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Jones RR, Turkoz I, Ait-Tihyaty M, DiBernardo A, Houtchens MK, Havrdová EK. Efficacy and Safety of Ponesimod Compared with Teriflunomide in Female Patients with Relapsing Multiple Sclerosis: Findings from the Pivotal OPTIMUM Study. J Womens Health (Larchmt) 2024; 33:480-490. [PMID: 38301149 DOI: 10.1089/jwh.2023.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Background: Multiple sclerosis (MS) is threefold more prevalent in women than men. However, sex-specific efficacy analysis for MS disease-modifying therapies is not typically performed. Methods: Post hoc analyses of data from female patients enrolled in the phase 3, double-blind OPTIMUM study of relapsing MS were carried out. Eligible adults were randomized to ponesimod 20 mg or teriflunomide 14 mg once daily for up to 108 weeks. The primary endpoint was annualized relapse rate (ARR); secondary endpoints included change in symptom domain of Fatigue Symptom and Impact Questionnaire-Relapsing Multiple Sclerosis (FSIQ-RMS) at week 108, number of combined unique active lesions (CUALs) per year on magnetic resonance imaging, and time to 12- and 24-week confirmed disability accumulation (CDA). Results: A total of 735 female patients (581 of childbearing potential) were randomized to ponesimod (n = 363, 49.4%) or teriflunomide (n = 372, 50.6%). Relative risk reduction in the ARR for ponesimod versus teriflunomide was 33.1% (mean, 0.192 vs. 0.286, respectively; p < 0.002). Mean difference in FSIQ-RMS for ponesimod versus teriflunomide was -4.34 (0.12 vs. 4.46; p = 0.002); rate ratio in CUALs per year, 0.601 (1.45 vs. 2.41; p < 0.0001), and hazard ratio for time to 12- and 24-week CDA risk estimates, 0.83 (10.7% vs. 12.9%; p = 0.38) and 0.91 (8.8% vs. 9.7%; p = 0.69), respectively. Incidence of treatment-emergent adverse events was similar between treatment groups (89.0% and 90.1%). Conclusions: Analyses demonstrate the efficacy and safety of ponesimod, versus active comparator, for women with relapsing MS, supporting data-informed decision-making for women with MS. Clinical Trial Registration Number: NCT02425644.
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Affiliation(s)
- Robyn R Jones
- Office of Chief Medical Officer, Johnson & Johnson, New Brunswick, New Jersey, USA
| | - Ibrahim Turkoz
- Department of Statistics and Decision Sciences, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Maria Ait-Tihyaty
- Global Medical Affairs, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Allitia DiBernardo
- Global Medical Affairs, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Maria K Houtchens
- Department of Neurology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eva Kubala Havrdová
- Department of Neurology, First Medical Faculty, Charles University, Prague, Czech Republic
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Saladino ML, Gualtieri C, Scaffa M, Lopatin MF, Kohler E, Bruna P, Blaya P, Testa C, López G, Reyna M, Piedrabuena R, Mercante S, Barboza A, Cáceres FJ. Neuro rehabilitation effectiveness based on virtual reality and tele rehabilitation in people with multiple sclerosis in Argentina: Reavitelem study. Mult Scler Relat Disord 2023; 70:104499. [PMID: 36645996 DOI: 10.1016/j.msard.2023.104499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 12/29/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023]
Abstract
Virtual Reality (VR) has emerged as a new treatment approach in neurorehabilitation (NR). REAVITELEM Study is a specific NR intervention program based on VR at center (VRC) and tele-rehabilitation (TR) in Argentina. Methods First national multicenter study with a 12-week program intervention of VRC and TR. Participants were assessed at baseline, at 6th and 12th week. Phase I: recruitment and gather of 5 NR Centers from Argentina by the coordinator center (INEBA) to unify evaluation and intervention criteria. Phase II, all centers completed VRC an TR programs. Intervention was 30-minute session, twice a week for 12 weeks. Outcome measures: Expanded Disability Status Scale (EDSS), Fist and Key Pinch Dynamometry, Beck Depression Inventory-Fast Screen, Fatigue Severity Scale, Functional Independence Measure (FIM), International Questionnaire investigating Quality of life in MS (MusiQol) and a Visual Analogue Scale (VAS) of satisfaction after treatment. Results A total of 54 PWMS (23 males) were recruited for VRC. Afterwards, 14 completed TR. The mean age for VRC was 44.72 (SD ± 13.74) and 41.71 (SD ± 10.5) for TR. The median EDSS was 4, 75 for VR. At VRC, 42 have RRMS, 8 have SPMS and 4 PPMS. At TR, 13 have RRMS and 1 have SPMS. The VAS reported an excellent level of satisfaction after treatment with an average of 9, 02 (SD±1.35) in VRC and 9.42 (SD±0.66) in TR. There were significant differences for MusiQol, which improved from baseline to the post-intervention assessment at VRC (p=<0.001) and at TR (p = 0.004) as well as FIM post-intervention assessment at VCR (p = 0.02) and TR (p = 0.04). Conclusion this study suggest that the NR treatment based on VR in MS in Argentina, is an additional effective tool, which favors improvements in the level of functioning in activities of daily living, quality of life, mood, and satisfaction with the treatment.
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Affiliation(s)
- Maria L Saladino
- INERE Instituto de Neurociencias Restaurativas, CABA Buenos Aires, Argentina.
| | - Carla Gualtieri
- INEBA, Instituto de neurociencias Buenos aires CABA Buenos Aires, Argentina
| | - Myriam Scaffa
- INEBA, Instituto de neurociencias Buenos aires CABA Buenos Aires, Argentina
| | | | | | | | | | | | | | | | | | | | | | - Fernando J Cáceres
- INERE Instituto de Neurociencias Restaurativas, CABA Buenos Aires, Argentina
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Graves JS, Krysko KM, Hua LH, Absinta M, Franklin RJM, Segal BM. Ageing and multiple sclerosis. Lancet Neurol 2023; 22:66-77. [PMID: 36216015 DOI: 10.1016/s1474-4422(22)00184-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 03/09/2022] [Accepted: 04/20/2022] [Indexed: 11/07/2022]
Abstract
The factor that is most relevant and strongly associated with the clinical course of multiple sclerosis is chronological age. Very young patients exclusively have relapsing remitting disease, whereas those with later onset disease face a more rapid development of permanent disability. For people with progressive multiple sclerosis, the poor response to current disease modifying therapies might be related to ageing in the immune system and CNS. Ageing is also associated with increased risks of side-effects caused by some multiple sclerosis therapies. Both somatic and reproductive ageing processes might contribute to development of progressive multiple sclerosis. Understanding the role of ageing in immune and neural cell function in patients with multiple sclerosis might be key to halting non-relapse-related progression. The growing literature on potential therapies that target senescent cells and ageing processes might provide effective strategies for remyelination and neuroprotection.
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Affiliation(s)
- Jennifer S Graves
- Department of Neurosciences, University of California, San Diego, CA, USA; Pediatric Multiple Sclerosis Center, Rady Children's Hospital, San Diego, CA, USA; Department of Neurology, San Diego VA Hospital, San Diego, CA, USA.
| | - Kristen M Krysko
- Division of Neurology, Department of Medicine, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Le H Hua
- Department of Neurology, Cleveland Clinic, Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Martina Absinta
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA; Division of Neuroscience, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Robin J M Franklin
- Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK
| | - Benjamin M Segal
- Department of Neurology and the Neuroscience Research Institute, The Ohio State University, Columbus, OH, USA
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Sandroff BM, Motl RW, Román CAF, Wylie GR, DeLuca J, Cutter GR, Benedict RHB, Dwyer MG, Zivadinov R. Thalamic atrophy moderates associations among aerobic fitness, cognitive processing speed, and walking endurance in persons with multiple sclerosis. J Neurol 2022; 269:5531-5540. [PMID: 35718819 PMCID: PMC9474622 DOI: 10.1007/s00415-022-11205-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Thalamic atrophy (TA) represents a biomarker of neurodegeneration and associated dysfunction/decline in physical and cognitive functioning among persons with multiple sclerosis (MS). Aerobic fitness, as an end point of exercise training, represents a promising target for restoring function in MS, but it is unknown if such effects differ by TA. This cross-sectional study examined whether aerobic fitness was differentially associated with cognitive processing speed and walking endurance in persons with MS who present with and without TA. METHODS 44 fully ambulatory persons with MS completed a graded exercise test for measuring aerobic fitness (VO2peak) and underwent 3T MRI for measuring TA, the Symbol Digit Modalities Test (SDMT), and the 6-min walk (6MW). We performed Spearman correlations (rs) among VO2peak, SDMT, and 6MW scores overall, and in persons with and without TA. We applied Fisher's z-test for comparing correlations based on TA status. RESULTS When controlling for age, EDSS score, and global MRI measures of atrophy, VO2peak was strongly associated with SDMT scores (prs = 0.74, p < 0.01) and 6MW performance (prs = 0.77, p < 0.01) in persons with TA, whereas VO2peak was not associated with SDMT scores (prs = - 0.01, p = 0.99) or 6MW performance (prs = 0.25, p = 0.38) in those without TA. The correlations between VO2peak and SDMT (z = 2.86, p < 0.01) and VO2peak and 6MW (z = 2.33, p = 0.02) were significantly stronger in the TA group. DISCUSSION This study provides initial evidence of strong, selective associations among aerobic fitness, cognitive processing speed, and walking endurance in persons with TA as a biomarker for MS-related neurodegeneration. Such data support TA as a moderator of the association among aerobic fitness, cognitive processing speed, and walking endurance in persons with MS. Future research should carefully consider the role of TA when designing trials of aerobic exercise, cognition, and mobility in MS.
