those with lesions on available spine MRI and anti-MOG testing performed on archived samples obtained close to clinical presentation were selected. Participants with poor-quality images and final diagnoses of nondemyelinating disease, anti-aquaporin 4 antibody positivity, and relapsing seronegative myelitis were excluded. Data analysis was performed from December 2019 to November 2020. MAIN OUTCOMES AND MEASURES Spinal cord involvement was evaluated on 324 MRI sequences, with reviewers blinded to clinical, serological, and brain MRI findings. Associated clinical features and disability scores at 5 years of follow-up were retrieved. Results were compared between groups. RESULTS A total of 107 participants (median [IQR] age at onset, 11.14 [5.59-13.39] years; 55 girls [51%]) were included in the analyses; 40 children had MOGAD, 21 had MS, and 46 had seronegative myelitis. Longitudinally extensive lesions were very common among children with MOGAD (30 of 40 children [75%]), less common among those with seronegative myelitis (20 of 46 children [43%]), and rare in children with MS (1 of 21 children [5%]). Axial gray matter T2-hyperintensity (ie, the H-sign) was observed in 22 of 35 children (63%) with MOGAD, in 14 of 42 children (33%) with seronegative myelitis, and in none of those with MS. The presence of leptomeningeal enhancement was highly suggestive for MOGAD (22 of 32 children [69%] with MOGAD vs 10 of 38 children [26%] with seronegative myelitis and 1 of 15 children [7%] with MS). Children with MOGAD were more likely to have complete lesion resolution on serial images (14 of 21 children [67%]) compared with those with MS (0 of 13 children). CONCLUSIONS AND RELEVANCE These findings suggest that several features may help identify children at presentation who are more likely to have myelitis associated with MOGAD. Prominent involvement of gray matter and leptomeningeal enhancement are common in pediatric MOGAD, although the pathological underpinning of these observations requires further study.
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Affiliation(s)
- Giulia Fadda
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Cesar A. Alves
- Division of Neuroradiology, Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julia O’Mahony
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Denise A. Castro
- Department of Diagnostic Radiology, Queen’s University, Kingston, Ontario, Canada
| | - E. Ann Yeh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Douglas L. Arnold
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Amit Bar-Or
- Center for Neuroinflammation and Neurotherapeutics, Multiple Sclerosis Division, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Arastoo Vossough
- Division of Neuroradiology, Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brenda Banwell
- Division of Child Neurology, Department of Neurology, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Elliott C, Momayyezsiahkal P, Arnold DL, Liu D, Ke J, Zhu L, Zhu B, George IC, Bradley DP, Fisher E, Cahir-McFarland E, Stys PK, Geurts JJG, Franchimont N, Gafson A, Belachew S. Abnormalities in normal-appearing white matter from which multiple sclerosis lesions arise. Brain Commun 2021; 3:fcab176. [PMID: 34557664 PMCID: PMC8453433 DOI: 10.1093/braincomms/fcab176] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/24/2022] Open
Abstract
Normal-appearing white matter is far from normal in multiple sclerosis; little is known about the precise pathology or spatial pattern of this alteration and its relation to subsequent lesion formation. This study was undertaken to evaluate normal-appearing white matter abnormalities in brain areas where multiple sclerosis lesions subsequently form, and to investigate the spatial distribution of normal-appearing white matter abnormalities in persons with multiple sclerosis. Brain MRIs of pre-lesion normal-appearing white matter were analysed in participants with new T2 lesions, pooled from three clinical trials: SYNERGY (NCT01864148; n = 