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Newsome SD, Binns C, Kaunzner UW, Morgan S, Halper J. No Evidence of Disease Activity (NEDA) as a Clinical Assessment Tool for Multiple Sclerosis: Clinician and Patient Perspectives [Narrative Review]. Neurol Ther 2023; 12:1909-1935. [PMID: 37819598 PMCID: PMC10630288 DOI: 10.1007/s40120-023-00549-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023] Open
Abstract
The emergence of high-efficacy therapies for multiple sclerosis (MS), which target inflammation more effectively than traditional disease-modifying therapies, has led to a shift in MS management towards achieving the outcome assessment known as no evidence of disease activity (NEDA). The most common NEDA definition, termed NEDA-3, is a composite of three related measures of disease activity: no clinical relapses, no disability progression, and no radiological activity. NEDA has been frequently used as a composite endpoint in clinical trials, but there is growing interest in its use as an assessment tool to help patients and healthcare professionals navigate treatment decisions in the clinic. Raising awareness about NEDA may therefore help patients and clinicians make more informed decisions around MS management and improve overall MS care. This review aims to explore the potential utility of NEDA as a clinical decision-making tool and treatment target by summarizing the literature on its current use in the context of the expanding treatment landscape. We identify current challenges to the use of NEDA in clinical practice and detail the proposed amendments, such as the inclusion of alternative outcomes and biomarkers, to broaden the clinical information captured by NEDA. These themes are further illustrated with the real-life perspectives and experiences of our two patient authors with MS. This review is intended to be an educational resource to support discussions between clinicians and patients on this evolving approach to MS-specialized care.
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Affiliation(s)
- Scott D Newsome
- Johns Hopkins University School of Medicine, 600 North Wolfe Street, Pathology 627, Baltimore, MD, 21287, USA.
| | - Cherie Binns
- Multiple Sclerosis Foundation, 6520 N Andrews Avenue, Fort Lauderdale, FL, 33309, USA
| | | | - Seth Morgan
- National Multiple Sclerosis Society, 1 M Street SE, Suite 510, Washington, DC, 20003, USA
| | - June Halper
- Consortium of Multiple Sclerosis Centers, 3 University Plaza Drive Suite A, Hackensack, NJ, 07601, USA
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Bunul SD, Alagoz AN, Piri Cinar B, Bunul F, Erdogan S, Efendi H. A Preliminary Study on the Meaning of Inflammatory Indexes in MS: A Neda-Based Approach. J Pers Med 2023; 13:1537. [PMID: 38003852 PMCID: PMC10672718 DOI: 10.3390/jpm13111537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/09/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a disease of the central nervous system characterized by inflammation, demyelination, and axonal degeneration. This study aimed to investigate the relationship between inflammatory indexes and MS disease activity and progression. METHODS A prospective cohort study was conducted at the Kocaeli University Neurology Clinic, involving 108 patients diagnosed with MS. Data related to patient demographics, clinical presentations, radiological findings, and laboratory results were recorded. Inflammatory markers such as NLR (neutrophil-to-lymphocyte ratio), PLR (platelet-to-lymphocyte ratio), MLR (monocyte-to-lymphocyte ratio), and indexes such as SII (systemic immune inflammation index), SIRI (systemic immune response index), and AISI (systemic total aggregation index) were examined to determine their correlation with MS disease activity and disability. When assessing the influence of SII, AISI, and SIRI in predicting NEDA, it was found that all three indexes significantly predict NEDA. All indexes demonstrated a significant relationship with the EDSS score. Notably, SII, SIRI, and AISI were significant predictors of NEDA, and all inflammatory indexes showed a strong intercorrelation. This study investigates the role of inflammation markers in MS patients. It suggests that one or more of these non-invasive, straightforward, and practical markers could complement clinical and radiological parameters in monitoring MS.
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Affiliation(s)
- Sena Destan Bunul
- Department of Neurology, Faculty of Medicine, Kocaeli University, Kocaeli 4100, Turkey; (A.N.A.); (S.E.); (H.E.)
| | - Aybala Neslihan Alagoz
- Department of Neurology, Faculty of Medicine, Kocaeli University, Kocaeli 4100, Turkey; (A.N.A.); (S.E.); (H.E.)
| | - Bilge Piri Cinar
- Department of Neurology, Faculty of Medicine, Samsun University, Samsun 5500, Turkey;
| | - Fatih Bunul
- Internal Medicine, Anadolu Medical Center, Kocaeli 4100, Turkey;
| | - Seyma Erdogan
- Department of Neurology, Faculty of Medicine, Kocaeli University, Kocaeli 4100, Turkey; (A.N.A.); (S.E.); (H.E.)
| | - Husnu Efendi
- Department of Neurology, Faculty of Medicine, Kocaeli University, Kocaeli 4100, Turkey; (A.N.A.); (S.E.); (H.E.)
