Economic burden of multiple sclerosis: a systematic review of the literature

Prevalence of multiple sclerosis in the Lazio region, Italy: use of an algorithm based on health information systems

Compared with other areas of the country, very limited data are available on multiple sclerosis (MS) prevalence in Central Italy. We aimed to estimate MS prevalence in the Lazio region and its geographical distribution using regional health information systems (HIS). To identify MS cases we used data from drug prescription, hospital discharge and ticket exemption registries. Crude, age- and gender-specific prevalence estimates on December 31, 2011 were calculated. To compare MS prevalence between different areas within the region, we calculated age- and gender-adjusted prevalence and prevalence ratios using a multivariate Poisson regression model. Crude prevalence rate was 130.5/100,000 (95 % CI 127.5–133.5): 89.7/100,000 for males and 167.9/100,000 for females. The overall prevalence rate standardized to the European Standard Population was 119.6/100,000 (95 % CI 116.8–122.4). We observed significant differences in MS prevalence within the region, with estimates ranging from 96.3 (95 % CI 86.4–107.3) for Latina to 169.6 (95 % CI 147.6–194.9) for Rieti. Most districts close to the coast showed lower prevalence estimates compared to those situated in the eastern mountainous area of the region. In conclusion, this study produced a MS prevalence estimate at regional level using population-based health administrative databases. Our results showed the Lazio region is a high-risk area for MS, although with an uneven geographical distribution. While some limitations must be considered including possible prevalence underestimation, HIS represent a valuable source of information to measure the burden of SM, useful for epidemiological surveillance and healthcare planning.

Multiple Sclerosis Therapy With Disease-Modifying Treatments in Germany: The PEARL (ProspEctive phArmacoeconomic cohoRt evaluation) Noninterventional Study Protocol

Background

Patients with multiple sclerosis (MS) require long-term therapy and have a wide variety of needs for health-related support. The efficacy and safety of MS therapy, as assessed by both clinicians and patients, are important parameters that need to be considered. However, few studies combine data on efficacy and safety outcomes with pharmacoeconomic data.

Objective

Here, we present the study design of the ProspEctive phArmacoeconomic cohoRt evaluation (PEARL), a prospective, multicenter, noninterventional cohort study on patients with relapsing-remitting MS (RRMS) treated with disease-modifying treatments (DMTs).

Methods

During a prospective observational phase of 24 months per patient, PEARL evaluated clinical and patient-perceived efficacy and safety measures, as well as pharmacoeconomic data on RRMS patients treated with DMTs—interferon beta and glatiramer acetate. Measurements of the patients' perceptions included the assessment of patient-reported quality of life, treatment satisfaction, and compliance. The study was planned to include 1800 outpatients from 180 German neurological practices who had continuously been treated with an approved DMT for at least 30 days. The primary statistical analyses of the PEARL study will be descriptive. Particular focus will be on specific subgroups, such as patients who switched DMTs during therapy and patients with disease worsening or disease activity. Subgroups will be compared using stratified analyses.

Results

Data collection for PEARL started in September 2010 and ended in July 2013. As of July 2015, the study is completed and is currently being analyzed and written up.

Conclusions

PEARL is evaluating both the health status and resource utilization of RRMS patients treated with DMTs in Germany. The combination of pharmacoeconomic data with clinical and patients' self-perceived efficacy and safety outcomes will add useful information to the currently incomplete picture of the overall RRMS burden in Germany.

Earnings and Financial Compensation from Social Security Systems Correlate Strongly with Disability for Multiple Sclerosis Patients

Background

Multiple sclerosis (MS) patients earn lower incomes and receive higher benefits. However, there is limited knowledge of how this is correlated with their disability.

Objective

To elucidate sources and levels of income among MS patients with different disability, assessed with the Expanded Disability Status Scale.

Methods

A total of 7929 MS patients aged 21–64 years and living in Sweden in 2010 were identified for this cross-sectional study. Descriptive statistics, logistic and truncated linear regression models were used to estimate differences between MS patients regarding earnings, disability pension, sickness absence, disability allowance, unemployment compensation, and social assistance.

Results

The average level of earnings was ten times lower and the average level of health- related benefits was four times higher when comparing MS patients with severe and mild disability. MS patients with severe disability had on average SEK 166,931 less annual income from earnings and SEK 54,534 more income from benefits compared to those with mild disability. The combined average income for MS patients was 35% lower when comparing patients in the same groups. The adjusted risk ratio for having earnings among MS patients with severe disability compared to the patients with mild disability was 0.33 (95% CI 0.29–0.39), while the risk ratio for having benefits was 1.93 (95% CI 1.90–1.94).

Conclusions

Disease progression affects the financial situation of MS patients considerably. Correlations between higher disability and patient income were observed, suggesting that earnings and benefits could be used as measures of MS progression and proxies of disability.

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

PURPOSE

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

METHODS

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

FINDINGS

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

IMPLICATIONS

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

[Difficulties experienced at work by patients with multiple sclerosis]

AIM

Multiple sclerosis (MS) is a disease of the central nervous system that affects young adults at a time when they launch into the workforce. The disease often has a great impact on working life. The objective of this survey was to identify the problems faced by people with multiple sclerosis in the context of their work.

METHODS

To describe the difficulties experienced at work by patients with multiple sclerosis, we carried out in 2010 a regional survey including neurology and functional rehabilitation centers.

RESULTS

Two hundred and seven MS patients of working age responded to the survey. The employment rate was 67.6%. Among difficulties expressed by patients, physical and mental fatigue appeared as the issues affecting work. For 41% of respondents, preventive measures at work could help maintain or resume employment.

CONCLUSION

Problems of fatigability put forward by MS patients are elements that can predict a loss of employment.

Long-term epidemiology of multiple sclerosis in the Northern Seville District

OBJECTIVES

Comprehensive epidemiologic data for multiple sclerosis (MS) in Spain are limited. The aim of this study was to collect epidemiologic data on MS in the Northern Seville District of Spain.

MATERIALS AND METHODS

This longitudinal study identified possible MS cases every year from nine centres between 1 January 1991 and 31 December 2011. Patients with a confirmed diagnosis of MS were included. MS data prior to enrolment were collected retrospectively from clinical records and prospectively during quarterly follow-up clinic visits. Variables included age at onset, age at diagnosis, treatment, follow-up duration, number of visits, number of relapses, change in the number of relapses over time and Expanded Disability Status Scale score. The incidence and prevalence of MS rate were calculated.

RESULTS

Overall, 156 patients with MS were identified (111 females; mean follow-up 7.5 years). Most patients had relapsing-remitting MS (73.7%); primary progressive disease was less frequent than secondary disease (10.9% vs 15.4%). The yearly incidence of MS was 4.6 per 100,000, and the prevalence at 31 December 2011 was 90.2 per 100,000.

CONCLUSIONS

The annual MS incidence rate in this southern region of Spain was higher than previously reported rates in Spanish studies.