85 with relapsing multiple sclerosis) was the test data set; ASCEND (NCT01416181; n = 154 with secondary progressive multiple sclerosis) and ADVANCE (NCT00906399; n = 261 with relapsing-remitting multiple sclerosis) were used as validation data sets. Focal normal-appearing white matter tissue state was analysed prior to lesion formation in areas where new T2 lesions later formed (pre-lesion normal-appearing white matter) using normalized magnetization transfer ratio and T2-weighted (nT2) intensities, and compared with overall normal-appearing white matter and spatially matched contralateral normal-appearing white matter. Each outcome was analysed using linear mixed-effects models. Follow-up time (as a categorical variable), patient-level characteristics (including treatment group) and other baseline variables were treated as fixed effects. In SYNERGY, nT2 intensity was significantly higher, and normalized magnetization transfer ratio was lower in pre-lesion normal-appearing white matter versus overall and contralateral normal-appearing white matter at all time points up to 24 weeks before new T2 lesion onset. In ASCEND and ADVANCE (for which normalized magnetization transfer ratio was not available), nT2 intensity in pre-lesion normal-appearing white matter was significantly higher compared to both overall and contralateral normal-appearing white matter at all pre-lesion time points extending up to 2 years prior to lesion formation. In all trials, nT2 intensity in the contralateral normal-appearing white matter was also significantly higher at all pre-lesion time points compared to overall normal-appearing white matter. Brain atlases of normal-appearing white matter abnormalities were generated using measures of voxel-wise differences in normalized magnetization transfer ratio of normal-appearing white matter in persons with multiple sclerosis compared to scanner-matched healthy controls. We observed that overall spatial distribution of normal-appearing white matter abnormalities in persons with multiple sclerosis largely recapitulated the anatomical distribution of probabilities of T2 hyperintense lesions. Overall, these findings suggest that intrinsic spatial properties and/or longstanding precursory abnormalities of normal-appearing white matter tissue may contribute to the risk of autoimmune acute demyelination in multiple sclerosis.
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Affiliation(s)
| | - Parya Momayyezsiahkal
- NeuroRx Research, Montreal, QC H2X 3P9, Canada.,McGill University, Montreal, QC H3A 0G4, Canada
| | - Douglas L Arnold
- NeuroRx Research, Montreal, QC H2X 3P9, Canada.,McGill University, Montreal, QC H3A 0G4, Canada
| | - Dawei Liu
- Biogen Digital Health, Biogen, Cambridge, MA 02142, USA
| | - Jun Ke
- Biogen, Cambridge, MA 02142, USA
| | - Li Zhu
- Biogen, Cambridge, MA 02142, USA
| | - Bing Zhu
- Biogen, Cambridge, MA 02142, USA
| | - Ilena C George
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | | | | | - Peter K Stys
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Jeroen J G Geurts
- Department of Anatomy and Neurosciences, Amsterdam UMC, 1081 HV Amsterdam, Netherlands
| | | | - Arie Gafson
- Biogen Digital Health, Biogen, Cambridge, MA 02142, USA
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Affiliation(s)
- Douglas L Arnold
- NeuroRx Research, Montreal, QC, Canada/McGill University, Montreal, QC, Canada
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Reich DS, Arnold DL, Vermersch P, Bar-Or A, Fox RJ, Matta A, Turner T, Wallström E, Zhang X, Mareš M, Khabirov FA, Traboulsee A. Safety and efficacy of tolebrutinib, an oral brain-penetrant BTK inhibitor, in relapsing multiple sclerosis: a phase 2b, randomised, double-blind, placebo-controlled trial. Lancet Neurol 2021; 20:729-738. [PMID: 34418400 PMCID: PMC8434816 DOI: 10.1016/s1474-4422(21)00237-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/21/2021] [Accepted: 07/07/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Tolebrutinib is an