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Wilbanks B, Maher LJ, Rodriguez M. Glial cells as therapeutic targets in progressive multiple sclerosis. Expert Rev Neurother 2019; 19:481-494. [PMID: 31081705 DOI: 10.1080/14737175.2019.1614443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Multiple sclerosis is a serious demyelinating disease of the central nervous system (CNS) with treatments generally restricted to immunosuppression to reduce attack rate and for symptom management. Glial cells may be useful targets for future CNS regenerative therapies to reverse disease. Areas covered: In this review, the authors cover currently available multiple sclerosis treatments and examine potential upcoming therapies targeting glial cells. The potential for new therapeutic approaches in the treatment of progressive multiple sclerosis is examined. Expert opinion: Microglia, astrocytes, and oligodendrocytes are each promising targets for the disease-altering treatment of multiple sclerosis. Though challenging, the opportunities presented have great potential for CNS regeneration and further investigation of glial cells in therapy is warranted. Patient-specific combinatorial therapy targeting the three glial cell types is expected to be the future of MS treatment.
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Affiliation(s)
- Brandon Wilbanks
- a Department of Biochemistry and Molecular Biology , Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - L J Maher
- a Department of Biochemistry and Molecular Biology , Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - Moses Rodriguez
- b Departments of Neurology and Immunology , Mayo Clinic College of Medicine and Science , Rochester , MN , USA
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202
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Vainio SK, Dickens AM, Tuisku J, Eskola O, Solin O, Löyttyniemi E, Anthony DC, Rinne JO, Airas L, Haaparanta-Solin M. Cessation of anti-VLA-4 therapy in a focal rat model of multiple sclerosis causes an increase in neuroinflammation. EJNMMI Res 2019; 9:38. [PMID: 31073768 PMCID: PMC6509289 DOI: 10.1186/s13550-019-0508-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/15/2019] [Indexed: 11/21/2022] Open
Abstract
Background Positron emission tomography (PET) can be used for in vivo evaluation of the pathology associated with multiple sclerosis. We investigated the use of longitudinal PET imaging and the 18-kDa translocator protein (TSPO) binding radioligand [18F]GE-180 to detect changes in a chronic multiple sclerosis-like focal delayed-type hypersensitivity experimental autoimmune encephalomyelitis (fDTH-EAE) rat model during and after anti-VLA-4 monoclonal antibody (mAb) treatment. Thirty days after lesion activation, fDTH-EAE rats were treated with the anti-VLA-4 mAb (n = 4) or a control mAb (n = 4; 5 mg/kg, every third day, subcutaneously) for 31 days. Animals were imaged with [18F]GE-180 on days 30, 44, 65, 86 and 142. Another group of animals (n = 4) was used for visualisation the microglia with Iba-1 at day 44 after a 2-week treatment period. Results After a 2-week treatment period on day 44, there was a declining trend (p = 0.067) in [18F]GE-180-binding in the anti-VLA-4 mAb-treated animals versus controls. However, cessation of treatment for 4 days after a 31-day treatment period increased [18F]GE-180 binding in animals treated with anti-VLA-4 mAb compared to the control group (p = 0.0003). There was no difference between the groups in TSPO binding by day 142. Conclusions These results demonstrated that cessation of anti-VLA-4 mAb treatment for 4 days caused a transient rebound increase in neuroinflammation. This highlights the usefulness of serial TSPO imaging in the fDTH-EAE model to better understand the rebound phenomenon.
