Treatment with interferon beta-1b delays conversion to clinically definite and McDonald MS in patients with clinically isolated syndromes

Interferon-beta-1b: in newly emerging multiple sclerosis

The mechanism of action of interferon-[beta]-1b in multiple sclerosis (MS) is not clearly understood, but is thought to involve immunoregulatory activities, including enhancing the suppressor activity of peripheral blood mononuclear cells. In the planned 3-year analysis of the BENEFIT study in patients with a single clinical event suggestive of MS, the relative risk of clinically definite (CD) MS was reduced by 41% in those receiving interferon-[beta]-1b 250 [micro]g every other day for 3 years (early-treatment group) compared with patients who were initially randomized to placebo then switched to interferon-[beta]-1b 250 [micro]g every other day at the end of 2 years or at the onset of CDMS (delayed-treatment group) [p < 0.01]. The relative risk of confirmed progression of the expanded disability status scale (EDSS) was reduced by 40% in the early-treatment group compared with the delayed-treatment group over 3 years (p < 0.05). At the end of the 2-year, randomized, placebo-controlled period of the BENEFIT study, the risk of developing CDMS (p < 0.0001) and McDonald-defined MS (p < 0.00001) was significantly lower in the interferon-[beta]-1b group than in the placebo group, and in the magnetic resonance imaging analysis, fewer newly active lesions developed in the interferon-[beta]-1b group (p < 0.001). Interferon-[beta]-1b was generally well tolerated. In the 3-year BENEFIT study, neutralizing activity, which was reported in about one-third of the early-treatment group, had no effect on outcome.

Interferon-beta1b for the treatment of multiple sclerosis

BACKGROUND

Multiple sclerosis is a debilitating autoimmune disorder that causes disability in young adults.

OBJECTIVE

To review the efficacy and safety of IFN-beta1b in the management of relapsing-remitting and secondary progressive multiple scleroses and clinical isolated syndrome.

METHODS

A MEDLINE (1966-May 2007) search of clinical trials using the terms 'multiple sclerosis' and 'interferon' was performed. Manual bibliographic search was conducted. English-language articles were evaluated.

RESULTS

IFN-beta1b is more efficacious than placebo and at least as efficacious as IFN-beta1a or glatiramer for the management of relapsing-remitting multiple sclerosis. IFN-beta1b also delayed the time to diagnosis of definite multiple sclerosis and reduced brain lesion burden in patients with clinical isolated syndrome. More long-term, large scale clinical data are warranted to ascertain its relative efficacy compared to other treatments.

CONCLUSION

IFN-beta1b is an effective treatment for multiple sclerosis. Common side effects are lymphopenia, injection site reactions, asthenia, flu-like symptoms and headache.

Management of acute optic neuritis: a survey of neurologists and ophthalmologists in Australia and New Zealand

Recent studies suggest that evidence-based medicine is not well translated into everyday practice. Studies of optic neuritis (ON) have generated clear treatment guidelines. Therefore, a survey was mailed to all Australian and New Zealand neurologists and ophthalmologists to evaluate the impact of recent studies on clinical practice. The response rate was 38.9%. Neurologists were more likely to use high dose corticosteroids and disease modifying agents (DMAs), and were more likely to be aware of relevant literature concerning DMAs. Both groups contained a significant minority of practitioners who would use corticosteroids for reasons not substantiated by available evidence. We conclude that most practitioners manage optic neuritis according to existing evidence and guidelines, but many do not. It is essential to instigate high-quality training programs to keep practitioners up-to-date, thereby optimising patient care and justifying the time and expense of large-scale clinical trials.

Subtraction MR images in a multiple sclerosis multicenter clinical trial setting

PURPOSE

To explore the applicability of subtraction magnetic resonance (MR) images to (a) detect active multiple sclerosis (MS) lesions, (b) directly quantify lesion load change, and (c) detect treatment effects (distinguish treatment arms) in a placebo-controlled multicenter clinical trial by comparing the subtraction scheme with a conventional pair-wise comparison of nonregistered MR images.

MATERIALS AND METHODS

Forty-six pairs of MR studies in 40 patients (31 women; mean age, 31.9 years) from a multicenter clinical trial were used. The clinical trial was approved by local ethics review boards, and all subjects gave written informed consent. Active MS lesions were scored by two independent raters, and lesion load measurements were conducted by using semiautomated software. Lesion counts were evaluated by using the Wilcoxon signed rank test, interrater agreement was evaluated by using the intraclass correlation coefficient (ICC), and treatment (interferon beta-1b) effect was evaluated by using the Mann-Whitney U test.

RESULTS

When subtraction images were used, there was a 1.7-fold increase in the detection of positive active lesions, as compared with native image pairs, and significantly greater interobserver agreement (ICC = 0.98 vs 0.91, P < .001). Subtraction images also allowed direct quantification of positive disease activity, a measure that provided sufficient power to distinguish treatment arms (P = .012) compared with the standard measurement of total lesion load change on native images (P = .455).

CONCLUSION

MR image subtraction enabled detection of higher numbers of active MS lesions with greater interobserver agreement and exhibited increased power to distinguish treatment arms, as compared with a conventional pair-wise comparison of nonregistered MR images.