oral, CNS-penetrant, irreversible inhibitor of Bruton's tyrosine kinase, an enzyme expressed in B lymphocytes and myeloid cells including microglia, which are major drivers of inflammation in multiple sclerosis. We aimed to determine the dose-response relationship between tolebrutinib and the reduction in new active brain MRI lesions in patients with relapsing multiple sclerosis. METHODS We did a 16-week, phase 2b, randomised, double-blind, placebo-controlled, crossover, dose-finding trial at 40 centres (academic sites, specialty clinics, and general neurology centres) in ten countries in Europe and North America. Eligible participants were adults aged 18-55 years with diagnosed relapsing multiple sclerosis (either relapsing-remitting or relapsing secondary progressive multiple sclerosis), and one or more of the following criteria: at least one relapse within the previous year, at least two relapses within the previous 2 years, or at least one active gadolinium-enhancing brain lesion in the 6 months before screening. Exclusion criteria included a diagnosis of primary progressive multiple sclerosis or a diagnosis of secondary progressive multiple sclerosis without relapse. We used a two-step randomisation process to randomly assign eligible participants (1:1) to two cohorts, then further randomly assign participants in each cohort (1:1:1:1) to four tolebrutinib dose groups (5, 15, 30, and 60 mg administered once daily as an oral tablet). Cohort 1 received tolebrutinib for 12 weeks, then matched placebo (ie, identical looking tablets) for 4 weeks; cohort 2 received 4 weeks of placebo followed by 12 weeks of tolebrutinib. Participants and investigators were masked for dose and tolebrutinib-placebo administration sequence; investigators, study team members, and study participants did not have access to unmasked data. MRI scans were done at screening and every 4 weeks over 16 weeks. The primary efficacy endpoint was the number of new gadolinium-enhancing lesions detected on the scan done after 12 weeks of tolebrutinib treatment (assessed at week 12 for cohort 1 and week 16 for cohort 2), relative to the scan done 4 weeks previously, and compared with the lesions accumulated during 4 weeks of placebo run-in period in cohort 2. Efficacy data were analysed in a modified intention-to-treat population, using a two-step multiple comparison procedure with modelling analysis. Safety was assessed for all participants who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov (NCT03889639), EudraCT (2018-003927-12), and WHO (U1111-1220-0572), and has been completed. FINDINGS Between May 14, 2019, and Jan 2, 2020, we enrolled and randomly assigned 130 participants to tolebrutinib: 33 to 5 mg, 32 to 15 mg, 33 to 30 mg, and 32 to 60 mg. 129 (99%) completed the treatment regimen and 126 were included in the primary analysis. At treatment week 12, there was a dose-dependent reduction in the number of new gadolinium-enhancing lesions (mean [SD] lesions per patient: placebo, 1·03 [2·50]; 5 mg, 1·39 [3·20]; 15 mg, 0·77 [1·48]; 30 mg, 0·76 [3·31]; 60 mg, 0·13 [0·43]; p=0·03). One serious adverse event was reported (one patient in the 60 mg group was admitted to hospital because of a multiple sclerosis relapse). The most common non-serious adverse event during tolebrutinib treatment was headache (in one [3%] of 33 in the 5 mg group; three [9%] of 32 in the 15 mg group; one [3%] of 33 in the 30 mg group; and four [13%] of 32 in the 60 mg group). No safety-related discontinuations or treatment-related deaths occurred. INTERPRETATION 12 weeks of tolebrutinib treatment led to a dose-dependent reduction in new gadolinium-enhancing lesions, the 60 mg dose being the most efficacious, and the drug was well tolerated. Reduction of acute inflammation, combined with the potential to modulate the immune response within the CNS, provides a scientific rationale to pursue phase 3 clinical trials of tolebrutinib in patients with relapsing and progressive forms of multiple sclerosis. FUNDING Sanofi.
