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

MR imaging in multiple sclerosis: review and recommendations for current practice

MR imaging is widely used for the diagnosis and monitoring of patients with MS. Applications and protocols for MR imaging continue to evolve, prompting a need for continual reassessments of the optimal use of this technique in clinical practice. This article provides updated recommendations on the use of MR imaging in MS, based on a review of the trial evidence and personal experiences shared at a recent expert meeting of radiologists and neurologists.

Cognitive impairment predicts conversion to multiple sclerosis in clinically isolated syndromes

Significant cognitive impairment has been found in 20—30% of patients with clinically isolated syndromes suggestive of multiple sclerosis. In this study we aimed to assess the prognostic value of the presence of cognitive impairment for the conversion to multiple sclerosis in patients with clinically isolated syndromes. All patients with clinically isolated syndromes consecutively referred to our centre since 2002 and who had been followed-up for at least one year underwent cognitive assessment through the Rao’s Battery and the Stroop test. Possible predictors of conversion to clinically definite multiple sclerosis were evaluated through the Kaplan Meier curves and Cox regression analysis. A total of 56 patients (41 women; age 33.2 ± 8.5 years; expanded disability scale score 1.2 ± 0.7) were recruited. At baseline, 32 patients (57%) fulfilled McDonald’s criteria for dissemination in space. During the follow-up (3.5 ± 2.3 years), 26 patients (46%) converted to a diagnosis of multiple sclerosis. In particular, 64% of patients failing ≥ 2 tests and 88% of patients failing ≥ 3 tests converted to multiple sclerosis. In the Cox regression model, the failure of at least three tests (HR 3.3; 95% CI 1.4—8.1; p = 0.003) and the presence of McDonald’s dissemination in space at baseline (HR 3.8; 95% CI 1.5—9.7; p = 0.005), were found to be predictors for conversion to multiple sclerosis. We conclude that cognitive impairment is detectable in a sizable proportion of patients with clinically isolated syndromes. In these subjects cognitive impairment has a prognostic value in predicting conversion to multiple sclerosis and may therefore play a role in therapeutic decision making.

Multiple sclerosis: an update for oral health care providers

Multiple sclerosis (MS) is a chronic, inflammatory, demyelinating disease of the central nervous system. The disease mostly affects young adults and is increasing in prevalence and incidence. Multiple sclerosis is characterized by periods of activity and remission which, after numerous relapses, cause permanent neurologic deficits. Diagnosis of MS is based on patient history and clinical examination supplemented by the findings of radiologic and laboratory tests. Numerous motor and sensory disturbances occur in MS and may present in the orofacial region. This medical management update highlights issues that are important to the oral health care provider, including orofacial manifestations of MS and dental considerations for patients with MS.

Magnetic resonance imaging in multiple sclerosis

OBJECTIVES

multiple sclerosis (MS) is an inflammatory disease of unknown origin affecting the central nervous system. Magnetic resonance imaging (MRI) plays an increasingly important role in its diagnosis and further monitoring of disease progress.

METHODS

the typical MRI appearance of MS on conventional MRI sequences and current diagnostic criteria for MS are discussed. Advanced imaging techniques are reviewed with respect to application in MS. Finally, the atypical variants of MS are briefly reviewed.

CONCLUSIONS

although MRI is not intended and will not replace clinical assessment in MS, the recognized MRI criteria may aid in establishing an earlier and more accurate diagnosis of MS in the context of a clinical suspicion or clinically isolated syndrome. In addition, MRI might contribute to rule out differential diagnoses for MS. Moreover, MRI may be used to monitor the evolution of MS and in pharmaceutical trials. Advanced imaging techniques might, in the future, further characterize MS lesion subtypes and potentially guide tailored therapy.

Assessing cost-effectiveness in the management of multiple sclerosis

Multiple sclerosis (MS) is one of the most common causes of neurological disability in young and middle-aged adults, with current prevalence rates estimated to be 30 per 100,000 populations. Women are approximately twice as susceptible as males, but males are more likely to have progressive disease. The onset of the disease normally occurs between 20 and 40 years of age, with a peak incidence during the late twenties and early thirties, resulting in many years of disability for a large proportion of patients, many of whom require wheelchairs and some nursing home or hospital care. The aim of this study is to update a previous review which considered the cost-effectiveness of disease-modifying drugs (DMDs), such as interferons and glatiramer acetate, with more up to date therapies, such as mitaxantrone hydrochloride and natalizumab in the treatment of MS. The development and availability of new agents has been accompanied by an increased optimism that treatment regimens for MS would be more effective; that the number, severity and duration of relapses would diminish; that disease progression would be delayed; and that disability accumulation would be reduced. However, doubts have been expressed about the effectiveness of these treatments, which has only served to compound the problems associated with endeavors to estimate the relative cost-effectiveness of such interventions.

Real-life impact of early interferon beta therapy in relapsing multiple sclerosis

OBJECTIVE

Recent findings support greater efficacy of early vs. delayed interferon beta (IFNbeta) treatment in patients with a first clinical event suggestive of multiple sclerosis (MS). We aimed to evaluate the effectiveness of early IFNbeta treatment in definite relapsing-remitting MS (RRMS) and to assess the optimal time to initiate IFNbeta treatment with regard to the greatest benefits on disability progression.

