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Chitnis T, Banwell B, Kappos L, Arnold DL, Gücüyener K, Deiva K, Saubadu S, Hu W, Benamor M, Le-Halpere A, Truffinet P, Tardieu M. Teriflunomide in pediatric patients with relapsing multiple sclerosis: Open-label extension of TERIKIDS. Mult Scler 2024; 30:833-842. [PMID: 38619037 PMCID: PMC11134969 DOI: 10.1177/13524585241242050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The double-blind TERIKIDS study demonstrated the efficacy and safety of teriflunomide. OBJECTIVE To evaluate the efficacy, safety, and tolerability of continuous teriflunomide treatment in the TERIKIDS open-label extension. METHODS In the double-blind period, children with relapsing MS were randomized to placebo or teriflunomide (14 mg adult-equivalent dose) for ⩽ 96 weeks. Participants received teriflunomide for ⩽ 192 weeks post-randomization in the open-label extension. RESULTS The mean age at screening was 14.6 years. For teriflunomide/teriflunomide versus placebo/teriflunomide, estimated clinical relapse risk was reduced by 38% (hazard ratio (HR) 0.62; 95% confidence interval (CI) 0.39-0.98; p = 0.11) and numbers of gadolinium-enhancing T1 and new/enlarging T2 lesions were reduced by 43% (relative risk (RR) 0.570; 95% CI 0.33-0.98; p = 0.043) and 49% (RR 0.511; 95% CI 0.34-0.76; p = 0.001), respectively, in the combined double-blind and open-label periods. There was a trend toward reduced risk of 24-week sustained disability progression for teriflunomide/teriflunomide versus placebo/teriflunomide (HR 0.47; 95% CI 0.23-0.96). During the open-label extension, incidences of safety-related discontinuations were 4.0% (teriflunomide/teriflunomide) and 13.5% (placebo/teriflunomide), including two children who developed pancreatitis in the teriflunomide/teriflunomide group. CONCLUSION Teriflunomide reduced the long-term risk of focal inflammatory activity, with generally manageable tolerability and no new safety signals. Further evidence would strengthen clinical efficacy findings.ClinicalTrials.gov: NCT02201108.
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Affiliation(s)
- Tanuja Chitnis
- Massachusetts General Hospital for Children, Boston, MA, USA
| | - Brenda Banwell
- Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University of Basel, Basel, Switzerland/MS Center and Neurologic Clinic and Policlinic, Departments of Biomedicine and Clinical Research, University Hospital of Basel, Basel, Switzerland
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada
- NeuroRx Research, Montréal, QC, Canada
| | - Kivilcim Gücüyener
- Gazi Universitesi Tip Fakultesi Pediatrik Nöroloji Bilim Dali, Ankara, Turkey
| | - Kumaran Deiva
- Department of Pediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Paris, France
| | | | | | | | | | | | - Marc Tardieu
- Department of Pediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Paris, France
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Graves JS, Thomas M, Li J, Shah AR, Goodyear A, Lange MR, Schmidli H, Häring DA, Friede T, Gärtner J. Improving pediatric multiple sclerosis interventional phase III study design: a meta-analysis. Ther Adv Neurol Disord 2022; 15:17562864211070449. [PMID: 35514529 PMCID: PMC9066624 DOI: 10.1177/17562864211070449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/13/2021] [Indexed: 11/16/2022] Open
Abstract
Background: To support innovative trial designs in a regulatory setting for pediatric-onset multiple sclerosis (MS), the study aimed to perform a systematic literature review and meta-analysis of relapse rates with interferon β (IFN β), fingolimod, and natalizumab and thereby demonstrate potential benefits of Bayesian and non-inferiority designs in this population. Methods: We conducted a literature search in MEDLINE and EMBASE from inception until 17 June 2020 of all studies reporting annualized relapse rates (ARR) in IFN β-, fingolimod-, or natalizumab-treated patients with pediatric-onset relapsing–remitting MS. These interventions were chosen because the literature was mainly available for these treatments, and they are currently used for the treatment of pediatric MS. Two researchers independently extracted data and assessed study quality using the Cochrane Effective Practice and Organization of Care – Quality Assessment Tool. The meta-analysis estimates were obtained by Bayesian random effects model. Data were summarized as ARR point estimates and 95% credible intervals. Results: We found 19 articles, including 2 randomized controlled trials. The baseline ARR reported was between 1.4 and 3.7. The meta-analysis-based ARR was significantly higher in IFN β-treated patients (0.69, 95% credible interval: 0.51–0.91) versus fingolimod (0.11, 0.04–0.27) and natalizumab (0.17, 0.09–0.31). Based on the meta-analysis results, an appropriate non-inferiority margin versus fingolimod could be in the range of 2.29–2.67 and for natalizumab 1.72–2.29 on the ARR ratio scale. A Bayesian design, which uses historical information for a fingolimod or natalizumab control arm, could reduce the sample size of a new trial by 18 or 14 patients, respectively. Conclusion: This meta-analysis provides evidence that relapse rates are considerably higher with IFNs versus fingolimod or natalizumab. The results support the use of innovative Bayesian or non-inferiority designs to avoid exposing patients to less effective comparators in trials and bringing new medications to patients more efficiently.
