Factors influencing long-term outcomes in relapsing-remitting multiple sclerosis: PRISMS-15

Early use of high-efficacy therapies in multiple sclerosis in the United States: benefits, barriers, and strategies for encouraging adoption

Multiple sclerosis (MS) is characterized by progressive neuroinflammation and neurodegeneration from disease onset that, if left untreated, can result in the accumulation of irreversible neurological disability. Early intervention with high-efficacy therapies (HETs) is increasingly recognized as the best strategy to delay or mitigate disease progression from the earliest stages of the disease and to prevent long-term neurodegeneration. Although there is growing clinical and real-world evidence supporting early HET intervention, foregoing this strategy in favor of a traditional escalation approach prioritizing lower-efficacy disease-modifying therapies remains a common approach in clinical practice. This review explores potential health care professional- and patient-related barriers to the early use of HETs in patients with MS in the United States. Barriers can include regulatory and reimbursement restrictions; knowledge gaps and long-term safety concerns among health care professionals; and various individual, cultural, and societal factors affecting patients. Potential strategies for overcoming these barriers and encouraging early HET use are proposed.

Recent advances in the treatment of primary and secondary progressive Multiple Sclerosis

BACKGROUND

The article highlights upcoming potential treatments, which target different phases of inflammation and offer remyelinating strategies as well as direct and indirect neuroprotective and oligodendrocyte protective effects, providing a hopeful outlook for patients with primary and secondary progressive multiple sclerosis (PPMS and SPMS).

OBJECTIVES

The review aims to identify potential treatments and ongoing clinical trials for PPMS and SPMS, and compare their mechanisms of action, efficacy, and side effects with current treatments.

METHODS

We reviewed ongoing clinical trials for PPMS and SPMS on the NIH website, as well as articles from PubMed, Embase, and clinicaltrails.gov since 2010.

RESULTS

BTKIs like, tolebrutinib, and fenebrutinib are being explored as potential PMS treatments. Vidofludimus calcium, an orally available treatment, has shown a reduction of active and new MRI lesions. Other treatments like simvastatin, N-acetylcysteine (NAC), and alpha-lipoic acid are being explored for their antioxidant properties. AHSCT and mesenchymal stem cell therapy are experimental options for younger patients with high inflammatory activity.

CONCLUSIONS

SPMS and PPMS are being studied for new treatments and future trials should consider combination therapies targeting inflammation, demyelination, and neuronal death, as the pathogenesis of PMS involves complex factors.

Twenty Years of Subcutaneous Interferon-Beta-1a for Multiple Sclerosis: Contemporary Perspectives

Multiple sclerosis (MS) is a chronic, progressive, inflammatory disorder of the central nervous system. Relapsing-remitting MS (RRMS), the most common form of the disease, is characterized by transient neurological dysfunction with concurrent accumulation of disability. Over the past three decades, disease-modifying therapies (DMTs) capable of reducing the frequency of relapses and slowing disability worsening have been studied and approved for use in patients with RRMS. The first DMTs were interferon-betas (IFN-βs), which were approved in the 1990s. Among them was IFN-β-1a for subcutaneous (sc) injection (Rebif®), which was approved for the treatment of MS in Europe and Canada in 1998 and in the USA in 2002. Twenty years of clinical data and experience have supported the efficacy and safety of IFN-β-1a sc in the treatment of RRMS, including pivotal trials, real-world data, and extension studies lasting up to 15 years past initial treatment. Today, IFN-β-1a sc remains an important therapeutic option in clinical use, especially around pregnancy planning and lactation, and may also be considered for aging patients, in which MS activity declines and long-term immunosuppression associated with some alternative therapies is a concern. In addition, IFN-β-1a sc is used as a comparator in many clinical studies and provides a framework for research into the mechanisms by which MS begins and progresses.

A scalable approach for continuous time Markov models with covariates

Existing methods for fitting continuous time Markov models (CTMM) in the presence of covariates suffer from scalability issues due to high computational cost of matrix exponentials calculated for each observation. In this article, we propose an optimization technique for CTMM which uses a stochastic gradient descent algorithm combined with differentiation of the matrix exponential using a Padé approximation. This approach makes fitting large scale data feasible. We present two methods for computing standard errors, one novel approach using the Padé expansion and the other using power series expansion of the matrix exponential. Through simulations, we find improved performance relative to existing CTMM methods, and we demonstrate the method on the large-scale multiple sclerosis NO.MS data set.

Interferon beta-1a sc at 25 years: a mainstay in the treatment of multiple sclerosis over the period of one generation

INTRODUCTION

Interferon beta (IFN beta) preparations are an established group of drugs used for immunomodulation in patients with multiple sclerosis (MS). Subcutaneously (sc) applied interferon beta-1a (IFN beta-1a sc) has been in continuous clinical use for 25 years as a disease-modifying treatment.

AREAS COVERED

Based on data published since 2018, we discuss recent insights from analyses of the pivotal trial PRISMS and its long-term extension as well as from newer randomized studies with IFN beta-1a sc as the reference treatment, the use of IFN beta-1a sc across the patient life span and as a bridging therapy, recent data regarding the mechanisms of action, and potential benefits of IFN beta-1a sc regarding vaccine responses.

EXPERT OPINION

IFN beta-1a sc paved the way to effective immunomodulatory treatment of MS, enabled meaningful insights into the disease process, and remains a valid therapeutic option in selected vulnerable MS patient groups.

Therapeutic Advances in Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system that causes significant disability and healthcare burden. The treatment of MS has evolved over the past three decades with development of new, high efficacy disease modifying therapies targeting various mechanisms including immune modulation, immune cell suppression or depletion and enhanced immune cell sequestration. Emerging therapies include CNS-penetrant Bruton's tyrosine kinase inhibitors and autologous hematopoietic stem cell transplantation as well as therapies aimed at remyelination or neuroprotection. Therapy development for progressive MS has been more challenging with limited efficacy of current approved agents for inactive disease and older patients with MS. The aim of this review is to provide a broad overview of the current therapeutic landscape for MS.

Early predictors of conversion to secondary progressive multiple sclerosis

BACKGROUND

We conducted this study to estimated the time of conversion from relapsing-remitting MS (RRMS) to SPMS and its early predictor factors.

METHODS

In this retrospective study, demographic, clinical, and imaging data from MS patients at diagnosis were extracted. Cox proportional hazards model was used to assess the association between various baseline characteristics and conversion to SPMS. We also assessed the association brtween escalation and early intensive therapy approaches with transition to progressive phase.

RESULTS

Out of 1903 patients with RRMS at baseline, 293 (15.4%) patients progressed to SPMS during follow-up. The estimated number of patients converted to SPMS was 10% at 10-years, 50% at 20-years, and 93% at 30-years. On multivariate Cox regression analysis older age at onset (HR: 1.067, 95%CI: 1.048-1.085, p < 0.001), smoking (HR: 2.120, 95%CI: 1.203-3.736, p = 0.009), higher EDSS at onset (HR: 1.199, 95%CI: 1.109-1.295, p < 0.001), motor dysfunction (HR: 2.470, 95%CI: 1.605-3.800, p < 0.001), cerebellar dysfunction (HR: 3.096, 95%CI: 1.840-5.211, p < 0.001), and presence of lesions in spinal cord (HR: 0.573, 95%CI: 0.297-0.989, p = 0.042) increased the risk of conversion from RRMS to SPMS. No significant difference between escalation and EIT groups in the risk of transition to progressive phase (weighted HR = 1.438; 95% CI: 0.963, 2.147; p = 0.076) was found.

CONCLUSION

Our data support previous observations that smoking is a modifiable risk factor for secondary progressive MS and confirms that spinal cord involvement, age, and more severe disease at onset are prognostic factors for converting to secondary progressive MS.

Secondary Progressive Multiple Sclerosis: New Insights

In most cases, multiple sclerosis (MS) begins with a relapsing-remitting course followed by insidious disability worsening that is independent from clinically apparent relapses and is termed secondary progressive MS (SMPS). Major differences exist between relapsing-remitting MS (RRMS) and SPMS, especially regarding therapeutic response to treatment. This review provides an overview of the pathology, differentiation, and challenges in the diagnosis and treatment of SPMS. We emphasize the criticality of conversion from a relapsing-remitting to a secondary progressive disease course not only because such conversion is evidence of disability progression, but also because, until recently, treatments that effectively reduced disability progression in relapsing MS were not proven to be effective in SPMS. Clear clinical, imaging, immunologic, or pathologic criteria marking the transition from RRMS to SPMS have not yet been established. Early identification of SPMS will require tools that, together with the use of appropriate treatments, may result in better long-term outcomes for the population of patients with SPMS.