METHODS

A cohort of 2,570 IFNbeta-treated RRMS patients was prospectively followed for up to 7 years in 15 Italian MS Centers. A Cox proportional hazards regression model adjusted for propensity score (PS) quintiles was used to assess differences between groups of patients with early vs. delayed IFNbeta treatment on risk of reaching a 1-point progression in the Expanded Disability Status Scale (EDSS) score, and the EDSS 4.0 and 6.0 milestones. A set of PS-adjusted Cox hazards regression models were calculated according to different times of treatment initiation (within 1 year up to within 5 years from disease onset). A sensitivity analysis was performed to assess the robustness of findings.

RESULTS

The lowest hazard ratios (HRs) for the three PS quintiles-adjusted models were obtained by a cutoff of treatment initiation within 1 year from disease onset. Early treatment significantly reduced the risk of reaching a 1-point progression in EDSS score (HR = 0.63; 95% CI = 0.48-0.85; p < 0.002), and the EDSS 4.0 milestone (HR = 0.56; 95% CI = 0.36-0.90; p = 0.015). Sensitivity analysis showed the bound of significance for unmeasured confounders.

INTERPRETATION

Greater benefits on disability progression may be obtained by an early IFNbeta treatment in RRMS.

Effect of glatiramer acetate on conversion to clinically definite multiple sclerosis in patients with clinically isolated syndrome (PreCISe study): a randomised, double-blind, placebo-controlled trial

BACKGROUND

Glatiramer acetate, approved for the treatment of relapsing-remitting multiple sclerosis, reduces relapses and disease activity and burden monitored by MRI. We assessed the efficacy of early treatment with glatiramer acetate in delaying onset of clinically definite multiple sclerosis.

METHODS

In this randomised, double-blind trial, undertaken in 80 sites in 16 countries, 481 patients presenting with a clinically isolated syndrome with unifocal manifestation, and two or more T2-weighted brain lesions measuring 6 mm or more, were randomly assigned to receive either subcutaneous glatiramer acetate 20 mg per day (n=243) or placebo (n=238) for up to 36 months, unless they converted to clinically definite multiple sclerosis. The randomisation scheme used SAS-based blocks stratified by centre, and patients and all personnel were masked to treatment assignment. The primary endpoint was time to clinically definite multiple sclerosis, based on a second clinical attack. Analysis was by intention to treat. A preplanned interim analysis was done for data accumulated from 81% of the 3-year study exposure. This study was registered with ClinicalTrials.gov, number NCT00666224.

FINDINGS

All randomly assigned participants were analysed for the primary outcome. Glatiramer acetate reduced the risk of developing clinically definite multiple sclerosis by 45% compared with placebo (hazard ratio 0.55, 95% CI 0.40-0.77; p=0.0005). The time for 25% of patients to convert to clinically definite disease was prolonged by 115%, from 336 days for placebo to 722 days for glatiramer acetate. The most common adverse events in the glatiramer acetate group were injection-site reactions (135 [56%] glatiramer acetate vs 56 [24%] placebo) and immediate post-injection reactions (47 [19%] vs 12 [5%]).

INTERPRETATION

Early treatment with glatiramer acetate is efficacious in delaying conversion to clinically definite multiple sclerosis in patients presenting with clinically isolated syndrome and brain lesions detected by MRI.

FUNDING

Teva Pharmaceutical Industries, Israel.

Multiple sclerosis, immunomodulators, and pregnancy outcome: a prospective observational study

BACKGROUND

There is still uncertainty about the management of pregnant women exposed to immunomodulatory therapy for treatment of multiple sclerosis (MS) in pregnancy.

OBJECTIVE

To assess the safety of interferon (IFN)-beta1a, IFN-beta1b, and glatiramer acetate (GA) for treatment of MS during pregnancy.

METHODS

A prospective observational cohort study was performed with patients enrolled through a drug risk assessment by the Teratology Information Service (TIS), Berlin, from 1996 to 2007. Pregnancy outcomes for four groups of women were compared: two exposed groups (IFN, n = 69; GA, n = 31), MS patients without exposure to IFN or GA (n = 64) and a healthy comparative group (n = 1556).

RESULTS

Spontaneous abortion rates were in normal range for all groups except the small subgroup of IFN-beta1b exposed (n = 21), where 28% aborted spontaneously. There were two major birth defects in the GA group (club feet and atrioventricular canal) and none in the IFN cohort. Preterm delivery was not significantly different between exposed cohorts and healthy controls. The adjusted mean birth weight was in normal range in all groups (>3200 g), but newborns exposed to IFN had a significantly lower birth weight.

CONCLUSION

Our findings suggest that neither GA nor IFN constitutes a major risk for prenatal developmental toxicity.

Shifting the paradigm toward earlier treatment of multiple sclerosis with interferon beta

BACKGROUND

Axonal damage occurs early in the course of multiple sclerosis (MS). Among untreated patients, 85% to 94% with a first clinically isolated syndrome (CIS) suggestive of MS and positive findings on magnetic resonance imaging (MRI) are at risk for developing MS.

OBJECTIVES

This article reviews the current literature concerning early diagnosis of MS, the rationale for early immunomodulatory treatment of patients with a CIS and MRI evidence of central nervous system lesions, and the efficacy of early treatment with interferon beta (IFN-beta).

METHODS

MEDLINE was searched from 1990 through the end of 2008 for papers published in English concerning the treatment of MS. Search terms included IFN-beta, early treatment, CIS, and multiple sclerosis, and limits were set to return results related to human clinical trials in adults.