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Newsome SD, Scott TF, Arnold DL, Altincatal A, Naylor ML. Early treatment responses to peginterferon beta-1a are associated with longer-term clinical outcomes in patients with relapsing-remitting multiple sclerosis: Subgroup analyses of ADVANCE and ATTAIN. Mult Scler Relat Disord 2022; 57:103367. [PMID: 35158473 DOI: 10.1016/j.msard.2021.103367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/28/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early intervention with well-tolerated disease-modifying therapies (DMTs) for relapsing-remitting multiple sclerosis (RRMS) is recommended in order to delay disease progression, reduce neurologic damage, preserve brain volume, and optimize long-term patient outcomes. Lack of conversion of new/newly enlarging T2 (NET2) or gadolinium-enhancing (Gd+) lesions to chronic hypointensities (black hole conversion) and achievement of no evidence of disease activity (NEDA) early in the course of treatment are considered potential indicators of treatment effect and predictors of longer-term clinical outcomes. METHODS Patients with RRMS who were treated with peginterferon beta-1a in the 2-year ADVANCE phase 3 clinical trial (NCT0090639) and its 2-year open-label extension study, ATTAIN (NCT01332019), were grouped as newly diagnosed (diagnosed ≤1 year prior to enrollment and DMT naive) or non-newly diagnosed. For analyses of the impact of early treatment and disease activity control, the newly diagnosed and non-newly diagnosed subgroups were further divided based on whether they initiated peginterferon beta-1a every 2 weeks (Q2W) starting in study year 1 (continuously treated) or peginterferon beta-1a Q2W or every 4 weeks in study year 2 (delayed treatment). Patient subgroups were evaluated for conversion of NET2 or Gd+ lesions to persistent black holes (PBHs), brain atrophy (percentage change in whole brain volume [WBV]), achievement of NEDA composite outcomes, and the association of these disease activity measures with longer-term clinical outcomes (annualized relapse rate [ARR] and confirmed disability worsening [CDW]). RESULTS At 2 years, significantly fewer PBHs developed from NET2 lesions or Gd+ lesions in newly diagnosed and non-newly diagnosed patients continuously treated with peginterferon beta-1a than in the corresponding delayed-treatment groups (all p<0.0001). Percentage decrease in WBV from 6 months (rebaselined) to 2 years was significantly lower for newly diagnosed and non-newly diagnosed patients who received continuous peginterferon beta-1a treatment than for patients who received delayed treatment (both p ≤ 0.0442). In study year 1, a higher proportion of newly diagnosed and non-newly diagnosed patients treated with peginterferon beta-1a than those treated with placebo achieved NEDA (newly diagnosed: 28.3% vs 13.5% [p = 0.0010]; non-newly diagnosed: 40.8% vs 15.8% [p<0.0001]). NEDA rates remained stable over study years 2-4 for the newly diagnosed (range: 50.0%-53.9%) and non-newly diagnosed (range: 54.4%-57.0%) subgroups. Patients without PBH conversion had significantly lower ARR at 2 years (newly diagnosed: p = 0.0109; non-newly diagnosed: p = 0.0044) and a lower proportion of patients with 12-week CDW at 2 years (newly diagnosed: p = 0.2787; non-newly diagnosed: p = 0.0045) than the corresponding patient subgroups with PBH conversion. Patients who achieved NEDA in ADVANCE (study years 1-2) had a significantly lower ARR in ATTAIN (study years 3-4) than patients who did not achieve NEDA (newly diagnosed, p = 0.0003; non-newly diagnosed, p = 0.0001). Over 4 years, safety outcomes did not differ for the newly diagnosed and non-newly diagnosed patient subgroups. CONCLUSIONS These results indicate that newly diagnosed and non-newly diagnosed patients treated continuously with peginterferon beta-1a Q2W experienced better disease control over time than those who received delayed treatment. Patients with NEDA or evidence of less radiological disease activity in the first 2 years of treatment had better longer-term clinical outcomes than those with evidence of greater disease activity.