Retinal nerve fiber layer and future risk of multiple sclerosis

BACKGROUND

Optical coherence tomography (OCT)--measured retinal nerve fiber layer (RNFL) values may represent a surrogate biomarker for axonal integrity in multiple sclerosis (MS). The purpose of this study was to determine whether RNFL measurements obtained within two years of an optic neuritis (ON) event distinguish patients at increased risk of developing clinically-definite MS (CDMS).

METHODS

Fifty consecutively sampled patients who experienced a single ON event were followed prospectively for a mean period of 34 months with OCT testing. Values of RNFL in clinically-affected and non-affected eyes were compared between patients who developed CDMS and those that did not develop MS after ON.

FINDINGS

Twenty-one patients (42%) developed CDMS during the course of the study, with a mean conversion time of 27 months. Mean RNFL values were thinner in the clinically-affected eyes of non-MS patients than CDMS eyes after one year (p = 0.0462) due to more severe ON events in the former. By year two, CDMS patients manifested more recurrent ON events and RNFL thinning than non-MS patients. Temporal RNFL values were thinner in the non-affected eyes of CDMS patients with a trend towards significance (p = 0.1302).

INTERPRETATION

Our results indicate that RNFL thickness does not reliably distinguish patients at higher risk of converting to CDMS after ON. The severity of ON has a greater effect on RNFL thickness than risk of CDMS at one year. The CDMS patients demonstrate progressive RNFL thinning likely due to recurrent sub-clinical ON events, which may help differentiate them from non-MS patients over time.

Basic and escalating immunomodulatory treatments in multiple sclerosis: current therapeutic recommendations

This review updates and extends earlier Consensus Reports related to current basic and escalating immunomodulatory treatments in multiple sclerosis (MS). The recent literature has been extracted for new evidence from randomized controlled trials, open treatment studies and reported expert opinion, both in original articles and reviews, and evaluates indications and safety issues based on published data. After data extraction from published full length publications and critically weighing the evidence and potential impact of the data, the review has been drafted and circulated within the National MS Societies and the European MS Platform to reach consensus within a very large group of European experts, combining evidence-based criteria and expert opinion where evidence is still incomplete. The review also outlines a few areas of controversy and delineates the need for future research.

Interferon-beta treatment for relapsing multiple sclerosis

BACKGROUND

Recombinant forms of IFN-beta were the first therapeutic intervention found to be effective at interfering with the course of multiple sclerosis (MS), a chronic and debilitating disease affecting the CNS in young adults.

OBJECTIVE/METHODS

To examine the application of IFN-beta to MS treatment by a review of relevant literature.

RESULTS

The different IFN-beta products available are similar in their clinical effects. However, the response to IFN-beta therapy is only partial and the most efficient individual-specific dose, route and frequency of administration are not elucidated fully. The mechanism of action of IFN-beta in MS is also not understood fully but its immunomodulatory effects are probably more important than its anti-proliferative and antiviral activities.

CONCLUSIONS

Although new therapeutic approaches are being sought to better treat MS, IFN-beta remains one of the most recognized and approved worldwide therapeutic options for this disease.

Management of optic neuritis and impact of clinical trials: an international survey

OBJECTIVE

1) To evaluate the management of acute isolated optic neuritis (ON) by ophthalmologists and neurologists; 2) to evaluate the impact of clinical trials; 3) to compare these practices among 7 countries.

METHODS

A survey on diagnosis and treatment of acute isolated ON was sent to 5,443 neurologists and 6,099 ophthalmologists in the southeast-USA, Canada, Australia/New Zealand, Denmark, France, and Thailand. USA data were compared to those of other countries.

RESULTS

We collected 3,142 surveys (1,449 neurologists/1,693 ophthalmologists) (29.8% response rate). In all countries, ON patients more frequently presented to ophthalmologists, and were subsequently referred to neurologists or subspecialists. Evaluation and management of ON varied among countries, mostly because of variations in healthcare systems, imaging access, and local guidelines. A brain MRI was obtained for 70-80% of ON patients; lumbar punctures were obtained mostly in Europe and Thailand. Although most patients received acute treatment with intravenous steroids, between 14% and 65% of neurologists and ophthalmologists still recommended oral prednisone (1 mg/kg/day) for the treatment of acute isolated ON. In all countries, steroids were often prescribed to improve visual outcome or to decrease the long-term risk of multiple sclerosis.

INTERPRETATION

Although recent clinical trials have changed the management of acute ON around the world, many neurologists and ophthalmologists do not evaluate and treat acute ON patients according to the best evidence from clinical research. This confirms that evaluation of the impact of major clinical trials ("translational T2 clinical research") is essential when assessing the effects of interventions designed to improve quality of care.

Neurotherapeutics in multiple sclerosis: novel agents and emerging treatment strategies

New insights into the complex immunopathogenesis of multiple sclerosis have led to a proliferation of promising new therapeutic strategies. While the current armamentarium of immunomodulatory medications has demonstrated beneficial effects on the disease, more effective and tolerable therapies are needed. Several novel therapeutic strategies under investigation include oral therapies, monoclonal antibodies, symptomatic treatments, insights into neuroprotection and repair as well as combination regimens. New therapies may prove more efficacious and tolerable than the available arsenal of treatments; however, decisions regarding first-line therapies will expectedly become more complicated, with greater influence if risk-to-benefit ratios in light of premature safety data. Biomarker profiles may help elucidate disease subtypes as well as therapeutic response in an effort to individualize treatment choice. This review will highlight recent promising therapeutic strategies under investigation in the field of MS.