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Affiliation(s)
- S K Vainio
- Turku PET Centre, Preclinical PET Imaging, University of Turku, Tykistökatu 6 A, 20520, Turku, Finland. .,MediCity Research Laboratory, University of Turku, Turku, Finland.
| | - A M Dickens
- Turku Centre for Biotechnology, University of Turku, Turku, Finland.,Department of Pharmacology, University of Oxford, Oxford, UK
| | - J Tuisku
- Turku PET Centre, Clinical Neurology, Turku University Hospital, Turku, Finland
| | - O Eskola
- Turku PET Centre, Radiopharmaceutical Chemistry Laboratory, University of Turku, Turku, Finland
| | - O Solin
- Turku PET Centre, Radiopharmaceutical Chemistry Laboratory, University of Turku, Turku, Finland.,Department of Chemistry, University of Turku, Turku, Finland.,Accelerator Laboratory, Åbo Akademi University, Turku, Finland
| | - E Löyttyniemi
- Department of Biostatistics, University of Turku, Turku, Finland
| | - D C Anthony
- Department of Pharmacology, University of Oxford, Oxford, UK
| | - J O Rinne
- Turku PET Centre, Clinical Neurology, Turku University Hospital, Turku, Finland
| | - L Airas
- Turku PET Centre, Clinical Neurology, Turku University Hospital, Turku, Finland.,Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland.,Department of Clinical Medicine, University of Turku, Turku, Finland
| | - M Haaparanta-Solin
- Turku PET Centre, Preclinical PET Imaging, University of Turku, Tykistökatu 6 A, 20520, Turku, Finland.,MediCity Research Laboratory, University of Turku, Turku, Finland
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203
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Wylezinski LS, Gray JD, Polk JB, Harmata AJ, Spurlock CF. Illuminating an Invisible Epidemic: A Systemic Review of the Clinical and Economic Benefits of Early Diagnosis and Treatment in Inflammatory Disease and Related Syndromes. J Clin Med 2019; 8:E493. [PMID: 30979036 PMCID: PMC6518102 DOI: 10.3390/jcm8040493] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022] Open
Abstract
Healthcare expenditures in the United States are growing at an alarming level with the Centers for Medicare and Medicaid Services (CMS) projecting that they will reach $5.7 trillion per year by 2026. Inflammatory diseases and related syndromes are growing in prevalence among Western societies. This growing population that affects close to 60 million people in the U.S. places a significant burden on the healthcare system. Characterized by relatively slow development, these diseases and syndromes prove challenging to diagnose, leading to delayed treatment against the backdrop of inevitable disability progression. Patients require healthcare attention but are initially hidden from clinician's view by the seemingly generalized, non-specific symptoms. It is imperative to identify and manage these underlying conditions to slow disease progression and reduce the likelihood that costly comorbidities will develop. Enhanced diagnostic criteria coupled with additional technological innovation to identify inflammatory conditions earlier is necessary and in the best interest of all healthcare stakeholders. The current total cost to the U.S. healthcare system is at least $90B dollars annually. Through unique analysis of financial cost drivers, this review identifies opportunities to improve clinical outcomes and help control these disease-related costs by 20% or more.
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Affiliation(s)
- Lukasz S Wylezinski
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- IQuity, Inc., Nashville, TN 37203, USA.
| | | | | | | | - Charles F Spurlock
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- IQuity, Inc., Nashville, TN 37203, USA.