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Affiliation(s)
- Brian M Sandroff
- Center for Neuropsychology and Neuroscience Research, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ, 07052, USA.
- Rutgers New Jersey Medical School, Newark, NJ, USA.
| | | | - Cristina A F Román
- Center for Neuropsychology and Neuroscience Research, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ, 07052, USA
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Glenn R Wylie
- Center for Neuropsychology and Neuroscience Research, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ, 07052, USA
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | - John DeLuca
- Center for Neuropsychology and Neuroscience Research, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ, 07052, USA
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Gary R Cutter
- University of Alabama at Birmingham, Birmingham, AL, USA
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Rojas JI, Patrucco L, Pappolla A, Sánchez F, Cristiano E. Brain volume loss and physical and cognitive impairment in naive multiple sclerosis patients treated with fingolimod: prospective cohort study in Buenos Aires, Argentina. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:699-705. [PMID: 36254442 PMCID: PMC9685825 DOI: 10.1055/s-0042-1755277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
BACKGROUND The percentage of brain volume loss (PBVL) has been classically considered as a biomarker in multiple sclerosis (MS). OBJECTIVE The objective of the present study was to analyze if the PBVL during the 1st year after the onset of the disease predicts physical and cognitive impairment (CI). METHODS Prospective study that included naïve patients without cognitive impairment who initiated MS treatment with fingolimod. Patients were followed for 3 years and relapses, expanded disability status scale (EDSS) progression (defined as worsening of 1 point on the EDSS), the annual PBVL (evaluated by structural image evaluation using normalization of atrophy [SIENA]), and the presence of CI were evaluated. Cognitive impairment was defined in patients who scored at least 2 standard deviations (SDs) below controls on at least 2 domains. The PBVL after 1 year of treatment with fingolimod was used as an independent variable, while CI and EDSS progression at the 3rd year of follow-up as dependent variables. RESULTS A total of 71 patients were included, with a mean age of 35.4 ± 3 years old. At the 3rd year, 14% of the patients were classified as CI and 6.2% had EDSS progression. In the CI group, the PBVL during the 1st year was - 0.52 (±0.07) versus -0.42 (±0.04) in the no CI group (p < 0.01; odds ratio [OR] = 2.24; 95% confidence interval [CI]: 1.72-2.44). In the group that showed EDSS progression, the PBVL during the 1st year was - 0.59 (±0.05) versus - 0.42 (±0.03) (p < 0.01; OR = 2.33; 95%CI: 1.60-2.55). CONCLUSIONS A higher PBVL during the 1st year in naïve MS patients was independently associated with a significant risk of CI and EDSS progression.
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Affiliation(s)
- Juan Ignacio Rojas
- Multiple Sclerosis Center of Buenos Aires, Buenos Aires, Argentina
- Hospital Universitario CEMIC, Neurology Service, Buenos Aires, Argentina
| | - Liliana Patrucco
- Hospital Italiano de Buenos Aires, Neurology Service, Buenos Aires, Argentina
| | - Agustín Pappolla
- Hospital Italiano de Buenos Aires, Neurology Service, Buenos Aires, Argentina
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Ziemssen T, Arnold DL, Alvarez E, Cross AH, Willi R, Li B, Kukkaro P, Kropshofer H, Ramanathan K, Merschhemke M, Kieseier B, Su W, Häring DA, Hauser SL, Kappos L, Kuhle J. Prognostic Value of Serum Neurofilament Light Chain for Disease Activity and Worsening in Patients With Relapsing Multiple Sclerosis: Results From the Phase 3 ASCLEPIOS I and II Trials. Front Immunol 2022; 13:852563. [PMID: 35432382 PMCID: PMC9009385 DOI: 10.3389/fimmu.2022.852563] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/07/2022] [Indexed: 11/27/2022] Open
Abstract
Objective This study aims to confirm the prognostic value of baseline serum neurofilament light chain (sNfL) for on-study disease activity and worsening in patients with relapsing MS (RMS). Background Previous post-hoc studies suggested that sNfL could be a prognostic biomarker in RMS. In the phase 3 ASCLEPIOS I/II trials in which ofatumumab demonstrated better efficacy outcomes than teriflunomide, treatment with ofatumumab also led to significantly reduced sNfL levels compared to teriflunomide treatment. Design/Methods In this study, we report protocol-planned analyses from the pooled ASCLEPIOS I/II trials (N=1882). Per protocol, patients were stratified by median baseline sNfL levels (9.3 pg/ml) into high (>median) and low (≤median) categories to prognosticate: annualized rate of new/enlarging T2 (neT2) lesions in year 1 and 2, annualized relapse rate, annual percentage change in whole brain (WB) and regional brain volume [thalamus, white matter (WM), cortical gray matter (cGM)], and disability outcomes. Similar analyses were performed for the recently diagnosed (within 3 years), treatment-naive patients (no prior disease-modifying therapy) subgroup. Results High versus low sNfL at baseline was prognostic of increased on-study T2 lesion formation at year 1 (relative increase: ofatumumab +158%; teriflunomide +69%, both p<0.001), which persisted in year 2 (+65%, p=0.124; +46%, p=0.003); of higher annual percentage change of WB volume (ofatumumab, −0.32% vs. −0.24%, p=0.044, and teriflunomide, −0.43% vs. −0.29%, p=0.002), thalamic volume (−0.56% vs. −0.31%, p=0.047 and −0.94% vs. −0.49%, p<0.001), and WM volume (−0.30% vs. −0.19%, p=0.083 and −0.38% vs. −0.18%, p=0.003) but not of cGM volume (−0.39% vs. −0.32%, p=0.337 and −0.49% vs. −0.46%, p=0.563). A single sNfL assessment at baseline was not prognostic for on-study relapses or disability worsening. Results were similar in the subgroup of recently diagnosed, treatment-naive patients. Conclusion This study confirms that baseline sNfL levels are prognostic of future on-study lesion formation and whole brain and regional atrophy in all RMS patients, including recently diagnosed, treatment-naive patients.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Clinic Carl-Gustav Carus, Dresden, Germany
- *Correspondence: Tjalf Ziemssen,
| | - Douglas L. Arnold
- Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
- NeuroRx Research, Montreal, QC, Canada
| | - Enrique Alvarez
- Department of Neurology, Rocky Mountain MS Center at the University of Colorado, Aurora, CO, United States
| | - Anne H. Cross
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, United States
| | | | - Bingbing Li
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | | | | | | | | | | | - Wendy Su
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | | | - Stephen L. Hauser
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic and MS Center, Department of Head, Spine and Neuromedicine, University Hospital Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Jens Kuhle
- Neurologic Clinic and Policlinic and MS Center, Department of Head, Spine and Neuromedicine, University Hospital Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
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Ajitomi S, Fujimori J, Nakashima I. Usefulness of two-dimensional measurements for the evaluation of brain volume and disability in multiple sclerosis. Mult Scler J Exp Transl Clin 2022; 8:20552173211070749. [PMID: 35024162 PMCID: PMC8743968 DOI: 10.1177/20552173211070749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 12/15/2021] [Indexed: 11/29/2022] Open
Abstract
Background Two-dimensional (2D) measures have been proposed as potential proxies for whole-brain volume in multiple sclerosis (MS). Objective To verify whether 2D measurements by routine MRI are useful in predicting brain volume or disability in MS. Methods In this cross-sectional analysis, eighty-five consecutive Japanese MS patients—relapsing-remitting MS (81%) and progressive MS (19%)—underwent 1.5 Tesla T1-weighted 3D MRI examinations to measure whole-brain and grey matter volume. 2D measurements, namely, third ventricle width, lateral ventricle width (LVW), brain width, bicaudate ratio, and corpus callosum index (CCI), were obtained from each scan. Correlations between 2D measurements and 3D measurements, the Expanded Disability Status Scale (EDSS), or processing speed were analysed. Results The third and lateral ventricle widths were well-correlated with the whole-brain volume (p < 0.0001), grey matter volume (p < 0.0001), and EDSS scores (p = 0.0001, p = .0004, respectively).The least squares regression model revealed that 78% of the variation in whole-brain volume could be explained using five explanatory variables, namely, LVW, CCI, age, sex, and disease duration. By contrast, the partial correlation coefficient excluding the effect of age showed that the CCI was significantly correlated with the EDSS and processing speed (p < 0.0001). Conclusion Ventricle width correlated well with brain volumes, while the CCI correlated well with age-independent (i.e. disease-induced) disability.