A non-parametric propensity score for estimating the effect of interferon-beta or glatiramer acetate on long-term outcomes of multiple sclerosis

BACKGROUND

The few observational studies that investigated the long-term effects of interferon-beta and glatiramer acetate were usually focused on progression to irreversible disability and other outcomes such as number of relapses and transition to secondary-progressive multiple sclerosis (SPMS) have been rarely studied. The objective of this paper is to estimate the effect of interferon-beta/glatiramer acetate on progression to irreversible disability, transition from relapsing-remitting multiple sclerosis (RRMS) to SPMS and the rate of relapses over 10 years.

METHODS

Analyses included 2498 patients with confirmed diagnosis of RRMS followed in Montréal from 1977 to 2016. Marginal structural models with propensity score for treatment and censoring were used to account for potential confounding and attrition. Specifically, we used pooled logistic regression for progression to irreversible disability and transition to SPMS, and Poisson models for the rate of relapses.

RESULTS

77% of subjects were female and the median age at RRMS diagnosis was 35 years. The hazard of progression to irreversible disability was lower among treated patients than untreated patients (HR=0.73, 95% CI [0.57-0.94]). We did not find evidence of an association between interferon-beta/glatiramer acetate and the rate of transition to SPMS either over the 3-month intervals or for the duration of treatment. Patients treated for >5 years had a lower rate of relapses compared to those untreated (HR=0.70, 95% CI [0.57-0.86]).

CONCLUSION

Treatment with interferon-beta/glatiramer acetate suggests a beneficial effect on progression to irreversible disability and rate of relapses, but not on transition to SPMS.

Relapse recovery in multiple sclerosis: Effect of treatment and contribution to long-term disability

Background

Although recovery from relapses in MS appears to contribute to disability, it has largely been ignored as a treatment endpoint and disability predictor.

Objective

To identify demographic and clinical predictors of relapse recovery in the first 3 years and examine its contribution to 10-year disability and MRI outcomes.

Methods

Relapse recovery was retrospectively assessed in 360 patients with MS using the return of the Expanded Disability Status Scale (EDSS), Functional System Scale and neurologic signs to baseline at least 6 months after onset. Univariate and multivariable models were used to associate recovery with demographic and clinical factors and predict 10-year outcomes.

Results

Recovery from relapses in the first 3 years was better in patients who were younger, on disease-modifying treatment, with a longer disease duration and without bowel or bladder symptoms. For every incomplete recovery, 10-year EDSS increased by 0.6 and 10-year timed 25-foot walk increased by 0.5 s. These outcomes were also higher with older age and higher baseline BMI. Ten-year MRI brain atrophy was associated only with older age, and MRI lesion volume was only associated with smoking.

Conclusions

Early initiation of disease-modifying treatment in MS was associated with improved relapse recovery, which in turn prevented long-term disability.

Interferon beta 1a (Rebif®) in relapsing remitting multiple sclerosis

Multiple sclerosis (MS) is an autoimmune neurodegenerative disease that affects the central nervous system. It is the second cause of neurological disability in young adults. The exact cause of the disease remains unknown and there is no curative treatment. It is imperative to evaluate the efficacy of newest, biotechnological products modifying the disease. This study was designed to evaluate the use of interferon beta 1a (Rebif®) in patients with relapsing remitting MS treated at International Center for Neurological Restoration. Thirty-one patients with relapsing remitting MS, between 10 and 65 years of age, four males and 27 females, were treated with Rebif® three times per week during 1 year. The safety of the treatment was evaluated based on the adverse events and the efficacy based on the disability scale score, the number of attacks and the number of lesions at magnetic resonance imaging (MRI). The public clinical trial is registered in Cuba (Number B-10-030-L03). Adverse effects occurred in 75% of the cases, but they were mild. A significant reduction in the number of attacks, the disability scale score and the number of lesions at MRI were observed in patients with relapsing remitting MS treated with Rebif®. The use of interferon beta 1a showed safety and efficacy in the treatment of patients with relapsing remitting MS.

MAGNIMS score predicts long-term clinical disease activity-free status and confirmed disability progression in patients treated with subcutaneous interferon beta-1a

BACKGROUND

Subcutaneous (sc) interferon (IFN) β-1a reduces relapse rates and delays disability progression in patients with MS. We examined the association of the year 1 Magnetic Resonance Imaging in MS (MAGNIMS) score with long-term clinical disease activity (CDA) -free status and confirmed disability progression in patients treated with sc IFN β-1a in PRISMS.

METHODS

Patients treated with sc IFN β-1a three-times-weekly (22 or 44 μg; pooled data) were classified by MAGNIMS score (0, n = 129; 1, n = 108; 2, n = 130) at year 1. Hazard ratios (HR; 95% confidence intervals [CI]) for risk of CDA and confirmed Expanded Disability Status Score (EDSS) progression were calculated by MAGNIMS score for up to 15 years of follow-up.

RESULTS

The risk of CDA was higher with a year 1 MAGNIMS score of 1 versus 0 (HR 1.82 [1.38-2.41]), 2 versus 0 (2.63 [2.01-3.45]) and 2 versus 1 (1.45 [1.11-1.89], all p < 0.0001). The same outcome was observed with the risk of confirmed EDSS progression (1 versus 0: 1.93 [1.23-3.02]; 2 versus 0: 2.95 [1.95-4.46]; 2 versus 1: 1.53 [1.05-2.23]; all p < 0.0001).

CONCLUSION

In PRISMS, MAGNIMS score at Year 1 predicted risk of CDA and confirmed disability progression in sc IFN β-1a-treated patients over up to 15 years. PRISMS-15 clinicaltrial.gov identifier: NCT01034644.

Treatment of Multiple Sclerosis: A Review

Multiple sclerosis (MS) is an autoimmune demyelinating and neurodegenerative disease of the central nervous system, and the leading cause of nontraumatic neurological disability in young adults. Effective management requires a multifaceted approach to control acute attacks, manage progressive worsening, and remediate bothersome or disabling symptoms associated with this illness. Remarkable advances in treatment of all forms of MS, and especially for relapsing disease, have favorably changed the long-term outlook for many patients. There also has been a conceptual shift in understanding the immune pathology of MS, away from a purely T-cell-mediated model to recognition that B cells have a key role in pathogenesis. The emergence of higher-efficacy drugs requiring less frequent administration have made these preferred options in terms of tolerability and adherence. Many experts now recommend use of these as first-line treatment for many patients with early disease, before permanent disability is evident.

Clinical Parameters to Predict Future Clinical Disease Activity After Treatment Change to Higher-Dose Subcutaneous Interferon Beta-1a From Other Platform Injectables in Patients With Relapsing-Remitting Multiple Sclerosis

Objective: To identify predictors of clinical disease activity after treatment change to higher-dose interferon beta-1a in relapsing-remitting multiple sclerosis (MS).

Methods: This was a retrospective-prospective observational multicenter study. We enrolled patients with at least one relapse on platform injectable therapy who were changed to 44 μg interferon beta-1a. Our primary endpoint was the clinical disease activity-free (cDAF) status at 6, 12, 18, and 24 months. Secondary endponts included relapse-free status and disability progression-free status at different timepoints. The primary predictor of interest was the monosymptomatic vs. polysymptomatic index relapse, based on the number of affected functional systems from the Kurtzke scale during the last relapse prior to baseline. Other secondary predictors of clinical disease activity were analyzed based on different demographic and relapse characteristics. Kaplan-Meier estimates of the cumulative probability of remaining in cDAF status were performed. The time to clinical disease activity was compared between groups using univariate Kaplan-Meier analysis and multivariate Cox regression. Multivariate analyses were processed in the form of CART (Classification & Regression Trees).

Results: A total of 300 patients entered the study; 233 (77.7%) of them completed the 24-month study period and 67 patients (22.3%) terminated early. The proportion of patients in cDAF status was 84.7, 69.5, 57.5, and 54.2% at 6, 12, 18, and 24 months. After 2 years of follow-up, 55.9% of patients remained relapse-free and 87.8% of patients remained disability progression-free. At all timepoints, the polysymptomatic index relapse was the most significant predictor of clinical disease activity of all studied variables. Hazard ratio of cDAF status for patients with monosymptomatic vs. polysymptomatic index relapse was 1.94 (95% CI 1.38–2.73). CART analyses also confirmed the polysymptomatic index relapse being the strongest predictor of clinical disease activity, followed by higher number of pre-baseline relapses with the most significant effect in the monosymptomatic index relapse group. The next strongest predictors of clinical disease activity were cerebellar syndrome as the most disabled Kurtzke functional system for the monosymptomatic relapse group, and age at first MS symptom ≥ 45 for the polysymptomatic relapse group.

