The efficacy of glatiramer acetate in beta-interferon-intolerant MS patients

Multiple sclerosis and immune system biomarkers: Novel comparison in glatiramer acetate and interferon beta-1a-treated patient groups

BACKGROUND

Multiple sclerosis (MS) is a chronic, demyelinating disease of the central nervous system (CNS). T cells and B lymphocytes are involved in the development of this disease.

METHODS

The following biomarkers were determined in peripheral blood in 28 patients treated with glatiramer acetate (GA) and 21 patients treated with interferon beta 1-a (IFN): IL-10, BAFF, Mx1, IgG, IgG1, IgG2, IgG3 and IgG4 (at baseline and after 6 months of treatment). All participants had confirmed MS diagnosis.

OBJECTIVES

The primary objective is to assess a percentual change of biomarkers after 6 months since the first-line treatment initiation with GA or IFN. The secondary objective is to explore correlations between the baseline biomarkers' values (levels).

RESULTS

A positive trend was observed in the increase in IL-10 concentration by 30.33 % (IFN) and by 15.65 % (GA). In the IFN group, we observed a statistically significant increase in the BAFF protein concentration by 29.9% (P < 0.001). We found that Mx1 protein levels did not change with the administration of GA, which can be explained by the different mechanisms of action of GA. The serum levels of IgG immunoglobulins and both IgG1 and IgG4 subclasses in both groups of patients were increased. Thus, our data were in accordance with the generally accepted assumption that both IFN and GA are capable of modulating the B cell system.

CONCLUSIONS

Our results suggest that treatment with IFN and GA has a more pronounced influence on the B cell system of MS.

Disease modifying agents for multiple sclerosis

Objective:

To summarize major clinical trials which evaluate the efficacy and safety data of approved disease modifying agents for the treatment of various types of multiple sclerosis.

Data Sources:

A MEDLINE (1966 to August 2008) search of clinical trials using the terms multiple sclerosis, interferon, glatiramer, mitoxantrone and natalizumab was performed. A manual bibliographic search was also conducted. English-language articles identified from the searches were evaluated. New agents under investigation in phase 3 clinical trials were identified using www.clinicaltrials.gov.

Study Selection & Data Extraction:

Relevant information was identified and selected based on clinical relevance and evidence-based strength. Prescribing information leaflets were used to provide usual dosage, contraindications, precautions, monitoring parameters and other relevant drug-specific information.

Data Synthesis:

Interferon beta products are more efficacious for the treatment of relapsing-remitting multiple sclerosis. Interferon beta 1-b also delayed the time to diagnosis of definite multiple sclerosis and reduced brain lesion burden in patients with clinical isolated syndrome. Glatiramer and natalizumab have both established efficacy in relapsing forms of multiple sclerosis; whereas mitoxantrone is more commonly used in patients with advanced disease. There are limited data the comparative efficacy among different disease modifying agents. New agents currently under investigation have showed promising results and may offer more treatment options in the future.

Conclusions:

MS is a complex and devastating disease with challenging treatment considerations and approaches. Interferon beta products continue to be the mainstay of therapy in many patients, however, other treatments are proving to be at least as effective in the management of various types of MS. Newer compounds are being developed and studied with much anticipation and promise for the clinical management of the disease.

Glatiramer acetate for multiple sclerosis

BACKGROUND

This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2004 , Issue 1 . Art. No.: CD004678. DOI: 10.1002/14651858.CD004678)Previous studies have shown that glatiramer acetate (Copaxone (R)), a synthetic amino acid polymer is effective in experimental allergic encephalomyelitis (EAE), and improve the outcome of patients with multiple sclerosis (MS).

OBJECTIVES

To verify the clinical efficacy of glatiramer acetate in the treatment of MS patients with relapsing remitting (RR) and progressive (P) course.

SEARCH STRATEGY

We searched the Cochrane MS Group Trials Register (26 March 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2009), MEDLINE (PubMed) (January 1966 to 26 March 2009), EMBASE (January 1988 to 26 March 2009) and hand searching of symposia reports (1990-2009).

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing glatiramer acetate and placebo in patients with definite MS, whatever the administration schedule and disease course, were eligible for this review.

DATA COLLECTION AND ANALYSIS

Both patients with RR and P MS were analysed. Study protocols were comparable across trials. No major flaws were found in methodological quality. However, efficacy of blinding should be balanced against side effects, including injection-site reactions.