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Affiliation(s)
- Satori Ajitomi
- School of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Juichi Fujimori
- Division of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Ichiro Nakashima
- Division of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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8
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Lublin FD, Häring DA, Ganjgahi H, Ocampo A, Hatami F, Čuklina J, Aarden P, Dahlke F, Arnold DL, Wiendl H, Chitnis T, Nichols TE, Kieseier BC, Bermel RA. OUP accepted manuscript. Brain 2022; 145:3147-3161. [PMID: 35104840 PMCID: PMC9536294 DOI: 10.1093/brain/awac016] [Citation(s) in RCA: 136] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/01/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with multiple sclerosis acquire disability either through relapse-associated worsening (RAW) or progression independent of relapse activity (PIRA). This study addresses the relative contribution of relapses to disability worsening over the course of the disease, how early progression begins and the extent to which multiple sclerosis therapies delay disability accumulation. Using the Novartis-Oxford multiple sclerosis (NO.MS) data pool spanning all multiple sclerosis phenotypes and paediatric multiple sclerosis, we evaluated ∼200 000 Expanded Disability Status Scale (EDSS) transitions from >27 000 patients with ≤15 years follow-up. We analysed three datasets: (i) A full analysis dataset containing all observational and randomized controlled clinical trials in which disability and relapses were assessed (n = 27 328); (ii) all phase 3 clinical trials (n = 8346); and (iii) all placebo-controlled phase 3 clinical trials (n = 4970). We determined the relative importance of RAW and PIRA, investigated the role of relapses on all-cause disability worsening using Andersen-Gill models and observed the impact of the mechanism of worsening and disease-modifying therapies on the time to reach milestone disability levels using time continuous Markov models. PIRA started early in the disease process, occurred in all phenotypes and became the principal driver of disability accumulation in the progressive phase of the disease. Relapses significantly increased the hazard of all-cause disability worsening events; following a year in which relapses occurred (versus a year without relapses), the hazard increased by 31–48% (all P < 0.001). Pre-existing disability and older age were the principal risk factors for incomplete relapse recovery. For placebo-treated patients with minimal disability (EDSS 1), it took 8.95 years until increased limitation in walking ability (EDSS 4) and 18.48 years to require walking assistance (EDSS 6). Treating patients with disease-modifying therapies delayed these times significantly by 3.51 years (95% confidence limit: 3.19, 3.96) and 3.09 years (2.60, 3.72), respectively. In patients with relapsing-remitting multiple sclerosis, those who worsened exclusively due to RAW events took a similar length of time to reach milestone EDSS values compared with those with PIRA events; the fastest transitions were observed in patients with PIRA and superimposed relapses. Our data confirm that relapses contribute to the accumulation of disability, primarily early in multiple sclerosis. PIRA begins in relapsing-remitting multiple sclerosis and becomes the dominant driver of disability accumulation as the disease evolves. Pre-existing disability and older age are the principal risk factors for further disability accumulation. The use of disease-modifying therapies delays disability accrual by years, with the potential to gain time being highest in the earliest stages of multiple sclerosis.
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Affiliation(s)
- Fred D Lublin
- Correspondence to: Professor Fred D. Lublin The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Icahn School of Medicine at Mount Sinai 5 East 98th Street, Box 1138 New York, NY 10029-6574, USA E-mail:
| | | | - Habib Ganjgahi
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Farhad Hatami
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | | | | | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Thomas E Nichols
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Robert A Bermel
- Department of Neurology, Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
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9
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Dahlke F, Arnold DL, Aarden P, Ganjgahi H, Häring DA, Čuklina J, Nichols TE, Gardiner S, Bermel R, Wiendl H. Characterisation of MS phenotypes across the age span using a novel data set integrating 34 clinical trials (NO.MS cohort): Age is a key contributor to presentation. Mult Scler 2021; 27:2062-2076. [PMID: 33507835 PMCID: PMC8564259 DOI: 10.1177/1352458520988637] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Oxford Big Data Institute, multiple sclerosis (MS) physicians and Novartis aim to address unresolved questions in MS with a novel comprehensive clinical trial data set. OBJECTIVE The objective of this study is to describe the Novartis-Oxford MS (NO.MS) data set and to explore the relationships between age, disease activity and disease worsening across MS phenotypes. METHODS We report key characteristics of NO.MS. We modelled MS lesion formation, relapse frequency, brain volume change and disability worsening cross-sectionally, as a function of patients' baseline age, using phase III study data (≈8000 patients). RESULTS NO.MS contains data of ≈35,000 patients (>200,000 brain images from ≈10,000 patients), with >10 years follow-up. (1) Focal disease activity is highest in paediatric patients and decreases with age, (2) brain volume loss is similar across age and phenotypes and (3) the youngest patients have the lowest likelihood (<25%) of disability worsening over 2 years while risk is higher (25%-75%) in older, disabled or progressive MS patients. Young patients benefit most from treatment. CONCLUSION NO.MS will illuminate questions related to MS characterisation, progression and prognosis. Age modulates relapse frequency and, thus, the phenotypic presentation of MS. Disease worsening across all phenotypes is mediated by age and appears to some extent be independent from new focal inflammatory activity.
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Affiliation(s)
| | - Douglas L Arnold
- Brain Imaging Centre, Montreal Neurological
Institute and Hospital, McGill University, Montréal, QC, Canada
| | | | - Habib Ganjgahi
- Oxford Big Data Institute, Li Ka Shing Centre
for Health Information and Discovery, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
| | | | | | - Thomas E Nichols
- Oxford Big Data Institute, Li Ka Shing Centre
for Health Information and Discovery, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
| | | | - Robert Bermel
- Department of Neurology, Mellen MS Center,
Cleveland Clinic, Cleveland, OH, USA
| | - Heinz Wiendl
- Department of Neurology, University Hospital
Münster, Münster, Germany
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Kappos L, Fox RJ, Burcklen M, Freedman MS, Havrdová EK, Hennessy B, Hohlfeld R, Lublin F, Montalban X, Pozzilli C, Scherz T, D'Ambrosio D, Linscheid P, Vaclavkova A, Pirozek-Lawniczek M, Kracker H, Sprenger T. Ponesimod Compared With Teriflunomide in Patients With Relapsing Multiple Sclerosis in the Active-Comparator Phase 3 OPTIMUM Study: A Randomized Clinical Trial. JAMA Neurol 2021; 78:558-567. [PMID: 33779698 PMCID: PMC8008435 DOI: 10.1001/jamaneurol.2021.0405] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/28/2021] [Indexed: 12/12/2022]
Abstract
Importance To our knowledge, the Oral Ponesimod Versus Teriflunomide In Relapsing Multiple Sclerosis (OPTIMUM) trial is the first phase 3 study comparing 2 oral disease-modifying therapies for relapsing multiple sclerosis (RMS). Objective To compare the efficacy of ponesimod, a selective sphingosine-1-phosphate receptor 1 (S1P1) modulator with teriflunomide, a pyrimidine synthesis inhibitor, approved for the treatment of patients with RMS. Design, Setting, and Participants This multicenter, double-blind, active-comparator, superiority randomized clinical trial enrolled patients from April 27, 2015, to May 16, 2019, who were aged 18 to 55 years and had been diagnosed with multiple sclerosis per 2010 McDonald criteria, with a relapsing course from the onset, Expanded Disability Status Scale (EDSS) scores of 0 to 5.5, and recent clinical or magnetic resonance imaging disease activity. Interventions Patients were randomized (1:1) to 20 mg of ponesimod or 14 mg of teriflunomide once daily and the placebo for 108 weeks, with a 14-day gradual up-titration of ponesimod starting at 2 mg to mitigate first-dose cardiac effects of S1P1 modulators and a follow-up period of 30 days. Main Outcomes and Measures The primary end point was the annualized relapse rate. The secondary end points were the changes in symptom domain of Fatigue Symptom and Impact Questionnaire-Relapsing Multiple Sclerosis (FSIQ-RMS) at week 108, the number of combined unique active lesions per year on magnetic resonance imaging, and time to 12-week and 24-week confirmed disability accumulation. Safety and tolerability were assessed. Exploratory end points included the percentage change in brain volume and no evidence of disease activity (NEDA-3 and NEDA-4) status. Results For 1133 patients (567 receiving ponesimod and 566 receiving teriflunomide; median [range], 37.0 [18-55] years; 735 women [64.9%]), the relative rate reduction for ponesimod vs teriflunomide in the annualized relapse rate was 30.5% (0.202 vs 0.290; P < .001); the mean difference in FSIQ-RMS, -3.57 (-0.01 vs 3.56; P < .001); the relative risk reduction in combined unique active lesions per year, 56% (1.405 vs 3.164; P < .001); and the reduction in time to 12-week and 24-week confirmed disability accumulation risk estimates, 17% (10.1% vs 12.4%; P = .29) and 16% (8.1% vs 9.9; P = .37), respectively. Brain volume loss at week 108 was lower by 0.34% (-0.91% vs -1.25%; P < .001); the odds ratio for NEDA-3 achievement was 1.70 (25.0% vs 16.4%; P < .001). Incidence of treatment-emergent adverse events (502 of 565 [88.8%] vs 499 of 566 [88.2%]) and serious treatment-emergent adverse events (49 [8.7%] vs 46 [8.1%]) was similar for both groups. Treatment discontinuations because of adverse events was more common in the ponesimod group (49 of 565 [8.7%] vs 34 of 566 [6.0%]). Conclusions and Relevance In this study, ponesimod was superior to teriflunomide on annualized relapse rate reduction, fatigue, magnetic resonance imaging activity, brain volume loss, and no evidence of disease activity status, but not confirmed disability accumulation. The safety profile was in line with the previous safety observations with ponesimod and the known profile of other S1P receptor modulators. Trial Registration ClinicalTrials.gov Identifier: NCT02425644.