Conclusions: Patients with a polysymptomatic index relapse and/or higher number of relapses within 2 years prior to baseline are at high risk of clinical disease activity, despite treatment change to higher-dose interferon beta-1a from other platform injectable therapy.

Trial registration: State Institute of Drug Control (SUKL), URL: http://www.sukl.eu/modules/nps/index.php?h=study&a=detail&id=958&lang=2, registration number 1205090000.

The apparently milder course of multiple sclerosis: changes in the diagnostic criteria, therapy and natural history

In the past decade, changes have occurred in the spectrum of multiple sclerosis courses. The natural history of multiple sclerosis appears milder from the first sign of demyelinating disease to the progressive course, probably as a result of an interplay between several factors including changes in the diagnostic criteria, changes in the epidemiology of multiple sclerosis, impact of early and appropriate disease-modifying treatment and improvement of the general state of health in the population. It has been suggested to regard incidental findings of demyelinating lesions in MRI in individuals without any history of clinical symptoms consistent with neurological dysfunction, so-called radiological isolated syndrome, as the initial course of multiple sclerosis. New diagnostic criteria have enabled the multiple sclerosis diagnosis in many patients at the first clinical demyelinating event, clinically isolated syndrome. The remaining patients with clinically isolated syndrome have a more benign prognosis, and for relapsing-remitting multiple sclerosis, the prognosis has become more favourable. Reduced disease activity in patients with relapsing-remitting multiple sclerosis can partly be ascribed to more efficacious new disease-modifying therapies but decrease in disease activity has also be seen in placebo-treated patients in clinical trials. This may be explained by several factors: change in the diagnostic criteria, more explicit inclusion criteria, exclusion of high-risk patients e.g. patients with co-morbidities, and more rigorous definitions of relapses and disease worsening. However, these factors also make the disease course in patients treated with disease-modifying therapies seem more favourable. In addition, change in the therapeutic target to stable disease (no evidence of disease activity = no relapses, no disease worsening and no MRI activity) could by itself change the course in relapsing-remitting multiple sclerosis. The effectiveness of disease-modifying drugs has reduced the transition from relapsing-remitting to secondary progressive multiple sclerosis. The concept of progressive multiple sclerosis has also evolved from two very distinct categories (primary progressive and secondary progressive multiple sclerosis) to a unified category of progressive multiple sclerosis, which can then be split into the categories of active or inactive. Also, an increasing tendency to treat progressive multiple sclerosis with disease-modifying therapies may have contributed to change the course in progressive multiple sclerosis. In conclusion, during the past decade the entire course of multiple sclerosis from the first sign of a demyelinating disorder through the progressive course appears to be milder due to a complex interplay of several factors.

The role of the brain in the treatment of multiple sclerosis as a connectomopathy

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system (CNS) causing a variety of symptoms. Although MS is recognized by the demyelinating process, the axonal injury can occur from the start of the disease and lead to neurodegenerative process in the disease. Although MS appears to damage the brain locally, the progressive and neurodegenerative nature of the disease indicate the general and global brain damage. Various studies have indicated this global damage at all areas of white and gray matter. Moreover, the earlier stages of mentioned disease can affect the structural and functional brain connections. Demyelinating lesions, which are local at first glance, lead to a global damage to the functional connections of the brain. Therefore, it seems that the brain network or brain connectome are broadly affected by this disease; therefore, MS can be referred as a connectomopathy. The drugs used in this disease all seek to suppress or regulate the immune system, and the human brain has always been considered as a therapeutic target. However, if the brain is generally involved in the disease, so the treatment should be general. In fact, the treatment process should target the connectomopathy. One of the methods that can be used to achieve the mentioned goal is attending to the role of the brain in its treatment.

Long-term effect of natalizumab in patients with RRMS: TYSTEN cohort

BACKGROUND

Data are needed on long-term effect of natalizumab (NTZ) in relapsing-remitting multiple sclerosis (RRMS).

OBJECTIVES

To evaluate the time of onset of secondary progressive phase in patients with an RRMS treated with NTZ and to investigate predictive factors.

METHODS

TYSTEN is an observational study. Patients starting NTZ between 2007 and 2012 were included and followed up until October 2018. Relapses, Expanded Disability Status Scale (EDSS) scores, and results of brain magnetic resonance imaging (MRI) were collected each year. Data were used to estimate the cumulative probability of several poor outcomes such as secondary progressive multiple sclerosis (SPMS) conversion, EDSS worsening, EDSS 4.0, and EDSS 6.0.

RESULTS

770 patients were included. The mean follow-up duration was 97 months and the mean time exposure to NTZ was 66 months. At 10 years, the cumulative probability of SPMS was 27.7%. Predictive factors for poor outcomes were a ⩾1-point increase in EDSS score from baseline, new T2 lesion or T1 gadolinium-enhancing lesion, the occurrence of relapse at 1 or 2 years and No Evidence of Disease Activity (NEDA-3; no relapse, no new T2 or T1 gadolinium-enhancing lesions, no progression) was a protective factor.

CONCLUSION

In our cohort of patients treated with NTZ, poor outcomes were infrequent and are driven by disease activity.

Frailty in ageing persons with multiple sclerosis

Background:

Recent progress in multiple sclerosis (MS) management has contributed to a greater life expectancy in persons with MS. Ageing with MS comes with unique challenges and bears the potential to greatly affect quality of life and socioeconomic burden.

Objectives:

To compare frailty in ageing persons with multiple sclerosis (pwMS) and controls; to correlate frailty with MS clinical characteristics.

Methods:

PwMS and controls over 50 years old were recruited in a cross-sectional study. Two validated frailty measures were assessed: the frailty index and the Fried’s phenotype. Several multiple linear regressions accounting for demographic and clinical characteristics were performed.

Results:

Eighty pwMS (57 females, mean age 58.5 ± 6 years old) and 37 controls (24 females, mean age 61 ± 6.5 years old) were recruited. Multivariable analysis identified significantly higher frailty index in pwMS (0.21 ± 0.12 vs 0.11 ± 0.08, p < 0.0001). Similarly, according to Fried’s phenotype, a significantly higher percentage of pwMS were frail compared to controls (28% vs 8%). In pwMS, frailty index was independently associated with expanded disability status scale (EDSS), comorbidities, education level and disease duration.

Conclusion:

Our results suggest that frailty can be routinely assessed in pwMS. Increased frailty in MS patients suggests that, along with MS therapeutics, a tailored multidisciplinary approach of ageing pwMS is needed.

Clinical Characteristics and Disability Progression of Early- and Late-Onset Multiple Sclerosis Compared to Adult-Onset Multiple Sclerosis

Background: Compared to the adult onset of multiple sclerosis (AOMS), both early-onset (EOMS) and late-onset (LOMS) are much less frequent, but are often under- or misdiagnosed. The aims of the present study were: 1. To compare demographic and clinical features of individuals with EOMS, AOMS and LOMS, and 2. To identify predictors for disability progression from relapsing remitting MS (RRMS) to secondary progressive MS (SPMS). Method: Data were taken from the Isfahan Hakim MS database. Cases were classified as EOMS (MS onset ≤18 years), LOMS (MS onset >50 years) and AOMS (MS >18 and ≤50 years). Patients’ demographic and clinical (initial symptoms; course of disease; disease patterns from MRI; disease progress) information were gathered and assessed. Kaplan–Meier and Cox proportional hazard regressions were conducted to determine differences between the three groups in the time lapse in conversion from relapsing remitting MS to secondary progressive MS. Results: A total of 2627 MS cases were assessed; of these 127 were EOMS, 84 LOMS and 2416 AOMS. The mean age of those with EOMS was 14.5 years; key symptoms were visual impairments, brain stem dysfunction, sensory disturbances and motor dysfunctions. On average, 24.6 years after disease onset, 14.2% with relapsing remitting MS (RRMS) were diagnosed with secondary progressive MS (SPMS). The key predictor variable was a higher Expanded Disability Status Scale (EDSS) score at disease onset. Compared to individuals with AOMS and LOMS, those with EOMS more often had one or two relapses in the first two years, and more often gadolinium-enhancing brain lesions. For individuals with AOMS, mean age was 29.4 years; key symptoms were sensory disturbances, motor dysfunctions and visual impairments. On average, 20.5 years after disease onset, 15.6% with RRMS progressed to SPMS. The key predictors at disease onset were: a higher EDSS score, younger age, a shorter inter-attack interval and spinal lesions. Compared to individuals with EOMS and LOMS, individuals with AOMS more often had either no or three and more relapses in the first two years. For individuals with LOMS, mean age was 53.8 years; key symptoms were motor dysfunctions, sensory disturbances and visual impairments. On average, 14 years after disease onset, 25.3% with RRMS switched to an SPMS. The key predictors at disease onset were: occurrence of spinal lesions and spinal gadolinium-enhancement. Compared to individuals with EOMS and AOMS, individuals with LOMS more often had no relapses in the first two years, and higher EDSS scores at disease onset and at follow-up. Conclusion: Among a large sample of MS sufferers, cases with early onset and late onset are observable. Individuals with early, adult and late onset MS each display distinct features which should be taken in consideration in their treatment.

