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Conway DS, Thompson NR, Cohen JA. Lack of magnetic resonance imaging lesion activity as a treatment target in multiple sclerosis: An evaluation using electronically collected outcomes. Mult Scler Relat Disord 2016; 9:129-34. [PMID: 27645360 DOI: 10.1016/j.msard.2016.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 07/21/2016] [Accepted: 07/26/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The appropriate treatment target in multiple sclerosis (MS) is unclear. Lack of magnetic resonance imaging (MRI) lesion activity, a component of the no evidence of disease activity concept, has been proposed as a treatment target in MS. We used our MS database to investigate whether aggressively pursuing MRI stability by changing disease modifying therapy (DMT) when MRI activity is observed leads to better clinical and imaging outcomes. METHODS The Knowledge Program (KP) is a database linked to our electronic medical record allowing capture of patient and clinician reported outcomes. Through KP query and chart review, we identified all relapsing-remitting MS patients visiting between 1 January 2008 and 31 December 2014 with active MRIs despite DMT. Propensity modeling based on demographic and disease characteristics was used to match DMT switchers to non-switchers. KP and MRI outcomes were compared 18 months after the active MRI using mixed-effects linear regression models. RESULTS We identified 417 patients who met criteria for our analysis. After propensity matching, 78 switchers and 91 non-switchers were analyzed. There was no difference in clinical or radiologic outcomes between these groups at 18 months. CONCLUSIONS We did not find a short-term benefit of changing DMT to pursue MRI stability.
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Affiliation(s)
- Devon S Conway
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundatio, 9500 Euclid Avenue/U10, Cleveland, OH, 44195 USA.
| | - Nicolas R Thompson
- Department of Quantitative Health Sciences, Neurological Institute Center for Outcomes Research and Evaluation, Cleveland Clinic Foundation, 9500 Euclid Avenue/JJ3, Cleveland, OH, 44195 USA
| | - Jeffrey A Cohen
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundatio, 9500 Euclid Avenue/U10, Cleveland, OH, 44195 USA
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O׳Connell K, Kelly S, Fogarty E, Duggan M, Buckley L, Hutchinson M, McGuigan C, Tubridy N. Economic costs associated with an MS relapse. Mult Scler Relat Disord 2014; 3:678-83. [DOI: 10.1016/j.msard.2014.09.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 08/31/2014] [Accepted: 09/04/2014] [Indexed: 10/24/2022]
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A 2-year observational study of patients with relapsing-remitting multiple sclerosis converting to glatiramer acetate from other disease-modifying therapies: the COPTIMIZE trial. J Neurol 2014; 261:2101-11. [PMID: 25119836 PMCID: PMC4221652 DOI: 10.1007/s00415-014-7446-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 07/14/2014] [Accepted: 07/15/2014] [Indexed: 12/17/2022]
Abstract
Studies suggest that patients with relapsing-remitting multiple sclerosis (RRMS) who do not benefit from other disease-modifying treatments (DMTs) may benefit from converting to glatiramer acetate (GA). COPTIMIZE was a 24-month observational study designed to assess the disease course of patients converting to GA 20 mg daily from another DMT. Eligible patients had converted to GA and had received prior DMT for 3-6 months, depending on the reasons for conversion. Patients were assessed at baseline and at 6, 12, 18, and 24 months. In total, 672 patients from 148 centers worldwide were included in the analysis. Change of therapy to GA was prompted primarily by lack of efficacy (53.6 %) or intolerable adverse events (AEs; 44.8 %). Over a 24-month period, 72.7 % of patients were relapse free. Mean annual relapse rate decreased from 0.86 [95 % confidence interval (CI) 0.81-0.91] before the change to 0.32 (95 % CI 0.26-0.40; p < 0.0001) at last observation, while the progression of disability was halted, as the Kurtzke Expanded Disability Status Scale (EDSS) scores remained stable. Patients improved significantly (p < 0.05) on measures of fatigue, quality of life, depression, and cognition; mobility scores remained stable. The results indicate that changing RRMS patients to GA is associated with positive treatment outcomes.