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Affiliation(s)
- Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Thomas F Scott
- Department of Neurology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, and NeuroRx Research, Montreal, QC, Canada
| | | | - Maria L Naylor
- Biogen, Cambridge, MA, USA, at the time of these analyses
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Zmira O, Halpern AI, Abraham L, Achiron A. Efficacy and safety of alemtuzumab treatment in a real-world cohort of patients with multiple sclerosis. Acta Neurol Belg 2021; 121:1513-1518. [PMID: 32447722 DOI: 10.1007/s13760-020-01375-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/12/2020] [Indexed: 12/15/2022]
Abstract
Alemtuzumab is a monoclonal anti-CD52 antibody prescribed to treat relapsing-remitting multiple sclerosis (RRMS). Alemtuzumab affects the balance of the immune system by depleting circulating lymphocytes, leading to the formation of a new immune repertoire less likely to induce autoimmune attack against CNS myelin. We collected real-world data of RRMS patients treated with alemtuzumab. We assessed relapse rate, disability progression, and MRI-related disease activity over a 24 month period. Our study included 35 RRMS patients (19 female and 16 male) with a mean age of 37.3 years (SD = 10.5). The patient cohort had a mean disease duration of 10.4 years, median previous disease modifying treatments (DMTs) of 3.0, and a median expanded disability status scale (EDSS) score of 4.0 (IQR 2.5-6.0). Neurological disability remained stable during treatment and there was no statistically significant change in EDSS score. Prior to treatment, the median relapse rate was 2.0 (IQR 1.0-3.0); after treatment the median relapse rate was 0.0. This 2.0 decrease in relapse rate is statistically significant (p < 0.0001). Moreover, the treated patients exhibited a statistically significant decrease in gadolinium (GD) enhancing lesions on MRI [both in number (p < 0.005) and volume (p < 0.005)]. Thirty-three percent of patients reached NEDA-3 (no evidence of disease activity) status by the end of treatment. In a real-world setting, alemtuzumab treatment significantly decreased relapse rate and GD-enhancing lesions while preventing disability progression. Tolerability of treatment was high, with patients experiencing only minor adverse events.
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Di Sabatino E, Gaetani L, Sperandei S, Fiacca A, Guercini G, Parnetti L, Di Filippo M. The no evidence of disease activity (NEDA) concept in MS: impact of spinal cord MRI. J Neurol 2021; 269:3129-3135. [PMID: 34820734 DOI: 10.1007/s00415-021-10901-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Measures to define treatment response, such as no evidence of disease activity (NEDA), are routinely used in multiple sclerosis (MS) clinical practice. Although spinal cord involvement is a frequent feature of MS, its magnetic resonance imaging (MRI) monitoring is not routinely performed. OBJECTIVE To assess the impact of spinal cord MRI in the definition of NEDA in a cohort of people with MS (pwMS) with available spinal cord imaging performed as for routine monitoring. METHODS We included 115 pwMS undergoing treatment with first-line disease-modifying therapies (DMTs) and retrospectively analyzed the presence of NEDA in the whole cohort, either considering or not spinal cord imaging. RESULTS When considering only clinical and brain MRI measures, 97 out of 115 pwMS (84.3%) satisfied the criteria for NEDA. In the same cohort, the number of pwMS with NEDA significantly decreased to 88 (76.5%) (p < 0.01) when considering also spinal cord imaging. CONCLUSION These findings suggest that, in routine clinical practice, spinal cord MRI monitoring in pwMS under first-line DMTs leads to a slight but significant change in the proportion of subjects classified as clinically and radiologically stable according to the NEDA definition.
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Affiliation(s)
- Elena Di Sabatino
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Piazzale Menghini 1, 06132, Perugia, Italy
| | - Lorenzo Gaetani
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Piazzale Menghini 1, 06132, Perugia, Italy
| | - Silvia Sperandei
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Piazzale Menghini 1, 06132, Perugia, Italy
| | - Andrea Fiacca
- Section of Neuroradiology, Santa Maria della Misericordia Hospital, Piazzale Menghini 1, 06132, Perugia, Italy
| | - Giorgio Guercini
- Section of Neuroradiology, Santa Maria della Misericordia Hospital, Piazzale Menghini 1, 06132, Perugia, Italy
| | - Lucilla Parnetti
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Piazzale Menghini 1, 06132, Perugia, Italy
| | - Massimiliano Di Filippo
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Piazzale Menghini 1, 06132, Perugia, Italy.