An observational study demonstrating the adherence and ease of use of the injector device, RebiSmart®

Background: Adherence to Multiple Sclerosis (MS) treatment is considered one of the crucial factors for ensuring optimal clinical outcomes. Research has shown that the use of self-injector devices improves patient compliance with treatment. Therefore, the main purpose of this study is to evaluate the ease of use of RebiSmart® 2.0 in clinically isolated syndrome/relapsing-remitting MS patients during 12 months treatment period.Methods: A total number of 290 subjects entered into data collection; 249 (86%) of them completed the whole 12 months study period. The primary endpoints and the secondary endpoints were assessed by the User Study Questionnaire. Adherence data were retrieved from RebiSmart® 2.0 (Menu - Dose History) on the respective patient's visit. Outcome measures also included Expanded Disability Status Score, Kurtzke Functional Systems, and Modified Social Support Survey, Modified Social Support Survey-5.Results: This study demonstrated a very high proportion (>95%) of patients with a positive rating of the overall ease of use and the overall convenience of RebiSmart®. The proportion of patients with a positive rating of the ease of use by individual domains and the functions of RebiSmart® were also high (>80%).Conclusion: The findings demonstrate a very good perception of the usability of the device by patients overall and in its individual functions.

Effectiveness of glatiramer acetate in neutralizing antibody-positive patients previously treated with interferon-β

BACKGROUND

Some patients with multiple sclerosis who are treated with interferon-β(IFNβ) develop neutralizing antibodies (NAbs), which reduce or abolish the therapeutic effects of the treatment. These patients are usually switched to a non-IFNβ treatment, such as glatiramer acetate (GA). It is unknown whether a patient's previous disease activity in combination with their NAb-status can provide further insights on their risk of future disease activity. Consequently, we investigated treatment outcomes in patients switching from IFNβ to GA according to NAb-status and clinical disease activity, while on IFNβ.

METHODS

We identified all patients switching from IFNβ to GA and having information on NAb-status from the Danish Multiple Sclerosis Registry and compared treatment outcomes while on GA according to previous disease activity and the presence of NAbs.

RESULTS

We included 568 patients in the study: 107 NAb-negative patients switched due to adverse events (group 1), 24 NAb-negative patients switched with disease activity (group 2), 397 NAb-positive patients switched without disease activity (group 3) and 40 NAb-positive patients switched with disease activity (group 4). Compared to the reference (group 1), group 2 had an increased risk of future relapses (HR 1.79 95% Confidence interval (CI): 1.00-3.19). Group 3 showed a trend of a lower risk of future relapses (HR 0.74, 95%CI: 0.53-1.04). Group 4 had, on average, a similar risk of future relapses (HR 1.15 95% CI: 0.69-1.92). Similarly, group 2 had a higher probability of treatment discontinuation due to disease activity compared to the other groups.

CONCLUSION

While on GA, patients switched from IFNβ in the context of disease activity and no NAbs had the highest risk of future disease activity, while NAb positive patients without previous activity had the lowest. We did not find any average difference between NAb-positive patients switching in a context of disease activity and NAb-negative patients switched due to adverse events, although carefulness in the interpretation of this result is advised.

Interferon β-1a subcutaneously 3 times/week clinical outcome in relapsing multiple sclerosis in Finland

Prognostic factors and long-term treatment response of interferon β-1a s.c tiw has not been studied in a real-life clinical cohort in Finland. The aim of the paper was to evaluate long-term treatment response, prognostic clinical factors and adherence among interferon β-1a s.c tiw treated patients in Finland. A retrospective review of medical records was performed. Confirmed relapsing multiple sclerosis patients treated with interferon β-1a s.c tiw 22μg or 44μg as their first treatment, from 1996 to 2010 in Western Finland, were included. Longitudinal generalized linear regression models were applied to assess risk of disability progression, using Expanded Disability Status Scale (EDSS), during the treatment period. Odd’s ratios with 95% confidence intervals (95% CI) were calculated for risk factors: gender, age at diagnosis, treatment delay, dose, baseline EDSS and EDSS change in one year. Kaplan-Meier was applied to study median time to discontinuation. Mean duration of treatment in 293 cases was 2.9 years (min 0.04, max 13.5). EDSS increase vs. no increase in one-year carried a significant risk for long-term disability progression (1.20, 1.08-1.33). Older age, defined by a 10-year increase in age at diagnosis (1.43, 1.07-1.91) and one-year delay to treatment start showed an increased risk for disability progression (1.05, 0.99-1.11), but gender (0.66, 0.38-1.15) or initial dose (1.00, 0.45-2.25) showed no risk. Treatment was stopped in 37% due to disease activation at median of 1.7 years, and in 25% due to side effects at 9.3 months. Our results show that young age, a short delay to treatment start and slower disability progression were identified as factors for better outcome among cases with interferon β-1a s.c tiw as their first disease modifying treatment.

The effectiveness of interferon beta versus glatiramer acetate and natalizumab versus fingolimod in a Polish real-world population

Objective

The aim of the study was to assess the effectiveness of disease-modifying therapies (DMTs) in relapsing-remitting multiple sclerosis (RRMS) patients treated in MS centres in Poland.

Methods

Demographic and clinical data of all Polish RRMS patients receiving DMTs were prospectively collected from 2014 to 2018 in electronic files using the Therapeutic Program Monitoring System (SMPT).

Results

The study included 10,764 RRMS patients treated with DMTs in first-line and 1,042 in second-line programmes. IFNβ more effectively lengthened the times to the first relapse, disability progression, and brain MRI activity than GA. After 2 and 4 years of follow-up, more patients on IFNβ showed no evidence of disease activity (NEDA-3) in comparison to GA (66.3% and 44.3% vs 55.2% and 33.2%, respectively; p<0.001). NAT more effectively reduced brain MRI activity than FTY (p = 0.001). More patients under NAT had NEDA-3 after 2 and 4 years of follow-up compared to FTY (66.2% and 42.1% vs 52.1% and 29.5%, respectively; p = 0.03). In adjusted analysis, a higher baseline Expanded Disability Status Score (EDSS) was a predictor of relapse (p<0.001) and NEDA-3 failure (p = 0.003).

Conclusion

IFNβ compared to GA and NAT compared to FTY more effectively reduced disease activity in a Polish population of RRMS patients.

Retrospectively acquired cohort study to evaluate the long-term impact of two different treatment strategies on disability outcomes in patients with relapsing multiple sclerosis (RE.LO.DI.MS): data from the Italian MS Register

BACKGROUND

The increase in disease-modifying drugs (DMDs) allows individualization of treatment in relapsing multiple sclerosis (RMS); however, the long-term impact of different treatment sequences is not well established. This is particularly relevant for MS patients who may need to postpone more aggressive DMD strategies.

OBJECTIVE

To evaluate different therapeutic strategies and their long-term outcomes, measured as relapses and confirmed disability progression (CDP), in MS 'real-world' settings.

METHODS

Multicentre, observational, retrospectively acquired cohort study evaluating the long-term impact of different treatment strategies on disability outcomes in patients with RMS in the Italian MS Register.

RESULTS

We evaluated 1152 RMS-naïve patients after propensity-score adjustment. Patients included were receiving: interferon beta-1a (IFN-β1a) 44 µg switching to fingolimod (FTY; IFN-switchers; n = 97); FTY only (FTY-stayers; n = 157); IFN-β1a only (IFN-stayers; n = 849). CDP and relapses did not differ between FTY-stayers and IFN-switchers [HR (95% CI) 0.99 (0.48-2.04), p = 0.98 and 0.81 (0.42-1.58), p = 0.55, respectively]. However, IFN-stayers showed increased risk of relapses compared with FTY-stayers [HR (95% CI) 1.46 (1.00-2.12), p = 0.05].

CONCLUSION

The ideal treatment option for MS is becoming increasingly complex, with the need to balance benefit and risks. Our results suggest that starting with FTY affects the long-term disease outcome similarly to escalating from IFN-β1a to FTY.