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Affiliation(s)
- Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA.
| | - Douglas L Arnold
- NeuroRx Research and Montréal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Patrick Vermersch
- Lille Neuroscience et Cognition, University Lille, INSERM UMR-S1172, CHU Lille, FHU Imminent, Lille, France
| | - Amit Bar-Or
- Center for Neuroinflammation and Neurotherapeutics and the Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert J Fox
- MellenCenter for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | - Miroslav Mareš
- Department of Neurology, Pardubice Regional Hospital, Pardubice, Czech Republic
| | | | - Anthony Traboulsee
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Colato E, Stutters J, Tur C, Narayanan S, Arnold DL, Gandini Wheeler-Kingshott CAM, Barkhof F, Ciccarelli O, Chard DT, Eshaghi A. Predicting disability progression and cognitive worsening in multiple sclerosis using patterns of grey matter volumes. J Neurol Neurosurg Psychiatry 2021; 92:995-1006. [PMID: 33879535 PMCID: PMC8372398 DOI: 10.1136/jnnp-2020-325610] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/18/2021] [Accepted: 03/20/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE In multiple sclerosis (MS), MRI measures at the whole brain or regional level are only modestly associated with disability, while network-based measures are emerging as promising prognostic markers. We sought to demonstrate whether data-driven patterns of covarying regional grey matter (GM) volumes predict future disability in secondary progressive MS (SPMS). METHODS We used cross-sectional structural MRI, and baseline and longitudinal data of Expanded Disability Status Scale, Nine-Hole Peg Test (9HPT) and Symbol Digit Modalities Test (SDMT), from a clinical trial in 988 people with SPMS. We processed T1-weighted scans to obtain GM probability maps and applied spatial independent component analysis (ICA). We repeated ICA on 400 healthy controls. We used survival models to determine whether baseline patterns of covarying GM volume measures predict cognitive and motor worsening. RESULTS We identified 15 patterns of regionally covarying GM features. Compared with whole brain GM, deep GM and lesion volumes, some ICA components correlated more closely with clinical outcomes. A mainly basal ganglia component had the highest correlations at baseline with the SDMT and was associated with cognitive worsening (HR=1.29, 95% CI 1.09 to 1.52, p<0.005). Two ICA components were associated with 9HPT worsening (HR=1.30, 95% CI 1.06 to 1.60, p<0.01 and HR=1.21, 95% CI 1.01 to 1.45, p<0.05). ICA measures could better predict SDMT and 9HPT worsening (C-index=0.69-0.71) compared with models including only whole and regional MRI measures (C-index=0.65-0.69, p value for all comparison <0.05). CONCLUSIONS The disability progression was better predicted by some of the covarying GM regions patterns, than by single regional or whole-brain measures. ICA, which may represent structural brain networks, can be applied to clinical trials and may play a role in stratifying participants who have the most potential to show a treatment effect.
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Affiliation(s)
- Elisa Colato
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Jonathan Stutters
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Carmen Tur
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Claudia A M Gandini Wheeler-Kingshott
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,Department of Brain & Behavioural Sciences, University of Pavia, Pavia, Italy.,Brain Connectivity Centre, IRCCS Mondino Foundation, Pavia, Italy
| | - Frederik Barkhof
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,Centre for Medical Image Computing (CMIC), Department of Computer Science, University College London, London, UK.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, NL
| | - Olga Ciccarelli
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,Institute for Health Research (NIHR), University College London Hospitals (UCLH) Biomedical Research Centre (BRC), London, UK
| | - Declan T Chard
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,Institute for Health Research (NIHR), University College London Hospitals (UCLH) Biomedical Research Centre (BRC), London, UK
| | - Arman Eshaghi
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,Centre for Medical Image Computing (CMIC), Department of Computer Science, University College London, London, UK