RESULTS

Three pivotal randomized controlled trials were identified, 2 involving IFN-beta-1a (30 microg IM once weekly and 22 microg SC once weekly) and 1 involving IFN-beta-1b (250 microg SC qod). In these trials, treatment with IFN-beta effectively reduced the risk of developing MS by up to 50% in patients with a CIS. Furthermore, compared with delayed treatment, early treatment was associated with a reduced risk of disease progression: a 40% reduction in risk for confirmed disability progression at 3 years and a 41% reduction in risk of MS at 3 years.

CONCLUSIONS

The evidence that axonal damage begins in the early stages of MS, before symptoms are evident, provides a rationale for early intervention with immunomodulatory agents. In 3 pivotal clinical trials, IFN-beta effectively reduced the risk of developing clinically definite MS in CIS patients with a first demyelinating event and positive brain MRI.

Multiple sclerosis risk in radiologically uncovered asymptomatic possible inflammatory-demyelinating disease

BACKGROUND

Natural history of patients with incidentally discovered lesions that fulfill magnetic resonance imaging (MRI) criteria for multiple sclerosis (MS) in the absence of objective clinical symptoms suggestive of central nervous system (CNS) inflammatory-demyelinating disease is not well defined.

OBJECTIVE

We evaluated the risk of developing symptomatic MS in patients with radiologically uncovered asymptomatic possible inflammatory-demyelinating disease (RAPIDD).

METHODS

We identified and longitudinally followed a cohort of 22 patients from two tertiary care MS centers: Istanbul University, Cerrahpasa School of Medicine, Istanbul, Turkey, and Mayo Clinic, Rochester, Minnesota, after an initial MRI study fulfilling the Barkhof-Tintore MRI criteria completed for other reasons unrelated to MS.

RESULTS

Eight of 22 patients developed an objective clinical symptom consistent with a CNS inflammatory-demyelinating syndrome and fulfilled dissemination in space and time criteria for definite MS. Median age at the time of diagnosis of MS was 44.8 years (range 28.3-71.4 years). Time taken for the development of definite MS was studied by survival analysis. Cumulative event rates were; 12 months: 9%, 24 months: 15%, 36 months: 30.4%, and 60 months: 44.6%. Six of 22 patients were followed beyond 60 months. Two of these six patients developed MS later (at 66 and 112 months, respectively). Three patients remained asymptomatic despite follow-up of 10 years.

CONCLUSIONS

PATIENTS

with RAPIDD develop MS at a similar rate to treated patients (and less frequently than placebo groups) with clinically isolated syndromes from prior randomized controlled studies. Some patients with RAPIDD continue to have radiological evolution of subclinical disease without MS symptoms despite long follow-up periods.

The effect of interferon beta-1a on optic neuritis relapse in patients with multiple sclerosis

BACKGROUND

To evaluate the clinical effect of interferon beta-1a on optic neuritis (ON) relapse in patients with multiple sclerosis (MS) in Taiwan.

METHODS

Data were collected from 23 MS patients with ON at National Taiwan University Hospital between January 1, 1993 and February 1, 2007. Twenty-three MS patients with ON received interferon beta-1a (Rebif) 44 microg via subcutaneous injection three times weekly. All patients received corticosteroids pulse therapy followed by oral prednisolone for acute ON. The annual relapse rate (ARR) of ON in these MS patients before and after the use of interferon beta-1a (Rebif) was the main clinical parameter of outcome in this study.

RESULTS

The ARR of ON was lower in the posttreatment period than in the pretreatment period (P = 0.0068). Thirteen patients (56.5%) had improved final visual acuity (>2 lines), and the other ten patients (43.5%) had stable final visual outcome (-2 lines < X < 2 lines). In addition, no recurrence of ON was noted in 15 patients (65.2%) during the posttreatment period.

CONCLUSIONS

The use of interferon beta-1a 44 microg via subcutaneous injection three times weekly did not increase the ON attacks in MS patients receiving this treatment. In addition, beneficial effects were found with the use of interferon beta-1a on these patients.

The diagnosis of multiple sclerosis and the clinical subtypes

The diagnosis of multiple sclerosis (MS) requires objective findings referable to the central nervous system. A wide differential diagnosis often has to be considered. Magnetic resonance imaging and electrophysiologic and cerebrospinal fluid studies can all contribute to an early definitive diagnosis. The McDonald diagnostic criteria for MS (2005) are the currently recognized MS diagnostic criteria. The clinical subtypes of MS and their diagnosis are discussed in this article. Being informed of the diagnosis may be a stressful experience for the patient and this is also dealt with.

The present efficacy of multiple sclerosis therapeutics: Is the new 66% just the old 33%?

A challenge for the clinician treating patients with multiple sclerosis (MS) is to determine the most effective treatment while weighing the benefits and risks. Results of the phase 2 and phase 3 studies on natalizumab were received with great interest, in part due to the "improved" risk reduction for relapse rate, disease progression, and MRI metrics observed in comparison to results in trials of beta-interferon and glatiramer acetate. However, comparison across trials is invalid, in large part due to differences in the study populations. The increased efficacy observed in more recent trials has also been attributed to a fundamental change in subjects with MS enrolled in recent trials compared with the prior decade. In this article, we debate the relative efficacy of natalizumab vs the older injectable therapies.