Labour productivity losses caused by premature death associated with hepatitis C in Spain

BACKGROUND AND AIMS

Hepatitis C virus (HCV) infection places a huge burden on healthcare systems. There is no study assessing the impact of HCV infection on premature deaths in Spain. The aim of this study was to estimate productivity losses because of premature deaths attributable to hepatitis C occurring in Spain during 2007-2011.

MATERIALS AND METHODS

We use data from several sources (Registry of Deaths, Labour Force Survey and Wage Structure Survey) to develop a simulation model based on the human capital approach and to estimate the flows in labour productivity losses in the period considered. The attributable fraction method was used to estimate the numbers of deaths associated with HCV infection. Two sensitivity analyses were developed to test the robustness of the results.

RESULTS

Our model shows total productivity losses attributable to HCV infection of 1054.7 million euros over the period analysed. The trend in productivity losses is decreasing over the period. This result is because of improvements in health outcomes, reflected in the reduction of the number of years of potential productive life lost. Of the total estimated losses, 18.6% were because of hepatitis C, 24.6% because of hepatocellular carcinoma, 30.1% because of cirrhosis, 15.9% because of other liver diseases and 10.7% because of HIV-HCV coinfection.

CONCLUSION

The results show that premature mortality attributable to hepatitis C involves significant productivity losses. This highlights the need to extend the analysis to consider other social costs and obtain a more complete picture of the actual economic impact of hepatitis C infection.

Cost-effectiveness of natalizumab vs fingolimod for the treatment of relapsing-remitting multiple sclerosis: analyses in Sweden

OBJECTIVE

To assess the cost-effectiveness of natalizumab vs fingolimod over 2 years in relapsing-remitting multiple sclerosis (RRMS) patients and patients with rapidly evolving severe disease in Sweden.

METHODS

A decision analytic model was developed to estimate the incremental cost per relapse avoided of natalizumab and fingolimod from the perspective of the Swedish healthcare system. Modeled 2-year costs in Swedish kronor of treating RRMS patients included drug acquisition costs, administration and monitoring costs, and costs of treating MS relapses. Effectiveness was measured in terms of MS relapses avoided using data from the AFFIRM and FREEDOMS trials for all patients with RRMS and from post-hoc sub-group analyses for patients with rapidly evolving severe disease. Probabilistic sensitivity analyses were conducted to assess uncertainty.

RESULTS

The analysis showed that, in all patients with MS, treatment with fingolimod costs less (440,463 Kr vs 444,324 Kr), but treatment with natalizumab results in more relapses avoided (0.74 vs 0.59), resulting in an incremental cost-effectiveness ratio (ICER) of 25,448 Kr per relapse avoided. In patients with rapidly evolving severe disease, natalizumab dominated fingolimod. Results of the sensitivity analysis demonstrate the robustness of the model results. At a willingness-to-pay (WTP) threshold of 500,000 Kr per relapse avoided, natalizumab is cost-effective in >80% of simulations in both patient populations.

LIMITATIONS

Limitations include absence of data from direct head-to-head studies comparing natalizumab and fingolimod, use of relapse rate reduction rather than sustained disability progression as the primary model outcome, assumption of 100% adherence to MS treatment, and exclusion of adverse event costs in the model.

CONCLUSIONS

Natalizumab remains a cost-effective treatment option for patients with MS in Sweden. In the RRMS patient population, the incremental cost per relapse avoided is well below a 500,000 Kr WTP threshold per relapse avoided. In the rapidly evolving severe disease patient population, natalizumab dominates fingolimod.

Sources and level of income among individuals with multiple sclerosis compared to the general population: A nationwide population-based study

Introduction:

Multiple sclerosis (MS) is associated with reduced work capacity, but there is limited knowledge about MS patients’ sources of income.

Objectives:

The purpose of this study was to elucidate MS patients’ earnings and social benefits compared to those of the general population.

Methods:

From nationwide registers of all residents in Sweden aged 21–64 years in 2010 ( n=5,291,764), those with an MS diagnosis ( n=13,979) were compared to a propensity score matched reference group ( n=69,895). Descriptive statistics and regression models were used to estimate the percentage difference between the MS patients and the matched references regarding the following annual incomes: earnings, disability pension, sickness absence, disability allowance, unemployment compensation and social assistance.

Results:

Both MS patients and the matched references received most of their income from earnings followed by disability pension and sickness absence. MS patients that were diagnosed in 2010 had 15% lower earnings than the matched references, while MS patients diagnosed before 2005 had 38% lower earnings. Corresponding figures regarding summed social benefits were 33% and 130% higher for MS patients, respectively.

Conclusion:

The results indicate that MS patients are overrepresented, in relative and absolute terms, regarding health-related benefits and have lower levels of earnings. However, the redistributing welfare systems appear to financially compensate the MS patients considerably.

Financial turning points and transitions for people with multiple sclerosis: Towards sustainable employment outcomes

People with disability experience significant levels of economic disadvantage potentially resulting in their poverty, social exclusion and dependence on welfare. Low labour participation rates are a large contributor to such economic and social exclusion. This study was conducted in Australia where 45% of people with disability are living at or below the poverty line. Within this context, this article first defines and examines the constructs of Financial Turning Points and Financial Transitions experienced by people with disability, an area not previously examined in the literature. Then, a collective case study is presented portraying the experiences of Financial Turning Points and Financial Transitions for people with multiple sclerosis (MS). Concluding remarks are directed towards the need to critically re-evaluate ways of thinking about work to enable people with disability to remain productive participants in employment, to better facilitate of their financial futures.

Financial turning points and transitions for people with multiple sclerosis: Towards sustainable employment outcomes

People with disability experience significant levels of economic disadvantage potentially resulting in their poverty, social exclusion and dependence on welfare. Low labour participation rates are a large contributor to such economic and social exclusion. This study was conducted in Australia where 45% of people with disability are living at or below the poverty line. Within this context, this article first defines and examines the constructs of Financial Turning Points and Financial Transitions experienced by people with disability, an area not previously examined in the literature. Then, a collective case study is presented portraying the experiences of Financial Turning Points and Financial Transitions for people with multiple sclerosis (MS). Concluding remarks are directed towards the need to critically re-evaluate ways of thinking about work to enable people with disability to remain productive participants in employment, to better facilitate of their financial futures.

Physical fitness assessment in multiple sclerosis patients: a controlled study

There is growing evidence to show the effectiveness of physical exercise for multiple sclerosis (MS) patients. Aim of this study was to evaluate aerobic capacity, strength, balance, and the rate of perceived exertion (RPE) after exercise, in ambulatory patients with mild MS and matched control healthy participants. Seventeen MS patients aged 48.09 ± 10.0 years, with mild MS disability (Expanded Disability Status Scale: EDSS 1.5 to 4.5) and 10 healthy sedentary age matched (41.9 ± 11.2 years) subjects volunteered for the study. MS patients underwent medical examination with resting electrocardiogram, arterial blood pressure, EDSS, and Modified Fatigue Impact Scale-MFIS. Both groups also underwent physical assessment with the Berg Balance Scale(,) test (Berg), Six Minutes Walking Test (6MWT), maximal isometric voluntary contraction (MIVC) of forearm, lower limb, shoulder strength test, and the Borg 10-point scale test. The one-way ANOVA showed significant differences for MFIS (F1.19=9.420; p<0.01), Berg (F1.19=13.125; p<0.01), handgrip MIVC (F1.19=4.567; p<0.05), lower limbs MIVC (F1.19=7.429; p<0.01), and 6MWT (F1.19=28.061; p<0.01) between groups. EDSS, Berg test and Borg scores explained 80% of 6MWT variation. Mild grade EDSS patients exhibited impaired balance, muscle strength, and low self pace-6MWT scores, whereas RPE response after the exercise was similar to that of sedentary individuals. Both groups showed similar global physiological adjustments to exercise.