MAIN RESULTS

Among 409 retrieved references, we identified 16 RCTs; six of them, published between 1987 and 2007, met the selection criteria and were included in this review. Five hundred and forty RR patients and 1049 PMS contributed to the analysis. In RR MS, a decrease in the mean EDSS score (-0.33 and -0.45), was found respectively at 2 years and 35 months without any significant effect on sustained disease progression. The reduction of mean number of relapse was evident at 1 year (-0.35 ) 2 years (-0.51 ) and 35 months (-0.64), but significant studies ' heterogeneity was found. The number of hospitalisations and steroid courses were significantly reduced. No benefit was shown in P MS patients. No major toxicity was found. The most common systemic adverse event was a transient and self-limiting patterned reaction of flushing, chest tightness, sweating, palpitations, anxiety. Local injection-site reactions were observed in up to a half of patients treated with glatiramer acetate, thus making a blind assessment of outcomes questionable.

AUTHORS' CONCLUSIONS

Glatiramer acetate did show a partial efficacy in RR MS in term of relapse -related clinical outcomes, without any significant effect on clinical progression of disease measured as sustained disability. The drug is not effective in progressive MS patients.

Current therapeutic recommendations in multiple sclerosis

Recent clinical studies in multiple sclerosis have provided new data on glatiramer acetate, interferon-beta preparations and natalizumab, which will have important implications for optimising patient care. Once a diagnosis has been made with confidence, early initiation of immunotherapy is warranted because of the presence of continuous inflammatory disease activity. Approval for therapy in patients with a clinically isolated syndrome has been granted to several first-line treatments, and most recently to glatiramer acetate. The utility of systematic frequent MRI monitoring of disease activity and response to therapy is not yet clearly established. Treatment efficacy after initiating therapy at the first demyelinating episode has to be followed carefully and re-evaluated whenever necessary. The occurrence of further relapses, confirmed disability progression or MRI evidence of persistent or aggravated disease activity would be regarded as evidence for an inadequate treatment response. However, limitations of clinical scores in faithfully reflecting disease activity at all times, as well as uncertainties about the discriminatory capacity of surrogate measures such as MRI, need to be clarified before clear-cut recommendations on treatment failure can be advocated. Escalation therapy is reserved for patients presenting with 'aggressive disease', which can be operationally defined as the occurrence of two severe relapses within twelve months, together with either MRI evidence for persistent disease activity or a two-point progression of disability on the EDSS.

Glatiramer acetate and interferon beta-1a for intramuscular administration: a study of outcomes among multiple sclerosis intent-to-treat and persistent-use cohorts

OBJECTIVE

To study outcomes of multiple sclerosis (MS) patients treated with either glatiramer acetate (Copaxone) or interferon beta-1a for once-weekly, intramuscular administration (Avonex).

METHODS

An 'intent-to-treat' (ITT) cohort (n=1282) was established, consisting of patients diagnosed with MS who began therapy on either glatiramer acetate (GA) or intramuscular interferon beta-1a (IFN beta-1a-IM) and had continuous insurance coverage from 6 months before to 24 months after the date when they began taking the medication. A 'persistent use' (PU) cohort (n=639) was also constructed, consisting of individuals who, in addition to the criteria listed above, had a claim for GA or IFN beta-1a-IM within 28 days of the end of the 2-year post-period. Data were obtained from the i3 InVision Data Mart Database from July 2001 to June 2006. Multivariate regressions were used to examine both the 2-year total direct medical costs and the likelihood of relapse associated with the use of each of these alternative MS medications. A relapse was defined as either being hospitalized with a principal diagnosis of MS or having an outpatient visit with a MS diagnosis followed within 7 days by a claim for a corticosteroid. All regressions controlled a wide range of factors that may potentially affect outcomes.

RESULTS

In the ITT cohort, patients who started therapy on GA had a significantly lower 2-year risk of relapse (10.01 vs. 5.18%; p=0.0034) as well as significantly lower 2-year total medical costs ($44,201 vs. $41,121; p=0.0294). In the PU cohort, patients who used GA also had a significantly lower 2-year risk of relapse (7.25 vs. 2.16%; p=0.0048) as well as significantly lower total medical costs ($67,744 vs. 63,714; p=0.0445).

LIMITATIONS

The analyses relies on an administrative claims database of an insured population and hence, may not be generalizeable to other populations. In addition, such a database precludes measurement of lost work time, unemployment, caregiver burden or other costs associated with MS.

CONCLUSIONS

Results from this study indicate that the use of GA is associated with significantly lower probability of relapse as well as significantly lower 2-year total direct medical costs than IFN beta-1a-IM.