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Affiliation(s)
- Jennifer S. Graves
- Department of Neurosciences, University of California, San Diego, Box 0662 ACTRI, 9452 Medical Center Drive, Suite 4W-222, San Diego, CA 92037, USA
| | | | - Jun Li
- Novartis Pharma AG, Basel, Switzerland
| | | | - Alexandra Goodyear
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA at the time of article development
| | | | | | | | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Jutta Gärtner
- Department of Pediatrics and Adolescent Medicine, German Center for Multiple Sclerosis in Childhood and Adolescence, University Medical Center Göttingen, Göttingen, Germany
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Baroncini D, Simone M, Iaffaldano P, Brescia Morra V, Lanzillo R, Filippi M, Romeo M, Patti F, Chisari CG, Cocco E, Fenu G, Salemi G, Ragonese P, Inglese M, Cellerino M, Margari L, Comi G, Zaffaroni M, Ghezzi A. Risk of Persistent Disability in Patients With Pediatric-Onset Multiple Sclerosis. JAMA Neurol 2021; 78:726-735. [PMID: 33938921 DOI: 10.1001/jamaneurol.2021.1008] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Availability of new disease-modifying therapies (DMTs) and changes of therapeutic paradigms have led to a general improvement of multiple sclerosis (MS) prognosis in adults. It is still unclear whether this improvement also involves patients with pediatric-onset MS (POMS), whose early management is more challenging. Objective To evaluate changes in the prognosis of POMS over time in association with changes in therapeutic and managing standards. Design, Setting, and Participants Retrospective, multicenter, observational study. Data were extracted and collected in May 2019 from the Italian MS Registry, a digital database including more than 59 000 patients. Inclusion criteria were MS onset before age 18 years, diagnosis before January 2014, and disease duration of at least 3 years. Exclusion criteria were primary progressive MS, Expanded Disability Status Scale (EDSS) score of at least 8 one year after onset, unavailability of diagnosis date, and less than 2 EDSS score evaluations. Eligible patients were 4704 patients with POMS. According to these criteria, we enrolled 3198 patients, excluding 1506. Exposures We compared time to reach disability milestones by epoch of MS diagnosis (<1993, 1993-1999, 2000-2006, and 2007-2013), adjusting for possible confounders linked to EDSS evaluations and clinical disease activity. We then analyzed the difference among the 4 diagnosis epochs regarding demographic characteristics, clinical disease activity at onset, and DMTs management. Main Outcomes and Measures Disability milestones were EDSS score 4.0 and 6.0, confirmed in the following clinical evaluation and in the last available visit. Results We enrolled 3198 patients with POMS (mean age at onset, 15.2 years; 69% female; median time to diagnosis, 3.2 years; annualized relapse rate in first 1 and 3 years, 1.3 and 0.6, respectively), with a mean (SD) follow-up of 21.8 (11.7) years. Median survival times to reach EDSS score of 4.0 and 6.0 were 31.7 and 40.5 years. The cumulative risk of reaching disability milestones gradually decreased over time, both for EDSS score of 4.0 (hazard ratio [HR], 0.70; 95% CI, 0.58-0.83 in 1993-1999; HR, 0.48; 95% CI, 0.38-0.60 in 2000-2006; and HR, 0.44; 95% CI, 0.32-0.59 in 2007-2013) and 6.0 (HR, 0.72; 95% CI, 0.57-0.90; HR, 0.44; 95% CI, 0.33-0.60; and HR, 0.30; 0.20-0.46). In later diagnosis epochs, a greater number of patients with POMS were treated with DMTs, especially high-potency drugs, that were given earlier and for a longer period. Demographic characteristics and clinical disease activity at onset did not change significantly over time. Conclusions and Relevance In POMS, the risk of persistent disability has been reduced by 50% to 70% in recent diagnosis epochs, probably owing to improvement in therapeutic and managing standards.
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Affiliation(s)
- Damiano Baroncini
- Multiple Sclerosis Center, Gallarate Hospital, ASST Valle Olona, Gallarate (VA), Italy
| | - Marta Simone
- Child Neuropsychiatry Unit, Department of Biomedical Sciences and Oncology, University of Bari "Aldo Moro," Bari, Italy
| | - Pietro Iaffaldano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Care and Research Center, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
| | - Roberta Lanzillo
- Multiple Sclerosis Clinical Care and Research Center, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
| | - Massimo Filippi
- Department of Neurology and Neurophysiology, MS Center, and Neuroimaging Research Unit, Vita-Salute San Raffaele University and San Raffaele Scientific Institute, Milan, Italy
| | - Marzia Romeo
- Department of Neurology and Neurorehabilitation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Patti
- Policlinico Catania, Department of Medical, Surgery Science and Advanced Technology "GF Ingrassia," Section of Neurosciences, MS Center, University of Catania, Catania, Italy
| | - Clara Grazia Chisari
- Policlinico Catania, Department of Medical, Surgery Science and Advanced Technology "GF Ingrassia," Section of Neurosciences, MS Center, University of Catania, Catania, Italy
| | - Eleonora Cocco
- Department of Medical Science and Public Health, University of Cagliari and Multiple Sclerosis Center, Cagliari, Italy
| | - Giuseppe Fenu
- Department of Medical Science and Public Health, University of Cagliari and Multiple Sclerosis Center, Cagliari, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neurosciences, and advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Paolo Ragonese
- Department of Biomedicine, Neurosciences, and advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Maria Cellerino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Lucia Margari
- Child Neuropsychiatry Unit, Department of Biomedical Sciences and Oncology, University of Bari "Aldo Moro," Bari, Italy
| | - Giancarlo Comi
- Multiple Sclerosis Center, Gallarate Hospital, ASST Valle Olona, Gallarate (VA), Italy.,Institute of Experimental Neurology and Multiple Sclerosis Center IRCCS, San Raffaele Hospital, Milan, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, Gallarate Hospital, ASST Valle Olona, Gallarate (VA), Italy
| | - Angelo Ghezzi
- Multiple Sclerosis Center, Gallarate Hospital, ASST Valle Olona, Gallarate (VA), Italy