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47
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Gold R, Arnold DL, Bar-Or A, Fox RJ, Kappos L, Mokliatchouk O, Jiang X, Lyons J, Kapadia S, Miller C. Long-term safety and efficacy of dimethyl fumarate for up to 13 years in patients with relapsing-remitting multiple sclerosis: Final ENDORSE study results. Mult Scler 2021; 28:801-816. [PMID: 34465252 PMCID: PMC8978463 DOI: 10.1177/13524585211037909] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dimethyl fumarate (DMF) demonstrated favorable benefit-risk in relapsing-remitting multiple sclerosis (RRMS) patients in phase-III DEFINE and CONFIRM trials, and ENDORSE extension. OBJECTIVE The main aim of this study is assessing DMF safety/efficacy up to 13 years in ENDORSE. METHODS Randomized patients received DMF 240 mg twice daily or placebo (PBO; Years 0-2), then DMF (Years 3-10; continuous DMF/DMF or PBO/DMF); maximum follow-up (combined studies), 13 years. RESULTS By January 2020, 1736 patients enrolled/dosed in ENDORSE (median follow-up 8.76 years (ENDORSE range: 0.04-10.98) in DEFINE/CONFIRM and ENDORSE); 52% treated in ENDORSE for ⩾6 years. Overall, 551 (32%) patients experienced serious adverse events (mostly multiple sclerosis (MS) relapse or fall; one progressive multifocal leukoencephalopathy); 243 (14%) discontinued treatment due to adverse events (4% gastrointestinal (GI) disorders). Rare opportunistic infections, malignancies, and serious herpes zoster occurred, irrespective of lymphocyte count. For DMF/DMF (n = 501), overall annualized relapse rate (ARR) remained low (0.143 (95% confidence interval (CI), 0.120-0.169)), while for PBO/DMF (n = 249), ARR decreased after initiating DMF and remained low throughout (ARR 0-2 years, 0.330 (95% CI, 0.266-0.408); overall ARR (ENDORSE, 0.151 (95% CI, 0.118-0.194)). Over 10 years, 72% DMF/DMF and 73% PBO/DMF had no 24-week confirmed disability worsening. CONCLUSION Sustained DMF safety/efficacy was observed in patients followed up to 13 years, supporting DMF's positive benefit/risk profile for long-term RRMS treatment.
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Affiliation(s)
- Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Douglas L Arnold
- Montreal Neurological Institute-Hospital, McGill University and NeuroRx Research, Montreal, QC, Canada
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
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48
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Ontaneda D, Raza PC, Mahajan KR, Arnold DL, Dwyer MG, Gauthier SA, Greve DN, Harrison DM, Henry RG, Li DKB, Mainero C, Moore W, Narayanan S, Oh J, Patel R, Pelletier D, Rauscher A, Rooney WD, Sicotte NL, Tam R, Reich DS, Azevedo CJ. Deep grey matter injury in multiple sclerosis: a NAIMS consensus statement. Brain 2021; 144:1974-1984. [PMID: 33757115 PMCID: PMC8370433 DOI: 10.1093/brain/awab132] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/28/2021] [Accepted: 02/01/2021] [Indexed: 11/13/2022] Open
Abstract
Although multiple sclerosis has traditionally been considered a white matter disease, extensive research documents the presence and importance of grey matter injury including cortical and deep regions. The deep grey matter exhibits a broad range of pathology and is uniquely suited to study the mechanisms and clinical relevance of tissue injury in multiple sclerosis using magnetic resonance techniques. Deep grey matter injury has been associated with clinical and cognitive disability. Recently, MRI characterization of deep grey matter properties, such as thalamic volume, have been tested as potential clinical trial end points associated with neurodegenerative aspects of multiple sclerosis. Given this emerging area of interest and its potential clinical trial relevance, the North American Imaging in Multiple Sclerosis (NAIMS) Cooperative held a workshop and reached consensus on imaging topics related to deep grey matter. Herein, we review current knowledge regarding deep grey matter injury in multiple sclerosis from an imaging perspective, including insights from histopathology, image acquisition and post-processing for deep grey matter. We discuss the clinical relevance of deep grey matter injury and specific regions of interest within the deep grey matter. We highlight unanswered questions and propose future directions, with the aim of focusing research priorities towards better methods, analysis, and interpretation of results.