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Broadley SA, Barnett MH, Boggild M, Brew BJ, Butzkueven H, Heard R, Hodgkinson S, Kermode AG, Lechner-Scott J, Macdonell RAL, Marriott M, Mason DF, Parratt J, Reddel SW, Shaw CP, Slee M, Spies J, Taylor BV, Carroll WM, Kilpatrick TJ, King J, McCombe PA, Pollard JD, Willoughby E. Therapeutic approaches to disease modifying therapy for multiple sclerosis in adults: an Australian and New Zealand perspective: part 3 treatment practicalities and recommendations. MS Neurology Group of the Australian and New Zealand Association of Neurologists. J Clin Neurosci 2014; 21:1857-65. [PMID: 24993136 DOI: 10.1016/j.jocn.2014.01.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 01/28/2014] [Indexed: 11/29/2022]
Abstract
In this third and final part of our review of multiple sclerosis (MS) treatment we look at the practical day-to-day management issues that are likely to influence individual treatment decisions. Whilst efficacy is clearly of considerable importance, tolerability and the potential for adverse effects often play a significant role in informing individual patient decisions. Here we review the issues surrounding switching between therapies, and the evidence to assist guiding the choice of therapy to change to and when to change. We review the current level of evidence with regards to the management of women in their child-bearing years with regards to recommendations about treatment during pregnancy and whilst breast feeding. We provide a summary of recommended pre- and post-treatment monitoring for the available therapies and review the evidence with regards to the value of testing for antibodies which are known to be neutralising for some therapies. We review the occurrence of adverse events, both the more common and troublesome effects and those that are less common but have potentially much more serious outcomes. Ways of mitigating these risks and managing the more troublesome adverse effects are also reviewed. Finally, we make specific recommendations with regards to the treatment of MS. It is an exciting time in the world of MS neurology and the prospects for further advances in coming years are high.
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Affiliation(s)
- Simon A Broadley
- School of Medicine, Griffith University, Gold Coast Campus, QLD 4222, Australia; Department of Neurology, Gold Coast University Hospital, Southport, QLD, Australia.
| | - Michael H Barnett
- Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia
| | - Mike Boggild
- Department of Neurology, The Townsville Hospital, Douglas, QLD, Australia
| | - Bruce J Brew
- Department of Neurology and St Vincent's Centre for Applied Medical Research, St Vincent's Hospital, University of New South Wales, Darlinghurst, NSW, Australia
| | - Helmut Butzkueven
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Department of Neurology, Eastern Health and Monash University, 2/5 Arnold Street, Box Hill VIC 3128, Australia
| | - Robert Heard
- Westmead Clinical School, University of Sydney, NSW, Australia
| | - Suzanne Hodgkinson
- South Western Sydney Clinical School, University of New South Wales, NSW, Australia
| | - Allan G Kermode
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, WA, Australia
| | | | | | - Mark Marriott
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Deborah F Mason
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - John Parratt
- Central Clinical School, University of Sydney, NSW, Australia
| | - Stephen W Reddel
- Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia
| | | | - Mark Slee
- Flinders Medical Centre, Flinders University, SA, Australia
| | - Judith Spies
- Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia
| | - Bruce V Taylor
- Menzies Research Institute, University of Tasmania, TAS, Australia
| | - William M Carroll
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, WA, Australia
| | | | - John King
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Pamela A McCombe
- University of Queensland Centre for Clinical Research, QLD, Australia
| | - John D Pollard
- Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia
| | - Ernest Willoughby
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
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Consider switching to another disease-modifying therapy when unacceptable disease activity occurs in relapsing multiple sclerosis. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-013-0086-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Michel L, Vukusic S, De Seze J, Ducray F, Ongagna JC, Lefrère F, Jacq-Foucher M, Confavreux C, Wiertlewski S, Laplaud DA. Mycophenolate mofetil in multiple sclerosis: a multicentre retrospective study on 344 patients. J Neurol Neurosurg Psychiatry 2014; 85:279-83. [PMID: 23704316 DOI: 10.1136/jnnp-2013-305298] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Mycophenolate mofetil (MMF) is an immunosuppressive agent, sometimes used as a disease-modifying therapy for multiple sclerosis (MS). Several studies have reported the relative safety of this treatment but, to date, its efficacy has rarely been described. We performed a retrospective study to assess the safety and efficacy of MMF in patients with MS. METHODOLOGY Three French MS centres included all of their patients treated by MMF. The main outcome criterion was annualised relapse rate (ARR) in the 1 year period after onset of MMF compared with the 1 year control period. Treatment with another immunosuppressive drug, such as mitoxantrone or cyclophosphamide, in the 2 years preceding initiation of MMF was included in a subgroup analysis. MMF safety and progression of the Expanded Disability Status Scale (EDSS) score were also assessed. RESULTS 344 patients were included; 149 patients were previously treated with another immunosuppressant (IS group). Mean MMF treatment duration was 25.3±1.1 months. During the 1 year control period, ARR was 1.11±0.08, and for the 1 year treatment period, ARR was reduced significantly to 0.35±0.05 (p<0.0001, Wilcoxon paired test). Adverse events (occurring in 11% of patients) were mainly digestive disorders, benign infections, asthenia and transitory lymphopenia. Concerning the progression of disability, in the subgroup of patients without previous immunosuppressant treatment, EDSS remained stable between initiation and 1 year after the beginning of MMF. INTERPRETATION Our results suggest that MMF can improve or stabilise MS patients and can be used as an alternative therapy.