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Affiliation(s)
- Ludwig Kappos
- Neurology and Research Center for Clinical Neuroimmunology and Neuroscience Basel, Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering University Hospital and University of Basel, Basel, Switzerland
| | | | - Michel Burcklen
- Actelion Pharmaceuticals, Part of Janssen Pharmaceutical Companies, Allschwil, Switzerland
| | - Mark S. Freedman
- Department of Medicine, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Eva K. Havrdová
- Department of Neurology, First Medical Faculty, Charles University, Prague, Czech Republic
| | - Brian Hennessy
- Actelion Pharmaceuticals, Part of Janssen Pharmaceutical Companies, Allschwil, Switzerland
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Ludwig Maximilians University Munich, Munich, Germany
- Munich Cluster of Systems Neurology (SyNergy), Ludwig Maximilians University Munich, Munich, Germany
| | - Fred Lublin
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Xavier Montalban
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Center of Catalonia, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Carlo Pozzilli
- Sant’Andrea Multiple Sclerosis Centre, Sapienza University of Rome, Rome, Italy
| | - Tatiana Scherz
- Actelion Pharmaceuticals, Part of Janssen Pharmaceutical Companies, Allschwil, Switzerland
| | - Daniele D'Ambrosio
- Actelion Pharmaceuticals, Part of Janssen Pharmaceutical Companies, Allschwil, Switzerland
- Now with Clinical Research Department, Galapagos GmbH, Basel, Switzerland
| | - Philippe Linscheid
- Actelion Pharmaceuticals, Part of Janssen Pharmaceutical Companies, Allschwil, Switzerland
| | - Andrea Vaclavkova
- Actelion Pharmaceuticals, Part of Janssen Pharmaceutical Companies, Allschwil, Switzerland
| | | | - Hilke Kracker
- Actelion Pharmaceuticals, Part of Janssen Pharmaceutical Companies, Allschwil, Switzerland
| | - Till Sprenger
- Neurology and Research Center for Clinical Neuroimmunology and Neuroscience Basel, Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering University Hospital and University of Basel, Basel, Switzerland
- DKD Helios Klinik Wiesbaden, Wiesbaden, Germany
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Abstract
PURPOSE OF REVIEW Multiple sclerosis (MS) is a clinically heterogeneous disease, which complicates expectant management as well as treatment decisions. This review provides an overview of both well established and emerging predictors of disability worsening, including clinical factors, imaging factors, biomarkers and treatment strategies. RECENT FINDINGS In addition to well known clinical predictors (age, male sex, clinical presentation, relapse behaviour), smoking, obesity, vascular and psychiatric comorbidities are associated with subsequent disability worsening in persons with MS. A number of imaging features are predictive of disability worsening and are present to varying degrees in relapsing and progressive forms of MS. These include brain volumes, spinal cord atrophy, lesion volumes and optical coherence tomography features. Cerebrospinal and more recently blood biomarkers including neurofilament light show promise as more easily attainable biomarkers of future disability accumulation. Importantly, recent observational studies suggest that initiation of early-intensive therapy, as opposed to escalation based on breakthrough disease, is associated with decreased accumulation of disability overall, although randomized controlled trials investigating this question are underway. SUMMARY Understanding risk factors associated with disability progression can help to both counsel patients and enhance the clinician's availability to provide evidence-based treatment recommendations.
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12
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Goodkin O, Prados F, Vos SB, Pemberton H, Collorone S, Hagens MHJ, Cardoso MJ, Yousry TA, Thornton JS, Sudre CH, Barkhof F. FLAIR-only joint volumetric analysis of brain lesions and atrophy in clinically isolated syndrome (CIS) suggestive of multiple sclerosis. NEUROIMAGE-CLINICAL 2020; 29:102542. [PMID: 33418171 PMCID: PMC7804983 DOI: 10.1016/j.nicl.2020.102542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/20/2020] [Indexed: 11/18/2022]
Abstract
Background MRI assessment in multiple sclerosis (MS) focuses on the presence of typical white matter (WM) lesions. Neurodegeneration characterised by brain atrophy is recognised in the research field as an important prognostic factor. It is not routinely reported clinically, in part due to difficulty in achieving reproducible measurements. Automated MRI quantification of WM lesions and brain volume could provide important clinical monitoring data. In general, lesion quantification relies on both T1 and FLAIR input images, while tissue volumetry relies on T1. However, T1-weighted scans are not routinely included in the clinical MS protocol, limiting the utility of automated quantification. Objectives We address an aspect of this important translational challenge by assessing the performance of FLAIR-only lesion and brain segmentation, against a conventional approach requiring multi-contrast acquisition. We explore whether FLAIR-only grey matter (GM) segmentation yields more variability in performance compared with two-channel segmentation; whether this is related to field strength; and whether the results meet a level of clinical acceptability demonstrated by the ability to reproduce established biological associations. Methods We used a multicentre dataset of subjects with a CIS suggestive of MS scanned at 1.5T and 3T in the same week. WM lesions were manually segmented by two raters, ‘manual 1′ guided by consensus reading of CIS-specific lesions and ‘manual 2′ by any WM hyperintensity. An existing brain segmentation method was adapted for FLAIR-only input. Automated segmentation of WM hyperintensity and brain volumes were performed with conventional (T1/T1 + FLAIR) and FLAIR-only methods. Results WM lesion volumes were comparable at 1.5T between ‘manual 2′ and FLAIR-only methods and at 3T between ‘manual 2′, T1 + FLAIR and FLAIR-only methods. For cortical GM volume, linear regression measures between conventional and FLAIR-only segmentation were high (1.5T: α = 1.029, R2 = 0.997, standard error (SE) = 0.007; 3T: α = 1.019, R2 = 0.998, SE = 0.006). Age-associated change in cortical GM volume was a significant covariate in both T1 (p = 0.001) and FLAIR-only (p = 0.005) methods, confirming the expected relationship between age and GM volume for FLAIR-only segmentations. Conclusions FLAIR-only automated segmentation of WM lesions and brain volumes were consistent with results obtained through conventional methods and had the ability to demonstrate biological effects in our study population. Imaging protocol harmonisation and validation with other MS phenotypes could facilitate the integration of automated WM lesion volume and brain atrophy analysis as clinical tools in radiological MS reporting.
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Affiliation(s)
- O Goodkin
- Centre for Medical Image Computing (CMIC), University College London, London, United Kingdom; Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom.
| | - F Prados
- Centre for Medical Image Computing (CMIC), University College London, London, United Kingdom; Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom; eHealth Centre, Universitat Oberta de Catalunya, Barcelona, Spain
| | - S B Vos
- Centre for Medical Image Computing (CMIC), University College London, London, United Kingdom; Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom; Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, United Kingdom
| | - H Pemberton
- Centre for Medical Image Computing (CMIC), University College London, London, United Kingdom; Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - S Collorone
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, University College London (UCL), London, United Kingdom
| | - M H J Hagens
- MS Center Amsterdam, Department of Neurology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M J Cardoso
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - T A Yousry
- Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom; Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, United Kingdom
| | - J S Thornton
- Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom; Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, United Kingdom
| | - C H Sudre
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Dementia Research Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - F Barkhof
- Centre for Medical Image Computing (CMIC), University College London, London, United Kingdom; Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom; Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, United Kingdom; Radiology & Nuclear Medicine, VU University Medical Center, Amsterdam, Netherlands
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13
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Al-Iedani O, Ribbons K, Gholizadeh N, Lechner-Scott J, Quadrelli S, Lea R, Andronesi O, Ramadan S. Spiral MRSI and tissue segmentation of normal-appearing white matter and white matter lesions in relapsing remitting multiple sclerosis patients ☆. Magn Reson Imaging 2020; 74:21-30. [PMID: 32898652 DOI: 10.1016/j.mri.2020.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate the performance of novel spiral MRSI and tissue segmentation pipeline of the brain, to investigate neurometabolic changes in normal-appearing white matter (NAWM) and white matter lesions (WML) of stable relapsing remitting multiple sclerosis (RRMS) compared to healthy controls (HCs). METHODS Spiral 3D MRSI using LASER-GOIA-W [16,4] was undertaken on 16 RRMS patients and 9 HCs, to acquire MRSI data from a large volume of interest (VOI) 320 cm3 and analyzed using LCModel. MRSI data and voxel tissue segmentation were compared between the two cohorts using t-tests. Support vector machine (SVM) was used to classify tissue types and assessed by accuracy, sensitivity and specificity. RESULTS Compared to HCs, RRMS demonstrated a statistically significant reduction in all mean brain tissues and increase in CSF volume. Within VOI, WM decreased (-10%) and CSF increased (41%) in RRMS compared to HCs (p < 0.001). MRSI revealed that total creatine (tCr) ratios of N-acetylaspartate and glutamate+glutamine in WML were significantly lower than NAWM-MS (-9%, -8%) and HCs (-14%, -10%), respectively. Myo-inositol/tCr in WML was significantly higher than NAWM-MS (14%) and HCs (10%). SVM of MRSI yielded accuracy, sensitivity and specificity of 86%, 95%, and 70%, respectively for HCs vs WML, which were higher than HC vs NAWM and WML vs NAWM models. CONCLUSION This study demonstrates the benefit of MRSI in evaluating MS neurometabolic changes in NAWM. SVM of MRSI data in the MS brain may be suited for clinical monitoring and progression of MS patients. Longitudinal MRSI studies are warranted.
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Affiliation(s)
- Oun Al-Iedani
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute, Newcastle, Australia
| | - Karen Ribbons
- Hunter Medical Research Institute, Newcastle, Australia
| | - Neda Gholizadeh
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Jeannette Lechner-Scott
- Hunter Medical Research Institute, Newcastle, Australia; Department of Neurology, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia; School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2305, Australia
| | - Scott Quadrelli
- Princess Alexandra Hospital, Radiology Department, Woolloongabba. QLD 4102, Australia; Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
| | - Rodney Lea
- Hunter Medical Research Institute, Newcastle, Australia
| | - Ovidiu Andronesi
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Saadallah Ramadan
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute, Newcastle, Australia.