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Krysko KM, Graves JS, Rensel M, Weinstock-Guttman B, Rutatangwa A, Aaen G, Belman A, Benson L, Chitnis T, Gorman M, Goyal MS, Harris Y, Krupp L, Lotze T, Mar S, Moodley M, Ness J, Rodriguez M, Rose J, Schreiner T, Tillema JM, Waltz M, Casper TC, Waubant E. Real-World Effectiveness of Initial Disease-Modifying Therapies in Pediatric Multiple Sclerosis. Ann Neurol 2020; 88:42-55. [PMID: 32267005 DOI: 10.1002/ana.25737] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To assess real-world effectiveness of initial treatment with newer compared to injectable disease-modifying therapies (DMTs) on disease activity in pediatric multiple sclerosis (MS) and clinically isolated syndrome (CIS). METHODS This is a cohort study of children with MS/CIS followed at 12 clinics in the US Network of Pediatric MS Centers, who received initial therapy with newer (fingolimod, dimethyl fumarate, teriflunomide, natalizumab, rituximab, ocrelizumab) or injectable (interferon-β, glatiramer acetate) DMTs. Propensity scores (PSs) were computed, including preidentified confounders. Relapse rate while on initial DMT was modeled with negative binomial regression, adjusted for PS-quintile. Time to new/enlarging T2-hyperintense and gadolinium-enhancing lesions on brain magnetic resonance imaging were modeled with midpoint survival analyses, adjusted for PS-quintile. RESULTS A total of 741 children began therapy before 18 years, 197 with newer and 544 with injectable DMTs. Those started on newer DMTs were older (15.2 vs injectable 14.4 years, p = 0.001) and less likely to have a monofocal presentation. In PS-quintile-adjusted analysis, those on newer DMTs had a lower relapse rate than those on injectables (rate ratio = 0.45, 95% confidence interval (CI) = 0.29-0.70, p < 0.001; rate difference = 0.27, 95% CI = 0.14-0.40, p = 0.004). One would need to treat with newer rather than injectable DMTs for 3.7 person-years to prevent 1 relapse. Those started on newer DMTs had a lower rate of new/enlarging T2 (hazard ratio [HR] = 0.51, 95% CI = 0.36-0.72, p < 0.001) and gadolinium-enhancing lesions (HR = 0.38, 95% CI = 0.23-0.63, p < 0.001) than those on injectables. INTERPRETATION Initial treatment of pediatric MS/CIS with newer DMTs led to better disease activity control compared to injectables, supporting greater effectiveness of newer therapies. Long-term safety data for newer DMTs are required. ANN NEUROL 2020 ANN NEUROL 2020;88:42-55.
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Affiliation(s)
- Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Jennifer S Graves
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA.,Department of Neurology, University of California, San Diego, La Jolla, CA
| | - Mary Rensel
- Department of Neurology, Cleveland Clinic, Cleveland, OH
| | | | - Alice Rutatangwa
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Gregory Aaen
- Department of Pediatrics, Loma Linda University, San Bernardino, CA
| | - Anita Belman
- Department of Neurology, New York University Langone Medical Center, New York, NY
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Tanuja Chitnis
- Department of Pediatric Neurology, Massachusetts General Hospital, Boston, MA
| | - Mark Gorman
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Manu S Goyal
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, St Louis, MO
| | - Yolanda Harris
- Department of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Lauren Krupp
- Department of Neurology, New York University Langone Medical Center, New York, NY
| | - Timothy Lotze
- Department of Neurology, Texas Children's Hospital, Houston, TX
| | - Soe Mar
- Department of Neurology, Washington University in Saint Louis, St Louis, MO
| | - Manikum Moodley
- Department of Pediatrics and Neurology, Dell Children's Hospital, University of Texas, Austin, TX
| | - Jayne Ness
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | | | - John Rose
- Department of Neurology, University of Utah, Salt Lake City, UT
| | - Teri Schreiner
- Departments of Neurology and Pediatrics, University of Colorado, Aurora, CO
| | | | - Michael Waltz
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Emmanuelle Waubant
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
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Abstract
PURPOSE OF REVIEW With the recognition that pediatric-onset multiple sclerosis (POMS) is characterized by more prominent disease activity, earlier age at onset of disability milestones, and more prominent cognitive impairment compared with physical disability earlier in the disease course compared with adult-onset multiple sclerosis (AOMS), there has been increasing interest in identifying optimal and safe treatment approaches to achieve better disease control in this group. Injectable therapies have been traditionally used as first line in this population, although not formally approved. This review focuses on current treatment and monitoring approaches in POMS. RECENT FINDINGS In the past few years, and despite the paucity of FDA-approved medications for use in POMS, an increasing trend toward using newer disease-modifying therapies (DMTs) in this group is observed. However, escalation (as opposed to induction) remains the most frequent approach, and many children continue to be untreated before age 18, particularly before age 12. The only FDA- and EMA-approved disease-modifying therapy in POMS is fingolimod; however, dimethyl fumarate, teriflunomide, natalizumab, ocrelizumab, and alemtuzumab either have been evaluated in observational studies or are being currently investigated in formal randomized controlled trials for use in POMS and appear to be safe in this group. Autologous hematopoietic stem cell transplantation has also been evaluated in a small series. Clinical outcome measures and MS biomarkers have been poorly studied in POMS; however, the use of composite functional scores, neurofilament light chain, optical coherence tomography, and imaging findings is being increasingly investigated to improve early diagnosis and efficient monitoring of POMS. Off-label use of newer DMTs in POMS is increasing, and based on retrospective data, and phase 2 trials, this approach appears to be safe in children. Results from ongoing trials will help clarify the safety and efficacy of these therapies in the future. Fingolimod is the only FDA-approved medication for use in POMS. Outcome measures and biomarkers used in AOMS are being studied in POMS and are greatly needed to quantify treatment response in this group.