Long-term effect of early treatment with interferon beta-1b after a first clinical event suggestive of multiple sclerosis: 5-year active treatment extension of the phase 3 BENEFIT trial

BACKGROUND

The Betaferon/Betaseron in newly emerging multiple sclerosis for initial treatment (BENEFIT) trial investigated the effect of treatment with interferon beta-1b after a clinically isolated syndrome. The 5-year active treatment extension compares the effects of early and delayed treatment with interferon beta-1b on time to clinically definite multiple sclerosis (CDMS) and other disease outcomes, including disability progression.

METHODS

Patients with a first event suggestive of multiple sclerosis and a minimum of two clinically silent lesions in MRI were randomly assigned to receive interferon beta-1b 250 microg (n=292; early treatment) or placebo (n=176; delayed treatment) subcutaneously every other day for 2 years, or until diagnosis of CDMS. All patients were then eligible to enter a prospectively planned follow-up phase with open-label interferon beta-1b up to a maximum of 5 years after randomisation. Patients and study personnel remained unaware of initial treatment allocation throughout the study. Primary endpoints were time to CDMS, time to confirmed disability progression measured with the expanded disability status scale, and the functional assessment of multiple sclerosis trial outcomes index (FAMS-TOI) at 5 years. Analysis of the primary endpoints was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00185211.

FINDINGS

235 (80%) patients from the early treatment and 123 (70%) from the delayed treatment group completed the 5-year study. Early treatment reduced the risk of CDMS by 37% (hazard ratio [HR] 0.63, 95% CI 0.48-0.83; p=0.003) compared with delayed treatment. The risk for confirmed disability progression was not significantly lower in the early treatment group (0.76, 0.52-1.11; p=0.177). At 5 years, median FAMS-TOI scores were 125 in both groups. No significant differences in other disability related outcomes were recorded. Frequency and severity of adverse events remained within the established safety and tolerability profile of interferon beta-1b.

INTERPRETATION

Effects on the rate of conversion to CDMS and the favourable long-term safety and tolerability profile support early initiation of treatment with interferon beta-1b, although a delay in treatment by up to 2 years did not affect long-term disability outcomes.

FUNDING

Bayer Schering Pharma.

Review: Treatment of early multiple sclerosis: the value of treatment initiation after a first clinical episode

Multiple sclerosis is a chronic, demyelinating disorder of the central nervous system. It is characterised by progressive neurological disability, which is likely to occur as a result of permanent axonal damage. Such damage may be reflected by brain atrophy, which can be identified early in the course of the disease. Patients who present with an initial episode of inflammatory demyelination, commonly referred to as a clinically isolated syndrome, are at high risk of developing clinically definite multiple sclerosis, especially if their magnetic resonance imaging studies suggest the presence of multi-focal disease. Treatment with disease-modifying therapies at the initial episode of demyelination may postpone this development. In this review we present an overview of evidence supporting early treatment initiation. We focus on three large placebo-controlled trials of interferon beta therapy: Controlled High-Risk Avonex® Multiple Sclerosis Prevention Study, Early Treatment of Multiple Sclerosis and Betaferon ® in Newly Emerging Multiple Sclerosis for Initial Treatment. Results from these early treatment studies are presented, and the impact of using interferon beta treatment in the early stages of disease is discussed with the aim of considering optimal therapeutic strategies to improve long-term patient outcome.

MRI in Multiple Sclerosis

The diagnosis of Multiple Sclerosis (MS) is based on clinical findings that are characterized by sudden neurological deficits in different parts of the CNS. Dissemination of lesions in space and time is the basic criterion. MRI can demonstrate most precisely any changes in the water content of brain tissue thus making it a very sensitive diagnostic tool to detect inflammatory processes like MS plaques. The following will briefly summarize the diagnostic features and procedures and will assess the appearance of typical MS lesions, their localization and configuration, which are essential for diagnosis and follow up examinations. It will propose the preferred sequences and technical parameters for standardized baseline examinations and follow-ups.

Optical coherence tomography is less sensitive than visual evoked potentials in optic neuritis

OBJECTIVES

Determine the utility of optical coherence tomography (OCT) to detect clinical and subclinical remote optic neuritis (ON), its relationship to clinical characteristics of ON and visual function, and whether the retinal nerve fiber layer (RNFL) thickness functions as a surrogate marker of global disease severity.

METHODS

Cross-sectional study of 65 subjects with at least 1 clinical ON episode at least 6 months prior. Measures included clinical characteristics, visual acuity (VA), contrast sensitivity (CS), OCT, and visual evoked potentials (VEP).

RESULTS

Ninety-six clinically affected optic nerves were studied. The sensitivity of OCT RNFL after ON was 60%, decreasing further with mild onset and good recovery. VEP sensitivity was superior at 81% (p = 0.002). Subclinical ON in the unaffected eye was present in 32%. VEP identified 75% of all subclinically affected eyes, and OCT identified <20%. RNFL thickness demonstrated linear correlations with VA (r = 0.65) and CS (r = 0.72) but was unable to distinguish visual categories <20/50. RNFL was thinner with severe onset and disease recurrence but was unaffected by IV glucocorticoids. OCT measurements were not related to overall disability, ethnicity, sex, or age at onset. The greatest predictor for RNFL in the unaffected eye was the RNFL in the fellow affected eye.

CONCLUSIONS

Visual evoked potentials (VEP) remains the preferred test for detecting clinical and subclinical optic neuritis. Optical coherence tomography (OCT) measures were unrelated to disability and demographic features predicting a worse prognosis in multiple sclerosis. OCT may provide complementary information to VEP in select cases, and remains a valuable research tool for studying optic nerve disease in populations.