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14
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Häring DA, Kropshofer H, Kappos L, Cohen JA, Shah A, Meinert R, Leppert D, Tomic D, Kuhle J. Long-term prognostic value of longitudinal measurements of blood neurofilament levels. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:e856. [PMID: 32817406 PMCID: PMC7428358 DOI: 10.1212/nxi.0000000000000856] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/19/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the long-term prognostic value of an integral of longitudinal measurements of plasma neurofilament light chain levels (NfLlong) over 12 and 24 months vs single neurofilament light chain (NfL) measurements in patients with relapsing-remitting MS (RRMS) and its additional value when combined with clinical and MRI measures. METHODS This analysis included continuously fingolimod-treated patients with RRMS from the 24-month FTY720 Research Evaluating Effects of Daily Oral therapy in Multiple Sclerosis (FREEDOMS)/12-month Trial Assessing Injectable Interferon vs FTY720 Oral in Relapsing-Remitting Multiple Sclerosis (TRANSFORMS) phase 3 trials and their long-term extension, LONGTERMS. Patients were classified into high (≥30 pg/mL, n = 110) and low (<30 pg/mL, n = 164) NfL categories based on the baseline (BL) NfL value or the geometric mean NfLlong calculated over 12 and 24 months to predict disability-related outcomes and brain volume loss (BVL). The additional prognostic value of NfL was quantified using the area under the receiver operating characteristic (ROC) curve. RESULTS A single high (vs low) NfL measure at BL was prognostic of a higher risk of reaching Expanded Disability Status Scale (EDSS) score ≥4 earlier (hazard ratio [HR] = 2.19; 95% CI = 1.21-3.97) and higher BVL over 120 months (difference: -1.12%; 95% CI = -2.07 to -0.17). When NfLlong was measured over 24 months, high NfL was associated with a higher risk of reaching EDSS score ≥4 (HR = 7.91; 95% CI = 2.99-20.92), accelerated 6-month confirmed disability worsening (HR = 3.14; 95% CI = 1.38-7.11), and 20% worsening in the Timed 25-Foot Walk Test (HR = 3.05; 95% CI = 1.38-6.70). Area under the ROC curve was consistently highest in models combining NfL with clinical and MRI measures. CONCLUSIONS NfLlong had a higher prognostic value than single NfL assessments on long-term outcomes in RRMS. Combining it with clinical and MRI measures increased sensitivity and specificity to predict long-term disease outcomes. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that NfLlong was more strongly associated with long-term outcomes than single NfL assessments in patients with RRMS.
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Affiliation(s)
- Dieter A Häring
- From the Novartis Pharma AG (D.A.H., H.K., D.T.), Basel; Research Center for Clinical Neuroimmunology and Neuroscience Basel (L.K., D.L., J.K.), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Department of Neurology (J.A.C.), Mellen MS Center, Neurological Institute, Cleveland Clinic, OH; Novartis Healthcare Pvt. Ltd. (A.S.), Hyderabad, India; and DATAMAP GmbH (R.M.), Freiburg, Germany
| | - Harald Kropshofer
- From the Novartis Pharma AG (D.A.H., H.K., D.T.), Basel; Research Center for Clinical Neuroimmunology and Neuroscience Basel (L.K., D.L., J.K.), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Department of Neurology (J.A.C.), Mellen MS Center, Neurological Institute, Cleveland Clinic, OH; Novartis Healthcare Pvt. Ltd. (A.S.), Hyderabad, India; and DATAMAP GmbH (R.M.), Freiburg, Germany
| | - Ludwig Kappos
- From the Novartis Pharma AG (D.A.H., H.K., D.T.), Basel; Research Center for Clinical Neuroimmunology and Neuroscience Basel (L.K., D.L., J.K.), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Department of Neurology (J.A.C.), Mellen MS Center, Neurological Institute, Cleveland Clinic, OH; Novartis Healthcare Pvt. Ltd. (A.S.), Hyderabad, India; and DATAMAP GmbH (R.M.), Freiburg, Germany
| | - Jeffrey A Cohen
- From the Novartis Pharma AG (D.A.H., H.K., D.T.), Basel; Research Center for Clinical Neuroimmunology and Neuroscience Basel (L.K., D.L., J.K.), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Department of Neurology (J.A.C.), Mellen MS Center, Neurological Institute, Cleveland Clinic, OH; Novartis Healthcare Pvt. Ltd. (A.S.), Hyderabad, India; and DATAMAP GmbH (R.M.), Freiburg, Germany
| | - Anuja Shah
- From the Novartis Pharma AG (D.A.H., H.K., D.T.), Basel; Research Center for Clinical Neuroimmunology and Neuroscience Basel (L.K., D.L., J.K.), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Department of Neurology (J.A.C.), Mellen MS Center, Neurological Institute, Cleveland Clinic, OH; Novartis Healthcare Pvt. Ltd. (A.S.), Hyderabad, India; and DATAMAP GmbH (R.M.), Freiburg, Germany
| | - Rolf Meinert
- From the Novartis Pharma AG (D.A.H., H.K., D.T.), Basel; Research Center for Clinical Neuroimmunology and Neuroscience Basel (L.K., D.L., J.K.), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Department of Neurology (J.A.C.), Mellen MS Center, Neurological Institute, Cleveland Clinic, OH; Novartis Healthcare Pvt. Ltd. (A.S.), Hyderabad, India; and DATAMAP GmbH (R.M.), Freiburg, Germany
| | - David Leppert
- From the Novartis Pharma AG (D.A.H., H.K., D.T.), Basel; Research Center for Clinical Neuroimmunology and Neuroscience Basel (L.K., D.L., J.K.), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Department of Neurology (J.A.C.), Mellen MS Center, Neurological Institute, Cleveland Clinic, OH; Novartis Healthcare Pvt. Ltd. (A.S.), Hyderabad, India; and DATAMAP GmbH (R.M.), Freiburg, Germany
| | - Davorka Tomic
- From the Novartis Pharma AG (D.A.H., H.K., D.T.), Basel; Research Center for Clinical Neuroimmunology and Neuroscience Basel (L.K., D.L., J.K.), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Department of Neurology (J.A.C.), Mellen MS Center, Neurological Institute, Cleveland Clinic, OH; Novartis Healthcare Pvt. Ltd. (A.S.), Hyderabad, India; and DATAMAP GmbH (R.M.), Freiburg, Germany
| | - Jens Kuhle
- From the Novartis Pharma AG (D.A.H., H.K., D.T.), Basel; Research Center for Clinical Neuroimmunology and Neuroscience Basel (L.K., D.L., J.K.), Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Department of Neurology (J.A.C.), Mellen MS Center, Neurological Institute, Cleveland Clinic, OH; Novartis Healthcare Pvt. Ltd. (A.S.), Hyderabad, India; and DATAMAP GmbH (R.M.), Freiburg, Germany.
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15
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Fujimori J, Uryu K, Fujihara K, Wattjes MP, Suzuki C, Nakashima I. Measurements of the corpus callosum index and fractional anisotropy of the corpus callosum and their cutoff values are useful to assess global brain volume loss in multiple sclerosis. Mult Scler Relat Disord 2020; 45:102388. [PMID: 32659734 DOI: 10.1016/j.msard.2020.102388] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/02/2020] [Accepted: 07/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Recent studies suggest that parameters of the corpus callosum (CC), such as the CC index (CCI) and fractional anisotropy (FA) of the CC, may be related to the degree of brain volume loss (BVL) in MS patients; however, cutoff values that determine the degree of BVL have not been set. METHODS Seventy-five MS patients and 21 healthy controls (HCs) underwent volumetric MRI examinations. MS patients were also evaluated for T2 lesion load, the CCI, and FA of the CC. Among the 75 MS patients, 20 had undergone cognitive assessments with the Symbol Digit Modalities Test (SDMT). After 75 MS patients were categorized into mild, moderate, or severe BVL subgroups according to our previous report, we performed receiver operating characteristic analysis to determine the cutoff values of CCI and FA, categorizing the MS patients into the three subgroups. RESULTS The volume of the CC was significantly reduced in MS patients compared to that in HCs. The CCI and FA were significantly associated with EDSS, disease duration, clinical phenotype, T2-lesion load, and whole brain volume. The FA was significantly correlated with the SDMT score. We identified optimal cutoff values for the CCI and FA of 0.32 (85% sensitivity, 92% specificity) and 0.39 (100% sensitivity, 92% specificity), respectively, which discriminated the severe BVL group from others, and 0.385 (84% sensitivity, 74% specificity) and 0.45 (81% sensitivity, 89% specificity), respectively, which discriminated the mild BVL group from others. CONCLUSION The CCI and FA cutoff values may be useful for evaluating the degree of MS brain atrophy in clinical practice.