Development of dalfampridine, a novel pharmacologic approach for treating walking impairment in multiple sclerosis

Walking impairment is a clinical hallmark of multiple sclerosis (MS). Dalfampridine-ER, an extended-release formulation of dalfampridine (also known by its chemical name, 4-aminopyridine, and its international nonproprietary name, fampridine), was developed to maintain drug plasma levels within a narrow therapeutic window, and assessed for its ability to improve walking in MS. The putative mechanism of action of dalfampridine-ER is restoration of axonal conduction via blockade of the potassium channels that become exposed during axonal demyelination. Two pivotal phase III clinical trials demonstrated that dalfampridine-ER 10-mg tablets administered twice daily improved walking speed and patient-reported perceptions of walking in some patients. Dalfampridine-ER was generally well tolerated, and, at the approved dose, risk of seizure was neither elevated relative to placebo nor higher than the rate in the MS population. Dalfampridine-ER (AMPYRA®) was approved in the United States for the treatment of walking in patients with MS as demonstrated by an increase in walking speed. The use of the dalfampridine-ER is contraindicated in patients with a history of seizure. It is the first pharmacologic therapy for this indication and has been incorporated into clinical management of MS.

Updated cost-of-care estimates for commercially insured patients with multiple sclerosis: retrospective observational analysis of medical and pharmacy claims data

Background

For patients with multiple sclerosis (MS), previous research identified key disease sequelae as important cost drivers and suggested that among users of disease-modifying drugs (DMDs) in 2004, DMDs represented 73% of the total cost of care. More recent studies were limited to incident disease/treatment and/or excluded DMDs from cost estimates. To support contemporary pharmacoeconomic analyses, the present study was conducted to provide updated information about MS-related costs and cost drivers including DMDs.

Methods

For each of 2 years, 2006 and 2011, commercially insured, continuously eligible patients with ≥ 1 medical claim diagnosis of MS were sampled. MS-related charges were based on medical claims with MS diagnosis plus medical/pharmacy claims for DMDs. 2006 charges were adjusted to 2011 $ using the medical care component of the consumer price index (CPI). Subgroups of patients using DMDs (interferon [IFN] beta-1a intramuscular or subcutaneous, IFN beta-1b, glatiramer, natalizumab) in 2011 were identified. By-group differences were tested with bivariate statistics.

Results

Mean (standard deviation [SD]) age of 15,902 sample patients in 2011 was 47.6 (11.8) years, 76% female. Mean [SD] MS charges ($26,520 [$38,478] overall) were significantly (P < 0.001) higher for patients with common disease sequelae: malaise/fatigue (n = 2,235; $39,948 [$48,435]), paresthesia (n = 1,566; $33,648 [$45,273]), depression (n = 1,255; $42,831 [$51,693]), and abnormality of gait (n = 1,196; $48,361 [$55,472]). From 2006 to 2011, CPI-adjusted MS charges increased by 60%. Among patients treated with a single DMD in 2011, inpatient care was 6% of charges (range = 4%-8%; P = 0.155); outpatient care was 19% (range = 14%-20% except for natalizumab [29%]; P < 0.001); and DMDs were 75% (range = 67%-81%; P < 0.001).

Conclusions

Common MS sequelae remain important cost drivers. Although MS treatment costs are increasing, the proportion of MS charges due to DMDs in 2011 is similar to that reported in 2004.

Social participation in patients with multiple sclerosis: correlations between disability and economic burden

BACKGROUND

Economic costs related to treatment of multiple sclerosis (MS) must be justified by health state, quality of life (QOL) and social participation improvement. This study aims to describe correlations between social participation, economic costs, utility and MS-specific QOL in a sample of patients with MS (pwMS).

METHODS

We interviewed 42 pwMS receiving natalizumab and collected clinical data, direct medical costs, productivity loss, utility (EQ5D-VAS), MS-specific QOL (SEP-59), social participation with the Impact on Participation and Autonomy questionnaire (IPA). We performed descriptive and correlation analyses.

RESULTS

41 pwMS, with a mean Expanded Disability Status Scale (EDSS) score of 4.0, completed questionnaires. Mean annual global cost per patient was 68448 +/-33374 Euros and increased with EDSS (r = 0.644), utility (r = -0.456) and IPA (r = 0.519-0.671) worsening. Mean utility was 0.52 +/- 0.28. Correlations between IPA and QOL (EQ5D-VAS or SEP-59) were observed (r = -0.53 to -0.78). Association between QOL and EDSS was smaller (EQ5D-VAS) or absent. Productivity losses were poorly correlated to EDSS (r = 0.375).

CONCLUSION

Moderate to strong correlations of social participation with clinical status (EDSS), QOL, utility and economic costs encourage exploring better these links in larger cohorts. The stronger correlation between social participation and QOL than between EDSS and QOL needs to be confirmed.

Comparisons of Costs between Black Caribbean and White British Patients with Advanced Multiple Sclerosis in the UK

Background. Multiple sclerosis (MS) is now more common among black and minority ethnic groups in the UK but little is known about the costs of care amongst different ethnic groups. Objective. This study examined and compared service use and costs for people severely affected with MS from Black Caribbean (BC) and White British (WB) backgrounds in the UK and identified predictors of cost for both groups. Method. Population-based cross-sectional study of 43 BC and 43 WB patients with MS (EDSS ≥ 6) and their informal caregivers recruited from an MS service in southeast London. Interviews collected data on health and social service use and informal care support. Costs were calculated using UK unit cost data. Using regression analyses we compared costs between the ethnic groups and identified possible predictors of cost. Results. The mean (SD) costs for the WB and BC groups were £ 25,778 ( £ 39,387) and £ 23,186 ( £ 30,433), respectively. Results identified no significant difference in total cost between the two ethnic groups. The EDSS score alone was a significant predictor of cost. Conclusion. Similar costs between ethnic groups indicate that with regard to this MS service and geographical area, access to care was not affected by ethnicity.

Clinical outcomes following surgical management of coexistent cervical stenosis and multiple sclerosis: a cohort-controlled analysis

BACKGROUND CONTEXT

The presentation of myelopathy in patients with the concomitant diagnosis of cervical stenosis (CS) and multiple sclerosis (MS) complicates both diagnosis and treatment because of the similarities of presentation and disease progression. There are only a few published case series that examine this unique patient population.

PURPOSE

To define the demographic features and presenting symptoms of patients with both MS and CS and to investigate the immediate and long-term outcomes of surgery in patients with MS and CS.