New options for early treatment of multiple sclerosis

It is now possible to diagnose patients with multiple sclerosis earlier than previously due to the integration of MRI parameters into the diagnostic criteria. This provides a window of opportunity to treat patients with disease-modifying treatments before clinically-manifest tissue destruction and disability has emerged. There are a number of reasons to believe that such early treatment will be particularly beneficial. For example, immunopathological studies have shown that the irreversible axonal damage that underlies accumulation of disability occurs very early in the course of the disease. In addition, natural history studies demonstrate that frequent relapses and accumulation of a high T2 lesion load in the first years following diagnosis are predictive of long-term disability outcome. Treating patients early, after a clinically isolated neurological syndrome suggestive of multiple sclerosis, appears to have a greater impact on relapse frequency than when treatment is initiated later in the disease course. The latest data comes from the PreCISe study, a placebo-controlled randomised study of glatiramer acetate in patients with a clinically isolated syndrome. The study showed that this treatment significantly reduced the risk of conversion to clinically definite multiple sclerosis, with the quartile time for conversion being prolonged by more than one year in the glatiramer acetate cohort compared to placebo-treated patients. The safety and tolerability of glatiramer acetate in this relatively healthy and independent patient population was acceptable and consistent with its known safety profile in patients with relapsing remitting multiple sclerosis. An application for an extension of the approved indication of glatiramer acetate to the treatment of patients with a first clinical event suggestive of multiple sclerosis has been filed with the regulatory authorities.

Current approaches to the identification and management of breakthrough disease in patients with multiple sclerosis

Disease-modifying drugs (DMDs) for relapsing-remitting multiple sclerosis (RRMS) are only partly effective -- breakthrough disease commonly occurs despite treatment. Breakthrough disease is predictive of continued disease activity and a poor prognosis. Availability of several DMDs offers the possibility of tailoring treatment to individual patients with RRMS and altering treatment in patients with breakthrough disease. However, no biological or imaging markers have been validated to guide initial treatment, markers of individual responsiveness to DMDs are scarce, and there is no class 1 evidence to guide alternative therapy in patients with breakthrough disease. In this Review, we discuss proposed strategies to monitor patients with RRMS being treated with DMDs, outline approaches to identifying therapeutic response in individual patients, review MRI and biological markers of treatment response, and summarise the role of antibodies in biological therapies. We also outline possible strategies for the management of patients with breakthrough disease and highlight areas in which research is needed.

Immunotherapy of multiple sclerosis

Multiple sclerosis (MS) is regarded as a prototypic inflammatory autoimmune central nervous system disorder causing neurological disability in young adults. Recommended basic immunomodulatory therapies of MS are currently interferon beta and glatiramer acetate. Both have proven to be clinically and paraclinically effective and clinical evidence suggests that treatment should be initiated as early as possible. However, despite the fact that therapeutic options for MS have significantly been widened over the past decade there is still tremendous activity in the search for new treatment options for MS. One important development in the field is reflected by the substantial number of promising results for oral therapies. Various phase III clinical trials are currently being initiated or are already underway evaluating the efficacy of a variety of orally administered agents, including cladribine, teriflunomide, laquinimod, fingolimod and fumaric acid. It is hoped that these oral therapies for MS further broaden our armament for MS therapy.

Efficacy of intramuscular interferon beta-1a in patients with clinically isolated syndrome: analysis of subgroups based on new risk criteria

Approximately 85% of multiple sclerosis (MS) cases begin as clinically isolated syndromes (CIS). Results from the Controlled High-Risk Subjects Avonex® Multiple Sclerosis Prevention Study (CHAMPS) demonstrated that, in patients with CIS, treatment with intramuscular (IM) interferon beta-1a (IFNβ-1a) 30 μg once weekly delayed conversion to clinically definite MS (CDMS) in the total population and in subgroups based on presenting syndromes and baseline magnetic resonance imaging (MRI) characteristics. Changes to clinical and MRI risk classification of presenting symptoms in recent studies prompted reanalysis of CHAMPS data. Presenting syndromes were assessed using a derived algorithm that stratifies patients into mono- or multifocal categories based on functional system scores. The ability of IM IFNβ-1a to delay progression to CDMS in subgroups based on clinical presentation and MRI characteristics was assessed. Reanalysis of CHAMPS patients showed that 30% could be classified by clinical criteria as having multifocal disease at baseline. IM IFNβ-1a initiated at a first demyelinating attack delayed CDMS in monofocal patients ( P = 0.0013), patients with or without gadolinium-enhancing lesions ( P = 0.0007, P = 0.0405) and patients with at least nine T2 lesions at baseline ( P = 0.0044). These data confirm that IM IFNβ-1a delays conversion to CDMS in patients with CIS.

Clinical trials of multiple sclerosis therapies: improvements to demonstrate long-term patient benefit

Background

The therapeutic goal for multiple sclerosis (MS) is to achieve a better long-term outcome. However, since available data come from short-term studies, it is important to review the evidence that current therapies provide long-term benefit.