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Affiliation(s)
- Juichi Fujimori
- Division of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan.
| | - Kengo Uryu
- School of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Neurology, Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Mike P Wattjes
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Chihiro Suzuki
- Division of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Ichiro Nakashima
- Division of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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16
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Gaetano L, Magnusson B, Kindalova P, Tomic D, Silva D, Altermatt A, Magon S, Müller-Lenke N, Radue EW, Leppert D, Kappos L, Wuerfel J, Häring DA, Sprenger T. White matter lesion location correlates with disability in relapsing multiple sclerosis. Mult Scler J Exp Transl Clin 2020; 6:2055217320906844. [PMID: 32128236 PMCID: PMC7031799 DOI: 10.1177/2055217320906844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/21/2020] [Indexed: 01/10/2023] Open
Abstract
Background Lesion location is a prognostic factor of disease progression and disability accrual. Objective To investigate lesion formation in 11 brain regions, assess correlation between lesion location and physical and cognitive disability measures and investigate treatment effects by region. Methods In 2355 relapsing–remitting multiple sclerosis patients from the FREEDOMS and FREEDOMS II studies, we extracted T2-weighted lesion number, volume and density for each brain region; we investigated the (Spearman) correlation in lesion formation between brain regions, studied association between location and disability (at baseline and change over 2 years) using linear/logistic regression and assessed the regional effects of fingolimod versus placebo in negative binomial models. Results At baseline, the majority of lesions were found in the supratentorial brain. New and enlarging lesions over 24 months developed mainly in the frontal and sublobar regions and were substantially correlated to pre-existing lesions at baseline in the supratentorial brain (p = 0.37–0.52), less so infratentorially (p = −0.04–0.23). High sublobar lesion density was consistently and significantly associated with most disability measures at baseline and worsening of physical disability over 24 months. The treatment effect of fingolimod 0.5 mg was consistent across the investigated areas and tracts. Conclusion These results highlight the role of sublobar lesions for the accrual of disability in relapsing–remitting multiple sclerosis.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Ludwig Kappos
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital and University of Basel, Switzerland
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Sastre-Garriga J, Pareto D, Battaglini M, Rocca MA, Ciccarelli O, Enzinger C, Wuerfel J, Sormani MP, Barkhof F, Yousry TA, De Stefano N, Tintoré M, Filippi M, Gasperini C, Kappos L, Río J, Frederiksen J, Palace J, Vrenken H, Montalban X, Rovira À. MAGNIMS consensus recommendations on the use of brain and spinal cord atrophy measures in clinical practice. Nat Rev Neurol 2020; 16:171-182. [PMID: 32094485 PMCID: PMC7054210 DOI: 10.1038/s41582-020-0314-x] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2020] [Indexed: 11/08/2022]
Abstract
Early evaluation of treatment response and prediction of disease evolution are key issues in the management of people with multiple sclerosis (MS). In the past 20 years, MRI has become the most useful paraclinical tool in both situations and is used clinically to assess the inflammatory component of the disease, particularly the presence and evolution of focal lesions - the pathological hallmark of MS. However, diffuse neurodegenerative processes that are at least partly independent of inflammatory mechanisms can develop early in people with MS and are closely related to disability. The effects of these neurodegenerative processes at a macroscopic level can be quantified by estimation of brain and spinal cord atrophy with MRI. MRI measurements of atrophy in MS have also been proposed as a complementary approach to lesion assessment to facilitate the prediction of clinical outcomes and to assess treatment responses. In this Consensus statement, the Magnetic Resonance Imaging in MS (MAGNIMS) study group critically review the application of brain and spinal cord atrophy in clinical practice in the management of MS, considering the role of atrophy measures in prognosis and treatment monitoring and the barriers to clinical use of these measures. On the basis of this review, the group makes consensus statements and recommendations for future research.
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Affiliation(s)
- Jaume Sastre-Garriga
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Deborah Pareto
- Section of Neuroradiology and Magnetic Resonance Unit, Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marco Battaglini
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Olga Ciccarelli
- NMR Research Unit, University College London Queen Square Institute of Neurology, London, UK
- National Institute for Health Research Biomedical Research Centre, University College London Hospitals, London, UK
| | - Christian Enzinger
- Department of Neurology and Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Jens Wuerfel
- Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Maria P Sormani
- Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy
- IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | - Frederik Barkhof
- National Institute for Health Research Biomedical Research Centre, University College London Hospitals, London, UK
- Amsterdam Neuroscience, MS Center Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, Netherlands
- Institutes of Neurology and Healthcare Engineering, University College London, London, UK
| | - Tarek A Yousry
- NMR Research Unit, University College London Queen Square Institute of Neurology, London, UK
- Lysholm Department of Neuroradiology, University College London Hospitals National Hospital for Neurology and Neurosurgery, University College London Institute of Neurology, London, UK
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Mar Tintoré
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Claudio Gasperini
- Multiple Sclerosis Center, Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Jordi Río
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jette Frederiksen
- Department of Neurology, Rigshospitalet-Glostrup and University of Copenhagen, Glostrup, Denmark
| | - Jackie Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Hugo Vrenken
- Amsterdam Neuroscience, MS Center Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, Netherlands
| | - Xavier Montalban
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Division of Neurology, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Àlex Rovira
- Section of Neuroradiology and Magnetic Resonance Unit, Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Quadrelli S, Ribbons K, Arm J, Al-Iedani O, Lechner-Scott J, Lea R, Ramadan S. 2D in-vivo L-COSY spectroscopy identifies neurometabolite alterations in treated multiple sclerosis. Ther Adv Neurol Disord 2019; 12:1756286419877081. [PMID: 31666809 PMCID: PMC6801886 DOI: 10.1177/1756286419877081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 08/15/2019] [Indexed: 11/16/2022] Open
Abstract
Background We have applied in vivo two-dimensional (2D) localized correlation spectroscopy (2D L-COSY), in treated relapsing relapsing-remitting multiple sclerosis (RRMS) to identify novel biomarkers in normal-appearing brain parenchyma. Methods 2D L-COSY magnetic resonance spectroscopy (MRS) spectra were prospectively acquired from the posterior cingulate cortex (PCC) in 45 stable RRMS patients undergoing treatment with Fingolimod, and 40 age and sex-matched healthy control (HC) participants. Average metabolite ratios and clinical symptoms including, disability, cognition, fatigue, and mental health parameters were measured, and compared using parametric and nonparametric tests. Whole brain volume and MRS voxel morphometry were evaluated using SIENAX and the SPM LST toolbox. Results Despite the mean whole brain lesion volume being low in this RRMS group (6.8 ml) a significant reduction in PCC metabolite to tCr ratios were identified for multiple N-acetylaspartate (NAA) signatures, gamma-aminobutyric acid (GABA), glutamine and glutamate (Glx), threonine, and isoleucine/lipid. Of the clinical symptoms measured, visuospatial function, attention, and memory were correlated with NAA signatures, Glx, and isoleucine/lipid in the brain. Conclusions 2D L-COSY has the potential to detect metabolic alterations in the normal-appearing MS brain. Despite examining only a localised region, we could detect metabolic variability associated with symptoms.
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Affiliation(s)
- Scott Quadrelli
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Karen Ribbons
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Jameen Arm
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - Oun Al-Iedani
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | | | - Rodney Lea
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Saadallah Ramadan
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
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Jakimovski D, Weinstock-Guttman B, Gandhi S, Guan Y, Hagemeier J, Ramasamy DP, Fuchs TA, Browne RW, Bergsland N, Dwyer MG, Ramanathan M, Zivadinov R. Dietary and lifestyle factors in multiple sclerosis progression: results from a 5-year longitudinal MRI study. J Neurol 2019; 266:866-875. [PMID: 30758665 DOI: 10.1007/s00415-019-09208-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 01/14/2019] [Accepted: 01/19/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Evidence regarding the role, if any, of dietary and lifestyle factors in the pathogenesis of multiple sclerosis (MS) is poorly understood. OBJECTIVE To assess the effect of lifestyle-based risk factors linked to cardiovascular disease (CVD) on clinical and MRI-derived MS outcomes. METHODS The study enrolled 175 MS or clinically isolated syndrome (CIS) patients and 42 age- and sex-matched healthy controls (HCs) who were longitudinally followed for 5.5 years. The 20-year CVD risk was calculated by Healthy Heart Score (HHS) prediction model which includes age, smoking, body mass index, dietary intake, exercise, and alcohol consumption. Baseline and follow-up MRI scans were obtained and cross-sectional and longitudinal changes of T2-lesion volume (LV), whole brain volume (WBV), white matter volume (WMV), gray matter volume (GMV), and lateral ventricular volume (LVV) were calculated. RESULTS After correcting for disease duration, the baseline HHS values of the MS group were associated with baseline GMV (rs = - 0.20, p = 0.01), and longitudinal LVV change (rs = 0.19, p = 0.01). The association with LVV remained significant after adjusting for baseline LVV volumes (rs = 0.2, p = 0.008) in MS patients. The diet component of the HHS was associated with the 5-year T2-LV accrual (rs = - 0.191, p = 0.04) in MS. In the HC group, the HHS was associated with LVV (rs = 0.58, p < 0.001), GMV (rs = - 0.57, p < 0.001), WBV (rs = - 0.55, p = 0.001), T2-LV (rs = 0.41, p = 0.027), and WMV (rs = - 0.38, p = 0.042). Additionally, the HC HHS was associated with the 5-year change in LVV (rs = 0.54, p = 0.001) and in WBV (rs = - 0.45, p = 0.011). CONCLUSION Lifestyle risk factors contribute to accelerated central brain atrophy in MS patients, whereas unhealthier diet is associated with MS lesion accrual. Despite the lower overall effect when compared to HCs, lifestyle-based modifications may still provide a beneficial effect on reducing brain atrophy in MS patients.
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Affiliation(s)
- Dejan Jakimovski
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 142013, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Multiple Sclerosis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Sirin Gandhi
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 142013, USA
| | - Yi Guan
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 142013, USA
| | - Jesper Hagemeier
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 142013, USA
| | - Deepa P Ramasamy
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 142013, USA
| | - Tom A Fuchs
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 142013, USA
| | - Richard W Browne
- Department of Biotechnical and Clinical Laboratory Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Niels Bergsland
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 142013, USA
| | - Michael G Dwyer
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 142013, USA
- Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Murali Ramanathan
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Robert Zivadinov
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY, 142013, USA.
- Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA.