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Affiliation(s)
- Daniel Ontaneda
- Cleveland Clinic Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland, OH 44195, USA
| | - Praneeta C Raza
- Cleveland Clinic Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland, OH 44195, USA
| | - Kedar R Mahajan
- Cleveland Clinic Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland, OH 44195, USA
| | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Michael G Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, The State University of New York, Buffalo, NY 14214, USA
| | - Susan A Gauthier
- Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Douglas N Greve
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA 02129, USA
- Department of Radiology, Harvard Medical School, Boston, MA 02129, USA
| | - Daniel M Harrison
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Roland G Henry
- Department of Neurology, Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94143, USA
- The UC San Francisco and Berkeley Bioengineering Graduate Group, University of California San Francisco, San Francisco, CA 94143, USA
| | - David K B Li
- Department of Radiology and Medicine (Neurology), University of British Columbia, Vancouver, British Columbia V6T 2B5, Canada
| | - Caterina Mainero
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA 02129, USA
- Department of Radiology, Harvard Medical School, Boston, MA 02129, USA
| | - Wayne Moore
- Department of Pathology and Laboratory Medicine, and International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Jiwon Oh
- Division of Neurology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada
| | - Raihaan Patel
- Cerebral Imaging Centre, Douglas Mental Health University Institute, Verdun, Quebec H4H 1R3, Canada
- Department of Biological and Biomedical Engineering, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Daniel Pelletier
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA
| | - Alexander Rauscher
- Physics and Astronomy, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada
| | - William D Rooney
- Advanced Imaging Research Center, Oregon Health and Science University, Portland, OR 97239, USA
| | - Nancy L Sicotte
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Roger Tam
- Department of Radiology and Medicine (Neurology), University of British Columbia, Vancouver, British Columbia V6T 2B5, Canada
- Biomedical Engineering, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada
| | - Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD 20824, USA
| | - Christina J Azevedo
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA
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Harris S, Comi G, Cree BAC, Arnold DL, Steinman L, Sheffield JK, Southworth H, Kappos L, Cohen JA. Plasma neurofilament light chain concentrations as a biomarker of clinical and radiologic outcomes in relapsing multiple sclerosis: Post hoc analysis of Phase 3 ozanimod trials. Eur J Neurol 2021; 28:3722-3730. [PMID: 34292643 PMCID: PMC9291872 DOI: 10.1111/ene.15009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/04/2021] [Accepted: 07/02/2021] [Indexed: 01/03/2023]
Abstract
Background and purpose We investigated plasma neurofilament light chain concentration (pNfL) as a biomarker for neuroaxonal damage and disease activity using data from Phase 3 trials of ozanimod in relapsing multiple sclerosis (RMS). Methods pNfL was measured before and after ozanimod 0.46 mg or 0.92 mg daily or interferon β‐1a 30 µg weekly in the randomized, double‐blind SUNBEAM and RADIANCE trials. In these post hoc analyses, we investigated relationships between pNfL (at baseline and median percentage change from baseline to Month 12 [SUNBEAM] or 24 [RADIANCE]) and clinical and magnetic resonance imaging outcomes. Results Median (Q1, Q3) baseline pNfL, available in 1244 of 1346 SUNBEAM participants, was 14.70 (10.16, 23.26) pg/ml and in 1109 of 1313 RADIANCE participants was 13.35 (9.42, 20.41) pg/ml. Baseline gadolinium‐enhancing (GdE) and T2 lesion counts increased and brain volume decreased with increasing baseline pNfL. Baseline pNfL was higher in those with versus without on‐treatment relapse. Median percentage reduction in pNfL at 12 months in SUNBEAM (n = 1238) and 24 months in RADIANCE (n = 1088) was greater for ozanimod (20%–27%) than interferon β‐1a (13%–16%; p < 0.01). Greater pNfL reduction was associated with fewer GdE lesions, fewer new/enlarging T2 lesions per scan, less loss of brain volume, lower annualized relapse rate (ARR), and no evidence of disease activity. The following models predicted ARR: 0.5111 + 0.0116 × ΔNfL at 12 months (SUNBEAM) and 0.4079 + 0.0088 × ΔNfL at 24 months (RADIANCE). Conclusions pNfL was associated with clinical and radiologic measures of disease and treatment effects in RMS, supporting its use as a biomarker.