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Affiliation(s)
- L Michel
- Service de Neurologie, CHU Nantes, , Nantes, France
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Wingerchuk DM, Carter JL. Multiple sclerosis: current and emerging disease-modifying therapies and treatment strategies. Mayo Clin Proc 2014; 89:225-40. [PMID: 24485135 DOI: 10.1016/j.mayocp.2013.11.002] [Citation(s) in RCA: 292] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 11/01/2013] [Accepted: 11/07/2013] [Indexed: 12/20/2022]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating central nervous system disease that typically strikes young adults, especially women. The pathobiology of MS includes inflammatory and neurodegenerative mechanisms that affect both white and gray matter. These mechanisms underlie the relapsing, and often eventually progressive, course of MS, which is heterogeneous; confident prediction of long-term individual prognosis is not yet possible. However, because revised MS diagnostic criteria that incorporate neuroimaging data facilitate early diagnosis, most patients are faced with making important long-term treatment decisions, most notably the use and selection of disease-modifying therapy (DMT). Currently, there are 10 approved MS DMTs with varying degrees of efficacy for reducing relapse risk and preserving neurological function, but their long-term benefits remain unclear. Moreover, available DMTs differ with respect to the route and frequency of administration, tolerability and likelihood of treatment adherence, common adverse effects, risk of major toxicity, and pregnancy-related risks. Thorough understanding of the benefit-risk profiles of these therapies is necessary to establish logical and safe treatment plans for individuals with MS. We review the available evidence supporting risk-benefit profiles for available and emerging DMTs. We also assess the place of individual DMTs within the context of several different MS management strategies, including those currently in use (sequential monotherapy, escalation therapy, and induction and maintenance therapy) and others that may soon become feasible (combination approaches and "personalized medicine"). We conducted this review using a comprehensive search of MEDLINE, PubMed, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from January 1, 1990, to August 31, 2013. The following search terms were used: multiple sclerosis, randomized controlled trials, interferon-beta, glatiramer acetate, mitoxantrone, natalizumab, fingolimod, teriflunomide, dimethyl fumarate, BG-12, alemtuzumab, rituximab, ocrelizumab, daclizumab, neutralizing antibodies, progressive multifocal leukoencephalopathy.
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Teter B, Agashivala N, Kavak K, Chouhfeh L, Hashmonay R, Weinstock-Guttman B. Characteristics influencing therapy switch behavior after suboptimal response to first-line treatment in patients with multiple sclerosis. Mult Scler 2013; 20:830-6. [PMID: 24277325 DOI: 10.1177/1352458513513058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 10/22/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Factors driving disease-modifying therapy (DMT) switch behavior are not well understood. OBJECTIVE The objective of this paper is to identify patient characteristics and clinical events predictive of therapy switching in patients with suboptimal response to DMT. METHODS This retrospective study analyzed patients with relapsing-remitting multiple sclerosis (MS) and a suboptimal response to initial therapy with either interferon β or glatiramer acetate. Suboptimal responders were defined as patients with ≥1 MS event (clinical relapse, worsening disability, or MRI worsening) while on DMT. Switchers were defined as those who changed DMT within six to 12 months after the MS event. RESULTS Of 606 suboptimal responders, 214 (35.3%) switched therapy. Switchers were younger at symptom onset (p = 0.012), MS diagnosis (p = 0.004), DMT initiation (p < 0.001), and first MS event (p = 0.011) compared with nonswitchers. Compared with one relapse alone, MRI worsening alone most strongly predicted switch behavior (odds ratio 6.3; 95% CI, 3.1-12.9; p < 0.001), followed by ≥2 relapses (2.8; 95% CI, 1.1-7.3; p = 0.040), EDSS plus MRI worsening (2.5; 95% CI, 1.1-5.9; p = 0.031) and EDSS worsening alone (2.2; 95% CI, 1.2-4.1; p = 0.009). CONCLUSIONS Younger patients with disease activity, especially MRI changes, are more likely to have their therapy switched sooner than patients who are older at the time of MS diagnosis and DMT initiation.