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204
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Tackling progression in multiple sclerosis. Lancet Neurol 2019; 17:489-491. [PMID: 29778353 DOI: 10.1016/s1474-4422(18)30158-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 04/16/2018] [Indexed: 11/21/2022]
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205
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206
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Mao Z, Álvarez-González C, Allen-Philbey K, De Trane S, Yildiz O, Campion T, Adams A, Turner BP, Marta M, Gnanapavan S, Espasandin M, Mathews J, Giovannoni G, Baker D, Schmierer K. Treating the ineligible: Disease modification in people with multiple sclerosis beyond NHS England commissioning policies. Mult Scler Relat Disord 2019; 27:247-253. [DOI: 10.1016/j.msard.2018.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 09/28/2018] [Accepted: 11/01/2018] [Indexed: 12/14/2022]
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207
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Rocca MA, Preziosa P, Filippi M. Application of advanced MRI techniques to monitor pharmacologic and rehabilitative treatment in multiple sclerosis: current status and future perspectives. Expert Rev Neurother 2018; 19:835-866. [PMID: 30500303 DOI: 10.1080/14737175.2019.1555038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Advances in magnetic resonance imaging (MRI) technology and analyses are improving our understanding of the pathophysiology of multiple sclerosis (MS). Due to their ability to grade the presence of irreversible tissue loss, microstructural tissue abnormalities, metabolic changes and functional plasticity, the application of these techniques is also expanding our knowledge on the efficacy and mechanisms of action of different pharmacological and rehabilitative treatments. Areas covered: This review discusses recent findings derived from the application of advanced MRI techniques to evaluate the structural and functional substrates underlying the effects of pharmacologic and rehabilitative treatments in patients with MS. Current applications as outcome in clinical trials and observational studies, their interpretation and possible pitfalls in their use are discussed. Finally, how these techniques could evolve in the future to improve monitoring of disease progression and treatment response is examined. Expert commentary: The number of treatments currently available for MS is increasing. The application of advanced MRI techniques is providing reliable and specific measures to better understand the targets of different treatments, including neuroprotection, tissue repair, and brain plasticity. This is a fundamental progress to move toward personalized medicine and individual treatment selection.
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Affiliation(s)
- Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy
| | - Paolo Preziosa
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy
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208
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Abstract
INTRODUCTION In the past decade, the role of B cells in the pathogenesis of multiple sclerosis (MS) is coming to the forefront. Depletion of B cells by anti-CD20 monoclonal antibodies (mAbs) has proved to decrease the activity of the relapsing-remitting MS (RRMS) and the progression of primary progressive MS (PPMS). Areas covered: In this review, the authors discuss the rationale of the depletion of B cells in RRMS and PPMS across recent studies on the role of B cells in the pathogenesis of MS; previous clinical trials with treatments targeting B cells; the mechanism of action of ocrelizumab - a second generation anti-CD20 mAb - and recent phase III clinical trials with ocrelizumab in RRMS and PPMS. Expert commentary: Ocrelizumab is the first anti-CD20 monoclonal antibody approved for RRMS and the first treatment approved for PPMS. The long-term effect and safety profile need to be evaluated in extension of clinical trials and in real-world studies.
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Affiliation(s)
- Kévin Bigaut
- a Département de Neurologie , Centre Hospitalier Universitaire de Strasbourg, Avenue Moliére , 67200 Strasbourg , France
| | - Jérôme De Seze
- a Département de Neurologie , Centre Hospitalier Universitaire de Strasbourg, Avenue Moliére , 67200 Strasbourg , France.,b Biopathologie de la Myéline,Neuroprotection et Stratégies Thérapeutiques, INSERM U1119, Fédération de Médecine Translationnelle de Strasbourg (FMTS) , Université de Strasbourg, Bâtiment 3 de la Faculté de Médecine , 11 rue Humann, 67000 Strasbourg , France.,c Centre d'investigation clinique , INSERM U1434, Centre Hospitalier Universitaire de Strasbourg , 1 Place de l'Hôpital, 67000 Strasbourg , France
| | - Nicolas Collongues
- a Département de Neurologie , Centre Hospitalier Universitaire de Strasbourg, Avenue Moliére , 67200 Strasbourg , France.,b Biopathologie de la Myéline,Neuroprotection et Stratégies Thérapeutiques, INSERM U1119, Fédération de Médecine Translationnelle de Strasbourg (FMTS) , Université de Strasbourg, Bâtiment 3 de la Faculté de Médecine , 11 rue Humann, 67000 Strasbourg , France.,c Centre d'investigation clinique , INSERM U1434, Centre Hospitalier Universitaire de Strasbourg , 1 Place de l'Hôpital, 67000 Strasbourg , France