Method and results

Long-term data from both registry studies and long-term follow-up studies, and efficacy treatment data were reviewed. Registry data show that the course of MS is predictable after a certain level of disability is reached, indicating that short-term efficacy data from randomized, controlled trials provide evidence of long-term benefit. Long-term studies of patients originally enrolled in pivotal randomized, controlled trials consistently show that delayed or discontinued treatment provides less benefit than continuous therapy. The 16-Year Long-Term Follow-Up Study of interferon beta-1b (IFNβ-1b; Betaferon®/Betaseron®) therapy had the highest ascertainment of long-term follow-up efforts of the pivotal trials, which led to the currently approved therapies. Disability scores at the start of treatment were predictive of their current disability scores. In addition, this 16-year study showed an excellent safety profile with no unexpected side effects to IFNβ-1b and a lower mortality rate after 16 years compared with those receiving placebo treatment during the pivotal study (6 deaths vs 20 deaths).

Conclusion

This article reviews the key data and provides recommendations for optimizing clinical studies in MS to demonstrate long-term patient benefit.

MRI characteristics are predictive for CDMS in monofocal, but not in multifocal patients with a clinically isolated syndrome

Background

To diagnose multiple sclerosis (MS), evidence for dissemination in space and time is required. There is no clear definition on how symptoms and signs of a patient indicate clinical dissemination in space. To provide a uniform approach on this subject, a clinical classification system was described recently differentiating patients with mono- and multifocal clinical presentation. Here we assess the predictive value of clinically defined dissemination in space at first presentation for time to clinically definite MS (CDMS).

Methods

Four hundred and sixty-eight patients with a first episode suggestive of MS were classified as clinically mono- or multifocal by two neurologists blinded to magnetic resonance imaging (MRI) results. These patients were part of the BENEFIT study in which 292 patients were randomized to interferon beta-1b (IFNB-1b) and 176 to placebo. By using Kaplan-Meier statistics the risk for CDMS was studied in mono- and multifocal patients of the placebo group, both with and without taking into account MRI measures of potential prognostic relevance.

Results

Time to CDMS was similar in monofocal and multifocal patients. In monofocal patients, the risk for CDMS over 2 years was significantly higher when ≥ 9 T2 lesions or at least one Gd-enhancing lesion were present at the first event or 3 or 6 months after the first event. In patients with multifocal presentation, these MRI measures had no significant added value in predicting time to CDMS.

Conclusion

These data indicate that a carefully performed neurological assessment of symptoms and signs, combined with lesions on MRI, is important for defining the risk of conversion to CDMS.

Trial Registration

The Benefit trial has been registered under NCT00185211

Differences in retinal nerve fiber layer atrophy between multiple sclerosis subtypes

OBJECTIVES

To determine whether retinal nerve fiber layer (RNFL) atrophy in the afferent visual pathway may complement existing tools used to describe and characterize differences across MS subtypes.

METHODS

Optical coherence tomography-measured RNFL values were compared over two years in 35 patients (70 eyes) with optic neuritis (ON) as a clinically isolated syndrome (CIS); 39 patients (78 eyes) with relapsing remitting MS (RRMS); and 7 patients (14 eyes) with secondary progressive MS (SPMS).

RESULTS

RNFL comparisons involving eyes without ON yielded greater differences between MS subtypes than ON-affected eyes. Overall RNFL values in non-affected eyes were reduced in SPMS patients (83.4 microm), relative to CIS (101.2 microm) (p=0.0009), and RRMS patients (103.7 microm) (p=0.001); and temporal RNFL atrophy was greater in RRMS (64.4 microm) eyes as compared to CIS eyes (73.2 microm) (p=0.02). In ON-affected eyes, RNFL atrophy was greater in SPMS patients (39.5 microm) than CIS patients (58.1 microm) (p=0.03), and in RRMS patients (48.2 microm) relative to CIS patients (p=0.05). RNFL values did not change significantly for any MS subtype during the two-year duration of the study.

INTERPRETATION

RNFL thickness may represent a structural marker, which can help distinguish MS subtypes, because the extent of atrophy is commensurate with disease progression. RNFL comparisons between non-affected eyes revealed greater differences between CIS, RRMS, and SPMS patients relative to ON-affected eyes, because the impact of prior ON may supplant the effects of disease subtype.

Optical coherence tomography: a window into the mechanisms of multiple sclerosis

The pathophysiology of multiple sclerosis (MS) is characterized by demyelination, which culminates in a reduction in axonal transmission. Axonal and neuronal degeneration seem to be concomitant features of MS and are probably the pathological processes responsible for permanent disability in this disease. The retina is unique within the CNS in that it contains axons and glia but no myelin, and it is, therefore, an ideal structure within which to visualize the processes of neurodegeneration, neuroprotection, and potentially even neurorestoration. In particular, the retina enables us to investigate a specific compartment of the CNS that is targeted by the disease process. Optical coherence tomography (OCT) can provide high-resolution reconstructions of retinal anatomy in a rapid and reproducible fashion and, we believe, is ideal for precisely modeling the disease process in MS. In this Review, we provide a broad overview of the physics of OCT, the unique properties of this method with respect to imaging retinal architecture, and the applications that are being developed for OCT to understand mechanisms of tissue injury within the brain.

The clinical epidemiology of multiple sclerosis

A comprehensive knowledge of the natural course and prognosis of multiple sclerosis is of utmost importance for a physician to make it affordable in simple descriptive terms to a patient when personal and medical decisions are to be taken. It is still topical because the currently acknowledged disease-modifying agents only marginally alter the overall prognosis of the disease. It provides reference for evaluating the efficacy of a therapeutic intervention in clinical trials; clues for public health services, health insurance companies, and pharmaceutical industry in their respective activities; and insights into the pathophysiology and the treatment of multiple sclerosis. Precise, consistent, and reliable data from appropriate cohorts have become available and knowledge is fairly comprehensive.