New treatment measurements for treatment effects on relapses and progression

Multiple sclerosis (MS) is considered to be a two stage disease: a first stage in which inflammatory phenomena are crucial and a later one in which degenerative processes become the hallmark. The role of magnetic resonance imaging (MRI) is nowadays of great help both to establish the diagnosis and to rule out other conditions. At the clinically isolated syndrome (CIS) stage, MRI is an important tool both to predict the appearance of a second attack or the development of disability at long term. In the relapsing-remitting (RR) phase of the disease conventional MRI is probably less helpful to predict future relapses and disability. Cross sectional and longitudinal studies have shown very weak correlations between lesion burden on brain T2 and disability in the progressive forms of MS. Regarding T2 burden of disease, a plateau effect for EDSS values greater than 4.5 has been observed. Measures related to brain or spinal cord atrophy together with MR Spectroscopy, Magnetization Transfer Imaging and Diffusion Tensor Imaging may be useful in the future to better monitor disease progression in the late degenerative phase of the condition. MRI has also been of great help in monitoring the effect of immunomodulatory drugs in CIS or RRMS clinical trials. Its role to predict treatment response is still controversial on an individual basis.

Management of optic neuritis in Canada: survey of ophthalmologists and neurologists

BACKGROUND

Acute isolated optic neuritis is often the first manifestation of multiple sclerosis (MS), and its management remains controversial. Over the past decade, with the advent of new disease-modifying agents, management of isolated optic neuritis has become more complicated.

OBJECTIVES

To evaluate the current practice patterns of Canadian ophthalmologists and neurologists in the management of acute optic neuritis, and to evaluate the impact of recently published randomized clinical trials.

DESIGN

Mail survey.

METHODS

All practicing ophthalmologists and neurologists in Canada were mailed a survey evaluating the management of isolated acute optic neuritis and familiarity with recent clinical trials. Surveys for 1158 were mailed, and completed surveys were collected anonymously through a datafax system. Second and third mailings were sent to non-respondents 6 and 12 weeks later.

RESULTS

The final response rate was 34.5%. Although many acute optic neuritis patients initially present to ophthalmologists, neurologists are the physicians primarily managing these patients. Ordering magnetic resonance imaging, and treating with high dose intravenous steroids has become the standard of care. However, 15% of physicians (14% of ophthalmologists and 16% of neurologists) continue to prescribe low dose oral steroids, and steroids are being given for reasons other than to shorten the duration of visual symptoms by 73% of ophthalmologists and 50% of neurologists. More neurologists than ophthalmologists are familiar with recent clinical trials involving disease-modifying agents.

CONCLUSION

Although the management of acute optic neuritis has been evaluated in large clinical trials that were published in major international journals, some ophthalmologists and neurologists are not following evidence-based recommendations.

[Choice of early and escalation treatment options for multiple sclerosis]

Recent advances in understanding of the immunopathogenesis of multiple sclerosis (MS) have led to the development of new treatment options. To date several immunomodulatory agents have been licensed for the treatment of relapsing-remitting MS. However, some debate remains on the optimal time point for initiating therapy. While there is general consensus on the benefit of an early treatment start, the issues of how to define "early MS" and how to identify patients with a "benign" disease course have not yet been finally addressed. Further open questions include the situations of treatment failure and therapeutic escalation. Here we summarize available data from studies on early treatment with immunomodulatory drugs for a first demyelinating event, also referred to as clinically isolated syndrome. Furthermore, options for the escalation of immunomodulatory therapy will be discussed, e.g. with the recently licensed monoclonal antibody natalizumab.

Differential diagnosis of suspected multiple sclerosis: a consensus approach

BACKGROUND AND OBJECTIVES

Diagnosis of multiple sclerosis (MS) requires exclusion of diseases that could better explain the clinical and paraclinical findings. A systematic process for exclusion of alternative diagnoses has not been defined. An International Panel of MS experts developed consensus perspectives on MS differential diagnosis.

METHODS

Using available literature and consensus, we developed guidelines for MS differential diagnosis, focusing on exclusion of potential MS mimics, diagnosis of common initial isolated clinical syndromes, and differentiating between MS and non-MS idiopathic inflammatory demyelinating diseases.

RESULTS

We present recommendations for 1) clinical and paraclinical red flags suggesting alternative diagnoses to MS; 2) more precise definition of "clinically isolated syndromes" (CIS), often the first presentations of MS or its alternatives; 3) algorithms for diagnosis of three common CISs related to MS in the optic nerves, brainstem, and spinal cord; and 4) a classification scheme and diagnosis criteria for idiopathic inflammatory demyelinating disorders of the central nervous system.

CONCLUSIONS

Differential diagnosis leading to MS or alternatives is complex and a strong evidence base is lacking. Consensus-determined guidelines provide a practical path for diagnosis and will be useful for the non-MS specialist neurologist. Recommendations are made for future research to validate and support these guidelines. Guidance on the differential diagnosis process when MS is under consideration will enhance diagnostic accuracy and precision.