STUDY DESIGN/SETTING

Matched cohort-controlled retrospective review of 77 surgical patients in the MS group and 77 surgical patients in the control group. Outcome measures were immediate and long-term postoperative neck pain, radiculopathy, and myelopathy; Nurick Disability and modified Japanese Orthopaedic Association scores were collected as well.

METHODS

Retrospective review was performed for all patients presenting at one institution between January 1996 and July 2011 with coexisting diagnoses of MS and CS who had presenting symptoms of myelopathy and who then underwent cervical decompression surgery. Each study patient was individually matched to a control patient of the same gender and age that did not have MS, but that did have cervical spondylotic myelopathy or myeloradiculopathy. Each control patient underwent the same surgical procedure within the same year.

RESULTS

A total of 154 patients were reviewed, including 77 MS patients and 77 control patients, for an average follow-up of 58 months and 49 months, respectively. Patients in the control group were more likely to have preoperative neck pain (78% vs. 47%; p=.0001) and preoperative radiculopathy (90% vs. 75%; p=.03) than their counterparts in the MS group. Patients in the MS group had a significantly lower rate of postoperative resolution of myelopathic symptoms in both the short-term (39% in the MS group did not improve vs. 23% in the control group; p=.04) and the long-term (44% in the MS group did not improve vs. 19% in the control group; p=.004). Preoperative myelopathy scores were worse for the MS cohort as compared with the control cohort (1.8 vs. 1.2 in the Nurick scale, p<.0001; 13.7 vs. 15.0 in the modified Japanese Orthopaedic Association scale, p=.002). This difference in scores became even greater at the last follow-up visit with Nurick scores of 2.4 versus 0.9 (p<.0001) and modified Japanese Orthopaedic Association scores of 16.3 versus 12.4 (p<.0001) for the MS and control patients, respectively.

CONCLUSIONS

Myelopathic patients with coexisting MS and CS improve after surgery, although at a lower rate and to a lesser degree than those without MS. Therefore, surgery should be considered for these patients. MS patients should be informed that myelopathy symptoms are less likely to be alleviated completely or may only be alleviated temporarily because of progression of MS and that surgery can help alleviate neck pain and radicular symptoms.

The Effect of Community Exercise Interventions for People with MS Who Use Bilateral Support for Gait

Background. Mobility limitations are a key feature of MS and 25% will require the use of a walking aid 15 years after diagnosis. Few studies have specifically evaluated the effectiveness of physiotherapy and exercise interventions delivered in the community for those with significant disability. Methods. An assessor blind, block randomised, and controlled study recruited participants who required bilateral assistance for gait and who occasionally used wheelchairs for longer distances. They were randomised to 10 weeks of group physiotherapy (balance and strengthening exercises), individual physiotherapy, yoga group, or a control group. Results. Repeated measures ANOVA found significant time effects for physical component of MSIS-29v2 (f = 7.993, P = 0.006) and MFIS (f = 8.695, P = 0.004). The group × time interaction was significant for the BBS (f = 4.391, P = 0.006). Post hoc analysis revealed no difference between group and individual physiotherapy for BBS. There was no significant difference between groups but the 6MWT improved for individual physiotherapy (P = 0.001) and MSIS-29v2 psychological score for group physiotherapy (P = 0.005). Discussion. This study found that balance and strengthening exercises, delivered in the community to those with significant mobility limitations, improve balance. The effect on walking endurance and patient-reported outcomes are unclear and warrants further investigation with a larger control group with similar baseline characteristics to the intervention groups.

Health care-resource utilization before and after natalizumab initiation in multiple sclerosis patients in the US

Objectives

To evaluate multiple sclerosis (MS)-related health care-resource utilization and costs prior to and after initiating natalizumab in the US.

Materials and methods

A retrospective administrative claims analysis was conducted using the Truven Health MarketScan Databases to identify adults diagnosed with MS who initiated natalizumab (index date) between January 1, 2007 and December 31, 2010. Patients had ≥24 months of continuous enrollment (12 months before [preperiod] and 12 months after [postperiod] the index date) and remained on natalizumab for the 12-month postperiod. Patients with and without other disease-modifying treatment (DMT) during the preperiod were examined. Patient characteristics, MS-related inpatient stays, and corticosteroid use were compared in the pre- and postperiods using paired statistical tests, where appropriate.

Results

The study comprised 1,458 patients, mean age 45.2 years (standard deviation 10.5), 74.2% female. The majority (70.3%) used a DMT during the preperiod. After initiating natalizumab, there was a significant reduction in the percentage of patients with MS-related inpatient stays (7.6% versus 2.4%, P<0.001), MS-related inpatient costs (median US $12,078 versus US $9,784, P<0.001), and length of stay (7.12 days versus 6.26 days, P=0.005). Both cohorts showed a reduction in the percentage of patients with MS-related inpatient stays and costs with greater reductions for patients without DMTs in the preperiod (−6.2% [P<0.001] and −US $1,496 [P=0.056], respectively) compared to those with a DMT in the preperiod (−4.8% and −US $1,262, respectively, P<0.001 for both). Compared to the preperiod, there were significant reductions in intravenous and oral corticosteroid use for natalizumab initiators (−60.1% and −52.9%, respectively, P<0.001 for both). These utilization reductions correspond to mean corticosteroid cost-per-patient reductions of −US $101 across all natalizumab users (P<0.001).

Conclusion

The initiation of natalizumab was associated with significant decreases in MS-related inpatient stays, and corticosteroid use with corresponding decreases in length of stay and costs among natalizumab users with and without DMTs in the prior year.

Cost-effectiveness of natalizumab in multiple sclerosis: an updated systematic review

As natalizumab (Tysabri; Elan Pharmaceuticals, Inc., Dublin, Ireland) and other disease-modifying drugs are entering the market for multiple sclerosis, the treatment repertoire is expanding beyond the established first-line treatments. This is creating new opportunities but also increasing the uncertainty in the appropriate management of this condition with its considerable societal burden. As a result, economic evaluations are increasingly influential in healthcare decision making. Seven evaluations that included natalizumab have been published to date. They largely report favorable results for this treatment compared with other drugs. However, the models used to reach these conclusions have been subjected to significant debate, owing to limited data availability as well as the methodological complexities and uncertainties in the pharmacoeconomics of multiple sclerosis. This review critically discusses the available evidence based on the cost-effectiveness of natalizumab and uses the data to explain more general issues in the evaluation of similar drugs. The review also suggests how shortcomings in current studies may potentially be addressed in the future.

Cost minimisation analysis of fingolimod vs natalizumab as a second line of treatment for relapsing-remitting multiple sclerosis

INTRODUCTION

At present, there is a lack of economic assessments of second-line treatments for relapsing-recurring multiple sclerosis. The aim of this study was to compare the efficiency between fingolimod and natalizumab in Spain.

METHODS

A cost minimisation analysis model was developed for a 2-year horizon. The same relapse rate was applied to both treatment arms and the cost of resources was calculated using Spain's stipulated rates for 2012 in euros. The analysis was conducted from the perspective of Spain's national health system and an annual discount rate of 3% was applied to future costs. A sensitivity analysis was performed to validate the robustness of the model.