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Krupp LB, Vieira MC, Toledano H, Peneva D, Druyts E, Wu P, Boulos FC. A Review of Available Treatments, Clinical Evidence, and Guidelines for Diagnosis and Treatment of Pediatric Multiple Sclerosis in the United States. J Child Neurol 2019; 34:612-620. [PMID: 31234708 DOI: 10.1177/0883073819855592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pediatric multiple sclerosis is associated with challenges in prompt diagnosis and uncertainty regarding optimal treatment. This review aimed to identify treatment guidelines or consensus statements for pediatric patients with multiple sclerosis, US Food and Drug Administration (FDA)-approved treatment options for pediatric multiple sclerosis, and any randomized controlled trials and observational studies examining available pharmacologic treatments in the pediatric multiple sclerosis population. Literature searches were performed in MEDLINE (1946-2016), EMBASE (1974-2016), and the Cochrane Central Register of Controlled Trials to identify treatment guidelines or consensus statements, pediatric multiple sclerosis treatment approvals, and randomized controlled trials and observation studies that examine the safety and effectiveness of available disease-modifying therapies. Only 3 consensus statements provided recommendations for pharmacologic treatments for children, all 3 published before the most recent revisions of the pediatric multiple sclerosis diagnostic guidelines. Despite the changes to the clinical landscape of pediatric multiple sclerosis with the introduction of diagnostic guidelines, fingolimod is the only FDA-approved treatment for pediatric multiple sclerosis in the United States. The effectiveness and safety of other disease-modifying therapies suggested by consensus statements have been reported in relatively small prospective and retrospective observational studies. Clinical evidence from a recently completed randomized controlled trial and future global registries can inform treatment decisions for the pediatric multiple sclerosis population.
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Affiliation(s)
| | | | - Haley Toledano
- 2 Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Desi Peneva
- 3 Precision Health Economics, Los Angeles, CA, USA
| | | | - Ping Wu
- 4 Precision Xtract, Vancouver, BC, USA
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8
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Konietschke F, Friede T, Pauly M. Semi-parametric analysis of overdispersed count and metric data with varying follow-up times: Asymptotic theory and small sample approximations. Biom J 2018; 61:616-629. [PMID: 30515878 PMCID: PMC6587510 DOI: 10.1002/bimj.201800027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 11/09/2018] [Accepted: 11/09/2018] [Indexed: 11/09/2022]
Abstract
Count data are common endpoints in clinical trials, for example magnetic resonance imaging lesion counts in multiple sclerosis. They often exhibit high levels of overdispersion, that is variances are larger than the means. Inference is regularly based on negative binomial regression along with maximum-likelihood estimators. Although this approach can account for heterogeneity it postulates a common overdispersion parameter across groups. Such parametric assumptions are usually difficult to verify, especially in small trials. Therefore, novel procedures that are based on asymptotic results for newly developed rate and variance estimators are proposed in a general framework. Moreover, in case of small samples the procedures are carried out using permutation techniques. Here, the usual assumption of exchangeability under the null hypothesis is not met due to varying follow-up times and unequal overdispersion parameters. This problem is solved by the use of studentized permutations leading to valid inference methods for situations with (i) varying follow-up times, (ii) different overdispersion parameters, and (iii) small sample sizes.
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Affiliation(s)
- Frank Konietschke
- Department of Mathematical Sciences, University of Texas at Dallas, Dallas, TX, USA
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Markus Pauly
- Institute of Statistics, Ulm University, Ulm, Germany
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Krysko KM, Graves J, Rensel M, Weinstock-Guttman B, Aaen G, Benson L, Chitnis T, Gorman M, Goyal M, Krupp L, Lotze T, Mar S, Rodriguez M, Rose J, Waltz M, Charles Casper T, Waubant E. Use of newer disease-modifying therapies in pediatric multiple sclerosis in the US. Neurology 2018; 91:e1778-e1787. [PMID: 30333163 PMCID: PMC6251604 DOI: 10.1212/wnl.0000000000006471] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/25/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To characterize the use and safety of newer disease-modifying therapies (DMTs) in children with multiple sclerosis (MS) and clinically isolated syndrome (CIS) treated under 18 years of age. METHODS This is a cohort study including children with MS or CIS followed at 12 outpatient practices participating in the US Network of Pediatric MS Centers. DMT use, including duration, dose, and side effects, was analyzed. Newer DMTs were defined as agents receiving Food and Drug Administration approval or with increased use in adult MS after 2005. RESULTS As of July 2017, 1,019 pediatric patients with MS (n = 748) or CIS (n = 271) were enrolled (65% female, mean onset 13.0 ± 3.9 years, mean follow-up 3.5 ± 3.1 years, median 1.6 visits per year). Of these, 78% (n = 587) with MS and 11% (n = 31) with CIS received DMT before 18 years of age. This consisted of at least one newer DMT in 42%, including dimethyl fumarate (n = 102), natalizumab (n = 101), rituximab (n = 57), fingolimod (n = 37), daclizumab (n = 5), and teriflunomide (n = 3). Among 17%, the initial DMT prescribed was a newer agent (36 dimethyl fumarate, 30 natalizumab, 22 rituximab, 14 fingolimod, 2 teriflunomide). Over the last 10 years, the use of newer agents has increased, particularly in those ≥12 years and to lesser extent in those <12 years. The short-term side effect profiles of newer DMTs did not differ from those reported in adults. CONCLUSION Newer DMTs are often used in pediatric MS, and have similar short-term safety, tolerability, and side effect profiles as in adults. These findings may help inform pediatric MS management.