Observational designs in clinical multiple sclerosis research: Particulars, practices and potentialities

Observational studies investigate a wide range of topics in multiple sclerosis research. This paper presents an overview of the various observational designs and their applications in clinical studies. Observational studies are well suited for making discoveries and assessing new explanations of phenomena, but less so for establishing causal relationships, due to confounding by indication (selection bias), co-morbidity, socio-economic or other factors. Whether observational findings are demonstrative, indicative or only suggestive, depends on the research question, whether and how the design fits this question, analytical techniques, and the quality of data. Observational studies may be cross-sectional vs. longitudinal, and prospective vs. retrospective. The term 'retrograde' is proposed to explicate that cross-sectional studies may obtain data that cover (long) preceding periods. Case reports and case series are usually based on accidental observations or routinely collected data. Cross-sectional studies, by simultaneously assessing clinical phenomena and external factors, enable the discovery and quantification of associations. In ecological studies the unit of analysis is population or group, and relationships on patient level cannot be established. A cohort study is a longitudinal study that investigates patients with a defining characteristic, e.g. diagnosis or specific treatment, by analyzing data acquired at various intervals. Prospective cohort studies use (some) data that are not yet available at the time the research is conceived, whereas in retrospective studies the data already exist. In a case-control study a representative group of patients with a specific clinical feature is compared with controls, and the frequencies at which an external factor, e.g. infection, has occurred in each group is compared; in a nested case-control study controls are drawn from a fully known cohort. Randomized controlled trial (RCT)-extension studies are informative because, due to RCT randomization, they are free from confounding by indication. Patient or disease registries are organised systems for the long-term collection of uniform data on a population that is defined by a particular disease, condition or exposure, with the purpose to study changes over time. In pharmacotherapeutic research, accidental observations of unexpected beneficial effects may lead to further research into a drug's efficacy in other conditions. Uncontrolled phase 1 studies investigate safety and dosing aspects. Observational studies are alternatives to RCTs when these are not feasible for ethical or practical reasons. Phase 4 observational studies play a crucial role in the evaluation of the effectiveness of treatments in daily practice, the validation of RCT-based side effect profiles, and the discovery of late occurring or rare, potentially life-threatening side effects. Combinations of multidisciplinary longitudinal data bases into large data sets enable the development of algorithms for personalized treatments. To improve the reporting of observational findings on treatment effectiveness, it is proposed that abstracts define the research question(s) the study was meant to answer, study design and analytical methods, and identify and quantify the patient population, treatment of interest, relevant outcomes and the study's strengths and limitations. The development of guidelines for Strengthening the Reporting of Observational Studies in Effectiveness Research (STROBER), as an extension of the guidelines used in epidemiology, is wanted.

RebiQoL: A randomized trial of telemedicine patient support program for health-related quality of life and adherence in people with MS treated with Rebif

RebiQoL was a phase IV multicenter randomized study to assess the impact of a telemedicine patient support program (MSP) on health-related quality of life (HRQoL) in patients with relapsing-remitting MS (RRMS) being administered with Rebif with the RebiSmart device. The primary endpoint was to assess the impact of MSP compared to patients only receiving technical support for RebiSmart on HRQoL at 12 months, using the psychological part of Multiple Sclerosis Impact Scale (MSIS-29), in patients administered with Rebif. A total of 97 patients diagnosed with RRMS were screened for participation in the study of which 3 patients did not fulfill the eligibility criteria and 1 patient withdrew consent. Of the 93 randomized patients, 46 were randomized to MSP and 47 to Technical support only. The demographic characteristics of the patients were well-balanced in the two arms. There were no statistical differences (linear mixed model) in any of the primary (difference of 0.48, 95% CI: -8.30–9.25, p = 0.91) or secondary outcomes (p>0.05). Although the study was slightly underpowered, there was a trend towards better adherence in the MSP group (OR 3.5, 95% CI 0.85–14.40, p = 0.08) although not statistically significant. No unexpected adverse events occurred. This study did not show a statistically significant effect of the particular form of teleintervention used in this study on HRQoL as compared to pure technical support, for MS patients already receiving Rebif with the RebiSmart device.

Trial Registration: ClinicalTrials.gov: NCT01791244.

Effects of cladribine tablets on lymphocyte subsets in patients with multiple sclerosis: an extended analysis of surface markers

Background

Cladribine tablets 3.5 mg/kg cumulative over 2 years (CT3.5) had significant clinical/imaging effects in patients with clinically isolated syndrome (CIS; ORACLE-MS) or relapsing-remitting MS (RRMS; CLARITY and CLARITY Extension). This analysis compared the effect of cladribine tablets on the dynamics of immune cell reduction and reconstitution in ORACLE-MS, CLARITY, and CLARITY Extension during the first year of treatment (i.e. the first course of CT1.75) in patients randomized to CT3.5.

Methods

Lymphocyte subtypes were analyzed using multiparameter flow cytometry. Changes in cell counts and relative proportions of lymphocytes were evaluated at weeks 5, 13, 24, and 48.

Results

Across studies, consistent and comparable selective kinetics of immune cell populations occurred following the first treatment year with CT. A rapid reduction in CD16⁺/CD56⁺ cells (week 5 nadir), a more marked reduction in CD19⁺ B cells (week 13 nadir), and a less-pronounced effect on CD4⁺ (week 13 nadir) and CD8⁺ T cells (week 24 nadir) was shown. There was little effect on neutrophils or monocytes. Lymphocyte recovery began after treatment with CT3.5. Regarding relative proportions of naïve and memory T-cell subtypes in ORACLE-MS, the proportion of naïve-like naturally occurring T-regulatory cells (nTregs) decreased, and the proportion of memory-like nTregs increased, relative to total CD4⁺ T cells.

Conclusions

CT3.5 has comparable effects on the immune systems of patients with CIS or RRMS. The pronounced reduction and recovery dynamics of CD19⁺ B cells and relative changes in the proportion of some immune cell subtypes may underlie the clinical effects of CT3.5.

Automated segmentation of changes in FLAIR-hyperintense white matter lesions in multiple sclerosis on serial magnetic resonance imaging

Longitudinal analysis of white matter lesion changes on serial MRI has become an important parameter to study diseases with white-matter lesions. Here, we build on earlier work on cross-sectional lesion segmentation; we present a fully automatic pipeline for serial analysis of FLAIR-hyperintense white matter lesions. Our algorithm requires three-dimensional gradient echo T1- and FLAIR- weighted images at 3 Tesla as well as available cross-sectional lesion segmentations of both time points. Preprocessing steps include lesion filling and intrasubject registration. For segmentation of lesion changes, initial lesion maps of different time points are fused; herein changes in intensity are analyzed at the voxel level. Significance of lesion change is estimated by comparison with the difference distribution of FLAIR intensities within normal appearing white matter. The method is validated on MRI data of two time points from 40 subjects with multiple sclerosis derived from two different scanners (20 subjects per scanner). Manual segmentation of lesion increases served as gold standard. Across all lesion increases, voxel-wise Dice coefficient (0.7) as well as lesion-wise detection rate (0.8) and false-discovery rate (0.2) indicate good overall performance. Analysis of scans from a repositioning experiment in a single patient with multiple sclerosis did not yield a single false positive lesion. We also introduce the lesion change plot as a descriptive tool for the lesion change of individual patients with regard to both number and volume. An open source implementation of the algorithm is available at http://www.statistical-modeling.de/lst.html.

•

Quantification of white matter lesion changes is important in multiple sclerosis.

•

We developed and validated an algorithm for automated detection of lesion changes.

•

Our algorithm requires T1-weighted and FLAIR images derived at 3 T as well as available cross-sectional lesion segmentations.

•

With data from 2 different scanners, the tool showed good agreement with manual tracing.

•

An open-source application is available.

Silent progression in disease activity-free relapsing multiple sclerosis

Objective

Rates of worsening and evolution to secondary progressive multiple sclerosis (MS) may be substantially lower in actively treated patients compared to natural history studies from the pretreatment era. Nonetheless, in our recently reported prospective cohort, more than half of patients with relapsing MS accumulated significant new disability by the 10th year of follow‐up. Notably, “no evidence of disease activity” at 2 years did not predict long‐term stability. Here, we determined to what extent clinical relapses and radiographic evidence of disease activity contribute to long‐term disability accumulation.

Methods

Disability progression was defined as an increase in Expanded Disability Status Scale (EDSS) of 1.5, 1.0, or 0.5 (or greater) from baseline EDSS = 0, 1.0–5.0, and 5.5 or higher, respectively, assessed from baseline to year 5 (±1 year) and sustained to year 10 (±1 year). Longitudinal analysis of relative brain volume loss used a linear mixed model with sex, age, disease duration, and HLA‐DRB1*15:01 as covariates.