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209
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Jacobs BM, Ammoscato F, Giovannoni G, Baker D, Schmierer K. Cladribine: mechanisms and mysteries in multiple sclerosis. J Neurol Neurosurg Psychiatry 2018; 89:1266-1271. [PMID: 29991490 DOI: 10.1136/jnnp-2017-317411] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The aims of this manuscript were to review the evidence for the efficacy and safety of cladribine in multiple sclerosis (MS) and to review the molecular and cellular mechanisms by which cladribine acts as a disease-modifying therapy in MS. METHODS This is a narrative review of the available clinical and preclinical data on the use of cladribine in MS. RESULTS Clinical trial data argue strongly that cladribine is a safe and effective therapy for relapsing MS and that it may also be beneficial in progressive MS. The pharmacology of cladribine explains how it is selectively toxic towards lymphocytes. Immunophenotyping studies show that cladribine depletes lymphocyte populations in vivo with a predilection for B cells. In vitro studies demonstrate that cladribine also exerts immunomodulatory influences over innate and adaptive immunity. CONCLUSIONS Cladribine is a safe and effective form of induction therapy for relapsing MS. Its mechanism of benefit is not fully understood but the most striking action is selective, long-lasting, depletion of B lymphocytes with a particular predilection for memory B cells. The in vivo relevance of its other immunomodulatory actions is unknown. The hypothesis that cladribine's action of benefit is to deplete memory B cells is important: if correct, it implies that selective targeting of this cell population and sparing of other lymphocytes could modify disease activity without predisposing to immunosuppression-related complications.
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Affiliation(s)
- Benjamin Meir Jacobs
- The Blizard Institute (Neuroscience), Queen Mary University of London, Barts and the London School of Medicine and Dentistry, London, UK
| | - Francesca Ammoscato
- The Blizard Institute (Neuroscience), Queen Mary University of London, Barts and the London School of Medicine and Dentistry, London, UK
| | - Gavin Giovannoni
- The Blizard Institute (Neuroscience), Queen Mary University of London, Barts and the London School of Medicine and Dentistry, London, UK.,Emergency Care and Acute Medicine Clinical Academic Group Neuroscience, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - David Baker
- The Blizard Institute (Neuroscience), Queen Mary University of London, Barts and the London School of Medicine and Dentistry, London, UK
| | - Klaus Schmierer
- The Blizard Institute (Neuroscience), Queen Mary University of London, Barts and the London School of Medicine and Dentistry, London, UK.,Emergency Care and Acute Medicine Clinical Academic Group Neuroscience, Barts Health NHS Trust, The Royal London Hospital, London, UK
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210
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Fox EJ, Markowitz C, Applebee A, Montalban X, Wolinsky JS, Belachew S, Fiore D, Pei J, Musch B, Giovannoni G. Ocrelizumab reduces progression of upper extremity impairment in patients with primary progressive multiple sclerosis: Findings from the phase III randomized ORATORIO trial. Mult Scler 2018; 24:1862-1870. [PMID: 30415593 PMCID: PMC6282157 DOI: 10.1177/1352458518808189] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Upper extremity (UE) impairment is common with primary progressive multiple
sclerosis (PPMS). Objective: This exploratory analysis examined the effects of ocrelizumab on confirmed
progression (CP) and confirmed improvement (CI) in UE impairment in patients
from ORATORIO. Methods: Patients with PPMS received ocrelizumab 600 mg or placebo every 24 weeks for
⩾120 weeks. The Nine-Hole Peg Test (9HPT) was administered at baseline (BL)
and every 12 weeks thereafter. Prespecified exploratory endpoints included
change in 9HPT time and proportion of patients with CP of ⩾20% in 9HPT.
Analysis populations included intention-to-treat (ITT) patients and
subgroups stratified by BL 9HPT time and Expanded Disability Status Scale.
Post hoc analyses included the proportion of patients achieving more severe
thresholds of CP and the proportion achieving CI in 9HPT. Results: Among ITT patients, ocrelizumab significantly reduced the change in 9HPT time
over 120 weeks, the risk of CP of ⩾20% in 9HPT time for both hands and the
risk of more severe 9HPT progression versus placebo. Numerical trends also
favoured ocrelizumab versus placebo with respect to achieving CI. Consistent
directional trends were observed in subgroup analyses. Conclusion: Ocrelizumab reduces the risk of UE disability progression and may increase
the possibility of improvement versus placebo in PPMS.