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Affiliation(s)
- Kristen M Krysko
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City.
| | - Jennifer Graves
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Mary Rensel
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Bianca Weinstock-Guttman
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Gregory Aaen
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Leslie Benson
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Tanuja Chitnis
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Mark Gorman
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Manu Goyal
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Lauren Krupp
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Timothy Lotze
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Soe Mar
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Moses Rodriguez
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - John Rose
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Michael Waltz
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - T Charles Casper
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
| | - Emmanuelle Waubant
- From the Department of Neurology (K.M.K., J.G., E.W.), University of California San Francisco; Department of Neurology (M. Rensel), Cleveland Clinic, OH; Department of Neurology (B.W.-G.), State University of New York at Buffalo; Department of Pediatrics (G.A.), Loma Linda University, CA; Department of Neurology (L.B., M. Gorman), Boston Children's Hospital, MA; Department of Neurology (T.C.), Massachusetts General Hospital, Boston; Department of Neurology (M. Goyal, S.M.), Washington University in Saint Louis, MO; Department of Neurology (L.K.), New York University Langone Medical Center, NY; Department of Neurology (T.L.), Texas Children's Hospital, Houston; Department of Neurology (M. Rodriguez), Mayo Clinic, Rochester, MN; and Department of Neurology (J.R.), Biostatistician II (M.W.), and Department of Pediatrics (T.C.C.), University of Utah, Salt Lake City
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10
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First-line therapy in relapsing remitting multiple sclerosis. Rev Neurol (Paris) 2018; 174:419-428. [DOI: 10.1016/j.neurol.2018.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/11/2018] [Accepted: 03/12/2018] [Indexed: 11/21/2022]
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11
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Mütze T, Konietschke F, Munk A, Friede T. A studentized permutation test for three-arm trials in the ‘gold standard’ design. Stat Med 2016; 36:883-898. [DOI: 10.1002/sim.7176] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/18/2016] [Accepted: 10/28/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Tobias Mütze
- Department of Medical Statistics; University Medical Center Göttingen; Humboldtallee 32 Göttingen 37073 Germany
| | - Frank Konietschke
- Department of Medical Statistics; University Medical Center Göttingen; Humboldtallee 32 Göttingen 37073 Germany
- Department of Mathematical Sciences; University of Texas at Dallas; Richardson 75080 TX U.S.A
| | - Axel Munk
- Institute for Mathematical Stochastics; Georg-August-University of Göttingen; Goldschmidtstraße 7 Göttingen 37077 Germany
- Max Planck Institute for Biophysical Chemistry; Am Faßberg 11 Göttingen 37077 Germany
| | - Tim Friede
- Department of Medical Statistics; University Medical Center Göttingen; Humboldtallee 32 Göttingen 37073 Germany
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12
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13
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Unkel S, Röver C, Stallard N, Benda N, Posch M, Zohar S, Friede T. Systematic reviews in paediatric multiple sclerosis and Creutzfeldt-Jakob disease exemplify shortcomings in methods used to evaluate therapies in rare conditions. Orphanet J Rare Dis 2016; 11:16. [PMID: 26897367 PMCID: PMC4761188 DOI: 10.1186/s13023-016-0402-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/12/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) are the gold standard design of clinical research to assess interventions. However, RCTs cannot always be applied for practical or ethical reasons. To investigate the current practices in rare diseases, we review evaluations of therapeutic interventions in paediatric multiple sclerosis (MS) and Creutzfeldt-Jakob disease (CJD). In particular, we shed light on the endpoints used, the study designs implemented and the statistical methodologies applied. METHODS We conducted literature searches to identify relevant primary studies. Data on study design, objectives, endpoints, patient characteristics, randomization and masking, type of intervention, control, withdrawals and statistical methodology were extracted from the selected studies. The risk of bias and the quality of the studies were assessed. RESULTS Twelve (seven) primary studies on paediatric MS (CJD) were included in the qualitative synthesis. No double-blind, randomized placebo-controlled trial for evaluating interventions in paediatric MS has been published yet. Evidence from one open-label RCT is available. The observational studies are before-after studies or controlled studies. Three of the seven selected studies on CJD are RCTs, of which two received the maximum mark on the Oxford Quality Scale. Four trials are controlled observational studies. CONCLUSIONS Evidence from double-blind RCTs on the efficacy of treatments appears to be variable between rare diseases. With regard to paediatric conditions it remains to be seen what impact regulators will have through e.g., paediatric investigation plans. Overall, there is space for improvement by using innovative trial designs and data analysis techniques.