Results

Relapses were associated with a transient increase in disability over 1‐year intervals (p = 0.012) but not with confirmed disability progression (p = 0.551). Relative brain volume declined at a greater rate among individuals with disability progression compared to those who remained stable (p < 0.05).

Interpretation

Long‐term worsening is common in relapsing MS patients, is largely independent of relapse activity, and is associated with accelerated brain atrophy. We propose the term silent progression to describe the insidious disability that accrues in many patients who satisfy traditional criteria for relapsing–remitting MS. Ann Neurol 2019;85:653–666

Association of circulating anti-CD64 IgM levels with favourable long-term clinical outcomes in multiple sclerosis patients

Circulating levels of IgM anti-CD64, an immunosuppressive antibody recently identified in long-term stable multiple sclerosis (MS) patients, were found to fluctuate over time in MS patients. Antibody-positive patients showed a significantly lower annualized relapse rate value as well as reached sustained disability worsening and had a relapse in a significantly longer median time than those without antibody. Disease-modifying therapies (DMTs) only were the covariate influencing both the relapse occurrence and the disability accrual. Serum IgM anti-CD64 levels are associated with maintenance of clinical stability in MS and may be tested as a candidate biomarker predictive of benign course and favourable long-term response to DMTs treatment.

Toward a Shared-Care Model of Relapsing-Remitting Multiple Sclerosis: Role of the Primary Care Practitioner

The objective of this study was to develop a shared-care model to enable primary-care physicians to participate more fully in meeting the complex, multidisciplinary healthcare needs of patients with multiple sclerosis (MS).

DESIGN

The design consisted of development of consensus recommendations and a shared-care algorithm.

PARTICIPANTS

A working group of 11 Canadian neurologists involved in the management of patients with MS were included in this study.

MAIN MESSAGE

The clinical management of patients with multiple sclerosis is increasing in complexity as new disease-modifying therapies (DMTs) become available, and ongoing safety monitoring is required. A shared-care model that includes primary care physicians is needed. Primary care physicians can assist in the early detection of MS of individuals presenting with neurological symptoms. Additional key roles for family physicians are health promotion, symptom management, and safety and relapse monitoring of DMT-treated patients. General principles of health promotion include counseling MS patients on maintaining a healthy lifestyle; performing standard screening measures; and identifying and treating comorbidities. Of particular importance are depression and anxiety, which occur in >20% of MS patients. Standard work-ups and treatments are needed for common MS-related symptoms, such as fatigue, pain, bladder dysfunction, sexual dysfunction, spasticity, and sleep disorders. Ongoing safety monitoring is required for patients receiving specific DMTs. Multiple sclerosis medications are generally contraindicated during pregnancy, and patients should be counseled to practice effective contraception.

CONCLUSIONS

Multiple sclerosis is a complex, disabling illness, which, similar to other chronic diseases, requires ongoing multidisciplinary care to meet the evolving needs of patients throughout the clinical course. Family physicians can play an invaluable role in maintaining general health, managing MS-related symptoms and comorbidities, monitoring for treatment-related adverse effects and MS relapses, and coordinating allied health services to ensure continuity of care to meet the complex and evolving needs of MS patients through the disease course. RÉSUMÉ: Élaborer un modèle de soins partagés dans les cas de sclérose en plaques récurrente-rémittente. Objectif: Élaborer un modèle de soins partagés afin de permettre aux médecins de première ligne de mieux répondre aux besoins complexes et multidisciplinaires de patients atteints de la sclérose en plaques (SP). Conception : Recommandations résultant d'un consensus et élaboration d'un algorithme en matière de soins partagés.

PARTICIPANTS

Un groupe de travail formé de onze neurologues canadiens impliqués dans la prise en charge de patients atteints de la SP. Message-clé : La prise en charge clinique de patients atteints de la SP est de plus en plus complexe dans la mesure où des médicaments modificateurs de l'évolution de la maladie (MMSP) deviennent accessibles et où un suivi permanent en matière de sécurité est nécessaire. Soulignons aussi qu'un modèle de soins partagés incluant les médecins de première ligne est nécessaire. Ces professionnels peuvent permettre un dépistage plus rapide de la SP chez des individus présentant des symptômes neurologiques. Ils peuvent aussi jouer un rôle de premier plan en matière de promotion de la santé, de soulagement des symptômes et de suivi de patients traités avec des MMSP en ce qui a trait à leur sécurité et à de possibles rechutes. Parmi les principes généraux de promotion de la santé, on peut inclure les suivants : offrir aux patients atteints de la SP des conseils leur permettant de maintenir de saines habitudes de vie ; adopter des mesures de dépistage standards ; identifier et traiter les comorbidités. À cet égard, l'anxiété et la dépression sont d'une importance particulière et sont fréquemment signalées (> 20 %) chez les patients atteints de SP. Des démarches d'investigation et des traitements standards sont nécessaires dans le cas des symptômes courants reliés à la SP, par exemple de la fatigue, des douleurs, une dysfonction vésicale, des dysfonctions sexuelles, de la spasticité et des troubles du sommeil. On l'a dit, un suivi permanent s'impose dans le cas de patients bénéficiant d'un traitement spécifique avec des MMSP. Les médicaments associés à la SP sont généralement contre-indiqués durant la grossesse de sorte qu'on devrait conseiller aux patients d'adopter des méthodes de contraception efficaces.

CONCLUSIONS

La SP est une maladie complexe et invalidante qui, à l'instar d'autres maladies chroniques, exige des soins multidisciplinaires continus afin de répondre, en lien avec un tableau clinique précis, aux besoins en constante évolution des patients. Les médecins de première ligne peuvent jouer un rôle irremplaçable à plusieurs égards : dans le maintien d'une bonne santé ; le suivi et le soulagement des symptômes et des comorbidités reliés à la SP ; le suivi des rechutes et des effets indésirables associés aux traitements. N'oublions pas non plus la coordination des services paramédicaux afin d'assurer, durant l'évolution de la SP, une continuité des soins répondant aux besoins complexes et en constante évolution des patients atteints de cette maladie.

Long Term Compliance for MS Patients in Treatment with Disease Modifying Drugs (DMDs)

Background:

Multiple Sclerosis (MS) is one of the most common causes of neurological disability in young and middle-aged adults. Patients with MS face many challenges, both physical and emotional, and see an overall reduction in their autonomy. There is no definitive treatment for MS, though Disease Modifying Drugs (DMDs) have proved effective in reducing the frequency and severity of relapses. Unfortunately, long-term adherence to these therapies is a significant challenge due to practical difficulties as well as a general distrust towards the drugs .

Objective:

This study follows an original research carried out in 2008. In the first study, patients answered questions on their clinical history and expressed their judgment on the pharmacological treatment, their perceived effectiveness and factors that may undermine compliance. They have been recalled after two years to verify if the reported symptoms have changed and to assess how their knowledge of the disease and “acceptance” of the treatment have been modified.

Methods:

In spite of the relatively high number of patients participating in the first study (141 patients followed at a single neurological centre), only 16 patients have completed the questionnaire for the long-term survey. A detailed descriptive analysis has been carried out, as well as a pairwise correlation analysis.

Results and Conclusions:

The interviews carried out gave an insight into how patients’ behavior may have changed over time. Compliance rate is different in newly-diagnosed patients and long-term patients; the latter are more likely to be compliant, given their personal experience with the disease. Communications with neurologists and health personnel should aim at forming therapeutic alliances with patients and detecting their preferences for a qualitatively adequate assistance throughout their illness.