Cognitive impairment in multiple sclerosis

BACKGROUND

Cognitive impairment is increasingly being recognized as a common and disabling symptom of multiple sclerosis (MS) that contributes to poor quality of life in affected patients. Despite the high prevalence of cognitive impairment in MS, cognitive function is not assessed routinely in clinical practice or in clinical trials. The perception that cognitive assessments are costly, time-consuming, complicated, and difficult to administer and interpret has contributed, at least in part, to the failure to incorporate cognitive testing into standard clinical evaluation of patients with MS. Detailed studies of cognitive impairment in MS are rare and guidelines for the assessment of cognitive function in MS are lacking.

TREATMENT

How to manage cognitive decline in MS also requires further study. Licensed disease-modifying drug (DMD) treatments for MS reduce brain lesion development, and associations between brain lesions and cognitive performance have been reported, providing a rationale for DMD treatment of MS-associated cognitive impairment. There is some evidence for cognitive benefits of DMDs, but as few pivotal DMD trials included cognitive assessments, the effects of these agents on cognition are not fully understood and more studies are needed.

CONCLUSIONS

It is only through further studies that it will be possible to identify patients with, or at risk of, cognitive impairment and to provide appropriate therapy to limit the effects of this potentially devastating symptom.

Acute inflammatory demyelinating optic neuritis: evidence-based visual and neurological considerations

BACKGROUND

Optic neuritis (ON) is an acute inflammatory demyelinating disorder of the optic nerve that occurs most often in young adults. It can be a monophasic or polyphasic disease isolated to the optic nerve(s) or can be associated with a more widespread demyelinating disorder of the central nervous system such as multiple sclerosis (MS) or neuromyelitis optica. Advances in therapeutics that modify the risk of progression to MS have emphasized accurate diagnosis and risk assessment of patients with ON.

REVIEW SUMMARY

ON usually presents with acute unilateral visual loss associated with ocular pain exacerbated by eye movements. Similar to results found in studies assessing corticosteroid used in MS relapses, intravenous methylprednisolone accelerates visual recovery from ON but has no impact on long-term visual outcome. A clinically isolated syndrome (CIS), such as ON, is a clinical demyelinating event that is often the initial attack of relapsing-remitting MS. Disease modifying drugs, in particular interferons-beta, have been shown to reduce the risk of MS conversion in high-risk patients presenting with a CIS. The exact timing and patient selection for the initiation of treatment remain controversial.

CONCLUSION

ON is the best studied CIS. The visual prognosis is excellent in most cases regardless of whether the patient is treated with corticosteroids or not. Three recently completed prospective, randomized, double-blinded, placebo-controlled studies have shown that starting a disease-modifying drug at the time of a CIS can reduce the rate of development of MS. However, better diagnostic tools are needed to precisely predict the conversion to MS and the factors influencing disease severity to determine the most appropriate therapeutic paradigm and avoid unnecessary treatment.

Abrogation of T cell quiescence characterizes patients at high risk for multiple sclerosis after the initial neurological event

Clinically isolated syndrome (CIS) refers to the earliest clinical manifestation of multiple sclerosis (MS). Currently there are no prognostic biological markers that accurately predict conversion of CIS to clinically definite MS (CDMS). Furthermore, the earliest molecular events in MS are still unknown. We used microarrays to study gene expression in naïve CD4(+) T cells from 37 CIS patients at time of diagnosis and after 1 year. Supervised machine-learning methods were used to build predictive models of disease conversion. We identified 975 genes whose expression segregated CIS patients into four distinct subgroups. A subset of 108 genes further discriminated patients in one of these (group 1) from other CIS patients. Remarkably, 92% of patients in group 1 converted to CDMS within 9 months. Consistent down-regulation of TOB1, a critical regulator of cell proliferation, was characteristic of group 1 patients. Decreased TOB1 expression at the RNA and protein levels also was confirmed in experimental autoimmune encephalomyelitis. Finally, a genetic association was observed between TOB1 variation and MS progression in an independent cohort. These results indicate that CIS patients at high risk of conversion have impaired regulation of T cell quiescence, possibly resulting in earlier activation of pathogenic CD4(+) cells.

Multiple sclerosis: new treatment trials and emerging therapeutic targets

PURPOSE OF REVIEW

This review focuses on new therapeutic strategies in multiple sclerosis.

RECENT FINDINGS

The past decade has marked the advent of various new therapeutic strategies in multiple sclerosis. Whereas the current armamentarium of immunomodulatory medications has demonstrated beneficial effects on the disease, more effective and tolerable therapies are needed. Several novel therapeutic strategies in testing include oral therapies, monoclonal antibodies, symptomatic treatments as well as insights into neuroprotection and repair. Ways to build upon existing therapies are also under investigation, including early initiation of treatment and various combination regimens.

SUMMARY

New therapies, along with variations of currently available treatments, may prove more efficacious and tolerable than the available arsenal of treatments. Nevertheless, as the treatment horizon broadens, choosing first-line therapies will become more complicated, with greater influence of risk-to-benefit ratios in light of premature safety data. Patient's clinical, paraclinical and biomarker fingerprint profiles may help elucidate disease subtypes as well as response to therapy in an effort to individualize treatment choice. A complete discussion of all studies currently underway is beyond the scope of this review, which will highlight recent promising therapeutic strategies under investigation in the field of multiple sclerosis.