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Affiliation(s)
- Steffen Unkel
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, 37073, Göttingen, Germany.
| | - Christian Röver
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, 37073, Göttingen, Germany
| | - Nigel Stallard
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Norbert Benda
- Biostatistics and Special Pharmacokinetics Unit, Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Martin Posch
- Section of Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Sarah Zohar
- Institut National de la Santé et de la Recherche Médicale (INSERM), Unité Mixte de Service 1138, Team 22, Centre de Recherche des Cordeliers, Université Paris 5 et Université Paris 6, Paris, France
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, 37073, Göttingen, Germany
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14
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Johnston J, So TY. First-line disease-modifying therapies in paediatric multiple sclerosis: a comprehensive overview. Drugs 2012; 72:1195-211. [PMID: 22642799 DOI: 10.2165/11634010-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Paediatric multiple sclerosis (MS) is defined as the onset of MS before the age of 18 years. Immunomodulatory disease-modifying therapies (i.e. the interferons [IFNs] and glatiramer acetate) are considered first-line treatments in adult patients with MS, but they are largely understudied in the paediatric population. IFNβ is a type 1 IFN produced by fibroblasts. The therapeutic effect achieved by IFNβ in MS is believed to be the result of a variety of mechanisms, including the inhibition of T-cell proliferation and a shift in cytokine production. There are currently two forms of recombinant IFNβ used therapeutically for MS: IFNβ-1a and IFNβ-1b. Two formulations of IFNβ-1a exist, one administered as an intramuscular injection once weekly and the other by subcutaneous injection three times per week. Only one type of IFNβ-1b product is on the market, a subcutaneous injection administered every other day. Pharmacokinetic studies of these agents in children do not exist and available data are primarily from studies in healthy adults. It does not appear that the various formulations differ significantly in terms of bioavailability or efficacy in adults. The toxicity profiles of the interferon formulations are similar, with the most common adverse effects in children including flu-like symptoms, injection site reactions and transient elevations in liver enzymes. Glatiramer acetate is a mixture of synthetic polypeptide chains consisting of four different amino acids. Glatiramer acetate appears to mimic the antigenic properties of myelin basic protein (MBP), and by doing so, alters T-cell activation in the periphery. Glatiramer acetate is administered as a once-daily subcutaneous injection. Similar to the IFNβ formulations, there are no pharmacokinetic studies of this agent in children. The most common adverse effects include injection site reactions and transient chest tightness. Fingolimod, a sphingosine 1-phosphate receptor modulator, is a new disease-modifying therapy that was approved by the US FDA in 2010 for the first-line treatment of relapsing forms of MS in adults. However, due to a lack of information and clinical data on this agent in the paediatric population, it is not included in this discussion. Dose-finding studies of the IFNs and glatiramer acetate in the paediatric population are limited. Dosing recommendations are largely based on tolerability studies, with most children and adolescents tolerating the full adult doses. Clinical studies of IFNs in children have not been objectively designed to establish the efficacy of these therapies, and evidence is limited to that of observational trials and retrospective case reports. However, the largest cohort (130 cases) of paediatric MS patients studied to date reported a reduction in annual relapse rate with all three of the different IFNβ formulations and glatiramer acetate after a follow-up period of more than 4 years. Treatment with one of the first-line agents should be offered to any patient after the occurrence of a second demyelinating episode. The efficacy of the four first-line disease-modifying agents is considered to be relatively equivalent, and the choice of agent should be determined on an individual patient basis, taking into account potential adverse effects and patient preferences. Current data suggest that the IFNs and glatiramer acetate are safe and effective therapies in paediatric patients with MS. However, further studies evaluating the pharmacokinetics, appropriate dosing and comparisons of efficacy among these agents are needed to determine the most appropriate and evidence-based treatment decisions in this population.
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Affiliation(s)
- Jessica Johnston
- University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
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15
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Abstract
Autoimmune diseases make up a significant portion of the acute and chronic caseload of all pediatric neurologists. By comparing these diseases and their treatments side by side, common themes become evident. Therapeutic decisions follow patterns dependent on the clinical situation. Physicians must adapt therapy based on individual clinical responses. This article provides an overview of the current therapeutic options as they relate to the more common pediatric neuroimmune disorders.
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Affiliation(s)
- Paul Golumbek
- Department of Neurology, Washington University, St Louis, MO 63110, USA.
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Arababadi MK, Mosavi R, Khorramdelazad H, Yaghini N, Zarandi ER, Araste M, Pourali R, Nekhei Z, Kennedy D. Cytokine patterns after therapy with Avonex®, Rebif®, Betaferon® and CinnoVex™ in relapsing–remitting multiple sclerosis in Iranian patients. Biomark Med 2010; 4:755-9. [DOI: 10.2217/bmm.10.81] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Several lines of evidence exist which suggest that changes in the expression of circulating cytokines are linked to the development or reoccurrence of multiple sclerosis (MS). This study aimed to evaluate the serum levels of relevant cytokines after therapy with IFN-β formulations in MS patients. Materials & methods: In this study, blood samples were collected from 70 MS patients undergoing four different types of IFN-β formulation treatment and 100 healthy controls. After 24 months of treatment, the serum levels of IL-17A, IL-12, IFN-γ and IL-10 in patients and healthy controls were analyzed by ELISA. Results: Our results demonstrated that serum levels of IL-17A were significantly higher in patients treated with CinnoVex™ and Avonex® when compared with healthy controls. Serum levels of IL-10 were significantly decreased after therapy with CinnoVex, whereas serum levels of IFN-β were elevated. No difference in serum levels of IL-12 were detected between patients and controls. Conclusion: Results of our study suggest that CinnoVex and Avonex modulate the immune system less than Rebif® and Betaferon® in MS patients, and an elevated dose of CinnoVex and Avonex may be required for better regulation of the immune system in MS patients.