Connexin 30 Deficiency Attenuates Chronic but Not Acute Phases of Experimental Autoimmune Encephalomyelitis Through Induction of Neuroprotective Microglia

Glial connexins (Cxs) form gap junction channels through which a pan-glial network plays key roles in maintaining homeostasis of the central nervous system (CNS). In multiple sclerosis (MS) and its animal model, experimental autoimmune encephalomyelitis (EAE), expression of astrocytic Cx43 is lost in acute lesions but upregulated in chronic plaques, while astrocytic Cx30 is very low in normal white matter and changes in its expression have not been convincingly shown. In Cx30 or Cx43 single knockout (KO) mice and even in Cx30/Cx43 double KO mice, acute EAE is unaltered. However, the effects of Cx30/Cx43 deficiency on chronic EAE remains to be elucidated. We aimed to clarify the roles of Cx30 in chronic neuroinflammation by studying EAE induced by myelin oligodendrocyte glycoprotein peptide 35–55 in Cx30 KO mice. We found that Cx30 deficiency improved the clinical symptoms and demyelination of chronic but not acute EAE without influencing CD3⁺ T cell infiltration. Furthermore, increased ramified microglia in the naïve state and induced earlier and stronger microglial activation in the acute and chronic phases of EAE was observed. These activated microglia had an anti-inflammatory phenotype, as shown by the upregulation of arginase-1 and brain-derived neurotrophic factor and the downregulation of nitric oxide synthase 2. In the naïve state, Cx30 deficiency induced modest enlargement of astrocytic processes in the spinal cord gray matter and a partial reduction of Cx43 expression in the spinal cord white matter. These astrocytes in Cx30 KO mice showed earlier and stronger activation during the acute phase of EAE, with upregulated A2 astrocyte markers and a significant decrease in Cx43 in the chronic phases. Spinal cord neurons and axons were more preserved in Cx30 KO mice than in littermates in the chronic phase of EAE. These findings suggest that Cx30 deficiency increased ramified microglia in the CNS in the naïve state and improved chronic EAE through redirecting microglia toward an anti-inflammatory phenotype, suggesting a hitherto unknown critical role of astrocytic Cx30 in regulating microglial number and functional state.

Seasonal adherence to, and effectiveness of, subcutaneous interferon β-1a administered by RebiSmart® in patients with relapsing multiple sclerosis: results of the 1-year, observational GEPAT-SMART study

BACKGROUND

Little is known about whether tolerability and adherence to treatment can be influenced by weather and temperature conditions. The objective of this study was to assess monthly and seasonal adherence to and safety of sc IFN-β1a (Rebif®, Merck) in relapsing-remitting multiple sclerosis (RRMS) patients using the RebiSmart® electronic autoinjector.

METHODS

A multicentre, prospective observational study in Greece in adult RRMS patients with EDSS < 6, under Rebif®/RebiSmart® treatment for ≤6 weeks before enrollment. The primary endpoint was monthly, seasonal and annual adherence over 12 months (defined in text). Secondary endpoints included number of relapses, disability, adverse events.

RESULTS

Sixty four patients enrolled and 47 completed all study visits (Per Protocol Set - PPS). Mean annual adherence was 97.93% ± 5.704 with no significant monthly or seasonal variations. Mean relapses in the pre- and post- treatment 12-months were 1.1 ± 0.47 and 0.2 ± 0.54 (p < 0.0001, PPS). 10 patients (22%) showed 3-month disability progression, 19 (40%) stabilization and 18 (38%) improvement. EDSS was not correlated to pre- (r = 0.024, p = 0.87) or post-treatment relapses (r = 0.022, p = 0.88).

CONCLUSION

High adherence with no significant seasonal or weather variation was observed over 12 months. While the efficacy on relapses was consistent with published studies, we could not identify a relationship between relapses and disability.

TRIAL REGISTRATION

Greek registry of non-interventional clinical trials ID: 200136 , date of registration: February 18th, 2013.

Real-World Effectiveness of Disease-Modifying Therapies in Korean Patients with Relapsing Multiple Sclerosis

BACKGROUND AND PURPOSE

This study assessed the long-term outcomes of disease-modifying therapies (DMTs) in Korean multiple sclerosis (MS) patients treated in real-world clinical settings in Korea.

METHODS

We retrospectively evaluated the medical records of 160 patients with an initial diagnosis of clinically isolated syndrome or relapsing-remitting MS who were treated for at least 2 years. A status of 3 for no evidence of disease activity (NEDA3) was defined as no relapse, disability progression, or active lesions in annual magnetic resonance imaging (MRI) evaluations.

RESULTS

Patients who were initially treated with interferon β (n=152), glatiramer acetate (n=6), or teriflunomide (n=2) were included. The mean disease duration was 8.2 years. Compared to pretreatment, annualized relapse rates were significantly reduced after treatment [from 1.0±0.8 to 0.2±0.4 (mean±standard deviation), p<0.001]. At the follow-up, 79 patients (49%) had changed their treatment regimen due to lack of efficacy (33%), side effects (14%), or other reasons (2%). Disability progression was observed in 18% of the patients over a mean treatment duration of 5.7 years. After 2 years, NEDA3 was observed in 38% of the patients. Loss of NEDA3 at 2 years was associated with long-term disability progression [odds ratio (OR)=17.975, p=0.003]. Poor response to first-line treatment was independently associated with a delay in treatment from disease onset (OR=1.238, p=0.049) and 10 or more brain lesions in the initial MRI (OR=3.648, p=0.047).

CONCLUSIONS

This study has provided real-world evidence that DMTs are effective in reducing disease activity and disability progression in Korean MS patients.

Effect of interferon beta-1a subcutaneously three times weekly on clinical and radiological measures and no evidence of disease activity status in patients with relapsing-remitting multiple sclerosis at year 1

Background

In the PRISMS study, interferon beta-1a subcutaneously (IFN β-1a SC) reduced clinical and radiological disease burden at 2 years in patients with relapsing–remitting multiple sclerosis. The study aimed to characterize efficacy of IFN β-1a SC 44 μg and 22 μg three times weekly (tiw) at Year 1.

Methods

Exploratory endpoints included annualized relapse rate (ARR), 3-month confirmed disability progression (1-point Expanded Disability Status Scale increase if baseline was < 6.0 [0.5-point if baseline was ≥6.0]), active T2 lesions, and no evidence of disease activity (NEDA; defined as no relapses [subanalyzed by relapse severity], 3-month confirmed progression, or active T2 lesions). Effect of IFN β-1a SC in prespecified patient subgroups was also assessed.

Results

Patients were randomized to IFN β-1a 22 μg (n = 189), 44 μg (n = 184), or placebo (n = 187). At 1 year, IFN β-1a SC tiw reduced ARR (p < 0.001), risk of disability progression (p ≤ 0.029), and mean number of active T2 lesions per patients per scan (p < 0.001) versus placebo. Clinical and radiological benefits were seen as early as Month 2 and 3. Outcomes in subgroups were consistent with those in the overall population. More patients treated with IFN β-1a SC tiw achieved NEDA status, versus placebo, regardless of relapse severity (p ≤ 0.006).

Conclusion

Clinical, radiological, and NEDA outcomes at Year 1 were consistent with Year 2 results. Treatment efficacy was consistent in pre-specified patient subgroups.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1145-x) contains supplementary material, which is available to authorized users.

Early versus later treatment start in multiple sclerosis: a register-based cohort study

BACKGROUND AND PURPOSE

To assess long-term treatment effectiveness of disease-modifying therapy (DMT) initiated early in disease course versus later treatment start.

METHODS

We included all Danish patients with multiple sclerosis (MS) treated with DMT through two nationwide population-based MS registries. Patients were categorized as early treated if treatment started within 2 years after the first MS symptom (n = 2316) and later treated if treatment started between 2 and 8 years after clinical onset (n = 1479). We compared time from treatment start to progression to an Expanded Disability Status Scale (EDSS) score of 6 and mortality between cohorts as hazard ratio (HR) using a Cox proportional hazards model with adjustment for stabilized inverse probability of treatment weights. Several sensitivity analyses were conducted.

RESULTS

The median follow-up time of 3795 patients was 7.0 (range 0.6-19.5) years for the EDSS score of 6 outcome and 10.4 (range 1.2-20.1) years for the mortality outcome. Patients with later treatment start showed a 42% increased hazard rate of reaching an EDSS score of 6 compared with the early-treated patients [HR, 1.42; 95% confidence interval (CI), 1.18-1.70; P < 0.001]. When stratified by sex, the increased hazard among later-treated women persisted (HR, 1.53; 95% CI, 1.22-1.93; P < 0.001), whereas the HR was lower in men (1.25; 95% CI, 0.93-1.69; P = 0.15). Mortality was increased by 38% in later starters (HR, 1.38; 95% CI, 0.96-1.99; P = 0.08).

CONCLUSIONS

Patients who started treatment with DMT later reached an EDSS score of 6 more quickly compared with patients who started early and the delay showed a tendency to shorten time to death. Our results support the use of early treatment.

Recent developments in interferon-based therapies for multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a chronic and disabling immune-mediated disease of the central nervous system. Beta-interferons are the first approved and still the most widely used first-line disease-modifying treatment in MS.