RESULTS

Indirect comparison of fingolimod with natalizumab revealed no significant differences (hazard ratio between 0.82 and 1.07). The total direct cost, considering a 2-year analytical horizon, a 7.5% discount stipulated by Royal Decree, and a mean annual relapse rate of 0.22, was € 40914.72 for fingolimod and € 45890.53 for natalizumab. Of the total direct costs that were analysed, the maximum cost savings derived from prescribing fingolimod prescription was € 4363.63, corresponding to lower administration and treatment maintenance costs. Based on the sensitivity analysis performed, fingolimod use was associated with average savings of 11% (range 3.1%-18.7%).

CONCLUSIONS

Fingolimod is more efficient than natalizumab as a second-line treatment option for relapsing-remitting multiple sclerosis and it generates savings for the Spanish national health system.

Teriflunomide reduces relapse-related neurological sequelae, hospitalizations and steroid use

Multiple sclerosis (MS) relapses impose a substantial clinical and economic burden. Teriflunomide is a new oral disease-modifying therapy approved for the treatment of relapsing MS. We evaluated the effects of teriflunomide treatment on relapse-related neurological sequelae and healthcare resource use in a post hoc analysis of the Phase III TEMSO study. Confirmed relapses associated with neurological sequelae [defined by an increase in Expanded Disability Status Scale/Functional System (sequelae-EDSS/FS) ≥ 30 days post relapse or by the investigator (sequelae-investigator)] were analyzed in the modified intention-to-treat population (n = 1086). Relapses requiring hospitalization or intravenous (IV) corticosteroids, all hospitalizations, emergency medical facility visits (EMFV), and hospitalized nights for relapse were also assessed. Annualized rates were derived using a Poisson model with treatment, baseline EDSS strata, and region as covariates. Risks of sequelae and hospitalization per relapse were calculated as percentages and groups were compared with a χ(2) test. Compared with placebo, teriflunomide reduced annualized rates of relapses with sequelae-EDSS/FS [7 mg by 32 % (p = 0.0019); 14 mg by 36 % (p = 0.0011)] and sequelae-investigator [25 % (p = 0.071); 53 % (p < 0.0001)], relapses leading to hospitalization [36 % (p = 0.015); 59 % (p < 0.0001)], and relapses requiring IV corticosteroids [29 % (p = 0.001); 34 % (p = 0.0003)]. Teriflunomide-treated patients spent fewer nights in hospital for relapse (p < 0.01). Teriflunomide 14 mg also decreased annualized rates of all hospitalizations (p = 0.01) and EMFV (p = 0.004). The impact of teriflunomide on relapse-related neurological sequelae and relapses requiring healthcare resources may translate into reduced healthcare costs.

Teriflunomide in relapsing multiple sclerosis: therapeutic utility

Teriflunomide is an oral, once-daily disease-modifying therapy (DMT) approved in the USA, Australia, and Argentina for the treatment of relapsing forms of multiple sclerosis (RMS). Teriflunomide reversibly limits the expansion of activated T and B cells associated with the inflammatory process purportedly involved in multiple sclerosis pathogenesis, while preserving lymphocytes for routine immune surveillance. In an extensive clinical development program, teriflunomide demonstrated consistent benefits on both clinical and magnetic resonance imaging outcomes. In long-term studies, teriflunomide treatment was associated with low rates of relapse and disability progression for up to 8 years. The safety profile of teriflunomide has been well characterized, with adverse events generally mild to moderate in nature and infrequently leading to permanent treatment discontinuation. The evidence reviewed here indicates that teriflunomide is an effective addition to the current DMTs used to treat RMS.

Laquinimod for multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, demyelinating, neurodegenerative disorder of the central nervous system, and it causes major socioeconomic burden for the individual patient and for society. An inflammatory pathology occurs during the early relapsing stage of MS and a neurodegenerative pathology dominates the later progressive stage of the disease. Not all MS patients respond adequately to currently available disease-modifying drugs (DMDs). Alternative MS treatments with new modes of action are required to expand the current options for disease-modifying therapies (DMTs) and to aim for freedom from relapses, inflammatory lesions, disability progression and neurodegeneration. Laquinimod has dual properties of immunomodulation and neuroprotection and is a potentially promising new oral DMD in the treatment of relapsing MS.

OBJECTIVES

To assess the effectiveness and safety profile of laquinimod as monotherapy or combination therapy versus placebo or approved DMDs (interferon-β, glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, dimethyl fumarate) for modifying the disease course in patients with MS.

SEARCH METHODS

The Review Group Trials Search Co-ordinator searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register which, among other sources, contains trials from CENTRAL (The Cochrane Library 2013, Issue 2), MEDLINE, EMBASE, CINAHL, LILACS, PEDro and Clinical trials registries (29 April 2013). We checked references in identified trials and manually searched the reports (2004 to March 2013) from neurological associations and MS societies. We also communicated with researchers participating in trials on laquinimod and contacted Teva Pharmaceutical Industries.

SELECTION CRITERIA

All randomised, double-blind, controlled, parallel group clinical trials (RCTs) with a length of follow-up of at least one year evaluating laquinimod, as monotherapy or combination therapy, versus placebo or approved DMDs for patients with MS.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. Disagreements were discussed and resolved by consensus among review authors. Principal investigators of included studies were contacted for additional data or confirmation of information.

MAIN RESULTS

Only one study met our inclusion criteria, involving 1106 adult patients with relapsing-remitting MS (RRMS) and an entry Expanded Disability Status Scale (EDSS) score of ≤ 5.5 and an entry disease duration of ≥ 6 months. Five hundred and fifty patients treated with laquinimod at a dose of 0.6 mg orally administered once daily in a capsule were compared with 556 patients treated with a matching placebo capsule. The study had a high risk for attrition bias (21.9%). Laquinimod had potential benefits in reducing relapse rates and was safe for most patients with RRMS in the short term. The most common adverse events included headache, back pain, arthralgia, diarrhoea, cough, urinary tract infection, elevated alanine aminotransferase, insomnia, nausea, abdominal pain and sinusitis. One ongoing trial was identified.

AUTHORS' CONCLUSIONS

We found low-level evidence for the use of laquinimod as a disease-modifying therapy for MS because only one study with limited quality (high risk of attrition bias) was included. The published study suggests that laquinimod at a dose of 0.6 mg orally administered once daily may be safe and have potential benefits for most patients with RRMS in the short term. We are waiting for the publication of ongoing trials.

The economic impact of multiple sclerosis in Australia in 2010

Background:

Multiple sclerosis (MS) has a major impact on health and is a substantial burden on patients and society. We estimated the annual costs of MS in Australia from individual and societal perspectives using data from the Australian MS Longitudinal Study (AMSLS) and prevalence figures from 2010.

Methods:

Direct and indirect costs were estimated from a subsample of 712 AMSLS subjects who completed baseline and follow-up economic impact surveys. All costs are in 2010 Australian dollars (AUD).