Best practice recommendations for the selection and management of patients with multiple sclerosis receiving natalizumab therapy

Natalizumab, a humanized monoclonal antibody directed against α4-integrin is a first-in-class disease-modifying therapy for the treatment of relapsing multiple sclerosis. Natalizumab is highly effective but has been associated with a risk of progressive multifocal leukoencephalopathy. Since the efficacy of natalizumab in relapsing forms of multiple sclerosis is viewed as superior to first-line agents, a growing number of neurologists are using natalizumab as the treatment of choice for patients with worsening MS. Owing to the recently reported cases of progressive multifocal leukoencephalopathy, a panel of neurologists met in February 2009 to discuss best practices for the use of natalizumab, with the goal of developing consensus-based recommendations on patient management to minimize the risk of progressive multifocal leukoencephalopathy. The panel consisted of a cross section of academic and community neurologists from the United States who treat multiple sclerosis in large centers and have extensive experience with natalizumab (approximating 2000 patient-years combined experience). This paper summarizes the panel's recommendations on the following: (1) appropriate patient selection for natalizumab; (2) routine monitoring and management of adverse events during natalizumab therapy; and (3) clinical vigilance monitoring and risk reduction for progressive multifocal leukoencephalopathy.

Improving compliance with interferon-beta therapy in patients with multiple sclerosis

Multiple sclerosis (MS) is an inflammatory demyelinating disease affecting young adults (with a peak of onset between the ages of 20 and 40 years). In 80-90% of cases, it is characterized by an early relapsing-remitting (RR) inflammatory phase, followed by a secondary progressive course in which disability progressively accumulates. Interferon-beta (IFNbeta) therapies represent the first-line treatment of RRMS. There are three IFNbeta formulations currently licensed for RRMS. Two are formulations of INFbeta-1a, one administered at a dosage of 30 mug intramuscularly weekly (Avonex(R)) and the other administered at a dosage of 22 or 44 microg subcutaneously (SC) three times a week (Rebif(R) 22 and 44). The third is a formulation of IFNbeta-1b, administered at a dosage of 250 microg SC every other day (Betaseron(R)). These treatments reduce the frequency of acute relapses and, to a lesser extent, disability progression. However, when starting an IFNbeta therapy, a treatment discontinuation rate ranging from 14% to 44% has to be expected. In a sizable proportion of patients, treatment suspension is caused by the occurrence of adverse effects (most commonly a flu-like syndrome and injection site reactions) and/or poor compliance. Individualized patient education and support are critical to improve adherence to therapy in the long term. Approaches aimed at reducing the proportion of subjects interrupting IFNbeta encompass both pharmacological and non-pharmacological interventions, and may involve several professional figures, such as the neurologist, the psychologist, the pharmacist, the physical and speech therapist, and the nurse. Recently, the development of new IFNbeta formulations, with reduced immunogenic potential, has offered an additional approach to improving patient adherence. Biferonex(R) is a pH neutral and human serum albumin-free IFNbeta-1a. A phase III, 2-year study of the product involving patients with RRMS has been conducted, but the results were not considered conclusive enough to allow approval in Europe. Rebif(R) New Formulation (RNF) is a formulation of INFbeta-1a that is not produced using fetal bovine serum and that does not have human serum albumin as an excipient. The formulation has been approved in Europe and an application for approval has been filed in the US. On the basis of the final analysis of a phase III trial, RNF showed higher tolerability, particularly in terms of injection site reactions, compared with the older formulation. Further studies assessing its usefulness as an alternative therapy for patients who are intolerant of other IFNbeta formulations are required.

Glatiramer acetate and interferon beta-1b: a study of outcomes among patients with multiple sclerosis

INTRODUCTION

To study the medical cost and probability of relapse in patients with multiple sclerosis (MS) treated with either glatiramer acetate (GA) or interferon beta-1b (IFN beta.1b).

METHODS

Data were obtained from the i3 InVision Data Mart Database from July 2001 to June 2006. We established an "intent-totreat" (ITT) cohort (n=842) of patients diagnosed with MS who began treatment with either GA or IFN beta-1b and had continuous insurance coverage from 6 months before to 2 years after the date when they began taking the medication. We also created a "continuous use" (CU) cohort (n=418) of individuals who, in addition to the criteria listed above, used either GA or IFN beta-1b within 28 days of the end of the 2-year postperiod. Using multivariate regressions, we examined both the 2-year total average direct medical costs and the likelihood of relapse within this period associated with the use of each of these MS medications. We defined relapse as being either hospitalization with a principal diagnosis of MS or having an outpatient visit with a diagnosis of MS and then prescribed steroids within a 7-day period. All regression analyses controlled for a wide range of factors that may potentially affect outcomes.