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Affiliation(s)
- Sarah Harris
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | | | - Bruce A C Cree
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Douglas L Arnold
- NeuroRx Research and Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Lawrence Steinman
- Department of Neurology and Neurological Sciences, Beckman Center for Molecular Medicine, Stanford University Medical Center, Stanford, California, USA
| | | | | | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Head, Spine and Neuromedicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Department of Neurology, Cleveland Clinic, Cleveland, Ohio, USA
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50
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Lee H, Nakamura K, Narayanan S, Brown RA, Nash RA, Griffith LM, Steinmiller KC, Devine SM, Hutton GJ, Popat U, Racke MK, Georges GE, Bowen JD, Arnold DL. Brain volume change after high-dose immunosuppression and autologous hematopoietic cell transplantation for relapsing-remitting multiple sclerosis. Mult Scler Relat Disord 2021; 54:103149. [PMID: 34284316 DOI: 10.1016/j.msard.2021.103149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/09/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Brain volume loss (BVL) is commonly observed after high-dose immunosuppression and autologous hematopoietic cell transplantation (HDIT/HCT) for treatment of multiple sclerosis (MS). To better understand the mechanisms of underlying BVL associated with this treatment, we characterized the time courses of whole-brain (WB), grey-matter (GM) and white-matter (WM) volume loss in relapsing-remitting MS (RRMS) patients who received BEAM-based HDIT/HCT. METHODS We used Jacobian integration to measure MRI-based WB, GM and WM volume changes up to 5 years after transplant in twenty-four RRMS participants who underwent BEAM-based HDIT/HCT. Using a two-piecewise mixed-effects model, we estimated the short-term (baseline to 1 year) and long-term (beyond 1 year) rates of BVL after HDIT/HCT. We also compared the rates based on the presence of gadolinium-enhancing lesions at baseline, and the maintenance of event-free survival during follow-up. RESULTS On average, accelerated short-term BVL of -1.37% (SE: 0.21), -0.86% (SE: 0.28) and -2.18% (SE: 0.26) occurred in WB, GM and WM, respectively. Baseline T1-weighted MRI WM lesion volume was a significant predictor in the WB (short-term) and the WM (short-term and long-term). The average rates of BVL after the initial acceleration were -0.22%/y (SE: 0.10), -0.13%/y (SE: 0.11) and -0.36%/y (SE: 0.11) in the WB, GM and WM, respectively. Participants with gadolinium-enhancing lesions at baseline had significantly higher short-term rates of GM (-1.56% vs. -0.27%, p = 0.01) and WB volume loss (-1.94% vs. -0.81%, p = 0.006) at 1 year follow-up as compared to those without gadolinium-enhancing lesions. WM volume loss was not significantly different (-2.59% vs. -1.66%, p = 0.16). Participants who maintained event-free survival had similar rates of BVL compared to those who did not. CONCLUSIONS BVL may accelerate for months after HDIT/HCT. However, over the long-term, adequate HDIT/HCT may reduce BVL rates to those similar to normal aging at the WB level.
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Affiliation(s)
- Hyunwoo Lee
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Kunio Nakamura
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; NeuroRx Research Inc., Montreal, QC, Canada
| | - Robert A Brown
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; ShadowLab Research Inc., Toronto, ON, Canada
| | | | - Linda M Griffith
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Steven M Devine
- Be The Match BioTherapies, National Marrow Donor Program (NMDP)/Be The Match, Center for International Blood and Marrow Transplant Research (CIBMTR), Minneapolis, MN, USA
| | - George J Hutton
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael K Racke
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; NeuroRx Research Inc., Montreal, QC, Canada
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