Results:

Annual costs per person with MS were AUD48,945 (95% CI: 45,138 to 52,752). Total costs were AUD1.042 (0.9707 to 1.1227) billion based on a prevalence of 21,283. The largest component was indirect costs due to loss of productivity (48%). Costs increased with increasing disability: AUD36,369, AUD58,890 and AUD65,305 per patient per year for mild, moderate and severe disability, respectively. Total costs of MS to Australian society have increased 58% between 2005 and 2010.

Conclusions:

This study confirms that MS imposes a substantial burden on Australian society, particularly impacting on productivity. The burden increases with worsening disability associated with the disease. Investment in interventions that slow progression, as well as resources, services and environments that assist people with MS to retain employment, is supported.

Direct and indirect cost burden associated with multiple sclerosis relapses: excess costs of persons with MS and their spouse caregivers

BACKGROUND

MS relapses are unpredictable and can be concerning to patients and their caregivers.

OBJECTIVE

To assess the direct and indirect cost burden associated with relapses of different severities in MS patients and with MS relapse frequency on spouse caregivers.

METHODS

Using a U.S. insurance claims and employee disability database (1999-2011), we studied adult MS patients (ICD-9-CM: 340.x) and their spouse caregivers. A previously published algorithm to identify relapses was used to stratify: (1) MS patients into cohorts of no, low/moderate, and high severity relapse based on the most severe relapse within one year of follow-up (if any); (2) caregivers into cohorts of no, less, and more frequent relapses based on the overall frequency of relapses of their spouse. Adjusted cost differences and 95% confidence intervals evaluating the yearly incremental costs at 12 months of follow-up (MS patients) and overall (caregivers) associated with relapses are reported.

RESULTS

Among the 9421 MS patients (N: no relapse=7686; low/moderate severity relapse=1220; high severity relapse=515) identified, both relapse cohorts incurred significantly higher annual incremental direct costs than the no relapse cohort (low/moderate severity=$8269 [6565-10,115]; high severity=$24,180 [20,263-28,482]) and indirect costs (low/moderate severity=$1429 [759-2147]; high severity=$2714 [1468-4035]). More frequent relapses versus no relapse also translated into a significantly greater cost burden for caregivers (direct+indirect=$1725 [376-2885]) but less frequent relapses did not.

CONCLUSIONS

Relapse severity was significantly and increasingly associated with greater direct and indirect costs in MS patients. More frequent relapses also translated into a significant cost burden in spouse caregivers.

Impact of mobility impairment on indirect costs and health-related quality of life in multiple sclerosis

This study was conducted to estimate the indirect costs and health-related quality of life (HRQoL) (utilities) of multiple sclerosis (MS) patients in the United States (US), and to determine the impact of worsening mobility on these parameters. In collaboration with the North American Research Committee on Multiple Sclerosis (NARCOMS) registry we conducted a cross-sectional study of participants who completed the biannual update and supplemental spring 2010 survey. Demographic, employment status, income, mobility impairment, and health utility data were collected from a sample of registry participants who met the study criteria and agreed to participate in the supplemental Mobility Study. Mean annual indirect costs per participant in 2011US$ and mean utilities for the population and for cohorts reporting different levels of mobility impairment were estimated. Analyses included 3,484 to 3,611 participants, based on survey completeness. Thirty-seven percent of registrants were not working or attending school and 46.7% of these reported retiring early. Indirect costs per participant per year, not including informal caregiver cost, were estimated at $30,601±31,184. The largest relative increase in indirect costs occurred at earlier mobility impairment stages, regardless of the measure used. Participants’ mean utility score (0.73±0.18) was lower than that of a similarly aged sample from the general US population (0.87). As with indirect costs, larger decrements in utility were seen at earlier mobility impairment stages. These results suggest that mobility impairment may contribute to increases in indirect costs and declines in HRQoL in MS patients.

The cost burden of multiple sclerosis in the United States: a systematic review of the literature

OBJECTIVES

To estimate average annual cost per multiple sclerosis (MS) patient in the US using published estimates from the literature.

METHODS

A search was performed of English-language literature published between 2007 and June 2012 in PubMed and Embase using the term 'multiple sclerosis' and the subject heading 'healthcare costs'. Included articles were primary studies with MS cost figures that could be converted to per patient per year values. Costs were inflated to 2011 dollars using the medical component of the Consumer Price Index.

RESULTS

Fifteen studies met the inclusion criteria. Eight presented only direct cost calculations; the remaining seven presented estimates of total cost, broken down into direct and indirect costs. Total all-cause healthcare costs for MS as reported by studies that included direct and indirect costs ranged from $8528-$54,244 per patient per year. On average, direct costs comprised 77% (range 64-91%) of total costs. Prescription medications accounted for the majority of direct costs. On average, indirect costs comprised 23% (range 9-36%) of total costs. Compared with direct all-cause medical costs for other chronic conditions reported in the literature, MS ranked second behind congestive heart failure.

LIMITATIONS

Data sources in these studies were dated, ranging from 1999-2008, and therefore do not include some of the newer, more costly therapies. In addition, this review does not include either assessment of the decrements in quality-of-life associated with MS or costs associated with increasing levels of disability or early retirement. Furthermore, variations in study designs, populations, methodologies, and cost inputs preclude more precise cost estimates.

CONCLUSIONS

MS is a costly chronic disease. Further research is needed to understand: costs by MS type, costs associated with increasing disability and early retirement, and the potential impact of new treatments expected to launch in coming years.

Review of the pharmacoeconomics of early treatment of multiple sclerosis using interferon beta

Multiple sclerosis (MS) is a common neurological disease with increasing incidence and prevalence. Onset of disease is most frequently in young adulthood when productivity is usually highest; it is of chronic nature and, in the majority of patients, it will result in accumulation of disability. Due to loss of productivity in patients and caregivers as well as high expenses for medical treatment, MS is considered a disease with high economic burden for patients and society. Several drugs have been approved for treatment of MS. While treatment ameliorates the course of the disease, it is very costly; therefore, pharmacoeconomics, evaluating costs and effects of disease-modifying treatment in MS, has become an important issue. Here, we review the economic impact and treatment strategies of MS and discuss recent studies on pharmacoeconomics of early treatment with interferon beta.

Anti-integrin therapy for multiple sclerosis

Integrins are the foremost family of cell adhesion molecules that regulate immune cell trafficking in health and diseases. Integrin alpha4 mediates organ-specific migration of immune cells to the inflamed brain, thereby playing the critical role in the pathogenesis of multiple sclerosis. Anti-alpha4 integrin therapy aiming to block infiltration of autoreactive lymphocytes to the inflamed brain has been validated in several clinical trials for the treatment of multiple sclerosis. This paper provides readers with an overview of the molecular and structural bases of integrin activation as well as rationale for using anti-alpha4 integrin therapy for multiple sclerosis and then chronicles the rise and fall of this treatment strategy using natalizumab, a humanized anti-alpha4 integrin.