Gadofluorine M enhancement allows more sensitive detection of inflammatory CNS lesions than T2-w imaging: a quantitative MRI study

Magnetic resonance imaging plays a pivotal role in the diagnosis and treatment monitoring of multiple sclerosis. Currently available magnetic resonance-techniques only partly reflect the extent of tissue inflammation and damage. In the present study, application of the experimental magnetic resonance-contrast agent Gadofluorine M significantly increased the sensitivity of lesion detection in myelin-oligodendrocyte glycoprotein-induced experimental autoimmune encephalomyelitis, an animal model for multiple sclerosis. Gadofluorine M-enhancement on T(1)-weighted (T(1)-w) images utilizing a clinical 1.5 T magnetic resonance unit showed numerous lesions in optic nerve, spinal cord and brain, the majority of which were not detectable on standard T(2)-weighted (T(2)-w) and Gd-DTPA enhanced T(1)-w sequences. Quantitative assessment by pixel counts revealed highly significant differences in sensitivity in favour of Gadofluorine M. Gadofluorine uptake closely corresponded to inflammation and demyelination on tissue sections. These unique features of Gadofluorine M in visualizing inflammatory CNS lesions hold promise for future clinical development in multiple sclerosis.

Smoking is a risk factor for early conversion to clinically definite multiple sclerosis

BACKGROUND

Cigarette smoking increases the risk for development of multiple sclerosis and modifies the clinical course of the disease. In this study, we determined whether smoking is a risk factor for early conversion to clinically definite multiple sclerosis after a clinically isolated syndrome.

METHODS

We included 129 patients with a clinically isolated syndrome, disseminated white-matter lesions on brain magnetic resonance imaging, and positive oligoclonal bands in the cerebrospinal fluid. The patients' smoking status was obtained at the time of the clinically isolated syndrome.

RESULTS

During a follow-up time of 36 months, 75% of smokers but only 51% of non-smokers developed clinically definite multiple sclerosis, and smokers had a significantly shorter time interval to their first relapse. The hazard ratio for progression to clinically definite multiple sclerosis was 1.8 (95% confidence interval, 1.2-2.8) for smokers compared with non-smokers (P = 0.008).

CONCLUSIONS

Smoking is associated with an increased risk for early conversion to clinically definite multiple sclerosis after a clinically isolated syndrome, and our results suggest that smoking is an independent but modifiable risk factor for disease progression of multiple sclerosis. Therefore, it should be considered in the counseling of patients with a clinically isolated syndrome.

Reproductive counselling, treatment and course of pregnancy in 73 German MS patients

Multiple sclerosis (MS) often affects women during the reproductive years of their life. During this period, issues such as choice of immunomodulatory treatment, seeking advice from specialists, relapse-induced steroid application before, during or after pregnancy in combination with breastfeeding gain importance. The objective was to investigate these issues retrospectively using a questionnaire among 73 MS patients with a total of 88 pregnancies. Eighty per cent of the participants consulted their neurologists before and 60% during pregnancy. The annual relapse rate decreased during pregnancy and significantly increased during the first 3 months after delivery. Immunomodulatory treatment was stopped due to desired pregnancy for a mean of 4 years. Fourteen of the MS patients received intravenous immunoglobulin treatment post-natal. Ninety per cent of the study subjects started breastfeeding. However, nearly 30% ablactated, as they received steroids due to a relapse. Weight and height of the full-term children of singleton pregnancies from MS patients were significantly lower compared with the ones of age-matched healthy controls. Our results confirm the known reduced relapse rate during pregnancy, which is followed by an increased relapse rate after delivery. They shed light on the epidemiology of childbirth in patients with MS.

Biological response genes after single dose administration of interferon beta-1b to healthy male volunteers

Treatment with interferon beta-1b (IFNB-1b) is clinically effective in multiple sclerosis patients. However, the mechanism of action is only partially understood, and validated biological response markers are lacking. We assessed IFNB-1b-induced transcriptional changes by microarray technology. Healthy male volunteers received 250 mug IFNB-1b or placebo in a double-blind, randomized controlled trial (n=5 per group). Most transcripts demonstrated peak levels after 6-12 h and returned to baseline after 48 h. We identified 227 differentially regulated genes including novel and previously described markers. This panel may become a valuable tool for development of new IFNB-1b formulations and assessment of clinical drug effects.

CSF IgG heavy-chain bias in patients at the time of a clinically isolated syndrome

Using FACS and single cell reverse transcriptase polymerase chain reaction, we examined the cerebrospinal fluid (CSF) IgG VH repertoires from 10 subjects with a clinically isolated demyelinating syndrome (CIS). B and plasma cell repertoires from individual subjects showed similar VH family germline usage, nearly identical levels of post-germinal center somatic hypermutation, and significant overlap in their clonal populations. Repertoires from 7 of 10 CIS subjects demonstrated a biased usage of VH4 and/or VH2 family gene segments in their plasma or B cell repertoires. V-regionbias, however, was not observed in the corresponding peripheral blood CD19+ B cell repertoires from 2 CIS subjects or in normal healthy adults. Clinically, subjects with VH4 or VH2 CSF IgG repertoire bias rapidly progressed to definite MS, whereas individuals without repertoire bias did not develop MS after a minimum of 2 years of follow-up (p=0.01).