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Abstract
Multiple sclerosis is a relatively common, immune-mediated neurologic disease of the central nervous system that can cause significant disability and lead to reduced quality of life. There are several currently approved disease-modifying therapies, and more in the pipeline being developed and tested. As the field learns more about the pathophysiology and natural course of the disease, the treatment approaches are also being investigated. This article reviews data on available treatments along with a discussion of future treatment targets under investigation.
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Affiliation(s)
- Carolyn Goldschmidt
- Mellen Center U-10, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Marisa P McGinley
- Mellen Center U-10, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Navigating the TOR of Multiple Sclerosis. Can J Neurol Sci 2020; 47:435-436. [PMID: 32326985 DOI: 10.1017/cjn.2020.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Koda T, Namba A, Kinoshita M, Nakatsuji Y, Sugimoto T, Sakakibara K, Tada S, Shimizu M, Yamashita K, Takata K, Ishikura T, Murata S, Beppu S, Kumanogoh A, Mochizuki H, Okuno T. Sema4A is implicated in the acceleration of Th17 cell-mediated neuroinflammation in the effector phase. J Neuroinflammation 2020; 17:82. [PMID: 32169103 PMCID: PMC7068964 DOI: 10.1186/s12974-020-01757-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/24/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Sema4A is a regulator of helper T cell (Th) activation and differentiation in the priming phase, which plays an important role in the pathogenesis of experimental autoimmune encephalomyelitis (EAE) and multiple sclerosis (MS). However, the role of Sema4A in the effector phase remains elusive. We aimed to investigate the role of Sema4A at the effector phase in adoptively transferred EAE model. Clinical features and cytokine profiles of MS patients with high Sema4A levels were also examined in detail to clarify the correlation between Sema4A levels and disease activity of patients with MS. METHODS We adoptively transferred encephalitogenic Th1 or Th17 cells to wild type (WT) or Sema4A-deficient (Sema4A KO) mice and assessed severity of symptoms and cellular infiltration within the central nervous system (CNS). In addition, we analyzed clinical and radiological features (n = 201), levels of serum IFN-γ and IL-17A (n = 86), complete remission ratio by IFN-β (n = 38) in all of relapsing-remitting multiple sclerosis (RRMS) patients enrolled in this study. RESULTS Sema4A KO recipient mice receiving Th17-skewed WT myelin oligodendrocyte glycoprotein (MOG)-specific encephalitogenic T cells showed a significant reduction in the clinical score compared to the WT recipient mice. However, Sema4A KO recipient mice showed similar disease activity to the WT recipient mice when transferred with Th1-skewed encephalitogenic T cells. Bone marrow chimeric study indicated that Sema4A expressed on hematopoietic cells, but not the CNS resident cells, are responsible for augmenting Th17-mediated neuroinflammation. Additionally, in contrast to comparable IFN-γ levels, IL-17A is significantly higher in RRMS patients with high Sema4A level than those with low Sema4A patients with high Sema4A levels showed earlier disease onset, more severe disease activity and IFN-β unresponsiveness than those with low Sema4A levels. CONCLUSIONS Sema4A is involved not only in the Th cell priming but also in the acceleration of Th17 cell-mediated neuroinflammation in the effector phase, which could contribute to the higher disease activity observed in RRMS patients with high serum Sema4A levels.
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Affiliation(s)
- Toru Koda
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Akiko Namba
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Makoto Kinoshita
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuji Nakatsuji
- Department of Neurology, Toyama University Hospital, Toyama, Japan
| | | | - Kaori Sakakibara
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Satoru Tada
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Mikito Shimizu
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kazuya Yamashita
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kazushiro Takata
- Department of Neurology, Hoshigaoka Medical Center, Hirakata, Osaka, Japan
| | - Teruyuki Ishikura
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Syo Murata
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shohei Beppu
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine, Allergy and Rheumatic Diseases, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Tatsusada Okuno
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
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Adverse events and monitoring requirements associated with monoclonal antibody therapy in patients with multiple sclerosis. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00682-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Observational designs in clinical multiple sclerosis research: Particulars, practices and potentialities. Mult Scler Relat Disord 2019; 35:142-149. [PMID: 31394404 DOI: 10.1016/j.msard.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/03/2019] [Accepted: 07/19/2019] [Indexed: 11/24/2022]