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Beadnall HN, Wang C, Van Hecke W, Ribbens A, Billiet T, Barnett MH. Comparing longitudinal brain atrophy measurement techniques in a real-world multiple sclerosis clinical practice cohort: towards clinical integration? Ther Adv Neurol Disord 2019; 12:1756286418823462. [PMID: 30719080 PMCID: PMC6348578 DOI: 10.1177/1756286418823462] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 11/09/2018] [Indexed: 11/30/2022] Open
Abstract
Background: Whole brain atrophy (WBA) estimates in multiple sclerosis (MS) correlate more robustly with clinical disability than traditional, lesion-based metrics. We compare Structural Image Evaluation using Normalisation of Atrophy (SIENA) with the icobrain longitudinal pipeline (icobrain long), for assessment of longitudinal WBA in MS patients. Methods: Magnetic resonance imaging (MRI) scan pairs [1.05 (±0.15) year separation] from 102 MS patients were acquired on the same 3T scanner. Three-dimensional (3D) T1-weighted and two-dimensional (2D)/3D fluid-attenuated inversion-recovery sequences were analysed. Percentage brain volume change (PBVC) measurements were calculated using SIENA and icobrain long. Statistical correlation, agreement and consistency between methods was evaluated; MRI brain volumetric and clinical data were compared. The proportion of the cohort with annualized brain volume loss (aBVL) rates ⩾ 0.4%, ⩾0.8% and ⩾0.94% were calculated. No evidence of disease activity (NEDA) 3 and NEDA 4 were also determined. Results: Mean annualized PBVC was −0.59 (±0.65)% and −0.64 (±0.73)% as measured by icobrain long and SIENA. icobrain long and SIENA-measured annualized PBVC correlated strongly, r = 0.805 (p < 0.001), and the agreement [intraclass correlation coefficient (ICC) 0.800] and consistency (ICC 0.801) were excellent. Weak correlations were found between MRI metrics and Expanded Disability Status Scale scores. Over half the cohort had aBVL ⩾ 0.4%, approximately a third ⩾0.8%, and aBVL was ⩾0.94% in 28.43% and 23.53% using SIENA and icobrain long, respectively. NEDA 3 was achieved in 35.29%, and NEDA 4 in 15.69% and 16.67% of the cohort, using SIENA and icobrain long to derive PBVC, respectively. Discussion: icobrain long quantified longitudinal WBA with a strong level of statistical agreement and consistency compared to SIENA in this real-world MS population. Utility of WBA measures in individuals remains challenging, but show promise as biomarkers of neurodegeneration in MS clinical practice. Optimization of MRI analysis algorithms/techniques are needed to allow reliable use in individuals. Increased levels of automation will enable more rapid clinical translation.
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Affiliation(s)
- H N Beadnall
- Brain and Mind Centre, The University of Sydney, Sydney, Australia Royal Prince Alfred Hospital, Sydney, Australia
| | - C Wang
- Brain and Mind Centre, The University of Sydney, Sydney, Australia Sydney Neuroimaging Analysis Centre, Sydney, Australia
| | | | | | | | - M H Barnett
- Royal Prince Alfred Hospital, Sydney, Australia Sydney Neuroimaging Analysis Centre, Sydney, Australia
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Rojas J, Sanchez F, Caro F, Miguez J, Patrucco L, Funes J, Cristiano E. Brain volume loss and no evidence of disease activity over 3 years in multiple sclerosis patients under interferon beta 1a subcutaneous treatment. J Clin Neurosci 2019; 59:175-178. [DOI: 10.1016/j.jocn.2018.10.095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/28/2018] [Accepted: 10/24/2018] [Indexed: 12/24/2022]
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D'hooghe MB, Gielen J, Van Remoortel A, D'haeseleer M, Peeters E, Cambron M, De Keyser J, Nagels G. Single MRI-Based Volumetric Assessment in Clinical Practice Is Associated With MS-Related Disability. J Magn Reson Imaging 2018; 49:1312-1321. [DOI: 10.1002/jmri.26303] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 11/11/2022] Open
Affiliation(s)
- Marie B. D'hooghe
- National MS Center, Neurology; Melsbroek Belgium
- Vrije Universiteit Brussel (VUB), Center for Neurosciences; Brussels Belgium
| | - Jeroen Gielen
- National MS Center, Neurology; Melsbroek Belgium
- Vrije Universiteit Brussel (VUB), Center for Neurosciences; Brussels Belgium
| | | | | | | | - Melissa Cambron
- National MS Center, Neurology; Melsbroek Belgium
- University Hospital Brussels, Vrije Universiteit Brussels (VUB), Neurology; Brussels Belgium
| | - Jacques De Keyser
- University Hospital Brussels, Vrije Universiteit Brussels (VUB), Neurology; Brussels Belgium
- University of Groningen, University Medical Center Groningen, Department of Neurology, Groningen, Neurology; Groningen Netherlands
| | - Guy Nagels
- National MS Center, Neurology; Melsbroek Belgium
- Vrije Universiteit Brussel (VUB), Center for Neurosciences; Brussels Belgium
- Vrije Universiteit Brussel (VUB), ETRO, Faculty of Engineering; Brussels Belgium
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Rasche L, Paul F. Ozanimod for the treatment of relapsing remitting multiple sclerosis. Expert Opin Pharmacother 2018; 19:2073-2086. [PMID: 30407868 DOI: 10.1080/14656566.2018.1540592] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Ozanimod is a selective sphingosine 1-phosphate receptor 1 and 5 modulator under development by Celgene, for the treatment of relapsing remitting multiple sclerosis. Extensive clinical experience has become available for the related compound fingolimod, favoring the sphingosine 1-phosphate therapeutic concept. Off-target effects have been attributed to its low receptor specificity and have prompted the development of next generation sphingosine 1-phosphate receptor modulators. Areas covered: The authors evaluate the literature of ozanimod, using the PubMed database as well as repositories of the European Committee for Treatment and Research in Multiple Sclerosis and the American and European Academy of Neurology. Specifically, the authors cover and discuss the preclinical data on ozanimod, pharmacokinetics and dynamics, and data on efficacy and safety from the pivotal trials. Expert opinion: Superiority of ozanimod over intramuscular interferon β-1a with regard to reduction in annualized relapse rate and magnetic resonance imaging outcomes has been shown in two phase III trials. The beneficial effect on brain volume and gray matter loss are encouraging and in line with data on other newer immunomodulators. Ozanimod is a valuable contribution to the therapeutic armamentarium in MS, although the effect on disability progression is unclear and requires further investigations.
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Affiliation(s)
- Ludwig Rasche
- a NeuroCure Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany
| | - Friedemann Paul
- a NeuroCure Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany.,b Experimental and Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany.,c Department of Neurology , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health , Berlin , Germany
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Garber JY, Barnett MH. We should focus more on finding therapeutic targets for the non-inflammatory damage in MS - Yes. Mult Scler 2018; 24:1272-1274. [PMID: 29656673 DOI: 10.1177/1352458518770970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Justin Y Garber
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
| | - Michael H Barnett
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia/Sydney Neuroimaging Analysis Centre, Sydney, NSW, Australia
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Gaetano L, Häring DA, Radue EW, Mueller-Lenke N, Thakur A, Tomic D, Kappos L, Sprenger T. Fingolimod effect on gray matter, thalamus, and white matter in patients with multiple sclerosis. Neurology 2018. [DOI: 10.1212/wnl.0000000000005292] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
ObjectiveTo study the effect of fingolimod on deep gray matter (dGM), thalamus, cortical GM (cGM), white matter (WM), and ventricular volume (VV) in patients with relapsing-remitting multiple sclerosis (RRMS).MethodsData were pooled from 2 phase III studies. A total of 2,064 of 2,355 (88%) contributed to the analysis: fingolimod 0.5 mg n = 783, fingolimod 1.25 mg n = 799, or placebo n = 773. Percentage change from baseline in dGM and thalamic volumes was evaluated with FMRIB’s Integrated Registration & Segmentation Tool; WM, cGM, and VV were evaluated with structural image evaluation using normalization of atrophy cross-sectional version (SIENAX) at months 12 and 24.ResultsAt baseline, compound brain volume (brain volume in the z block [BVz] = cGM + dGM + WM) correlated with SIENAX-normalized brain volume (r = 0.938, p < 0.001); percentage change from baseline in BVz over 2 years correlated with structural image evaluation using normalization of atrophy percentage brain volume change (r = 0.713, p < 0.001). For placebo, volume reductions were most pronounced in cGM, and relative changes from baseline were strongest in dGM. Over 24 months, there were significant reductions with fingolimod vs placebo for dGM (0.5 mg −14.5%, p = 0.017; 1.25 mg −26.6%, p < 0.01) and thalamus (0.5 mg −26.1%, p = 0.006; 1.25 mg −49.7%, p < 0.001). Reduction of cGM volume loss was not significant. Significantly less WM loss and VV enlargement were seen with fingolimod vs placebo (all p < 0.001). A high T2 lesion volume at baseline predicted on-study cGM, dGM, and thalamic volume loss (p < 0.0001) but not WM loss. Patients taking placebo with high dGM (hazard ratio [HR] 0.54, p = 0.0323) or thalamic (HR 0.58, p = 0.0663) volume at baseline were less likely to show future disability worsening.ConclusionsFingolimod significantly reduced dGM volume loss (including thalamus) vs placebo in patients with RRMS. Reducing dGM and thalamic volume loss might improve long-term outcome.