Diagnosis and treatment of multiple sclerosis

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system that usually has onset between 20 and 40 years of age. The causes of MS are unknown, but it probably evolves among genetically susceptible individuals as an infrequent response to environmental factors. The diagnosis is based on careful evaluation of the disease history, clinical examination as well as paraclinical examination, aiming to document disseminated disease in both time and space. No cure is available, but corticosteroids can be used for relapses, various symptomatic treatments exist, and several long-term, disease-modifying therapies are available. This article reviews the diagnosis and treatment of MS, focusing on treatment of relapses and disease-modifying therapies.

Magnetic resonance imaging metrics and their correlation with clinical outcomes in multiple sclerosis: a review of the literature and future perspectives

Magnetic resonance imaging (MRI) has revolutionized the diagnosis and management of patients with multiple sclerosis (MS). Conventional MRI metrics are employed as primary endpoints in proof-of-concept clinical trials evaluating new drugs for MS and as secondary endpoints in definitive phase III trials. Metrics derived from non-conventional MRI techniques are now emerging and hold significant promise since they appear to be more correlated with the most disabling features of MS. However, none of these has been approved for use as a surrogate endpoint for accumulation of physical disability, which is the most important clinical endpoint of this disease. Taking into account the large numbers of patients needed, the extensive exposure to placebo, and the relatively long duration required for phase III clinical trials to show a meaningful effect on progression of disability, the need for a valid, reliable, and objective paraclinical marker of disease evolution cannot be overemphasized. This paper reviews the most up-to-date data regarding MRI techniques, their relationship with central nervous system pathology, as well as with clinical endpoints, and proposes future insights into the use of MRI metrics as surrogate endpoints in clinical trials of MS.

Recombinant interferon beta or glatiramer acetate for delaying conversion of the first demyelinating event to multiple sclerosis

BACKGROUND

Immunomodulatory drugs have been shown to be only modestly effective in clinically definite relapsing remitting multiple sclerosis (RRMS). It has been hypothesized that their efficacy could be higher if used at the first appearance of symptoms, that is in the clinically isolated syndromes (CIS) suggestive of demyelinating events, a pathology which carries a high risk to convert to clinically definite MS (CDMS).

OBJECTIVES

The objective of this review was to assess the effects of immunomodulatory drugs compared to placebo in adults in preventing conversion from CIS to CDMS which means the prevention of a second attack.

SEARCH STRATEGY

We searched the Cochrane MS Group Trials Register (June 2007), Cochrane Central Register of Controlled Trials (CENTRAL)The Cochrane Library Issue 3, 2007, MEDLINE (January 1966 to June 2007), EMBASE (January 1974 to June 2007) and reference lists of articles. We also contacted manufacturers and researchers in the field.

SELECTION CRITERIA

The trials selected were double-blind, placebo-controlled, randomised trials of CIS patients treated with immunomodulatory drugs.

DATA COLLECTION AND ANALYSIS

Study selection have been independently done by two reviewers. Two further reviewers independently assessed trial quality and extracted and analysed data. Study authors were contacted for additional informations. Adverse effects information was collected from the trials.

MAIN RESULTS

Only three trials tested the efficacy of interferon (IFN) beta including a total of 1160 participants (639 treatment, 521 placebo); no trial tested the efficacy of glatiramer acetate (GA). The metanalyses showed that the proportion of patients converting to CDMS was significantly lower in IFN beta-treated than in placebo-treated patients both after one year (pooled OR 0.53; 95% CI, 0.40 to 0.71; p <0.0001) as well as after two years of follow-up (pooled OR 0.52; 95% CI, 0.38 to 0.70; p <0.0001). Early treatment with IFN beta was associated with the side effect profile reported by the randomised controlled trials with this drug. Since side effects were reported with some heterogeneity in the three studies the metanalysis was possible only for the frequency of serious adverse events, not significantly different in IFN beta-treated or placebo-treated patients.

AUTHORS' CONCLUSIONS

The efficacy of IFN beta treatment on preventing the conversion from CIS to CDMS was confirmed over two years of follow-up. Since patients had some clinical heterogeneity (length of follow-up, clinical findings of initial attack), it could be useful for the clinical practice to further analyse the efficacy of IFN beta treatment in different patient subgroups.