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Affiliation(s)
- Barbara Teter
- Department of Neurology, Jacobs Neurological Institute, State University of New York at Buffalo, USA New York State Multiple Sclerosis Consortium, USA
| | | | - Katelyn Kavak
- Department of Neurology, Jacobs Neurological Institute, State University of New York at Buffalo, USA New York State Multiple Sclerosis Consortium, USA
| | - Lynn Chouhfeh
- Department of Neurology, Jacobs Neurological Institute, State University of New York at Buffalo, USA
| | | | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Neurological Institute, State University of New York at Buffalo, USA New York State Multiple Sclerosis Consortium, USA
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Cascione M, Wynn D, Barbato LM, Pestreich L, Schofield L, McCague K. Randomized, open-label study to evaluate patient-reported outcomes with fingolimod after changing from prior disease-modifying therapy for relapsing multiple sclerosis: EPOC study rationale and design. J Med Econ 2013; 16:859-65. [PMID: 23647445 DOI: 10.3111/13696998.2013.802239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The study to Evaluate Patient OutComes, Safety, and Tolerability of Fingolimod (EPOC; NCT01216072) aimed to test the hypothesis that therapy change to oral Gilenya (Novartis AG, Stein, Switzerland) (fingolimod) improves patient-reported outcomes compared with standard-of-care disease-modifying therapy (DMT) in patients with relapsing multiple sclerosis; safety and tolerability were also assessed. This communication describes the study rationale and design. METHODS EPOC is a phase 4, open-label, multi-center study conducted in the US and Canada of patients with relapsing forms of multiple sclerosis who are candidates for therapy change. Therapy change eligibility was determined by the treating physician (US patients) or required an inadequate response to or poor tolerance for at least 1 MS therapy (Canadian patients). Patients were randomly assigned in a 3:1 ratio to 6 months of treatment with once-daily oral fingolimod 0.5 mg or standard-of-care DMTs. The primary study end-point was the change from baseline in treatment satisfaction as determined by the global satisfaction sub-scale of the Treatment Satisfaction Questionnaire for Medication. Secondary end-points included changes from baseline in perceived effectiveness and side-effects, and measures of activities of daily living, fatigue, depression, and quality-of-life. A 3-month open-label fingolimod extension was available for patients randomly assigned to the DMT group who successfully completed all study visits. RESULTS Enrollment has been completed with 1053 patients; the patient population is generally older and has a longer duration of disease compared with populations from phase 3 studies of fingolimod. LIMITATIONS Inclusion criteria selected for patients with a sub-optimal experience with a previous DMT, limiting the collection of data on therapy change in patients who were satisfied with their previous DMT. CONCLUSIONS Results of the EPOC study are anticipated in early 2013 and will inform treatment selection by providing patient-centered data on therapy switch to fingolimod or standard-of-care DMTs. TRIAL REGISTRATION ClinicalTrials.gov NCT01216072.
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Affiliation(s)
- Mark Cascione
- Tampa Neurology Associates, South Tampa Multiple Sclerosis Center, Tampa, FL 33609, USA.
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Abstract
There are currently nine approved disease modifying therapies for relapsing forms of multiple sclerosis, with six distinct mechanisms of action. All have side effects, and none are cures. When a patient cannot tolerate therapy, or there is unacceptable breakthrough disease activity, the most common approach is to change drug. No universal guidelines exist for switching therapy. This overview will propose switch principles and suggestions.
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Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University Medical Center, HSC T12-020, Stony Brook, NY 11794-8121, USA.
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Rudick RA, Polman CH. Current approaches to the identification and management of breakthrough disease in patients with multiple sclerosis. Lancet Neurol 2009; 8:545-59. [PMID: 19446274 DOI: 10.1016/s1474-4422(09)70082-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Disease-modifying drugs (DMDs) for relapsing-remitting multiple sclerosis (RRMS) are only partly effective -- breakthrough disease commonly occurs despite treatment. Breakthrough disease is predictive of continued disease activity and a poor prognosis. Availability of several DMDs offers the possibility of tailoring treatment to individual patients with RRMS and altering treatment in patients with breakthrough disease. However, no biological or imaging markers have been validated to guide initial treatment, markers of individual responsiveness to DMDs are scarce, and there is no class 1 evidence to guide alternative therapy in patients with breakthrough disease. In this Review, we discuss proposed strategies to monitor patients with RRMS being treated with DMDs, outline approaches to identifying therapeutic response in individual patients, review MRI and biological markers of treatment response, and summarise the role of antibodies in biological therapies. We also outline possible strategies for the management of patients with breakthrough disease and highlight areas in which research is needed.
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Affiliation(s)
- Richard A Rudick
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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