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Dwyer MG, Hagemeier J, Bergsland N, Horakova D, Korn JR, Khan N, Uher T, Medin J, Silva D, Vaneckova M, Havrdova EK, Zivadinov R. Establishing pathological cut-offs for lateral ventricular volume expansion rates. NEUROIMAGE-CLINICAL 2018. [PMID: 29527505 PMCID: PMC5842310 DOI: 10.1016/j.nicl.2018.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background A percent brain volume change (PBVC) cut-off of −0.4% per year has been proposed to distinguish between pathological and physiological changes in multiple sclerosis (MS). Unfortunately, standardized PBVC measurement is not always feasible on scans acquired outside research studies or academic centers. Percent lateral ventricular volume change (PLVVC) is a strong surrogate measure of PBVC, and may be more feasible for atrophy assessment on real-world scans. However, the PLVVC rate corresponding to the established PBVC cut-off of −0.4% is unknown. Objective To establish a pathological PLVVC expansion rate cut-off analogous to −0.4% PBVC. Methods We used three complementary approaches. First, the original follow-up-length-weighted receiver operating characteristic (ROC) analysis method establishing whole brain atrophy rates was adapted to a longitudinal ventricular atrophy dataset of 177 relapsing-remitting MS (RRMS) patients and 48 healthy controls. Second, in the same dataset, SIENA PBVCs were used with non-linear regression to directly predict the PLVVC value corresponding to −0.4% PBVC. Third, in an unstandardized, real world dataset of 590 RRMS patients from 33 centers, the cut-off maximizing correspondence to PBVC was found. Finally, correspondences to clinical outcomes were evaluated in both datasets. Results ROC analysis suggested a cut-off of 3.09% (AUC = 0.83, p < 0.001). Non-linear regression R2 was 0.71 (p < 0.001) and a − 0.4% PBVC corresponded to a PLVVC of 3.51%. A peak in accuracy in the real-world dataset was found at a 3.51% PLVVC cut-off. Accuracy of a 3.5% cut-off in predicting clinical progression was 0.62 (compared to 0.68 for PBVC). Conclusions Ventricular expansion of between 3.09% and 3.51% on T2-FLAIR corresponds to the pathological whole brain atrophy rate of 0.4% for RRMS. A conservative cut-off of 3.5% performs comparably to PBVC for clinical outcomes. Pathological atrophy in MS can be measured on clinical T2-FLAIR images alone. Ventricular enlargement of 3.5% per year separates MS/HC as well as PBVC on T1 images. Ventricular cut-offs also correspond to clinical outcome. This cut-off can substitute in NEDA-4 when only clinical T2-FLAIR images are available.
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Affiliation(s)
- Michael G Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.
| | - Jesper Hagemeier
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | | | | | - Tomas Uher
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | | | - Diego Silva
- Novartis Pharmaceuticals AG, Basel, Switzerland
| | - Manuela Vaneckova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Translational Imaging Center at Clinical and Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
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Miller DH, Lublin FD, Sormani MP, Kappos L, Yaldizli Ö, Freedman MS, Cree BAC, Weiner HL, Lubetzki C, Hartung HP, Montalban X, Uitdehaag BMJ, MacManus DG, Yousry TA, Gandini Wheeler-Kingshott CAM, Li B, Putzki N, Merschhemke M, Häring DA, Wolinsky JS. Brain atrophy and disability worsening in primary progressive multiple sclerosis: insights from the INFORMS study. Ann Clin Transl Neurol 2018; 5:346-356. [PMID: 29560379 PMCID: PMC5846448 DOI: 10.1002/acn3.534] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/19/2017] [Accepted: 12/22/2017] [Indexed: 11/09/2022] Open
Abstract
Objective To investigate the relationship between brain volume and disability worsening over ≥3 years in the natural history of primary progressive multiple sclerosis using data from the placebo group of the INFORMS trial (n = 487; clinicaltrials.gov NCT00731692). Methods Magnetic resonance imaging scans were collected annually. Brain volume loss was determined using SIENA. Patients were stratified by baseline normalized brain volume after adjusting for demographic and disease-burden covariates. Results Baseline normalized brain volume was predictive of disability worsening: Risk of 3-month confirmed disability progression was reduced by 36% for high versus low baseline normalized brain volume (Cox's model hazard ratio 0.64, P = 0.0339; log-rank test: P = 0.0297). Moreover, on-study brain volume loss was significantly associated with disability worsening (P = 0.012) and was evident in patients with or without new lesions or relapses. Brain volume loss depended significantly on baseline T2 lesion volume (P < 0.0001). Despite low inflammatory activity at baseline (13% of patients had gadolinium-enhancing lesions) and throughout the study (mean 0.5 new/enlarging T2 lesions and 172 mm3 T2 lesion volume increase per year), baseline T2 lesion volume was substantial (mean 10 cm3). Lower normalized brain volume at baseline correlated with higher baseline T2 volume and older age (both P < 0.0001). Interpretation Baseline brain volume and the rate of ongoing brain atrophy are significantly associated with disability worsening in primary progressive multiple sclerosis. Brain volume loss is significantly related to baseline T2 lesion volume, but partially independent of new lesion activity, which might explain the limited efficacy of anti-inflammatory treatment.
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Affiliation(s)
- David H Miller
- Queen Square MS Centre UCL Institute of Neurology London UK
| | - Fred D Lublin
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Icahn School of Medicine at Mount Sinai New York New York
| | - Maria Pia Sormani
- Biostatistics Unit Department of Health Sciences (DISSAL) University of Genoa Via Pastore 1 Genoa 16132 Italy
| | - Ludwig Kappos
- Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering University Hospital University of Basel Basel Switzerland
| | - Özgür Yaldizli
- Department of Neurology University Hospital Basel Basel Switzerland
| | - Mark S Freedman
- The Ottawa Hospital Research Institute University of Ottawa Ottawa Ontario
| | - Bruce A C Cree
- Multiple Sclerosis Center University of California San Francisco California
| | - Howard L Weiner
- Brigham and Women's Hospital Harvard Medical School Boston Massachusetts
| | - Catherine Lubetzki
- Center of Clinical Investigation Salpêtrière Hospital APHP University Paris 6 Paris France
| | - Hans-Peter Hartung
- Department of Neurology Medical Faculty Heinrich-Heine University Düsseldorf Germany
| | | | | | | | - Tarek A Yousry
- Queen Square MS Centre UCL Institute of Neurology London UK
| | | | - Bingbing Li
- Novartis Pharmaceuticals Corporation East Hanover New Jersey
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Puz P, Steposz A, Lasek-Bal A, Bartoszek K, Radecka P, Karuga-Pierścieńska A. Diagnostic methods used in searching for markers of atrophy in patients with multiple sclerosis. Neurol Res 2017; 40:110-116. [DOI: 10.1080/01616412.2017.1403729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Przemyslaw Puz
- Department of Neurology, Medical University of Silesia, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
- School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Arkadiusz Steposz
- Department of Neurology, Medical University of Silesia, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
- School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Anetta Lasek-Bal
- Department of Neurology, Medical University of Silesia, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
- School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Karina Bartoszek
- Department of Neurology, Medical University of Silesia, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
| | - Patrycja Radecka
- Department of Neurology, Medical University of Silesia, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
| | - Aleksandra Karuga-Pierścieńska
- Department of Neurology, Medical University of Silesia, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
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Bovis F, De Stefano N, Steinerman JR, Knappertz V, Sormani MP. Validating the use of brain volume cutoffs to identify clinically relevant atrophy in RRMS. Mult Scler 2017; 25:217-223. [PMID: 29154721 DOI: 10.1177/1352458517743804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Baseline brain volume (BV) is predictive at a group level but is difficult to interpret at the single patient level. OBJECTIVE To validate BV cutoffs able to identify clinically relevant atrophy in relapsing-remitting multiple sclerosis (RRMS) patients. METHODS The expected normalized brain volume (NBV) for each patient was calculated using RRMS patients from two phase III clinical trials, applying a linear formula developed on the baseline variable of an independent data set. The difference between these expected NBV values and those actually observed was calculated and used to categorize the patients in the low-NBV, medium-NBV, and high-NBV groups. RESULTS The 2-year probability of 3-month confirmed disability worsening was significantly associated with the NBV categorization ( p = 0.006), after adjusting for treatment effect. Taking the high-NBV group as a reference, the hazard ratios for the medium-NBV and low-NBV groups were 1.22 (95% confidence interval (CI): 0.85-1.76, p = 0.27) and 1.69 (95% CI: 1.11-2.57, p = 0.01), respectively. CONCLUSION This study validates the use of BV cutoffs to identify clinically relevant atrophy in RRMS study by showing that the three groups classified according to the baseline NBV adjusted for the other prognostic variables have a significant prognostic impact on the risk of disability progression.
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Affiliation(s)
- Francesca Bovis
- Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | | | | | - Volker Knappertz
- Teva Pharmaceuticals, Malvern, PA, USA/Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Maria Pia Sormani
- Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Abstract
Brain atrophy occurs at a faster rate in patients with multiple sclerosis (MS) than in healthy individuals. In three randomized, controlled, phase III trials, fingolimod reduced the annual rate of brain volume loss (BVL) in patients with relapsing MS (RMS) by approximately one-third relative to that in individuals receiving placebo or intramuscular interferon beta-1a. Analysis of brain volume changes during study extensions has shown that this reduced rate of BVL is sustained in patients with RMS receiving fingolimod continuously. Subgroup analyses of the core phase III and extension studies have shown that reductions in the rate of BVL are observed irrespective of levels of inflammatory lesion activity seen by magnetic resonance imaging at baseline and on study; levels of disability at baseline; and treatment history. The rate of BVL in these studies was predicted independently by T2 lesion and gadolinium-enhancing lesion burdens at baseline, and correlations observed between BVL and increasing levels of disability strengthened over time. In another phase III trial in patients with primary progressive MS (PPMS), fingolimod did not reduce BVL overall relative to placebo; however, consistent with findings in RMS, there was a treatment effect on BVL in patients with PPMS with gadolinium-enhancing lesion activity at baseline. The association between treatment effects on BVL and future accumulation of disability argues in favor of measuring BVL on a more routine basis and with a more structured approach than is generally the case in clinical practice. Despite several practical obstacles, progress is being made in achieving this goal.
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