Teriflunomide for multiple sclerosis

BACKGROUND

Disease-modifying therapies (DMTs) for multiple sclerosis aim to specifically reduce inflammation in relapsing multiple sclerosis and promote neuroprotection and neurorepair in progressive multiple sclerosis (MS). Most of the currently available disease-modifying drugs (DMDs) require regular and frequent parenteral administration, which imposes a burden on patients and leads to reduced adherence. Not all MS patients respond adequately to current DMDs and, therefore, alternative MS treatments with less invasive routes of administration and new modes of action are required to expand the current treatment repertoire, increase adherence, and thereby improve efficacy. As one of the oral DMDs, teriflunomide is a potentially promising new oral agent in the treatment of relapsing MS. It inhibits dihydro-orotate dehydrogenase (DHODH) and the synthesis of pyrimidine and has selective immunosuppressive and immunomodulatory properties.

OBJECTIVES

To explore the potential benefits of teriflunomide and so expand the available DMT options, the effectiveness and safety of teriflunomide, as monotherapy or combination therapy, were assessed versus placebo or approved DMDs (IFN-β, glatiramer acetate, natalizumab, mitoxantrone, fingolimod) for modifying disease in patients with MS.

SEARCH METHODS

The Trials Search Co-ordinator searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register (27 June 2012). We checked references in identified trials and manually searched the reports (2004 to June 2012) from neurological associations and MS societies. We also communicated with researchers participating in trials on teriflunomide and contacted Sanofi-Aventis.

SELECTION CRITERIA

All randomised, double-blind, controlled, parallel clinical trials (RCTs) with a length of follow-up of at least one year evaluating teriflunomide, as monotherapy or combination therapy, versus placebo or other treatments (IFN-β, glatiramer acetate, natalizumab, mitoxantrone, fingolimod) for patients with MS. Titles and abstracts of the citations retrieved by the literature search were screened independently for inclusion or exclusion by two review authors. Any disagreement regarding inclusion was resolved by discussion or by referral to a third assessor if necessary.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. Disagreements were discussed and resolved by consensus among review authors. Principal investigators of included studies were contacted for additional data or confirmation of information.

MAIN RESULTS

Two studies involving 1204 people evaluated the efficacy and safety of teriflunomide 7 mg and 14 mg, alone or with add-on IFN-β, versus placebo for adult patients with relapsing forms of MS (relapsing-remitting (RRMS), secondary progressive (SPMS) with relapse, and progressive relapsing MS (PRMS)) and an entry Expanded Disability Status Scale (EDSS) score of ≤ 5.5. Both studies had high attrition bias (26.8% and 36.4% attrition respectively). Teriflunomide 7 or 14 mg alone had potential benefits on reducing relapse rates, and alone or with add-on IFN-β was safe for patients with relapsing forms of MS in the short term. The most common adverse events included nasopharyngitis, headache, diarrhoea, fatigue, elevated alanine aminotransferase levels, nausea, hair thinning or decreased hair density, influenza, back pain, urinary tract infection, and pain in the arms or legs. Four ongoing trials were identified.

AUTHORS' CONCLUSIONS

We found low-level evidence for the use of teriflunomide as a disease-modifying therapy for MS, due to the limited quality of the available RCTs. We did not conduct meta-analysis because of the clinical and methodological diversity of the included studies. Short-term teriflunomide, 7 or 14 mg alone or with add-on IFN-β, was safe for patients with relapsing MS. Both teriflunomide 7 and 14 mg alone had potential benefits for patients with relapsing forms of MS. We are waiting for the publication of ongoing trials. RCTs with high methodological quality and longer periods of observation are needed to assess safety, disability progression, neuroprotection and quality of life.

BG-12 and its potential for the prevention of relapse in multiple sclerosis

Multiple sclerosis (MS) arises from an immune attack on the central nervous system producing demyelination and axonal loss. Clinically the relapsing-remitting course is characterized by subacute onset of neurological symptoms usually with partial or complete recovery, while the progressive course, predominant in the later stages, is characterized by progressive disability in the absence of relapses. A number of disease-modifying treatments have been developed and are increasingly effective at targeting relapses. Early injectable therapies such as interferon and glatiramer acetate are only partially effective, but have a good safety record. Recently, natalizumab, an intravenous therapy, demonstrated increased effectiveness, but side effects complicate its use. The first oral therapy offering good efficacy and convenience, fingolimod, was approved in USA in 2010 and Europe in 2011. BG-12 is a potential novel oral therapy for MS, which has previously been used as a different formulation for psoriasis. It has anti-inflammatory and neuroprotective actions in vitro, which makes it a promising candidate for future therapies. Phase II studies showed that BG-12 reduced MRI inflammatory activity over placebo, which was confirmed in two Phase III studies indicating immune modulation may be its principal action rather than neuroprotection. In these studies, BG-12 reduced relapse rates consistently with variable effects on progression and few serious adverse events. With its favorable efficacy-tolerability profile, BG-12 could offer a substantial step forward for the care for subjects affected by relapsing MS.

Multiple sclerosis and pregnancy: therapeutic considerations

For women with multiple sclerosis (MS) who become pregnant, the risks and benefits of ongoing therapy for the health of both the mother and the fetus must be carefully considered. Based on a literature review and our MS center's standard practices, we provide guidance to aid clinical decision making in the absence of clear evidence-based clinical practice guidelines. Women seeking to achieve pregnancy should generally discontinue disease-modifying therapy use prior to attempting conception. For example, the immunosuppressant mitoxantrone is teratogenic and should be prescribed only with the assurance of effective contraception. Conception should be discouraged for patients on fingolimod, because of the limited information available on human pregnancy outcomes. Current evidence, including data from pregnancy registries for glatiramer acetate (GA), interferon beta-1a (IFNβ-1a), and natalizumab, has not shown specific patterns of malformations suggesting teratogenicity. Pregnancy registry data have not been published for IFNβ-1b. During breastfeeding, intravenous immunoglobulin and corticosteroids are generally safe and may be associated with a reduction in postpartum relapses; however, a washout period is recommended between corticosteroid administration and the resumption of breastfeeding. Clinical data on the use of IFNβ, GA, and natalizumab during lactation are limited. Mitoxantrone is contraindicated during breastfeeding, and fingolimod should be avoided in nursing mothers, because of a lack of data.

Long-term cost-effectiveness model of interferon beta-1b in the early treatment of multiple sclerosis in the United States

BACKGROUND

Multiple sclerosis (MS) is a potentially debilitating autoimmune disease that affects the brain and spinal cord. Disease-modifying therapies have been shown to slow disease progression but were not believed to prolong the survival of patients with MS. The recent 21-Year Long-Term Follow-Up (21Y-LTF) study found a significant survival advantage for patients receiving early treatment with interferon beta (IFNβ)-1b compared with placebo (no early treatment).

OBJECTIVES

The aim of this study was to conduct cost-effectiveness analyses estimating the long-term benefit of early treatment with IFNβ-1b among MS patients from a US societal perspective.