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Affiliation(s)
- Mohammad Kazemi Arababadi
- Department of Microbiology, Hematology & Immunology, Rafsanjan University of Medical Sciences, Iran; Department of Microbiology & Immunology School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
- Molecular-Medicine Research Center, Rafsanjan University of Medical Sciences, Iran
| | - Reza Mosavi
- Department of Neurosurgery, Faculty of Medicine, Rafsanjan University of Medical Sciences, Iran
| | | | - Narges Yaghini
- Department of Biochemistry, Rafsanjan University of Medical Sciences, Iran
| | - Ebrahim Rezazadeh Zarandi
- Department of Microbiology, Hematology & Immunology, Rafsanjan University of Medical Sciences, Iran; Department of Microbiology & Immunology School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
- Molecular-Medicine Research Center, Rafsanjan University of Medical Sciences, Iran
| | - Majid Araste
- Samenoalaeme Special Diseases Center, Kerman University of Medical Sciences, Iran
| | - Reza Pourali
- Bahonar Hospital, Kerman University of Medical Sciences, Iran
| | - Zohre Nekhei
- Samenoalaeme Special Diseases Center, Kerman University of Medical Sciences, Iran
| | - Derek Kennedy
- School of Biomolecular & Physical Science, Eskitis Institute for Cell & Molecular Therapies, Griffith University, Nathan, Australia
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17
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Ghezzi A, Banwell B, Boyko A, Amato MP, Anlar B, Blinkenberg M, Boon M, Filippi M, Jozwiak S, Ketelslegers I, Kornek B, Ming Lim, Lindstrom E, Nadj C, Neuteboom R, Rocca MA, Rostasy K, Tardieu M, Wassmer E, Catsman-Berrevoets C, Hintzen R. Meeting Review: The management of multiple sclerosis in children: a European view. Mult Scler 2010; 16:1258-67. [DOI: 10.1177/1352458510375568] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
About 3—5% of all patients with multiple sclerosis experience the onset of their disease under the age of 16. A significant proportion of paediatric multiple sclerosis patients develop significant cognitive disturbances and persistent physical disability. The high relapse rate and the morbidity in the paediatric multiple sclerosis population has triggered the use of disease-modifying therapies that have been shown to reduce relapse rate, disease progression and cognitive decline in adult patients with multiple sclerosis. Hard evidence for the right treatment and its appropriate timing is scarce in paediatric multiple sclerosis. Nevertheless, expertise in this field has grown thanks to recent open-label trials and experience generated in specialized centres. In spring 2009, a first meeting was held in Rotterdam with clinicians from 11 European countries (one from Canada) that are all active in the management of paediatric multiple sclerosis. One of the aims was to generate a common view on the management of paediatric multiple sclerosis patients. The result of this meeting is presented here to help standardize treatment and to support clinicians with less experience in this field.
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Affiliation(s)
- Angelo Ghezzi
- Centro Studi SM, H S. Antonio Abate, Gallarate, VA, Italy
| | - Brenda Banwell
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alexey Boyko
- Russian State Medical University, Department of Neurology and Neurosurgery, Moscow, Russia
| | - Maria Pia Amato
- University of Florence, Department of Neurological and Psychiatric Sciences, Florence, Italy
| | - Banu Anlar
- Hacettepe University, Hospital, Department of Pediatric Neurology, Ankara, Turkey
| | - Morten Blinkenberg
- Copenhagen University Hospital, The Neuroscience Centre, Rigshospitalet, Copenhagen, Denmark
| | - Maartje Boon
- University Medical Centre, Groningen, Department of Pediatric Neurology, Groningen, The Netherlands
| | - Massimo Filippi
- University San Raffaele, Neuroimaging Research Unit, Milan, Italy
| | - Sergiusz Jozwiak
- The Children's Memorial Health Institute, Departments of Neurology and Epileptology, Warsaw, Poland
| | | | - Barbara Kornek
- University of Vienna Medical School, Department of Neuropsychiatry of Childhood and Adolescence, Vienna, Austria
| | - Ming Lim
- Evelina's Children's Hospital at Guys and St.Thomas' Hospitals, Department of Pediatric Neurology, London, UK
| | - Eva Lindstrom
- Karolinska Institute, Department of Neurology, Stockholm, Sweden
| | - Congor Nadj
- Institute of Neurology, Novi Sad, Republic of Serbia
| | - Rinze Neuteboom
- Erasmus MC, Department of Neurology, Rotterdam, The Netherlands
| | - Maria A Rocca
- University San Raffaele, Neuroimaging Research Unit, Milan, Italy
| | - Kevin Rostasy
- Medical University Innsbruck, Division of Pediatric Neurology and Inherited Metabolic Disorders, Innsbruck, Austria
| | - Marc Tardieu
- Bicêtre Hospital, Department of Neuropediatrics, University Paris Sud, France
| | | | | | - Rogier Hintzen
- Erasmus MC, Department of Neurology, Rotterdam, The Netherlands,
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18
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Abstract
Multiple sclerosis (MS) in children and adolescents accounts for 3-10% of the whole MS population, and is characterized by a relapsing course in almost all cases. The frequency of relapses is higher than in adult onset MS, at least in the first years of evolution. The objective of treatment is to speed the recovery after a relapse, to prevent the occurrence of relapses, and to prevent disease progression and neurodegeneration. The use of drugs for MS in children and adolescents has not been studied in clinical trials, so their use is mainly based on results from trials in adults and from observational studies. There is a consensus to treat acute relapses with intravenous high-dose corticosteroids. The possibility of preventing relapses and disease progression is based on the use of immunomodulatory agents. Interferon-beta (IFNB) and glatiramer acetate (GA) have been demonstrated to be safe and well tolerated in pediatric MS patients, and also to reduce relapse rate and disease progression. Cyclophosphamide and natalizumab could be offered as second-line treatment in patients with a poor response to IFNB or GA. New oral and injectable drugs will be available in the near future: if safe and well tolerated in the long-term follow up of adults with MS, they could be tested in the pediatric MS population.