RESULTS

In the ITT cohort, patients who started treatment with GA had a significantly lower 2-year estimated risk of relapse (13.54% vs. 5.31%; P=0.0006). In the CU cohort, patients who used GA also had a significantly lower 2-year estimated risk of relapse (10.91% vs. 2.09%; P=0.0018), as well as significantly lower average total medical costs ($53,157 vs. $48,130; P=0.0345).

CONCLUSIONS

Results from this study indicate that users of GA have a significantly lower probability of 2-year relapse than users of IFN beta-1b. In addition, among continuous users, the 2-year total average direct medical costs are significantly lower for users of GA than for users of IFN beta-1b.

Basic and escalating immunomodulatory treatments in multiple sclerosis: current therapeutic recommendations

This review updates and extends earlier Consensus Reports related to current basic and escalating immunomodulatory treatments in multiple sclerosis (MS). The recent literature has been extracted for new evidence from randomized controlled trials, open treatment studies and reported expert opinion, both in original articles and reviews, and evaluates indications and safety issues based on published data. After data extraction from published full length publications and critically weighing the evidence and potential impact of the data, the review has been drafted and circulated within the National MS Societies and the European MS Platform to reach consensus within a very large group of European experts, combining evidence-based criteria and expert opinion where evidence is still incomplete. The review also outlines a few areas of controversy and delineates the need for future research.

Glatiramer acetate versus interferon beta-1a for subcutaneous administration: comparison of outcomes among multiple sclerosis patients

INTRODUCTION

We compared the outcomes of multiple sclerosis (MS) patients treated with either glatiramer acetate (GA) (Copaxone, Teva Pharmaceutical Industries, Israel) or interferon beta-1a for subcutaneous administration (IFN beta-1a-SC) (Rebif, Merck Serono, Switzerland).

METHODS

Data were obtained from i3's Lab Rx Database from July 2001 to June 2006. We established an 'intent-to-treat' (ITT) cohort (n=845) of patients diagnosed with MS who began therapy on either GA (n=542) or IFN beta-1a-SC (n=303) and had continuous insurance coverage from 6 months before to 24 months after the date they began taking the medication. We also created a 'continuous use' (CU) cohort (n=410) of individuals who, in addition to the criteria listed above, used either GA or IFN beta-1a-SC within 28 days of the end of the 2-year-post period. Using multivariate regressions, we examined both the 2-year total direct medical costs and the likelihood of relapse associated with the use of these two MS medications. We defined relapse as either being hospitalised with a diagnosis of MS, or being diagnosed with MS during an outpatient visit and then prescribed steroids within a 7-day period. All regressions controlled a wide range of factors that have potentially affected outcomes.

RESULTS

In the ITT cohort, patients who started therapy on GA had a significantly lower 2-year risk of relapse (5.92% versus 10.89%; P=0.0305), as well as significantly lower 2-year total medical costs (US$41,786 versus US$49,030; P=0.0002). In the CU cohort, patients who used GA also had a significantly lower 2-year risk of relapse (1.94% versus 9.09%; P=0.0049) and significantly lower total medical costs (US$45,213 versus US$57,311; P<0.0001).

CONCLUSIONS

Results indicate that, compared with the use of IFN beta-1a-SC, use of GA is associated with significantly lower probability of relapse as well as significantly lower 2-year total direct medical costs. In addition, these results are more pronounced among patients defined as continuous users.

Switching algorithms: from one immunomodulatory agent to another

In spite of the availability of six disease-modifying treatments for multiple sclerosis, a significant minority of patients fail to respond adequately to treatment. Switching immunomodulatory therapy is a potentially useful treatment strategy in such patients. Several factors contribute to the need to switch between immunomodulatory treatments, including the variable response to drug treatment, the timing and choice of therapy, disease severity, and the occurrence of neutralising antibodies. Guidelines have been proposed to define treatment response, integrating both clinical and imaging criteria. Several observational studies, principally evaluating a switch from beta-interferons to glatiramer acetate, have demonstrated that switching treatments is both safe and effective in patients with inadequate control of disease activity or who are experiencing unacceptable side effects with their original treatment. A treatment algorithm is proposed for decision-making when switching therapies appears warranted.