METHODS

A Markov model was developed to simulate the experience of patients with MS from the 21Y-LTF study over a lifetime. Patients were randomized to receive either IFNβ-1b or placebo for up to 5 years and then receive a variety of MS treatments (including no treatment) thereafter. Survival data reported from the 21Y-LTF study were incorporated into the model. The model assumes that patients' MS was managed in similar ways for both groups during the uncontrolled phase of the 21Y-LTF study (ie, survival difference between the 2 groups is the result of early use of IFNβ-1b). Health outcomes were life-years and quality-adjusted life-years (QALYs). Costs included treatments, direct disease management, informal care, and lost productivities and were reported in 2011 US dollars.

RESULTS

In the modeled placebo group, the median age at death was predicted to be 63.7 years, and the median survival time from disease onset was 36.7 years. Early treatment with IFNβ-1b reduced the lost health benefits by 2.8 life-years and 1.9 QALYs, respectively, after discounting. Total discounted cost for IFNβ-1b-treated patients was $86,223 higher than that of patients receiving placebo. The incremental cost-effectiveness ratio was $46,357 per QALY gained and $30,967 per life-year gained. Sensitivity analyses indicate the robustness of the model's results.

CONCLUSIONS

Treatment with IFNβ-1b during the earlier disease phase of patients with MS significantly increased patient life-years and QALYs. IFNβ-1b is likely to be a cost-effective intervention for MS.

Rituximab for relapsing-remitting multiple sclerosis

BACKGROUND

More than 80% of individuals with multiple sclerosis (MS) experience a relapsing-remitting disease course. Approximately ten years after disease onset, an estimated 50% of individuals with relapsing-remitting MS (RR-MS) convert to secondary progressive MS. Quality of life is considerably impaired in early RR-MS. The increased costs are associated with relapse occurrence and increasing disease severity. Pharmaceutical interventions aimed at delaying the progression of disease may help to reduce the economic burden of MS. It has been showed that B lymphocytes involve in the pathophysiology of MS and rituximab lyses B cells via complement and antibody-dependent cellular cytotoxicity. Current clinical trials are evaluating the role of rituximab as a B-cell-targeted therapy in the treatment of RR-MS.

OBJECTIVES

The effectiveness and safety of rituximab alone or as add-on, versus placebo or other treatments for RR-MS were assessed.

SEARCH METHODS

The Trials Search Co-ordinator searched the Cochrane Multiple Sclerosis Group's Specialised Register (3 March 2011). We checked references in identified trials and manually searched the reports (2004 to May 2011) from neurological associations and MS Societies in Europe and America. We also communicated with researchers who were participating in trials on rituximab and contacted Genentech, BiogenIdec, Roche.

SELECTION CRITERIA

All randomised double-blind controlled parallel clinical trials with a length of follow-up ≥ one year, evaluating rituximab, alone or as add-on with other therapies, versus placebo, or any other treatment for patients with RR-MS, without restrictions regarding dosage, administration frequency and duration of treatment. Titles and abstracts of the citations retrieved by the literature search were screened independently for inclusion/exclusion by two review authors. Any disagreement regarding inclusion was resolved by discussion, or by referral to a third assessor if necessary.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Disagreements were discussed and resolved by consensus among review authors. Principal investigators of included studies were contacted for additional data or confirmation.

MAIN RESULTS

One trial involving 104 adult RR MS patients with an entry score ≤ 5.0 EDSS and at least one relapse during the preceding year was included. This trial evaluated rituximab alone versus placebo with a single course of rituximab (on day 1 and 15). Treated patients had a lower rate of relapse at 24 weeks but not at 48 weeks. The MRI data were available only at 24 weeks. A significant attrition bias was found at 48 week (40.0% in the placebo group and 15.9% in the rituximab group). Mild-to-moderate infusion-associated adverse events within 24 hours after the first rituximab infusion occurred in the rituximab group.

AUTHORS' CONCLUSIONS

We are unable to give any clear recommendations for the use of rituximab as a therapy for RR-MS. The beneficial effects of rituximab for RR-MS remain inconclusive because of the high attrition bias, the small number of participants and the short follow-up. However, short-term treatment with a single course of rituximab resulted to be safe for most patients with RR-MS. The potential benefits of rituximab for treating RR-MS need to be evaluated in large scale studies along with long-term safety. Disability progression and quality of life should be addressed in future research.

Additional efficacy endpoints from pivotal natalizumab trials in relapsing-remitting MS

Standard clinical endpoints in multiple sclerosis (MS) studies, such as disability progression defined by the expanded disability status scale (EDSS) and annualized relapse rate, may not fully reflect all aspects of therapeutic benefit experienced by patients. Pivotal studies showed that natalizumab is effective both as monotherapy (AFFIRM study) and in combination with interferon beta-1a (IFNβ-1a) (SENTINEL study) in patients with relapsing MS. We present AFFIRM and SENTINEL data demonstrating the efficacy of natalizumab on prespecified tertiary endpoints, including extent of confirmed change in EDSS score from baseline, time to sustained progression to EDSS milestone scores, hospitalizations, corticosteroid use, and time to confirmed progression of cognitive deficits. Natalizumab significantly reduced changes in EDSS scores (P < 0.001) and proportion of patients progressing to an EDSS score ≥4.0 (P < 0.001) and ≥6.0 (P = 0.002) compared with placebo. Natalizumab + IFNβ-1a significantly reduced changes in EDSS scores compared with placebo + IFNβ-1a (P = 0.011). Based on 0.5 standard deviation change in paced auditory serial addition test-3 score, natalizumab treatment reduced the risk of confirmed progression of cognitive deficits by 43% compared with placebo (HR 0.57 [95% CI 0.37, 0.89], P = 0.013); however, no significant difference between groups was seen in SENTINEL. Natalizumab, both as monotherapy and in combination with IFNβ-1a, significantly reduced the annualized rate of MS-related hospitalizations (by 64 and 61%, respectively) and the annualized rate of relapses severe enough to require steroid treatment (by 69 and 61%, respectively) compared with placebo and placebo + IFNβ-1a (P < 0.001). These analyses underline beneficial effects of natalizumab therapy in relapsing MS patients.

Factors influencing healthy aging with multiple sclerosis: a qualitative study

PURPOSE

The purpose of this study was to describe the factors influencing healthy aging from the perspective of the older person with multiple sclerosis (MS) in order to build curricula for MS self-management programs.

METHOD

We sourced participants, older than 55 years with MS for more than 20 years, from a database of MS clinic and outpatient rehabilitation visits. Recruitment continued until data saturation was reached (n = 18). Semi-structured interviews explored perspectives on aging and health and lifestyle habits. Demographic, lifestyle and perceived health status information was also gathered. We analyzed the transcribed text for themes and theme relationships.

RESULTS

Work and social engagement, effective and accessible health care, healthy lifestyle habits, and maintaining independence at home were found to be critical proximal factors for healthy aging. The presence of financial flexibility, social support, cognitive and mental health, and resilience provided a supporting foundation to these critical proximal factors. These factors comprised a two-tiered model of healthy aging with MS.

CONCLUSIONS

This two-tiered conceptual model of health aging, based on the perspectives of older persons with MS, provides a potential framework for the development of MS self-management program curricula aimed at optimizing quality of life. Further empirical testing may validate its utility in predicting healthy aging with MS.