Abstract
Observational studies investigate a wide range of topics in multiple sclerosis research. This paper presents an overview of the various observational designs and their applications in clinical studies. Observational studies are well suited for making discoveries and assessing new explanations of phenomena, but less so for establishing causal relationships, due to confounding by indication (selection bias), co-morbidity, socio-economic or other factors. Whether observational findings are demonstrative, indicative or only suggestive, depends on the research question, whether and how the design fits this question, analytical techniques, and the quality of data. Observational studies may be cross-sectional vs. longitudinal, and prospective vs. retrospective. The term 'retrograde' is proposed to explicate that cross-sectional studies may obtain data that cover (long) preceding periods. Case reports and case series are usually based on accidental observations or routinely collected data. Cross-sectional studies, by simultaneously assessing clinical phenomena and external factors, enable the discovery and quantification of associations. In ecological studies the unit of analysis is population or group, and relationships on patient level cannot be established. A cohort study is a longitudinal study that investigates patients with a defining characteristic, e.g. diagnosis or specific treatment, by analyzing data acquired at various intervals. Prospective cohort studies use (some) data that are not yet available at the time the research is conceived, whereas in retrospective studies the data already exist. In a case-control study a representative group of patients with a specific clinical feature is compared with controls, and the frequencies at which an external factor, e.g. infection, has occurred in each group is compared; in a nested case-control study controls are drawn from a fully known cohort. Randomized controlled trial (RCT)-extension studies are informative because, due to RCT randomization, they are free from confounding by indication. Patient or disease registries are organised systems for the long-term collection of uniform data on a population that is defined by a particular disease, condition or exposure, with the purpose to study changes over time. In pharmacotherapeutic research, accidental observations of unexpected beneficial effects may lead to further research into a drug's efficacy in other conditions. Uncontrolled phase 1 studies investigate safety and dosing aspects. Observational studies are alternatives to RCTs when these are not feasible for ethical or practical reasons. Phase 4 observational studies play a crucial role in the evaluation of the effectiveness of treatments in daily practice, the validation of RCT-based side effect profiles, and the discovery of late occurring or rare, potentially life-threatening side effects. Combinations of multidisciplinary longitudinal data bases into large data sets enable the development of algorithms for personalized treatments. To improve the reporting of observational findings on treatment effectiveness, it is proposed that abstracts define the research question(s) the study was meant to answer, study design and analytical methods, and identify and quantify the patient population, treatment of interest, relevant outcomes and the study's strengths and limitations. The development of guidelines for Strengthening the Reporting of Observational Studies in Effectiveness Research (STROBER), as an extension of the guidelines used in epidemiology, is wanted.
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Efficacy and safety of alemtuzumab in a real-life cohort of patients with multiple sclerosis. J Neurol 2019; 266:1405-1411. [DOI: 10.1007/s00415-019-09272-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 10/27/2022]
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Abstract
PURPOSE OF REVIEW To summarize recent findings from the application of MRI in the diagnostic work-up of patients with suspected multiple sclerosis (MS), and to review the insights into disease pathophysiology and the utility of MRI for monitoring treatment response. RECENT FINDINGS New evidence from the application of MRI in patients with clinically isolated syndromes has guided the 2017 revision of the McDonald criteria for MS diagnosis, which has simplified their clinical use while preserving accuracy. Other MRI measures (e.g., cortical lesions and central vein signs) may improve diagnostic specificity, but their assessment still needs to be standardized, and their reliability confirmed. Novel MRI techniques are providing fundamental insights into the pathological substrates of the disease and are helping to give a better understanding of its clinical manifestations. Combined clinical-MRI measures of disease activity and progression, together with the use of clinically relevant MRI measures (e.g., brain atrophy) might improve treatment monitoring, but these are still not ready for the clinical setting. SUMMARY Advances in MRI technology are improving the diagnostic work-up and monitoring of MS, even in the earliest phases of the disease, and are providing MRI measures that are more specific and sensitive to disease pathological substrates.