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Affiliation(s)
- Edward J Fox
- Central Texas Neurology Consultants and Dell Medical School, The University of Texas at Austin, Round Rock, TX, USA
| | - Clyde Markowitz
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Angela Applebee
- Department of Neurology, St. Peter's Health Partners, Albany, NY, USA
| | - Xavier Montalban
- Division of Neurology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada/ Department of Neurology/Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (CEMCAT), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jerry S Wolinsky
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | | | | | - Jinglan Pei
- Genentech, Inc., South San Francisco, CA, USA
| | - Bruno Musch
- Genentech, Inc., South San Francisco, CA, USA
| | - Gavin Giovannoni
- Department of Neurology, Queen Mary University of London, London, UK
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211
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Abstract
Multiple sclerosis (MS) is the most common chronic inflammatory, demyelinating and neurodegenerative disease of the central nervous system in young adults. This disorder is a heterogeneous, multifactorial, immune-mediated disease that is influenced by both genetic and environmental factors. In most patients, reversible episodes of neurological dysfunction lasting several days or weeks characterize the initial stages of the disease (that is, clinically isolated syndrome and relapsing-remitting MS). Over time, irreversible clinical and cognitive deficits develop. A minority of patients have a progressive disease course from the onset. The pathological hallmark of MS is the formation of demyelinating lesions in the brain and spinal cord, which can be associated with neuro-axonal damage. Focal lesions are thought to be caused by the infiltration of immune cells, including T cells, B cells and myeloid cells, into the central nervous system parenchyma, with associated injury. MS is associated with a substantial burden on society owing to the high cost of the available treatments and poorer employment prospects and job retention for patients and their caregivers.
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Affiliation(s)
- Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy. .,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Amit Bar-Or
- Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Neuroimmunology Unit, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Paolo Preziosa
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sandra Vukusic
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Fondation Eugène Devic EDMUS Contre la Sclérose en Plaques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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212
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Mills EA, Begay JA, Fisher C, Mao-Draayer Y. Impact of trial design and patient heterogeneity on the identification of clinically effective therapies for progressive MS. Mult Scler 2018; 24:1795-1807. [PMID: 30303445 DOI: 10.1177/1352458518800800] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clinically effective immunomodulatory therapies have been developed for relapsing-remitting multiple sclerosis (RRMS), but they have generally not translated to a corresponding slowing of disability accumulation in progressive forms of multiple sclerosis (MS). Since disability is multifaceted, progressive patients are heterogeneous, and the drivers of disease progression are still unclear, it has been difficult to identify the most informative outcome measures for progressive trials. Historically, secondary outcome measures have focused on inflammatory measures, which contributed to the recent identification of immunomodulatory therapies benefiting younger patients with more inflammatory progressive MS. Meanwhile, agents capable of treating late-stage disease have remained elusive. Consequently, measures of neurodegeneration are becoming common. Here, we review completed clinical trials testing immunomodulatory therapies in primary progressive multiple sclerosis (PPMS) or secondary progressive multiple sclerosis (SPMS) and discuss the features contributing to trial design variability in relation to trial outcomes, and how efforts toward better patient stratification and inclusion of reliable progression markers could improve outcomes.