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Affiliation(s)
- Angelo Ghezzi
- Centro Studi Sclerosi Multipla, Via Pastori 4, 21013 Gallarate, Cagliari, Italy
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Mah JK, Thannhauser JE. Management of multiple sclerosis in adolescents - current treatment options and related adherence issues. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2010; 1:31-43. [PMID: 24600259 PMCID: PMC3916015 DOI: 10.2147/ahmt.s7594] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Multiple sclerosis (MS) is a progressive inflammatory demyelinating disorder of the central nervous system that is increasingly recognized in children and adolescents. This realization comes with additional concerns about existing therapeutic options and the impact of the disease on health-related outcomes of adolescents with MS. This five-part review provides an update on management strategies relevant to the pediatric MS population. The first section gives an overview on the epidemiology and natural history of early onset MS. The second section outlines currently available MS treatments, including medications during acute relapses and long-term immunomodulatory therapies. The third section highlights adherence issues pertaining to MS, including the challenges uniquely faced by adolescents. The fourth section provides a summary of research into quality of life and psychosocial consequences of pediatric onset MS. Attention is drawn to the grief experience of affected adolescents and the importance of peer relationships. Finally, the family resilience framework is presented as a conceptual model to facilitate optimal adaptation of adolescents with MS. Healthcare professionals can promote resilience and treatment adherence by ensuring that these individuals and their families are sufficiently informed about available MS treatments, providing instrumental support for managing potential medication side effects, and addressing age-appropriate developmental needs.
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Affiliation(s)
- Jean K Mah
- Division of Neurology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer E Thannhauser
- Division of Applied Psychology, Faculty of Education, University of Calgary, Calgary, Alberta, Canada
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Abstract
BACKGROUND Pediatric multiple sclerosis (MS), once considered a rare childhood illness, has been increasingly identified as an important childhood acquired neurologic disease requiring early recognition and intervention. SUMMARY We present a comprehensive review of the current terminology of acquired central nervous system demyelination in children, pertinent investigations, including magnetic resonance imaging and cerebrospinal fluid cerebrospinal fluid studies, and an approach to the differential diagnosis of pediatric onset MS. In addition, the recent studies exploring the epidemiology and pathobiology will be discussed. Finally, we present an algorithm for the treatment of episodes of demyelination along with chronic immunomodulatory therapeutic options in this patient population. CONCLUSIONS Although some similarities exist to adult onset MS, MS onset during childhood and adolescence presents unique diagnostic challenges and requires specialized multidisciplinary care for optimal management. National and international collaborative studies are underway to aid in the understanding of the early and ongoing pathogenesis of MS.
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Long-term results of immunomodulatory treatment in children and adolescents with multiple sclerosis: the Italian experience. Neurol Sci 2009; 30:193-9. [DOI: 10.1007/s10072-009-0083-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 03/27/2009] [Indexed: 10/20/2022]
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Epidemiology, immunopathogenesis and management of pediatric central nervous system inflammatory demyelinating conditions. Curr Opin Neurol 2008; 21:366-72. [DOI: 10.1097/wco.0b013e3282fd172b] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tayal V, Kalra BS. Cytokines and anti-cytokines as therapeutics--an update. Eur J Pharmacol 2007; 579:1-12. [PMID: 18021769 DOI: 10.1016/j.ejphar.2007.10.049] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 10/12/2007] [Accepted: 10/18/2007] [Indexed: 02/06/2023]
Abstract
Cytokines which comprise of a family of proteins--interleukins, lymphokines, monokines, interferons, and chemokines, are important components of the immune system. They act in concert with specific cytokine inhibitors and soluble cytokine receptors to regulate the human immune response. Their physiologic role in inflammation and pathologic role in systemic inflammatory states are now well recognized. An imbalance in cytokine production or cytokine receptor expression and/or dysregulation of a cytokine process contributes to various pathological disorders. Research is progressing rapidly in the area of cytokines and their therapeutic targets, the two major therapeutic modalities being the administration of purified recombinant cytokines and the use of their antagonists in various inflammatory disorders. However, given the large number of cytokines, it is disappointing that only relatively few can be used clinically. In the present article, we have made an attempt to review and present a glimpse of the history as well as up to date information that is pertinent to cytokines and anti-cytokine therapies in the treatment of cancer, autoimmune disorders and various other related diseases.
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Affiliation(s)
- Vandana Tayal
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, 110002, India.
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Banwell B, Ghezzi A, Bar-Or A, Mikaeloff Y, Tardieu M. Multiple sclerosis in children: clinical diagnosis, therapeutic strategies, and future directions. Lancet Neurol 2007; 6:887-902. [PMID: 17884679 DOI: 10.1016/s1474-4422(07)70242-9] [Citation(s) in RCA: 235] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The onset of multiple sclerosis (MS) in childhood poses diagnostic and therapeutic challenges, particularly if the symptoms of the first demyelinating event resemble acute disseminated encephalomyelitis (ADEM). MRI is an invaluable diagnostic tool but it lacks the specificity to distinguish ADEM from the first attack of MS. Advanced MRI techniques might have the required specificity to reveal whether the loss of integrity in non-lesional tissue occurs as a fundamental feature of MS. Although the onset of MS in childhood typically predicts a favourable short-term prognosis, some children are severely disabled, either physically or cognitively, and more than 50% are predicted to enter the secondary-progressive phase of the disease by the age of 30 years. Immunomodulatory therapies for MS and their safe application in children can improve long-term prognosis. Genetic and environmental factors, such as viral infection, might be uniquely amenable to study in paediatric patients with MS. Understanding the immunological consequences of these putative exposures will shed light on the early pathological changes in MS.
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Affiliation(s)
- Brenda Banwell
- Department of Paediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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