Review of the clinical evidence for interferon beta 1a (Rebif) in the treatment of multiple sclerosis

Interferon (INF) beta 1a 22 or 44 mug (Rebif((R))) administered s.c. 3 times a week (t.i.w) is a well established immunomodulating treatment for relapsing remitting multiple sclerosis (RRMS). This review focuses on its mechanisms of action, evidence of efficacy, safety, and tolerability. Several pharmacodynamic properties explain the immunomodulatory actions of INF beta 1a 22 or 44 mug s.c. t.i.w. Pivotal trials and post-marketing studies proved that the drug is effective in reducing disease activity and likely in slowing disease progression. Head-to-head comparative studies with other marketed INFs beta in RRMS suggested a better therapeutic response associated with higher doses and frequency of administration of Rebif((R)). Additional evidence indicated a beneficial effect of INF beta 1a in patients with clinically isolated syndromes (CIS) suggestive of MS, as treatment reduced time to conversion to clinically definite (CD) disease. Further, although the drug did not prove to slow time to progression there were benefits on relapse- and MRI-related secondary outcome measures in secondary progressive (SP) MS. Pivotal trials, their cross-over extensions, and post-marketing studies consistently showed that INF beta 1a 22 or 44 mug s.c. t.i.w. is safe and well tolerated, as adverse drug reactions are usually mild and manageable.

[Subcutaneous interferon-beta-1a in the treatment of multiple sclerosis]

During the last 10 years recombinant interferon-beta-1a administered subcutaneously has been the subject of several clinical trials in relapsing remitting multiple sclerosis (RRMS), in secondary progressive MS (SPMS), as well as in clinically isolated syndromes. All of them met the criteria of evidence level class I. Consistent evidence for moderate immunomodulatory effects on clinical parameters of disease activity was gained, and even higher efficacy of IFN-beta-1a sc. on MRI activity of multiple sclerosis was proven. Indirect evidence confirmed the hypothesis of a dose-response curve for IFN-beta-1a formulations in MS. The higher efficacy of IFN-beta-1a 44 microg sc. TIW, however, also includes more adverse events such as injection site reactions, flu-like symptoms and a moderate immunogenicity. Current evidence does not allow a recommendation of IFN-beta-1a sc. as most effective first line therapy, because also the individual patient's choice in the route of administration and long-term effects of neutralizing antibodies to IFN-beta-1a sc. must be taken into account. In the long-term, IFN-beta-1a showed a beneficial safety-tolerability profile with 50 % of patients sticking to the initial immunomodulatory treatment. There were no teratogenic effects, IFN-beta-1a sc. did not enhance depressive symptoms. Data on inhibition of the progression of disease, however, remained inconclusive. Probable beneficial effects of IFN-beta-1a sc. on cognitive function or "chronic fatigue" have not been investigated yet.

The therapy of multiple sclerosis with immune-modulating or immunosuppressive drug. A critical evaluation based upon evidence based parameters and published systematic reviews

Today many different drugs are available for treatment of multiple sclerosis (MS). Interferons, glatiramer acetate, mitoxantrone, and natalizumab have been approved by the regulatory authorities of many countries for the treatment of MS. Evidence based medicine (EBM) principles allow physicians to better address the correct treatment for patients. This article aimed to review all the clinical trials on immune-modulating and immunosuppressive drugs on the basis of the EBM principles. Based on the evidence to date interferon beta represents the best therapeutic option, particularly if given at high doses and with multiple injections per week. Due to its lower efficacy, glatiramer acetate should be used as a second choice in case of intolerable side effects or toxicity of interferon beta. Great efficacy has been demonstrated for mitoxantrone and natalizumab. These drugs should be, however, used with particular attention for their potential toxic effects.

Clinical, magnetic resonance imaging, cerebrospinal fluid and electrophysiological characteristics of the earliest multiple sclerosis

OBJECTIVES

The vast majority of clinically isolated syndrome (CIS) patients with at least two silent brain MRI lesions progress to multiple sclerosis (MS) as early as after 2 years meaning that they actually have MS, the earliest MS. Effective therapy with interferon beta preparations in patients with the earliest MS demands early and accurate diagnosis of the disease.

PATIENTS AND METHODS

In order to find the differentiating clinical and paraclinical characteristics of patients with the earliest MS we compared clinical, MRI, CSF and evoked potential findings in patients with the earliest MS and patients with relapsing-remitting (RR) MS. Retrospective analysis included 149 patients (103 women), among them 40 patients with the earliest MS and 95 patients with RR MS.

RESULTS

Patients with the earliest MS had more often predominant afferent symptoms (p=0.023) but less often predominant cerebellar (p=0.033) and efferent symptoms (p=0.012) than patients with RR MS. They were less likely to fulfill the Barkhof brain MRI criteria (p=0.050) and had less often prolonged latencies of visual evoked potentials (VEP) (p=0.006) than patients with RR MS. On the other hand they were more likely to have elevated CSF cells (p=0.010) than patients with RR MS and had as often present CSF oligoclonal bands (p=0.112).

CONCLUSION

The differentiating characteristics of patients with the earliest MS are predominance of afferent symptoms, less brain MRI dissemination and more frequently normal VEP, but on the other hand abnormal CSF findings with elevated CSF cells and positive oligoclonal bands.

A three-year, multi-parametric MRI study in patients at presentation with CIS

OBJECTIVES

To define the extent of overall brain damage in patients with clinically isolated syndromes (CIS) suggestive of multiple sclerosis (MS) and to identify non-conventional magnetic resonance (MR) metrics predictive of evolution to definite MS.