AREAS COVERED

Here we focus on recent developments in pharmacology and delivery systems of beta-interferons, and discuss their place within current state of the art therapeutic approaches. We briefly review the clinical trials for classical and PEGylated formulations, emphasizing effectiveness, safety concerns, and tolerability. The mechanisms of action of IFN-β in view of MS pathogenesis are also debated

EXPERT OPINION

Though only modestly efficient in reducing the annualized relapse rate, beta-interferons remain a valid first-line option due to their good long-term safety profile and cost-efficacy. Moreover, they are endogenous class II cytokines essential for mounting an effective antiviral response, and they may interact with putative MS triggering factors such as Epstein-Barr virus infection and human endogenous retroviruses. Recent improvements in formulations, delivery devices and drug regimens tackle the tolerability and adherence issues frequently seen with these drugs, and scientific advances may offer means for a better selection of patients. Although a well-established immunomodulatory treatment, beta-interferons have not said their last word in the management of MS.

Prevalence and factors leading to unemployment in MS (multiple sclerosis) patients undergoing immunomodulatory treatment in Poland

Multiple Sclerosis (MS) is the most common, primary neurogenic cause of disability among young adults. We investigated demographic and clinical factors associated with unemployment on the example of 150 MS patients receiving immunomodulatory treatment in Poland. This study was based on clinical evaluation and collection of self-reported questionnaires, with an attention to self-motivation, severe fatigue and moderate disability. Patients who were unemployed (40% of all patients) had a mean disease duration of almost 5 years. Older (p<0.001), less educated (p = 0.007) and more severely disabled patients (p<0,001) were most likely to be unemployed. Moderate disability (OR = 11.089 95% CI: 4.11-34.201, p<0,001), severe fatigue (OR = 2.625 95% CI: 1.02-6.901, p = 0,046) and lower level of self-motivation (KNS) (OR = 0.947, 95% CI: 0.896-0.006, p = 0.042) were independently associated with unemployment.

Psychosocial and Medical Determinants of Health-related Quality of Life in Patients with Relapsing-Remitting Multiple Sclerosis

INTRODUCTION

Relapsing-remitting multiple sclerosis is a debilitating neurological disease accompanied with adverse consequences for quality of life. The purpose of this study was to investigate the role of relapsing-remitting multiple sclerosis on psychological, disease-related, socioeconomic, and demographic determinants of health-related quality of life of patients.

METHODS

In this cross-sectional descriptive study, 193 patients with relapsing-remitting multiple sclerosis were selected by compliance sampling method among the patients who attended the Iranian Multiple Sclerosis Association in Tehran from March 2014 to July 2014; and they completed the Multiple Sclerosis Quality of Life Questionnaire, the Depression Anxiety and Stress Scales, and the Socio-demographical Questionnaire. Then, a hierarchical multiple regression analysis with the stepwise method is used for data analysis by the PASW-18.

RESULTS

According to the findings, in model 1, low socioeconomic status (SES) had a negative coefficient (beta=-0.30, p<0.01), and treatment history had a positive coefficient (beta=0.22, p<0.01). In model 2, while all variables of model 1 were controlled, depression had a negative coefficient (beta=-0.26, p<0.05), while disorder severity of multiple sclerosis had positive coefficients in lower level (beta=0.35, p<0.001), moderate level (beta=0.23, p<0.01), and severe level (beta=0.22, p<0.01). Other studied variables in model 1, and stress and anxiety in model 2 were not predicted in terms of the quality of life (p>0.05).

CONCLUSION

Unfavorable SES, lack of effective treatment history, higher depression, and signs and symptoms severity of multiple sclerosis significantly predict decreased health-related quality of life in patients with relapsing-remitting multiple sclerosis. Thus, it is consequential to emphasize the value of tailored intervention for attending to these factors in the treatment and rehabilitation agendas for improvement of health-related quality of life in relapsing-remitting multiple sclerosis.

[An analysis of clinical trials on the registration of similars of the original disease-modifying therapies]

The article discusses the design and results of recently published study of an analog of the original glatiramer acetate. The necessity of the correct planning and analysis of the data of such studies is stressed, showing equal efficacy, tolerability and safety of analog and original drug. The optimal design of such studies, their duration, selection of primary endpoint, adequate assessment of clinical and MRI changes and side-effects are discussed. The authors reckon that it is impossible to plan studies the results of which are based on the design, i.e. the absence of differences from the original drug. The authors invite specialists in MS to participate in the discussion.

Treatment satisfaction significantly improves in patients with multiple sclerosis switching from interferon beta therapy to peginterferon beta-1a every 2 weeks

OBJECTIVES

Posthoc analysis of treatment satisfaction in patients switching to subcutaneous (SC) peginterferon beta-1a in the ALLOW study.

PATIENTS AND METHODS

Patients with relapsing multiple sclerosis treated with intramuscular interferon (IFN) beta-1a or SC IFN beta-1a or beta-1b remained on their current therapy for a 4-week run-in period, followed by a switch to SC peginterferon beta-1a 125 mcg every 2 weeks for 48 weeks. Treatment satisfaction was measured using the Treatment Satisfaction Questionnaire for Medication (TSQM), which covers effectiveness, side effects, convenience, and global satisfaction. Patients completed the TSQM at baseline (prior to starting the 4-week run-in period) and 4, 12, 24, 36, and 48 weeks after switching, and scores were analyzed for the overall population and compared to baseline. Patients reported the severity of flu-like symptoms (FLS) at baseline and with each peginterferon beta-1a injection; clinicians evaluated the occurrence of injection-site reactions (ISRs) after the first dose of peginterferon beta-1a and every 12 weeks thereafter. TSQM scores were stratified by the presence of FLS or ISRs during the study period and by prior IFN therapy use.

RESULTS

For the overall population (n=194), convenience and global satisfaction scores significantly improved from baseline at all time points, and side effect satisfaction scores significantly improved up to week 36. Convenience scores significantly improved regardless of FLS, ISRs, or prior IFN therapy. Patients without FLS during the study period showed significant improvements in global satisfaction, but not side effect satisfaction, versus those with FLS. Patients switching from SC IFN therapies achieved greater improvements in treatment satisfaction than patients who switched from intramuscular IFN beta-1a.

CONCLUSIONS

Switching relapsing multiple sclerosis patients to SC peginterferon beta-1a from other IFN therapies significantly improved treatment satisfaction and convenience.

A 8-year retrospective cohort study comparing Interferon-β formulations for relapsing-remitting multiple sclerosis

BACKGROUND

Interferon-β has been approved for the treatment of relapsing-remitting (RR) multiple sclerosis (MS), whereas its efficacy in preventing long-term disability and conversion to secondary progressive (SP) MS is still debated. We aim to compare long-term clinical evolution of newly-diagnosed RRMS patients treated with different Interferon-β formulations.

METHODS

507 patients were included in the analysis and followed-up for 8.5 ± 3.9 years. 37.6% were treated with subcutaneous Interferon-β1a 44mcg, 33.4% with intramuscular Interferon-β1a 30mcg, and 29.0% with subcutaneous Interferon-β1b 250mcg. Relapse occurrence, 1-point EDSS progression, reaching of EDSS 4.0 and conversion to SP were recorded as outcome measures. To reduce the selection bias, we calculated the propensity score of receiving the specific treatment considering age (32.7 ± 8.3 years), gender (female 63.1%), disease duration (2.7 ± 2.8 years), and baseline EDSS (1.5, range 1.0-3.5). Propensity score and covariates (age, gender, disease duration and EDSS) were included in the statistical models.

RESULTS

At Cox regression models, the reaching of EDSS 4.0 was not-significantly higher for Interferon-β1b 250mcg (HR = 1.207; p = 0.063) and for Interferon-β1a 30mcg (HR = 1.363; p = 0.095), when compared with Interferon-β1a 44mcg. The rate of SP conversion was higher for Interferon-β1b 250mcg (HR = 2.054; p = 0.042), and not-significantly higher for Interferon-β1a 30mcg (HR = 1.884; p = 0.081), when compared with Interferon-β1a 44mcg.

CONCLUSIONS

Patients treated with Interferon-β1a 44mcg presented with a marginally reduced risk of disability accrual in the long-term, when compared with Interferon-β1b 250mcg and, at least in part, with Interferon-β1a 30mcg. Formulation, frequency of administration and dose of Interferon-β might affect the long-term clinical evolution of RRMS.

The innovative development in interferon beta treatments of relapsing-remitting multiple sclerosis

The introduction of interferon beta therapies more than 20 years ago marked a milestone in the treatment of relapsing-remitting multiple sclerosis (RRMS) with a significant impact on the approach to modern multiple sclerosis (MS) care. Key learnings and perspectives from the early days of disease modifying therapies in MS have improved the knowledge base of MS, need for treatment, and patient care. The continuous development of interferons over the past two decades outlines a journey with increased understanding of the pharmacodynamics and pharmacokinetic mechanisms of interferons, leading to innovative formulations with an improved benefit/risk profile.