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Affiliation(s)
- Elizabeth A Mills
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Joel A Begay
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Caitlyn Fisher
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA/Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
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213
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Edan G, Vukusic S. Where there is inflammation, treatment may reduce disability progression - No. Mult Scler 2018; 24:1352458518795417. [PMID: 30295565 DOI: 10.1177/1352458518795417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Gilles Edan
- CICP 1414 INSERM, Équipe Neurosciences, CHU Hôpital Pontchaillou, Rennes, France/ CRC-SEP, Pôle Neurosciences, CHU Hôpital Pontchaillou, Rennes, France/ Institut des Neurosciences Cliniques de Rennes, Rennes, France/ Université Rennes 1 and Université Bretagne Loire (UBL), Rennes, France
| | - Sandra Vukusic
- Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation and Fondation Eugène Devic EDMUS contre la Sclérose en Plaques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France/Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR5292, Lyon, France/ Faculté de Médecine Lyon-Est, Université Claude Bernard Lyon 1, Villeurbanne, France
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214
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Therapeutic Advances and Challenges in the Treatment of Progressive Multiple Sclerosis. Drugs 2018; 78:1549-1566. [DOI: 10.1007/s40265-018-0984-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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215
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Yildiz O, Mao Z, Adams A, Dubuisson N, Allen-Philbey K, Giovannoni G, Malaspina A, Baker D, Gnanapavan S, Schmierer K. Disease activity in progressive multiple sclerosis can be effectively reduced by cladribine. Mult Scler Relat Disord 2018; 24:20-27. [PMID: 29860198 DOI: 10.1016/j.msard.2018.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/18/2018] [Accepted: 05/11/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Evidence suggests people with non-relapsing deteriorating ("progressive") multiple sclerosis (pwPMS) may benefit from disease-modifying immune therapy (DMT). However, only one such treatment (ocrelizumab) has been licensed and is highly restricted to pwPMS suffering from the primary progressive phenotype. The difficulties assessing treatment outcome in pwPMS is one important reason for the lack of respective DMT. The concentration of neurofilaments in the cerebrospinal fluid (CSF) provides a biomarker of neuro-axonal damage, and both neurofilament light (NfL) and heavy chain (NfH) levels have been used as outcome indices and to guide treatment choices. METHODS We report on two pwPMS, who were treated with subcutaneous cladribine undergoing CSF NfL testing, alongside MRI and clinical follow-up, before and after treatment. RESULTS Cladribine treatment was well tolerated without any side effects. CSF NfL after treatment revealed significant reduction (by 73% and 80%, respectively) corroborating the MRI detectable drop in disease activity. Disability mildly progressed in one, and remained stable in the other pwPMS. CONCLUSIONS pwPMS with detectable disease activity (MRI, elevated NfL) should be considered for DMT. NfL appears to be a sensitive index of treatment effect in pwPMS, and may be a useful outcome in clinical trials targeting this patient group. Over and above its licensed indication (relapsing MS), cladribine may be an effective treatment option for pwPMS.
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Affiliation(s)
- O Yildiz
- The Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom; Clinical Board: Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Z Mao
- The Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom; Department of Neurology, Shenzhen University General Hospital, Shenzhen University, Shenzhen, China; Shenzhen University Clinical Medical Academy, Shenzhen University, Shenzhen, China
| | - A Adams
- Department of Neuroradiology, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - N Dubuisson
- The Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom
| | - K Allen-Philbey
- Clinical Board: Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - G Giovannoni
- The Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom; Clinical Board: Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - A Malaspina
- The Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom; Clinical Board: Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - D Baker
- The Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom
| | - S Gnanapavan
- The Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom; Clinical Board: Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - K Schmierer
- The Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom; Clinical Board: Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.