METHODS

Brain conventional and magnetization transfer (MT) MRI scans were obtained from 208 CIS patients and 55 matched healthy controls, recruited in four centres. Patients were assessed clinically at the time of MRI acquisition and after a median period of 3.1 years from disease onset. The following measures were derived: T2, T1 and gadolinium (Gd)- enhancing lesion volumes (LV), normalized brain volume (NBV), MTR histogram-derived quantities of the normal-appearing white matter (NAWM) and grey matter (GM).

RESULTS

During the follow-up, 43 % of the patients converted to definite MS. At baseline, a significant inter-centre heterogeneity was detected for T2 LV (p = 0.003), T1 LV (p = 0.006), NBV (p < 0.001) and MTR histogram-derived metrics (p < 0.001). Pooled average MTR values differed between CIS patients and controls for NAWM (p = 0.003) and GM (p = 0.01). Gdactivity and positivity of International Panel (IP) criteria for disease dissemination in space (DIS), but not NAWM and GM MTR and NBV, were associated with evolution to definite MS. The final multivariable model retained only MRI IP criteria for DIS (p = 0.05; HR = 1.66, 95 % CI = 1.00-2.77) as an independent predictor of evolution to definite MS.

CONCLUSIONS

Although irreversible tissue injury is present from the earliest clinical stages of MS, macroscopic focal lesions but not "diffuse" brain damage measured by MTR are associated to an increased risk of subsequent development of definite MS in CIS patients.

The role of optical coherence tomography in multiple sclerosis: Expert panel consensus

Optic neuritis (ON), a common manifestation of multiple sclerosis (MS), often occurs as the initial manifestation of central nervous system demyelination or develops during the course of this disease. Since the retinal nerve fiber layer (RNFL) is composed only of unmyelinated axons, measuring RNFL thickness represents a viable method of monitoring axonal loss in these patients. Optical coherence tomography (OCT) is a noninvasive, noncontact, accurate, and reproducible technique that quantitates the thickness of the peripapillary RNFL, fovea, and macula. Because of its potential role in defining axonal loss in ON and in assessing longitudinal changes in the RNFL before and after MS treatment, a multidisciplinary expert panel was charged with the following tasks: assess the current capabilities of OCT; review the current data about OCT, ON, and MS; and determine whether OCT could be a primary or secondary outcome measure in future MS clinical trials. The panel concluded that: [1] OCT is valid and reproducible; [2] OCT has yielded some important limited data concerning cross-sectional studies with ON and MS; [3] more studies are required to correlate OCT results with other measures of MS disease activity; [4] after correlation with these other measures and upon agreement of standardized technical and statistical methods, OCT may evolve into a important primary or secondary outcome metric for MS clinical trials and patient care.

Subgroups of the BENEFIT study: risk of developing MS and treatment effect of interferon beta-1b

BACKGROUND

The BENEFIT study examined interferon beta (IFNB)-1b treatment in patients with clinically isolated syndrome (CIS) and > or = 2 clinically silent brain MRI lesions.

METHODS

Subgroups of 468 patients (IFNB-1b: n = 292; placebo: n = 176) were created for demographics, clinical, laboratory, and MRI findings at onset. The 'natural' risk of clinically definite MS (CDMS) over 2 years was estimated by Kaplan Meier statistics in placebo-treated patients; the IFNB-1b treatment effect was analysed by Cox proportional hazards regression.

RESULTS

The risk of CDMS was increased in placebo-treated patients (overall 45 %) if they were younger (< 30 years: 60%), were cerebrospinal fluid (CSF)-positive (49 %), or had received steroid treatment (48 %). MRI parameters implied a higher risk in placebo-treated patients with > or = 9 T2-lesions (48%) or > or = 1 gadolinium (Gd)-enhancing lesions (52 %). The CDMS risk was highest (75 %) in placebo-treated patients with monofocal disease onset displaying MRI disease activity (> or = 1 Gd-lesion) and dissemination (> or = 9 T2-lesions). Treatment effects were significant across almost all subgroups including patients with less disease dissemination/activity at onset (monofocal: 55%; < 9 T2-lesions: 60%; no Gd-lesions: 57%) and patients without steroid treatment for the CIS (62 %). Monofocal patients had greater treatment effects if they had > or = 9 T2-lesions (61 %), Gd-lesions (58 %), or both (65 %).

CONCLUSIONS

This study confirms the impact of age of onset, CSF and MRI findings on risk of conversion from CIS to CDMS. IFNB-1b treatment effect was robust across the study population including patients without MRI disease activity and less clinical or MRI disease dissemination at onset and patients not receiving steroids for the CIS.

Interferon-beta treatment for multiple sclerosis

Multiple sclerosis (MS) is the leading nontraumatic cause of neurologic disability in young adults. Interferon-beta, approved for use in 1993, was the first treatment to modify the course and prognosis of the disease and remains a mainstay of MS treatment. Numerous large-scale clinical trials in early, active patient populations have established the clinical efficacy of interferon-beta in reducing relapses and delaying disability progression. Although its mechanism of action remains incompletely understood, a reduction in active lesions seen on magnetic resonance imaging implies primary anti-inflammatory properties, a mechanism supported by basic immunologic research. Variation in individual patient responsiveness to interferon-beta may be due to disease variability or differential induction of interferon-stimulated genes. The magnitude of the therapeutic effect appears to be similar among products, but the optimal dose, route, and frequency of administration of the drug remain uncertain.