Dose response to interferon therapy in multiple sclerosis: an evaluation of the evidence

BACKGROUND

Interferon beta (IFNbeta) is a disease-modifying therapy for multiple sclerosis (MS). Although clinical benefits have been demonstrated in several large, randomized, double-blind studies, the optimal dosing of IFNbeta is controversial.

METHODS

A search was conducted using the key words IFNbeta, multiple sclerosis, Avonex, Rebif, Betaseron/Betaferon, efficacy, MRI, and dose-response relationship in MEDLINE, EMBASE, and other databases to locate relevant pivotal clinical trials, other prospective studies, and systematic reviews evaluating the efficacy and tolerability of IFNbeta published between 1985 and 2007. This review summarizes the findings of these studies with regard to defining the value of high-dose, high-frequency (HDHF) IFNbeta regimens.

REVIEW SUMMARY

All IFNbeta formulations and dosages have demonstrated efficacy in well-designed phase 3 trials. Two head-to-head trials suggesting that HDHF regimens result in increased efficacy contained shortfalls in study design that precluded definitive conclusions.

CONCLUSION

Defining the optimal dose and frequency strategy for IFNbeta in patients with MS is complicated by the differences in dosage, route, and frequency of administration among the various agents. Results of well-controlled pivotal trials do not suggest that HDHF IFNbeta regimens provide better long-term benefits for patients with MS than low-dose or low-frequency regimens. In addition, HDHF therapies may increase the incidence of side-effects and neutralizing antibodies that reduce efficacy over time. Although the two head-to-head comparisons of different IFNbeta therapies found HDHF regimens to be more efficacious than lower-dose/lower-frequency regimens, the design limitations of these studies must be considered when weighing the potential value of the findings for recommending treatment strategies.

Multiple sclerosis: clinical features, pathophysiology, neuroimaging and future therapies

Multiple sclerosis (MS) is a common immune-mediated progressive neurodegenerative disease of the CNS that typically manifests with periods of disease activity followed by intervals of remission. The etiology of MS remains unknown; however, existing evidence indicates that MS is a ‘whole-brain disease’ that is driven by a potent immune response against CNS antigen(s), particularly myelin peptide antigens. The immunopathogenesis of MS includes both the cell- and humorally-mediated arms of the immune system. Genetic and environmental factors play important roles in the development of MS. Application of various neuroimaging techniques to the world of MS have expanded our knowledge concerning its pathogenesis and assist us in the more accurate diagnosis of MS versus its imitators. Current treatments target acute attacks and aim to reduce future clinical relapses. A summary of the potential future therapies for MS is presented.

Disease-modifying agents for multiple sclerosis: recent advances and future prospects

Multiple sclerosis (MS) is a chronic autoimmune disease of the CNS. Currently, six medications are approved for immunmodulatory and immunosuppressive treatment of the relapsing disease course and secondary-progressive MS. In the first part of this review, the pathogenesis of MS and its current treatment options are discussed. During the last decade, our understanding of autoimmunity and the pathogenesis of MS has advanced substantially. This has led to the development of a number of compounds, several of which are currently undergoing clinical testing in phase II and III studies. While current treatment options are only available for parenteral administration, several oral compounds are now in clinical trials, including the immunosuppressive agents cladribine and laquinimod. A novel mode of action has been described for fingolimod, another orally available agent, which inhibits egress of activated lymphocytes from draining lymph nodes. Dimethylfumarate exhibits immunomodulatory as well as immunosuppressive activity when given orally. All of these compounds have successfully shown efficacy, at least in regards to the surrogate marker contrast-enhancing lesions on magnetic resonance imaging. Another class of agents that is highlighted in this review are biological agents, namely monoclonal antibodies (mAb) and recombinant fusion proteins. The humanized mAb daclizumab inhibits T-lymphocyte activation via blockade of the interleukin-2 receptor. Alemtuzumab and rituximab deplete leukocytes and B cells, respectively; the fusion protein atacicept inhibits specific B-cell growth factors resulting in reductions in B-cells and plasma cells. These compounds are currently being tested in phase II and III studies in patients with relapsing MS. The concept of neuro-protection and -regeneration has not advanced to a level where specific compounds have entered clinical testing. However, several agents approved for conditions other than MS are highlighted. Finally, with the advent of these highly potent novel therapies, rare, but potentially serious adverse effects have been noted, namely infections and malignancies. These are critically reviewed and put into perspective.

Prospective combined brain and spinal cord MRI in clinically isolated syndromes and possible early multiple sclerosis: impact on dissemination in space and time

BACKGROUND

The diagnosis of multiple sclerosis (MS) is based on dissemination in space (DIS) and time (DIT). The aim of the study was to assess the impact of spinal cord (SC) imaging on the evidence of DIS and DIT.

METHODS

Thirty-five treatment-naive patients with a first clinical symptom suggestive of MS were examined in a 2-year prospective longitudinal follow-up assessment. Brain and SC magnetic resonance imaging (MRI), Expanded Disability Status Scale and multiple sclerosis functional composite were analysed at baseline and after 1 and 2 years.