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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
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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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Oral Disease-Modifying Treatments for Relapsing Multiple Sclerosis: A Likelihood to Achieve No Evidence of Disease Activity or Harm Analysis. CNS Drugs 2018; 32:1069-1078. [PMID: 30069684 DOI: 10.1007/s40263-018-0547-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The likelihood to help or harm (LHH) is an absolute measure of the benefit versus risk profile of a medication, which can be used to assess the potential for benefit versus harm of different disease-modifying treatments (DMTs) for relapsing multiple sclerosis (R-MS) and facilitate clinical decision-making. OBJECTIVE The objective of this study was to assess absolute differences in benefit:risk ratios of oral DMTs for R-MS, using LHH analysis with no evidence of disease activity (NEDA) as beneficial outcome. DESIGN/METHODS The number needed to treat for a paient to achieve NEDA (NNTBNEDA) was used as an effect size metric of efficacy and the number needed to treat for a patient to experience an adverse event (NNTHAE), a serious adverse event (NNTHSAE), or treatment discontinuation due to an adverse event (NNTHAE-D) were used as measures of risk. The LHH-which is the ratio of NNTH:NNTB-values were calculated from published phase III trial data for oral DMTs. RESULTS The values for likelihood to achieve NEDA than experience any AE ratio (LHH(AE/NEDA)) were 3.5, 6.8, 12.5 and 2.6, the likelihood to achieve NEDA than experience a SAE ratio (LHH(SAE/NEDA)) values were 13.0, 3.5, 23.5 and 2.7, and the likelihood to achieve NEDA versus discontinue treatment (LHH(AE-D/NEDA)) values were 17.7, 6.5, 4.6 and 3.0 for cladribine, dimethyl-fumarate, fingolimod, and teriflunomide, respectively. CONCLUSIONS With all of the oral DMTs examined, R-MS patients are more likely to achieve NEDA than experience any adverse event.
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Nothing Ventured, Nothing Gained? Navigating Disease-Modifying Treatment in Multiple Sclerosis. Can J Neurol Sci 2018; 45:487-488. [DOI: 10.1017/cjn.2018.317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Parks NE, Pittock SJ, Mandrekar J, Kantarci OH, Lucchinetti CF, Weinshenker BG, Keegan BM, Tobin WO, Tillema JM, Toledano M, Flanagan EP. Population-based study of "no evident disease activity" in MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e495. [PMID: 30211251 PMCID: PMC6134213 DOI: 10.1212/nxi.0000000000000495] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/17/2018] [Indexed: 11/29/2022]
Abstract
Objective To determine the persistence of no evident disease activity (NEDA) in a population-based relapsing-remitting MS (RRMS) cohort. Methods All incident cases of RRMS in Olmsted County between 2000 and 2011 were identified using a medical records linkage system. Persistence of NEDA after RRMS diagnosis was determined by retrospective chart review. MRI activity, relapse, or Expanded Disability Status Scale (EDSS) worsening resulted in failure of NEDA. Results We identified 93 incident cases of RRMS including 82 individuals with sufficient follow-up to determine the persistence of NEDA. There were 44 individuals not on disease-modifying therapy (DMT), whereas 37 individuals were prescribed an injectable DMT and 1 received mitoxantrone during the interval over which NEDA was maintained. NEDA was maintained by 63% at 1 year, 38% at 2 years, 19% at 5 years, and 12% at 10 years according to routine care assessment. At 10 years, there was no difference in EDSS disability among patients who maintained NEDA vs those who failed NEDA at 1 year (p = 0.3). Conclusions NEDA infrequently persists beyond 2 years in a population-based cohort of newly diagnosed patients with RRMS.
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Affiliation(s)
- Natalie E Parks
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - Sean J Pittock
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - Jay Mandrekar
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - Orhun H Kantarci
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - Claudia F Lucchinetti
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - Brian G Weinshenker
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - B Mark Keegan
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - W Oliver Tobin
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - Jan-Mendelt Tillema
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - Michel Toledano
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
| | - Eoin P Flanagan
- Department of Neurology (N.E.P., S.J.P., O.H.K., C.F.L., B.G.W., B.M.K., W.O.T., J.M.T., M.T., E.P.F.), Department of Laboratory Medicine & Pathology (S.J.P., E.P.F.), and Department of Biomedical Statistics and Informatics (J.M.), Mayo Clinic, Rochester, MN; and Department of Medicine (Division of Neurology) (N.E.P.), Dalhousie University, Halifax, Canada
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The Shifting Landscape of Disease-Modifying Therapies for Relapsing Multiple Sclerosis. J Neuroophthalmol 2018; 38:210-216. [PMID: 29750735 DOI: 10.1097/wno.0000000000000659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is the most common nontraumatic neurological disorder of young adults, and roughly 85% of patients present with the relapsing form of the disease. Over the past 2 decades, the treatment arsenal for relapsing MS has expanded and evolved from mildly effective and relatively benign injectable agents to potent cell-depleting monoclonal agents. The latter have the potential to achieve disease remission coupled with risk of moderate to severe adverse events with which all MS care providers will need to acquaint themselves. METHODS This review is based on a detailed assessment of MS pivotal trials, extension studies, and expert reviews of the agents discussed. RESULTS/CONCLUSIONS The following review should aid those practitioners directly and indirectly involved in the care of MS patients in understanding the benefits and risks associated with the medications they prescribe.
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