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De Angelis F, Plantone D, Chataway J. Pharmacotherapy in Secondary Progressive Multiple Sclerosis: An Overview. CNS Drugs 2018; 32:499-526. [PMID: 29968175 DOI: 10.1007/s40263-018-0538-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Multiple sclerosis is an immune-mediated inflammatory disease of the central nervous system characterised by demyelination, neuroaxonal loss and a heterogeneous clinical course. Multiple sclerosis presents with different phenotypes, most commonly a relapsing-remitting course and, less frequently, a progressive accumulation of disability from disease onset (primary progressive multiple sclerosis). The majority of people with relapsing-remitting multiple sclerosis, after a variable time, switch to a stage characterised by gradual neurological worsening known as secondary progressive multiple sclerosis. We have a limited understanding of the mechanisms underlying multiple sclerosis, and it is believed that multiple genetic, environmental and endogenous factors are elements driving inflammation and ultimately neurodegeneration. Axonal loss and grey matter damage have been regarded as amongst the leading causes of irreversible neurological disability in the progressive stages. There are over a dozen disease-modifying therapies currently licenced for relapsing-remitting multiple sclerosis, but none of these has provided evidence of effectiveness in secondary progressive multiple sclerosis. Recently, there has been some early modest success with siponimod in secondary progressive multiple sclerosis and ocrelizumab in primary progressive multiple sclerosis. Finding treatments to delay or prevent the courses of secondary progressive multiple sclerosis is an unmet and essential goal of the research in multiple sclerosis. In this review, we discuss new findings regarding drugs with immunomodulatory, neuroprotective or regenerative properties and possible treatment strategies for secondary progressive multiple sclerosis. We examine the field broadly to include trials where participants have progressive or relapsing phenotypes. We summarise the most relevant results from newer investigations from phase II and III randomised controlled trials over the past decade, with particular attention to the last 5 years.
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Affiliation(s)
- Floriana De Angelis
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK.
| | - Domenico Plantone
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK
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217
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Romme Christensen J, Komori M, von Essen MR, Ratzer R, Börnsen L, Bielekova B, Sellebjerg F. CSF inflammatory biomarkers responsive to treatment in progressive multiple sclerosis capture residual inflammation associated with axonal damage. Mult Scler 2018; 25:937-946. [PMID: 29775134 DOI: 10.1177/1352458518774880] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Development of treatments for progressive multiple sclerosis (MS) is challenged by the lack of sensitive and treatment-responsive biomarkers of intrathecal inflammation. OBJECTIVE To validate the responsiveness of cerebrospinal fluid (CSF) inflammatory biomarkers to treatment with natalizumab and methylprednisolone in progressive MS and to examine the relationship between CSF inflammatory and tissue damage biomarkers. METHODS CSF samples from two open-label phase II trials of natalizumab and methylprednisolone in primary and secondary progressive MS. CSF concentrations of 20 inflammatory biomarkers and CSF biomarkers of axonal damage (neurofilament light chain (NFL)) and demyelination were analysed using electrochemiluminescent assay and enzyme-linked immunosorbent assay (ELISA). RESULTS In all, 17 natalizumab- and 23 methylprednisolone-treated patients had paired CSF samples. CSF sCD27 displayed superior standardised response means and highly significant decreases during both natalizumab and methylprednisolone treatment; however, post-treatment levels remained above healthy donor reference levels. Correlation analyses of CSF inflammatory biomarkers and NFL before, during and after treatment demonstrated that CSF sCD27 consistently correlates with NFL. CONCLUSION These findings validate CSF sCD27 as a responsive and sensitive biomarker of intrathecal inflammation in progressive MS, capturing residual inflammation after treatment. Importantly, CSF sCD27 correlates with NFL, consistent with residual inflammation after anti-inflammatory treatment being associated with axonal damage.
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Affiliation(s)
- Jeppe Romme Christensen
- Department of Neurology, Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mika Komori
- Neuroimmunological Diseases Unit, National Institute of Neurological Diseases and Stroke, National Institute of Health, Bethesda, MD, USA
| | - Marina Rode von Essen
- Department of Neurology, Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Ratzer
- Department of Neurology, Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars Börnsen
- Department of Neurology, Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Bibi Bielekova
- Neuroimmunological Diseases Unit, National Institute of Neurological Diseases and Stroke, National Institute of Health, Bethesda, MD, USA
| | - Finn Sellebjerg
- Department of Neurology, Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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218
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Edan G. Natalizumab in secondary progressive multiple sclerosis. Lancet Neurol 2018; 17:384-385. [DOI: 10.1016/s1474-4422(18)30108-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 11/16/2022]
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