RESULTS

At study entry, 21 patients were classified as clinically isolated syndrome suggestive of MS (CIS) and 14 patients as possible early MS. SC lesions were detected at baseline in 14 CIS patients (67%, median: 1.0, enhancing 29%) and in 11 patients with possible early MS (79%, median: 2.0, enhancing 29%). DIS as depicted by additive SC imaging was detected in two additional individuals according to the revised versus the 2001 McDonald criteria. All patients with emerging cord lesions showed new brain lesions. Five individuals developed clinically asymptomatic cord lesions.

CONCLUSIONS

Spinal cord abnormalities are frequent in CIS patients and in patients with possible early MS. SC imaging slightly improved the establishment of DIS, but had no impact on the evidence of DIT.

Relapse management in multiple sclerosis

Relapses, exacerbations, and attacks are synonymous for new or worsened neurologic symptoms that are the hallmark of relapsing-remitting multiple sclerosis. Management of relapses is not always straightforward. The clinician must distinguish between true relapses, symptom fluctuation, and pseudo-relapses. Risks and benefits of treating a relapse must be considered. Once the decision to treat is made, most clinicians would pursue a course of corticosteroids. Consensus may end there, as there is no clear-cut "best" route of administration or dosing schedule. The patient presenting with their first relapse or clinically isolated syndrome may be at risk for the development of multiple sclerosis. Clinical presentation, CSF findings, and MRI may all give clues as to the risk for future demyelinating events.

Optimizing Outcomes in Multiple Sclerosis – A Consensus Initiative

Background

Initiation of immunomodulators in patients experiencing a clinically isolated syndrome (CIS) may delay progression to clinically definite MS. However, lack of consensus remains on many issues affecting optimal management of MS.

Method

A panel of 21 MS experts met during 9 meetings to explore key issues in MS and CIS. Meetings addressed 3 phases: 1. CIS definition and diagnosis; 2. initial therapy; and 3. monitoring disease progression and treatment efficacy. Newsletters covering each phase were sent to 5000 U.S.-based neurologists who were invited to participate in an online survey on key issues.

Results

Most panel members agreed that early treatment may minimize neurodegeneration and most would recommend it for patients; that a dose-response relationship exists for beta-interferon therapy; that more aggressive therapy was most effective early in the disease course; and, that MRI has a role in monitoring disease progression. In face of suboptimal response, most would switch patients to a different therapy; while combination therapy would be reserved for those failing monotherapy regimes. Most online survey respondents agreed with these positions.

Conclusions

There was uniform consensus from this panel of MS experts that early initiation of immunomodulator therapy was beneficial for CIS patients.

The contribution of cerebrospinal fluid oligoclonal bands to the early diagnosis of multiple sclerosis

Background

McDonald Criteria (MDC) have been validated in selected patients at high risk for multiple sclerosis (MS). However, possible overdiagnosis of MS can represent critical issues in less controlled clinical settings.

Objective

To assess the contribution of oligoclonal bands (OB) to MS diagnosis in current clinical practice.

Methods

We included all the patients admitted to our Department since 2001 who had undergone diagnostic workup for a possible MS diagnosis, followed up for at least 1 year. We assessed the accuracy of MDC, OB, and two MDC definitions of dissemination in space (DIS-MRI: fulfillment of MRI criteria, DIS-OB: two MRI lesions+OB).

Results

We included 118 patients (median follow-up 4.0 years). Twenty-eight cases received an alternative diagnosis, whereas none of these presented OB, 43% fulfilled the DIS-MRI criteria. OB were present in 70% of the remaining 90 patients. By the end of the follow-up, 56% of the diagnoses had converted to clinically definite MS and OB showed higher accuracy than DIS-MRI fulfillment (70% vs 58%). Moreover, after 1 year and at the end of the follow-up, DIS-OB yielded a higher Specificity level in comparison with DIS-MRI.

Conclusion

OB can improve overall diagnostic Accuracy by increasing Specificity and negative predictive value.

A review of disease-modifying therapies for MS: maximizing adherence and minimizing adverse events

BACKGROUND

In a chronic disabling disorder such as multiple sclerosis (MS), adherence to treatment is of critical importance in maximizing benefits of therapy over the long term. Adverse events (AEs) are often cited by patients who discontinue therapy.

METHODS

Databases including Medline, CINAHL, and International Pharmaceutical Abstracts were searched for literature pertaining to adherence and AEs in MS published between January 1970 and August 2008. Clinical studies and case reports of AEs were included, as were papers that outlined factors that influence adherence. An advisory board with extensive experience in managing patients with MS developed guidelines to assist healthcare providers in maximizing adherence to disease-modifying therapy.

DISCUSSION

Internally based factors such as self-image, and externally based factors such as AEs, may influence patients' willingness and ability to adhere to therapy. Management of AEs associated with disease-modifying therapies and other therapies is reviewed, including intramuscular and subcutaneous interferon beta (IFNbeta)-1a, IFNbeta-1b, glatiramer acetate, natalizumab, methylprednisolone, mitoxantrone, cyclophosphamide, methotrexate, azathioprine, and intravenous immunoglobulin.

CONCLUSIONS

Effective management of MS is an ongoing, dynamic process that can enhance patients' adherence to therapy. Healthcare practitioners may address factors influencing adherence among patients with MS by managing treatment expectations, maintaining good communication with the patient, and managing AEs of treatment. Although the guidelines proposed herein originate from a single advisory board, it seems clear that by addressing patient concerns, healthcare practitioners can work with patients to enhance their ability to continue to adhere to their therapies and thereby gain the benefits of their treatment over the long term.