Immunomodulator therapy migration in relapsing remitting multiple sclerosis: a study of 152 cases

BACKGROUND: Since 1997, immunological modulators have been used for treatment of Relapsing Remitting Multiple Sclerosis (RRMS) in the Multiple Sclerosis Attendance and Treatment Center (CATEM) with significant alterations in this disease natural history. AIM: To add data on the experience of CATEM for the treatment of RRMS patients that had immunomodulators. METHOD: RRMS patients that received continuously immunomodulator drugs were evaluated on adherence, migration, withdrawal and progression rates. The patients were divided in three groups by the period of immunomodulators intake. RESULTS: There were registered in Group 1 withdrawal in 98 patients (25%) and adherence in 292 cases (74%); Group 2 interruption of therapy in 140 patients, 92 (31%) due to progression for PSMS, 14 (5%) for pregnancy, withdrawal in 34 (11%), adherence in 88%; Group 3 progression in 41 (26%), pregnancy in 3 (2%) withdrawal in 42 (27%) and adherence in 72%. The migration rate was about one third (31.57%) and the principal cause was therapeutic failure; the mean migrating time was 0.5-2.5 years in group 3. CONCLUSION: Immunomodulatory treatment for RRMS patients may have significant levels of failure and side effects; the adherence was compatible with the international literature.

A longitudinal observational study of a cohort of patients with relapsing-remitting multiple sclerosis treated with glatiramer acetate

Immunomodulatory treatments for relapsing-remitting multiple sclerosis (RRMS) are not efficacious or tolerated in all patients. It is important to evaluate alternative classes of treatment in patients failing first-line therapy. The objective of this prospective observational study was to evaluate the efficacy and safety of glatiramer acetate in patients, to whom beta-interferons could not be administered. The study included patients with RRMS who were intolerant to or had contraindications to beta-interferon. After initiation of glatiramer acetate treatment, follow-up visits were made every 3 months, when data on neurologist-ascertained relapses and disability [Expanded Disability Status Scale (EDSS) score] were collected. Tolerability was evaluated by spontaneous adverse event reporting. Overall, 205 patients were studied and 113 (55.1%) treated for at least 4 years. The proportion of patients presenting over three relapses per year decreased from 51.2% to 8.4% in the 2 years following treatment initiation. Over 5 years of treatment, mean annualized relapse rates and mean EDSS scores remained stable (0.4-0.6 relapses/year and 3.6 +/- 1.8-3.3 +/- 2.1 respectively). Adverse events were reported by 179 patients, leading to discontinuation of treatment in 10 patients. Patients with RRMS to whom beta-interferons cannot be prescribed can benefit from treatment with glatiramer acetate.

Fortschritte im Verständnis von Pathogenese und Immuntherapie der Multiplen Sklerose

In this article recent advances in research on the pathogenesis of multiple sclerosis (MS) are summarized. New evidence from molecular histopathology is discussed focussing on neurodegenerative aspects. In addition findings with a direct effect on therapeutic decisions are presented which have contributed to improved immunotherapy. During the last decade important advances in immunotherapy have proven especially useful for patients with relapsing-remitting MS. Escalating algorithms are available for both relapses and long-term immunotherapy. Novel therapeutic approaches with monoclonal antibodies have increasing importance, yet side effects are not completely understood. The pathogenetic insights presented here may open new avenues for novel immunotherapies and lead to individualized MS therapy in the future. Limitations are given for primary progressive MS due to the lack of suitable tissue specimens and experimental models. Neuroprotective treatment strategies aiming at the protection of glial and neuronal cells are still in early stages of development.

Immunmodulatorische Stufentherapie der Multiplen Sklerose

The updated recommendations presented here reflect new developments in the diagnostic work-up and immunotherapy of multiple sclerosis (MS) as well as optimization of medical care for MS patients. Monoclonal antibodies provide considerable improvement of treatment, but their use in basic therapy is restricted by their side effect profile. Thus, for the time being, natalizumab is only approved for monotherapy after basic treatment has failed or for rapidly progressive relapsing-remitting MS. In contrast, long-term data on recombinant beta-interferons and glatiramer acetate (Copaxone) show that even after several years no unexpected side effects occur and that a prolonged therapeutic effect can be assumed which correlates with the dose or frequency of treatment. Recently IFN-beta1b (Betaferon) was approved for prophylactic treatment after the first attack (clinically isolated syndrome, CIS). During treatment with beta-interferons, neutralizing antibodies can emerge with possible loss of effectivity. In contrast, antibodies play no role in treatment with glatiramer acetate. During or after therapy with mitoxantrone, serious side effects (cardiomyopathy, acute myeloid leukemia) appeared in 0.2-0.4% of cases. Plasmapheresis is limited to individual curative attempts in escalating therapy of a severe attack. According to the revised McDonald criteria, the diagnosis of MS can be made as early as the occurrence of the first attack (CIS). Recommendations for optimized care of MS patients are also new, thus implementing a resolution of the European Parliament.